COLLEGE STUDENT BINGE DRINKING AND THE...

J. DRUG EDUCATION, Vol. 34(3) 247-266, 2004

COLLEGE STUDENT BINGE DRINKING AND THE

“PREVENTION PARADOX”: IMPLICATIONS FOR

PREVENTION AND HARM REDUCTION*

ELISSA R. WEITZMAN, SC.D., M.SC.

TOBEN F. NELSON, M.S.

Harvard School of Public Health

ABSTRACT

Considerable attention has been paid to heavy episodic or “binge” drinking

among college youth in the United States. Despite widespread use, the binge

measure is perceived by some as a low intervention threshold. We use data

from the Harvard School of Public Health College Alcohol Study (n = 49,163)

to describe patterns of consumption and harms along a continuum including

the binge measure to demonstrate the validity of the binge threshold and

prevention paradox in college. While the heaviest drinkers are at greatest risk

for harm, they are relatively few and generate proportionately small amounts

of all drinking-harms. The risk of harms is not zero among lower level

drinkers in college. Because they are numerous, they account for the majority

of harms. This paradoxical pattern suggests we moderate consumption among

the majority using environmental approaches, the efficacy of which are

described using case study data from a national prevention demonstration.

Implications for prevention policy, programming, and media advocacy are

discussed.

*Data used in this article were collected with the generous support from the Robert Wood Johnson

Foundation.

247

� 2004, Baywood Publishing Co., Inc.

INTRODUCTION

The problem of heavy episodic or “binge” drinking among young adults in college

in the United States has received considerable attention from researchers, college

administrators, substance abuse educators, students, parents, politicians, and the

media [1]. Defined as 5/4 consecutive drinks among men/women at least once in

the two weeks prior to be surveyed, binge drinking occurs among two out of

every five U.S. college students, half of whom did so multiple times [2]. Binge

drinking may typify consumption among other populations of drinkers in the

United States as well [3].

Despite its common use and its stability in repeated national surveys [1, 4], the

binge measure is controversial. Some think that the 5/4 drinking measure is too

low a threshold on which to base preventive interventions [5, 6]. This perspective

may reflect a belief that heavy drinking among youth is a normal expression of

experimentation and development and that chronic effects of long-term alcohol

use and diagnosable alcoholism are more salient consequences, which college

students are likely to avoid when they reduce their consumption after leaving

college [7]. This perspective is not supported by recent longitudinal study [8].

Attempts to address problems associated with the heavy drinking of college

students have employed a variety of methods, including increased punitive

sanctions, expedited judicial process, and counseling and treatment for problem

drinkers [9]. Social marketing strategies that promote a latent healthy drinking

norm in hopes that it will encourage students to reduce their own consumption

have also become popular, although the empirical evidence for these programs

is mixed [10-12].

No major shifts in the prevalence of alcohol-related problems among college

students have been noted during the 1990s [1, 2]. Both traditional and newer

approaches have attempted to intervene among drinkers deemed at “high risk”

for alcohol-related problems based on self-reported consumption patterns or

harms. These high-risk or secondary prevention efforts which often rely on

screening, counseling, and brief interventions, hold a great deal of appeal for

university administrators, health professionals, and interested activists. At the

same time, students who are considered to be normal and not at high-risk are not

targeted by interventions that may potentially limit their consumption. Unfor-

tunately, little evidence exists to support the efficacy of high-risk approaches

[13]. Very few students perceive that they have a problem with alcohol and even

fewer voluntarily present to a passive health care system for alcohol treatment

or help [1]. Increased emphasis on screening and the development of screening

tools to identify problem drinkers have largely been unsuccessful [13], a difficulty

associated with use of a screening approach and not this health problem or

population [14, 15]. Within the college setting and population, high-risk students

typically come to the attention of authorities such as the Office for Student Affairs

or the local police department. Individual motivation to stop drinking is low

248 / WEITZMAN AND NELSON

among college student drinkers [16, 17], and lasting change is difficult to attain

in the face of underlying environmental conditions that promote alcohol use in

this population, such as a saturation of alcohol outlets in some college environ-

ments [18, 19] and targeted marketing practices [20].

One strategy that has received less attention in college health prevention is

the population approach, which looks at the entire population rather than focus-

ing solely on the members of that group whose behavior is the most extreme

[21]. This view acknowledges that risk is distributed throughout the entire

population and deviance in the group is directly related to the prevailing norma-

tive behavior in the population. Interventions to reduce problem behaviors

thus focus on the community and are directed at producing incremental change

throughout a population, rather than wholesale change among subgroups with

extreme behavior patterns.

Population approaches that address alcohol have demonstrated effectiveness in

reducing the problems that result from alcohol consumption [22-24]. Decreasing

availability of alcohol to underage drinkers, raising alcohol taxes and prices,

instituting mandatory responsible beverage service, and changing the conditions

of availability by limiting outlets are examples of specific population-based

approaches that appear effective at reducing consumption and harms. These inter-

ventions influence all members of a population and result in incremental change

at the individual level, yielding large public health benefits.

The observation underlying population approaches to prevention is the “pre-

vention paradox” [21, 25]. This phenomenon is observed for a range of health

areas including alcohol, tobacco, obesity and injury [15, 26]. It is observed when

a large number of people at small risk contribute more cases of a disease or

negative health outcome in a population than do a small number of people at

large risk. Researchers in the United States and internationally have demonstrated

the importance of this perspective for alcohol using large representative data

sets for a variety of negative alcohol related outcomes [27-31].

A major implication of the preventive paradox, when it is used to shape

prevention strategies, is that there may be substantial benefits to the community

from these approaches but relatively small gains to specific individuals. As a

consequence, these types of prevention strategies may be both controversial—by

seeking to incrementally change the behavior of a majority who may correctly

perceive they are at low individual risk of harm—and counterintuitive—by invest-

ing prevention resources and attention toward changing the upstream determinants

of behaviors that may appear benign individually while seemingly ignoring the

easily identified problems of persons with more acute symptoms or disease.

For these reasons, it may be important to demonstrate both the validity of the

prevention paradox through examining interrelationships of consumption and

harms, and the impacts of prevention program models that take their cue from

its logic. The “A Matter of Degree” (AMOD) program is a community-based

prevention demonstration that is guided by the prevention paradox and uses a

COLLEGE STUDENT BINGE DRINKING / 249

population prevention approach [32]. Funded by the Robert Wood Johnson

Foundation, the goal of the AMOD program is to produce sustained reductions in

alcohol consumption and harms among college students by addressing features

of the college environment that promote heavy and harmful consumption. These

include factors related to alcohol’s accessibility and availability, marketing,

promotion and pricing.

In this article we use aggregated data from four national cycles of the Harvard

School of Public Health College Alcohol Study (CAS) conducted in 1993, 1997,

1999, and 2001 to examine whether the prevention paradox can be observed for

alcohol consumption and related harms among college students. By describing

the balance of harms according to drinking levels in the population we aim to

identify targets and strategies for intervention efforts that would yield the greatest

population or public health benefit. We also use case study data to describe how

environmental prevention programs that are consistent with strategies suggested

by the prevention paradox may be reducing harms in select college communities

participating in the “A Matter of Degree” (AMOD) program. Findings are dis-

cussed in the context of their significance for policy, programming, and media

advocacy efforts.

METHODS

The Survey

The study is based on student reports about drinking behaviors and harms

collected through the Harvard School of Public Health College Alcohol Study

(CAS). The CAS is a national survey program that describes patterns of alcohol

and drug use and other health risk behaviors among a representative sample of

young adults in college. CAS data are collected using a 20-page anonymous

mailed questionnaire administered to students enrolled in a representative sample

of four-year postsecondary institutions in the United States. The CAS has

ongoing approval from the Harvard School of Public Health Human Subject

Committee for analysis of the data. This study used aggregated panel data from

the 1993, 1997, 1999, and 2001 College Alcohol Study. In all four surveys, the

administrators at each college were asked to provide a random sample of approxi-

mately 225 undergraduates drawn from the total enrollment of full-time students.

Further details about the sampling, design and characteristics of the CAS have

been published elsewhere [1, 16, 33, 34].

Measures

We selected four measures of alcohol consumption that represent a continuum

of consumption behaviors and five measures of alcohol-related harms that repre-

sent salient self-reported problems to the population and setting. We examined the


usual number of drinks consumed on a drinking occasion during the past 30

days (responses ranged from one to nine or more), number of drinking occasions

in the past 30 days (responses ranged from 1 to 20 or more), number of occasions

where the respondent drank enough to become drunk (i.e., unsteady, dizzy, or sick

to your stomach) (responses ranged from 1 to 20 or more), and number of drinks

consumed in the past 30 days. These data were transformed into categories

for analysis.

We selected five measures of alcohol-related harms from the 15 measures

collected in the CAS. Measures were selected as exemplary and for salience.

Other measures of harm showed similar distributions of risk throughout the

college student population and are summarized in the results section for brevity

and efficiency.

The harms were self-reported experience of adverse consequences of drinking

at least one time since the beginning of the school year due to student’s own

alcohol use. Subjects were asked to respond to the following question: “Since

the beginning of the school year, how often has your drinking caused you to . . . ?”

A list of consequences from drinking were provided, which are described in

greater detail elsewhere [1]. The selected measures were: 1) fell behind in school

work; 2) did not use protection during sex; 3) damaged property (vandalism); and

4) got hurt or injured. An aggregate measure of five or more harms is also reported

that draws from the full set alcohol-related problems from the CAS survey. In

addition to the above listed harms, the full set includes self-report of: miss a class;

do something later regretted; forget where you were/what you did; argue with

friends; engage in unplanned sexual activity; get into trouble with the campus or

local police; require medical treatment for an alcohol overdose; and among those

who drove a vehicle in the past 30 days, driving after drinking.

Since each of these questions were asked for drinkers only, we identified

all respondents who reported that they abstained from using alcohol using a

separate survey question and assigned a value of zero. We did this to include

those students who did not consume alcohol in the population of all college

students for this analysis.

Students with missing data on any of these variables of interest for this manus-

cript were deleted from the analysis, resulting in a sample size of 49,163 across

the four national survey samples. No differences in the relationship between

consumption and experience of harm were observed by survey year.

Case Study Data

This report also draws on case study data about the “A Matter of Degree”

(AMOD) program to reduce binge drinking and harms in college. Ten CAS

schools are participating in AMOD, which tests the efficacy of environmental

prevention programs. AMOD schools were selected because of their high

levels (>50%) of binge drinking and their commitment to testing environmental


strategies to reduce heavy drinking and harms. As part of a comprehensive

evaluation of AMOD being conducted by HSPH investigators, all preventive

interventions are described and characterized formally at each site and compared

over time to a time series of that site’s CAS data. Trained on-site evaluators at each

site characterize interventions by: chronology, purpose/objective, strategy and

methods, target groups, resources, barriers and facilitators. Intervention-related

data are collected using participant observation, one-on-one interviewing with

key program personnel, and document review (i.e., quarterly reports, minutes, and

other program communications). All intervention-related data are stored in a

standardized tracking database after they are coded using a uniform observation

protocol developed by the evaluation. The tracking database is then combined

with CAS reports about alcohol-related beliefs and behaviors, including harms.

CAS data are collected from an expanded sample of students (n = 750) at each

AMOD site on an annual basis to generate a complete program time series.

Detailed methods about the evaluation are published elsewhere [32, 35].

Within each AMOD site, intervention and CAS data are compared over time

to assess the impact on student drinking beliefs and behaviors of the range

of prevention activities undertaken. Aggregate and subgroups analyses are

conducted. Tests for trends in each site’s CAS data are conducted using student

data adjusted for age, sex and race. Point estimates and 95% confidence intervals

are generated for each time series measure. This report describes significant

behavioral trends and related harms within given settings that were targets of

specific environmental intervention initiatives at two exemplary sites. This

approach is consistent with methodology in case study research [36, 37].

Data Analysis

Cross-tabulation analyses of experience of each alcohol-related harm with each

of the four measures of alcohol consumption were conducted. The percentage of

students who experienced the harm at each level of alcohol consumption was

considered the risk of experiencing that harm at the population level. The total

percent of students (the number of students per level divided by the total number of

students) at each drinking level was the percentage of students in the population.

We selected the measure being hurt or injured to demonstrate the relation-

ship of harms to several measures of alcohol consumption (Figure 1, parts a-d)

and we selected the measure of usual number of drinks consumed when drink-

ing to examine the relationship of consumption to multiple measures of harms

(Figure 2, parts a-e). These measures were exemplary and representative of

the consumption and harms relationship. Additional analyses are available upon

request from the authors.

Logistic regression models were fit to examine the consumption-harm relation-

ship using the aggregate national survey data. We modeled all of the 12 alcohol-

related harm measures, plus the measure driving after five or more drinks and an


aggregate measure of five or more of these harms with each of the three alcohol

consumption measures. Additionally a spearman rho correlation coefficient was

calculated to examine the relationship between each of the alcohol consumption

measures. The change in alcohol related harms at the exemplary AMOD sites

was examined using logistic regression.


Figure 1. Individual risk of being hurt or injured from one’s own drinking

overlaid on population distribution of this harm by four consumption measures.

All analyses were conducted using SAS version 8.2 [38] on the Unix platform.

Consistent with other analyses of multiple year CAS data [1, 35], the data sets

were directly standardized for age, sex, and race to a single survey year to ensure

valid aggregation and longitudinal assessment.


Figure 1. (Cont’d.)


Figure 2. Percentage of students reporting specific drinking-related harms

by usual number of drinks per drinking occasion in the past 30 days.


Figure 2. (Cont’d.)

RESULTS

Consumption and Harms

Individual reports of drinking-related harms increased as level of consumption

increased for multiple measures of drinking style.

Figure 1.a displays the relationship between self-report of being hurt or

injured across usual number of drinks consumed when drinking. Figure 1.b shows

this same relationship for being hurt or injured and the number of drinking

occasions in the past 30 days. Figure 1.c shows the same relationship between

being hurt or injured and the number of drunken occasions in the past 30 days.

Figure 1.d shows the same relationship for the number of drinks consumed in

the past 30 days.

These results are exemplary of the consumption-harms relationship. For all 12

of the harms, driving after five or more drinks and the five or more aggregate

harm measure, we found a significant linear relationship (p < .0001 for every

tested relationship) with each of the alcohol consumption measures using logistic

regression. For the usual number of drinks per occasion (modeled as a continuous

variable with 10 categories, min = 0, max = 9 or more) the slope for each of the

harms ranged from 0.28 to 0.75 (0.40 for being hurt or injured). For number of

drinking occasions in the past 30 days (modeled as a continuous variable with six

categories, min = 0 times, max = 20 or more times) the slope for each of the harms

ranged from 0.51 to 1.26 (0.73 for being hurt or injured). For the number of

drunken occasions in the past 30 days (modeled as a continuous variable with

six categories, min = 0 times, max = 20 or more times) the slope for each of the

harms ranged from 0.68 to 1.91 (0.85 for being hurt or injured). Finally, for the

total number of drinks consumed in the past 30 days (modeled as a continuous

variable, min = 0 drinks, max = 360 drinks) the slope for each of the harms ranged

from 0.01 to 0.08 (0.02 for being hurt or injured).

The similarity of results by consumption measure is not surprising given

the very high correlations between the measures of alcohol consumption. The

usual number of drinks on a drinking occasion was strongly correlated with

drinking occasions (rho = 0.71; p < .0001), drunken occasions (rho = 0.72;

p < .0001), and number of drinks in the past 30 days (rho = 0.88; p < .0001).

Similarly, drinking occasions was correlated with drunken occasions (rho = 0.70;

p < .0001) and number of drinks in the past 30 days (rho = 0.94; p < .0001), as

was drunken occasions with number of drinks in the past 30 days (rho = 0.77;

p < .0001).

Despite this relationship of increasing risk with increasing alcohol consump-

tion, there were very few students who consumed alcohol at the highest levels

in these distributions. The majority of harms at the population level occurred

among drinkers consuming at a less extreme level, as evident by the popula-

tion patterns of consumption. This results from the larger percentage of students


overall who drank at a level associated with a lower, but non-zero, level of

risk. The percentage of students who experienced a given alcohol-related harm

at each level of alcohol consumption is illustrated by the pie charts shown

in Figure 2 parts a-e.

Shifting Drinking Distributions and Reducing

Harms at AMOD Sites: Two Case Studies

Consumption shifted downward incrementally at several AMOD sites as indi-

cated by time series analyses of two sites’ student samples adjusted for age,

sex, and race. Larger proportions of students consumed fewer drinks per drinking

occasion and/or on fewer occasions when we looked at student self-reports about

consumption in off-campus and Greek-house party settings. Sites with substantial

downward shifts in consumption among students attending these events reported

declines in harms among these same groups, as predicted by the prevention

paradox (Figures 3.a–b., and 4.a–b.). Patterns of declining consumption and harms

are consistent with preventive interventions undertaken at these sites that target

the upstream determinants of drinking. At site A, where we described moderation

of off-campus consumption and declines in related harms, interventions included:

increased enforcement and sanctions in judicial system; new standards for

Greek systems students; parental notification practices to inform parents of

students’ illegal behaviors; an increase in substance-free residence halls; man-

datory beverage server training; making minor-in-possession a civil not criminal

offense; and an off-campus accountability project with compliance and keg checks

at liquor licensees. At site B, where we described moderation in Greek-party

consumption and declines in related harms, interventions included: institutional-

ization of a uniform police reporting form; prohibitions of alcohol advertisements

in campus publications; landlord ordinances to promote responsible rental prac-

tices to youth; institutionalization of a two-strikes and suspension behavioral

code; off-campus transportation events policy; parental notification; party host

rules (to discourage supply of alcohol to underage students); and a freshman

sanction policy to strengthen policy enforcement. All of these changes focused

on restricting access and availability of alcohol to youth, limiting advertising

about alcohol to youth, and increasing the linkages among authorities that

supervise youth.

DISCUSSION

Our analyses of national survey data show that the bulk of drinking-related

harms reported by college students accrue to drinkers who consume at non-

extreme levels, the groups some might consider to be at less than “high-risk."

While we found that a given individual’s risk for experiencing harms increases

with consumption, most drinkers do not consume extreme amounts of alcohol.



Figure 3. Moderation of consumption at off-campus parties and concomitant

moderation in harms among drinking youth at those events over time.


Figure 4. Moderation of consumption at Greek parties and concomitant

moderation in harms among drinking youth at those events over time.

Rather, the abundance of drinking-related harms in college results from a com-

bination of low to moderate individual risk multiplied by the large number of

non-extreme drinkers. This pattern held in national analyses of CAS data across

multiple consumption measures and in analyses of survey data from each of

ten high binge schools participating in the “A Matter of Degree” program. The

reported consumption-harms relationship is consistent with predictions of the

prevention paradox.

Our finding suggests that, from a public health perspective, targeting the

entire population, including non-extreme drinkers, using environmental preven-

tion strategies is both logical and likely to yield substantial community-wide

reductions in harm. In addition to having the greatest public health benefit,

encouraging small reductions in consumption among the majority of drinkers

may be more feasible for prevention practitioners in college than the goal of

dramatically changing consumption among frequent heavy drinkers. The latter

may have longstanding patterns of frequent heavy drinking that require intensive

individual efforts and/or treatment from clinicians.

The Promise of Environmental Strategies

Case study analyses of the AMOD demonstration data indicate that: a) designng

and implementing environmental interventions even in high prevalence com-

munities is possible; and b) downward shifts in consumption appear to be

associated with downward shifts in harms, as predicted by theory. In par-

ticular, it appears that environmental strategies to alter access and availability and

increase linkages among supervisory agents hold promise for harm reduction

in the college setting, as suggested by other studies [19, 39, 40].

These analyses are not experimental, and do not completely rule out alter-

native hypotheses about a causal relationship between intervention and outcome.

However, they do provide a longitudinal perspective in the context of known

intervention activity. Further, they are consistent with theory and suggest

a plausible mechanism through which change in patterns of harm can occur.

Additional research using quasi-experimental study designs of both naturally

occurring and planned interventions can provide evidence about the utility of

environmental approaches.

Implications and Challenges

This study lends support to the use of primary prevention efforts targeting

low to moderate drinkers to achieve maximum alcohol-related harm reduction.

Drinkers consuming at or below a binge level may best be reached by prevention

that targets for change environmental influences (such as outlet density, price,

and advertising) while more extreme drinkers may best be reached using indi-

vidually based secondary or tertiary (treatment-related) approaches. In all like-

lihood, shifting the distribution of drinking and harms will require a range


of strategies—including ones characteristic of environmental prevention. Ulti-

mately, we need to become more sophisticated in crafting and targeting preven-

tion efforts so that the field moves away from the misconception that “one size

fits all” when designing prevention programs.

There are several challenges to creating more rational and environmentally-

based prevention programs. The first challenge reflects the need for data

resources. A rational approach generally requires good surveillance data in

order to match problems to strategies and to monitor change. Investment in

epidemiological surveillance may be important for addressing these problems. A

second challenge relates to changing public perceptions about the nature of the

alcohol abuse problem and its likely solutions. Our findings about the relationship

between consumption and harms at the community level may be contrary to

conceptions of the problem and its solution held by the lay public and policy

makers. If communities think that the bulk of alcohol abuse problems comes

from the small number of extreme drinkers (with their highly visible drinking

problems), then education about the actual distribution of harms by consumption

may an be important step in building support for prevention efforts that focus

on the majority. Targets for education would include both the lay public and

policymakers since the support of both groups is required to design, enact and

sustain environmental prevention efforts. This type of media advocacy effort

around alcohol [41-43] is different from the strategy of the social norms approach

that has gained popularity in the prevention community. Efforts to change social

norms about drinking recently have been based on efforts to correct students’

misperceptions about the drinking levels of other students, to encourage the

adoption of moderate drinking norms. While popular, these efforts have not been

effective in changing behaviors [10]. Rather, our analyses suggest a two-pronged

approach to prevention. First, use media advocacy to explain the links between

low levels of consumption and harms and promote harm reduction. To the best of

our knowledge, no comprehensive effort has been made to educate the public or

policy makers about the relationship between consumption and harms from the

perspective of the prevention paradox. Second, use policy controls to limit access

to and availability of alcohol to incrementally shift consumption toward lower

average levels.

A third challenge relates to generating the political will and wherewithal to

implement environmental changes to reduce harms. Within AMOD, efforts to

target individual drinkers using traditional information-based approaches met with

little resistance but appeared to produce few or no results [35]. However enacting

environmental changes at the demonstration sites, including changes to patterns

of pricing and promotion of alcohol, met with considerable resistance, including

aggressive efforts from the alcohol industry [18, 32]. Being able to generate and

sustain the political will be necessary to change the environment to reduce harms

may require both a well educated public and policy sector, as well as time and

other resources.


ACKNOWLEDGMENTS

Dr. Henry Wechsler at the Harvard School of Public Health provided a critical

reading of this manuscript and Lisa Irish and Amanda Rudman at the HSPH

helped with manuscript preparation.

REFERENCES

1. H. Wechsler, J. E. Lee, M. Kuo, M. Seibring, T. F. Nelson, and H. Lee, Trends in

Alcohol Use, Related Problems and Experience of Prevention Efforts among U.S.

College Students 1993-2001: Results from the 2001 Harvard School of Public Health

College Alcohol Study, Journal of American College Health, 50, pp. 203-217, 2002.

2. P. M. O’Malley and L. D. Johnston, Epidemiology of Alcohol and other Drug Use

among American College Students, Journal of Studies on Alcohol, S14, pp. 23-39,

2002.

3. T. S. Naimi, R. D. Brewer, A. Mokdad, C. Denny, M. K. Serdula, and J. S. Marks,

Binge Drinking among U.S. Adults, Journal of the American Medical Association,

289, pp. 70-75, 2003.

4. Centers for Disease Prevention and Control (CDC), Youth Risk Behavior Surveillance:

National College Health Risk Behavior Survey—United States, 1995, Morbidity and

Mortality Weekly Report, 46, pp. 1-54, 1997.

5. W. DeJong, Finding Common Ground for Effective Campus-Based Prevention,

Psychology of Addictive Behaviors, 15:4, pp. 292-296, December 2001.

6. W. DeJong, Definitions of Binge Drinking [Letter to the Editor]. Journal of the

American Medical Association, 289, p. 1635, 2003.

7. K. M. Jackson, K. J. Sher, H. J. Gotham, and P. K. Wood, Transitioning Into and Out

of Large-Effect Drinking in Young Adulthood, Journal of Abnormal Psychology,

110, pp. 378-391, 2001.

8. A. C. Merline, P. M. O’Malley, J. E. Schulenberg, J. E. Bachman, and L. D. Johnston,

Substance Use Among Adults 35 Years of Age: Prevalence, Adulthood Predictors,

and Impact of Adolescent Substance Use, American Journal of Public Health, 94,

pp. 96-102, 2004.

9. H. Wechsler, K. Kelly, E. Weitzman, J. P. SanGiovanni, and M. Seibring, What

Colleges are Doing about Binge Drinking: A Survey of College Presidents. Journal of

American College Health, 48, pp. 219-226, 2000.

10. H. Wechsler, T. F. Nelson, J .E. Lee, M. Seibring, C. Lewis, and R. P. Keeling,

Perception and Reality: A National Evaluation of Social Norms Marketing

Interventions to Reduce College Students’ Heavy Alcohol Use, Journal of Studies on

Alcohol, 64:4, pp. 484-494, 2003.

11. S. Campo, D. Brossard, M. S. Frazer, T. Marchell, D. Lewis, and J. Talbot, Are Social

Norms Campaigns Really Magic Bullets? Assessing the Effects of Students’ Misper-

ceptions on Drinking Behavior, Health Communication, 15:4, pp. 481-497 2003.

12. J. D. Clapp, J. E. Lange, C. Russell, A. Shillington, R. B. Voas, A Failed Norms Social

Marketing Campaign, Journal of Studies on Alcohol, 64:3, pp. 409-414, May 2003.

13. M. E. Larimer and J. M. Cronce, Identification, Prevention and Treatment: A Review

of Individual-Focused Strategies to Reduce Problematic Alcohol Consumption by

College Students, Journal of Studies on Alcohol, S14, pp. 148-163, 2002.


14. G. Rose, The Strategy of Preventive Medicine, Oxford University Press, Oxford, 1992.

15. B. Lewis and G. Rose, Prevention of Coronary Heart Disease: Putting Theory into

Practice, Journal of the Royal College of Physicians of London, 25, pp. 21-26, 1991.

16. H. Wechsler, G. W. Dowdall, G. Maenner, J. Gledhill-Hoyt, and H. Lee, Changes in

Binge Drinking and Related Problems among American College Students between

1993 and 1997, Journal of American College Health, 47, pp. 57-68, 1998.

17. J. R. Knight, H. Wechsler, M. Kuo, M. Seibring, E. R. Weitzman, and M. A. Schuckit,

Alcohol Abuse and Dependence among U.S. College Students, Journal of Studies on

Alcohol, 63:3, pp. 263-270, 2002.

18. H. Wechsler and B. Wuethrich, Dying to Drink: Confronting Binge Drinking on

College Campuses, Rodale Books, Emmaus, Pennsylvania, 2002.

19. E. R. Weitzman, A. Folkman, K. L. Folkman, and H. Wechsler, The Relationship

of Alcohol Outlet Density to Heavy and Frequent Drinking and Drinking-Related

Problems among College Students at Eight Universities, Health and Place, 9, pp. 1-6,

2003.

20. Center on Alcohol Marketing and Youth, Overexposed: Youth as a Target of Alcohol

Advertising in Magazines, October 3, 2002, Available at: http://campy.org/research/

21. G. Rose, Sick Individuals and Sick Populations, International Journal of Epidemi-

ology, 14, pp. 32-38, 1985.

22. Substance Abuse and Mental Health Services Administration (SAMHSA), Center

for Substance Abuse Prevention, Division of State and Community Systems

Development, Preventing Problems Related to Alcohol Availability: Environmental

Approaches, Reference Guide, Third in the PEPS Series, DHHS Publication No.:

(SMA) 99-3298, Rockville, MD, Department of Health and Human Services, 1999.

Available at http://www.health.org/govpubs/PHD822/aar.htm)

23. National Institute on Alcohol Abuse and Alcoholism (NIAAA) Task Force on

College Drinking. A Call to Action: Changing the Culture of Drinking at U.S. Colleges,

NIH Publication No: 02-5010, National Institute on Alcohol Abuse and Alcoholism,

Bethesda, Maryland, 2002. Available at

http://www.collegedrinkingprevention.gov/Reports/TaskForce/TaskForce_TOC.aspx

24. R. J. Bonnie and M. E. O’Connell (eds.), Reducing Underage Drinking, National

Academies Press,Washington, D.C., 2003.

25. G. Rose, The Strategy of Preventive Medicine, Oxford University Press, Oxford, 1992.

26. T. Stockwell, J. Toumbourou, P. Letcher, D. Smart, A. Sanson, and L. Bond, Risk

and Protection Factors for Different Intensities of Adolescent Substance Use: When

Does the Prevention Paradox Apply? Drug and Alcohol Review, 23:1, pp. 67-77,

March 2004.

27. R. Caetano and C. Cunradi, Alcohol Dependence: A Public Health Perspective,

Addiction, 97, pp. 633-645, 2002.

28. D. A. Cohen, K. Mason, and R. Scribner, The Population Consumption Model, Alcohol

Control Practices and Alcohol-Related Traffic Fatalities, Preventive Medicine, 34,

pp. 187-198, 2001.

29. G. Gmel, S. Klingemann, R. Muller, and D. Brenner, Revising the Preventive Paradox:

The Swiss Case, Addiction, 96, pp. 273-284, 2001.

30. L. T. Midanik, T. W. Tam, T. K. Greenfield, and R. Caetano, Risk Functions

for Alcohol-Related Problems in a 1988 U.S. National Sample, Addiction, 91,

pp. 1427-1437, 1996.


31. O.-J. Skog, The Prevention Paradox Revisited, Addiction, 94, pp. 751-757, 1999.

32. E. R. Weitzman, T. F. Nelson, and H. Wechsler, Assessing Success in a Coalition-

Based Environmental Preventionn Programme Targeting Alcohol Abuse and Harms,

Nordic Journal of Substance Use, 20, pp. 1-9, 2003.

33. H. Wechsler, A. Davenport, G. Dowdall, B. Moeykens, and S. Castillo, Health

and Behavioral Consequences of Binge Drinking in College: A National Survey

of Students at 140 Campuses, Journal of the American Medical Association, 272,

pp. 1672–1677, 1994.

34. H. Wechsler, J. E. Lee, M. Kuo, and H. Lee, College Binge Drinking in the 1990s: A

Continuing Problem Results of the Harvard School of Public Health 1999 College

Alcohol Study, Journal of American College Health, 48, pp. 199-210, 2000.

35. E. R. Weitzman, T. N. Nelson, H. Lee, and H. Wechsler, Reducing Drinking and

Related Harms in College: Evaluation of the “A Matter of Degree” Program, American

Journal of Preventive Medicine, 27, pp. 187-196, 2004.

36. P. H. Rossi and H. E. Freeman, Evaluation: A Systematic Approach, Sage Publications,

Inc., Newbury Park, California, 1989.

37. R. K. Yin, Case Study Research Design and Methods, Applied Social Research

Methods Series, Vol. 5, Sage Publications, Newbury Park, California, 1989.

38. SAS Institute, SAS/STAT User’s Guide, Version 6 (4th ed.), SAS Institute, Cary,

North Carolina, 1994.

39. E. R. Weitzman, T. F. Nelson, and H. Wechsler, Taking Up Binge Drinking in College:

The Influence of Personal, Social and Environmental Factors, Journal of Adolescent

Health, 32, pp. 26-35, 2003.

40. H. Wechsler, J. E. Lee, T. F. Nelson, and H. Lee, Drinking Levels, Alcohol Problems,

and Secondhand Effects in Substance-Free College Residences: Results of a National

Study, Journal of Studies on Alcohol, 62, pp. 23-31, 2001.

41. L. Wallack, Two Approaches to Health Promotion in the Mass Media, World Health

Forum, 11, pp. 143-154; discussion, pp. 155-164, 1990.

42. L. Wallack and L. Dorfman, Media Advocacy: A Strategy for Advancing Policy

and Promoting Health, Health Education Quarterly, 23, pp. 293-317, 1996.

43. J. M. Moskowitz, The Primary Prevention of Alcohol Problems: A Critical Review

of the Research Literature, Journal of Studies on Alcohol, 50, pp. 54-88, 1989.

Direct reprint requests to:

Elissa R. Weitzman, ScD, MSc

Dept. of Society, Human Development and Health

Harvard School of Public Health

Landmark Center

401 Park Drive

P.O. Box 15678

Boston, MA 02215

e-mail: [email protected]


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