Why College Binge Drinking is Relevant to EAPS

Transcription

1 Why College Binge Drinking is Relevant to EAPS Dale A. Masi Suzie Foster-Sanda SUMMARY. Binge drinking is a significant public health concern that is highly prevalent among college students. College students who binge drink often experience a range of negative consequences, including legal complications, health impairments, increased risk for mortality, and academic failure. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) awarded 15 colleges and universities grant money for the purpose of empirically evaluating how various intervention programs affect students binge drinking behaviors. This review presents a potential area for Employee Assistance Program (EAP) practice as it describes the Northeastern University grant which applied EAP concepts to college binge drinking as an effective strategy to reach students with alcohol issues. It also points out the importance of understanding how such practices affect the workplace. Dale Masi, PhD, is a Professor Emeritus in the School of Social Work at the University of Maryland and is the President=CEO of Masi Research Consultants, Inc., which specializes in designing and evaluating EAPs. Dr. Masi was the Project Director for the NIAAA grant at Northeastern University. Suzanne M. Foster-Sanda, MS, is a graduate research fellow for the University Assistance Program at Northeastern University in Boston, Massachusetts. Suzanne is currently enrolled in the combined Counseling and School Psychology doctoral program at Northeastern University. Address correspondence to: Dr. Dale Masi 100 Belvedere Street, Unit 4B, Boston, MA ( dalemasi@eapmasi.com). Journal of Workplace Behavioral Health, Vol. 23(4) 2008 # 2008 by The Haworth Press. All rights reserved. doi: /

2 382 JOURNAL OF WORKPLACE BEHAVIORAL HEALTH KEYWORDS. Binge drinking, college students, employee assistance program INTRODUCTION As the readers know, the Employee Assistance Program (EAP) field had its origins in occupational alcoholism. Early leaders in the field had an expertise in identifying the signs of alcoholism, educating workplace managers to the extent of the problem, and how to handle employees that were afflicted. The EAP professionals have continued to be recognized as being specifically trained in this area and have, through the years, successfully provided training, education programs, and counseling to thousands of workplaces and millions of workers. Up to this time, this expertise has been delivered to employer= employee settings. The purpose of this article is to show the EAP field the extent of the problem of alcoholism in another setting, that is, universities, and to encourage it to reach out and adapt its expertise to this group. In addition, this article also demonstrates how the problem of university binge drinking is, and will, continue to affect employers and employees. DEFINING BINGE DRINKING The National Institute on AlcoholAbuse and Alcoholism (NIAAA) defines binge drinking as a pattern of drinking alcohol that brings blood alcohol content levels to about 0.08 gram-percent or above in approximately two hours (NIAAA, 2002). For the typical adult, this pattern corresponds to approximately five or more standard drinks for males or four or more standard drinks for females. Concerning the amount of liquor constituting a standard drink, the U.S. Department of Health and Human Services (DHHS), NIAAA, and the U.S. Department of Agriculture (USDA, 1995) consider a standard beer to contain 12 ounces, a standard glass of wine to contain 5 ounces, and a standard shot of liquor or mixed drink to contain 1.5 ounces. Other countries utilize different definitions, with the United Kingdom recognizing binge drinking as a male s consumption of eight or more alcohol units, and a female s consumption of six or more units in 1 sitting, with a standard unit

3 Dale A. Masi and Suzie Foster-Sanda 383 equaling 8 grams ( ounces) of ethanol. Frequent binge drinking is defined as binge drinking three or more times over 2 weeks (Wechsler, Dowdall, Maenner, Gledhill-Hoyt, & Hang, 1998). College Students LITERATURE REVIEW College students, including 48% of full-time students younger than age 21 years, engage in risky, heavy episodic drinking at a rate significantly higher than nonenrolled peers and the general population (Dawson, Grant, Stinson, & Chou, 2004; Gill, 2002; Kypri, Paschall, Maclennan, & Langley, 2007). As frequent consumers of alcohol, 49.4% of full-time college students consume four or five drinks in one sitting within the previous 2 weeks (Wechsler, 1996). Among college drinkers, students between ages 18 and 25 years have the highest likelihood of engaging in binge drinking, and often report consuming 15 or more drinks per sitting. Coupled with the fact that there has not been a significant decline in the proportion of undergraduates who drink, the proportion of college students who binge drink frequently has increased by 15.7% between 1993 and 2005, rising from 19.7% to 22.8% (NIAAA, 2004). It is notable that the aforementioned statistics may be underestimates of the frequency of students drinking, as many undergraduates are unaware of how much alcohol constitutes a single drink and, accordingly, overpour their drinks and underreport the extent of their consumption (White et al., 2005). Negative Consequences Many individuals acknowledge the high proportion of college students who binge drink and deem it a normative behavior for this age group, despite ample research that posits strong associations between binge drinking and a myriad of harmful consequences that pervade various aspects of their life. With regard to academic success, college students who binge drink have lower Grade Point Averages than peers who do not engage in heavy episodic drinking. More than 5% of binge-drinking students have been suspended, and 50.6% indicate that they have fallen behind in their school work. Concerning

4 384 JOURNAL OF WORKPLACE BEHAVIORAL HEALTH school absenteeism, approximately 68.1% miss classes on a consistent basis (Hildebrand, Johnson, & Bogle, 2001; Nezlek, Pilkington, & Bilbro, 1994; Perkins, 2002). Between 2001 and 2005, the average number of alcohol-related arrests per college campus increased by 21%. In 2005, alcohol-related arrests comprised 83% of on-campus arrests. Concerning law abidance, American undergraduates who drive present a special interest group, as 50% and 35% of male and female drinkers, respectively, reporting driving while under the influence of alcohol. Among these drinkers, binge drinkers are 14 times more likely to drive while impaired. Binge drinkers not only have an increased risk of initiating unlawful activity, but also have an increased likelihood of being victimized in date rape and sexual assault (Naimi et al., 2003; Wechsler & Isaac, 1992). Research draws strong associations between binge drinking and an increase in the number of alcohol-related injuries, illness, and fatalities within the United States and internationally (Pridemore & Kim, 2006; Webb et al., 2005). Between 1993 and 2001, approximately 500,000 college students experience alcohol-related injuries, with a 38% increase during that period in the proportion of students who became injured as a result of their own drinking. The number of alcohol-related injuries and subsequent deaths among American undergraduates has risen by approximately 6% between 1998 and 2001, increasing from 1,600 to 1,700 deaths per year (Hingson, Heeren, Winter, & Wechsler, 2005). This phenomenon has been demonstrated internationally, particularly in Europe, where research indicates a 25% alcohol-related mortality rate among young men (Popova, Rehn, Patra, & Zatonski, 2007). Risk Factors Certain populations of college students have a higher probability of engaging in high-risk drinking. The duration of students undergraduate student status presents as a risk factor, that is, students who attend 4-year colleges demonstrate an increasing linear rate of change in drinking than those attending 2-year colleges (Dawson et al., 2004). Additionally, part-time students have been shown to drink less than full-time students. First-year undergraduates are at a particularly high risk for alcohol-related problems and binge drinking, given that their drinking increases substantially upon matriculation

5 Dale A. Masi and Suzie Foster-Sanda 385 and throughout their first year at school (O Malley & Johnston, 2002; Sher & Rutledge, 2007). Research nonetheless suggests that male freshman tend to drink less heavily than male upperclassmen, whereas female freshman demonstrate a converse trend as they drink more frequently than female upperclassmen (Bon, Hittner, & Lawandales, 2001). Individual risk factors that enhance the likelihood of binge drinking in college include (1) early age of initiation to drinking (e.g., high school), (2) genetics and family history of problematic alcohol use, (3) comorbid substance use, and (4) clinical mental health problems (Baer, 2002; Sher, Bartholow, & Wood, 2000; Wechsler, Davenport, Dowdall, Moeykens, & Castillo, 1994). Research has identified a range of psychological factors, mood conditions, and personality traits that hold a central place in etiological theories of substance use and have been empirically connected with a higher likelihood of heavy episodic drinking, including proneness to impulsivity, anxiety, and depression, and sensation seeking (Comeau, Stewart, & Loba, 2001; Conrod, Stewart, Comeau, & Maclean, 2006; Cooper, Frone, Russell, & Mudar, 1995). Additionally, college students who report significant suicidal ideation in the past 12 months are more likely than other students to engage in binge drinking (41.9% vs. 39.6%). Social risk factors have been shown to appreciably affect the frequency of college students binge drinking. Fraternity and sorority membership presents as the highest predictor, with 80% of sorority house residents and 86% of fraternity house residents identifying as binge drinkers (Larimer, Anderson, Baer, & Marlatt, 2000; Wechsler, 1996). Meilman, Leichliter, and Presley (1999) corroboratively observed that students who combine Greek membership and athletic affiliation demonstrate the most elevated consumption of alcohol on college campuses, followed by Greek nonathletes, and non-greek athletes. Self-selection into a heavy drinking social group and residing in a residential hall with heavy drinking peers also presents as a risk factor (Sher & Rutledge, 2007). Likewise, students who are less engaged in the learning process (i.e., spend 5 or less hours participating in nonrequired campus or community service activities) are more likely to engage in binge drinking than peers who demonstrate 6 or more hours of engaged learning, presenting with a discrepancy of 36.1% versus 26.3%. Finally, certain social events elicit particularly binge drinking rates. Celebrating a 21st birthday has been linked to intense binge drinking

6 386 JOURNAL OF WORKPLACE BEHAVIORAL HEALTH with associated alcohol poisoning and death. Spring break is another occasion marked by heavy episodic drinking, with 75% of males and 40% of females reporting daily intoxication. Drinking rates are also high during winter break, as well as holidays including Thanksgiving, Christmas, and New Year s Day (National Center on Addiction and Substance Abuse at Columbia University [CASA], 2007; Perkins, 2002). Race and Ethnicity Research suggests that race and ethnicity play a role in the extent of students drinking behaviors. White non-hispanic undergraduates drink more frequently and consume larger quantities of alcohol than same-aged peers with other racial and ethnic identities, that is, they exhibit the highest percentage of binge drinking in a 2-week period (43.8%) followed by Native American (40.6%), Hispanic (31.3%), Asian (22.7%), and Black non-hispanic (22.5%) college students (Ham & Hope, 2003; O Malley & Johnston, 2002). Students who attend historically Black colleges and universities (HBCUs), regardless of their race=ethnicity, are less likely to binge drink (22.3%) than students from predominately White college (37.5%). Sex and Gender Early literature suggests that males consume more alcohol and exhibit elevated binge drinking rates as compared to females, with male undergraduates engaging in particularly high levels of heavy episodic drinking (Capraro, 2000; Grant, 1997; Wechsler, Kuo, Lee, & Dowdall, 2000). Some recent research corroborates this claim, with 39% and 50% of American female and male undergraduates, respectively, reporting that they binge drank within a 2-week period. Many international studies continue to implicate higher levels of binge drinking amongst males (Naimi et al., 2003; Valencia-Martin, Galan, & Rodriguez-Artalejo, 2007). Research historically posits differences between male and female drinking behaviors, yet recent data suggests a gender convergence, with a change in gender roles (e.g., women adopting career and familial responsibilities) being linked to the shrinking discrepancy between gender-based drinking behaviors. Dating back to the 1970s, when young women began experiencing increased stress due to conflicts between pursuing a career and raising a family, they

7 simultaneously exhibited a tendency to engage in higher rates of binge drinking (Fillmore, 1984; Johnson & Gerstein, 1998). Between 1993 and 2001, college females, as opposed to male undergraduates, were more likely to (1) engage in frequent binge drinking, (2) report being drunk 3 or more times, and (3) drink on 10 or more occasions in the past 30 days. Over the course of a decade, the drinking habits of women attending all-female schools, as opposed to females attending coeducational institutions, has drastically changed in that the frequent binge drinking behaviors of the former group has more than doubled, with 5.3% binge drinking in 1993 and 11.9% endorsing the same in 2005 (Wechsler et al., 2002). National Difference Many individuals purport that college students from countries with lower legal-drinking ages (i.e., 15 to 18) engage in less binge drinking and experience fewer negative consequences as compared to age-similar peers from countries with a 21-years-of-age drinking limit. Research disputes this claim as anecdotal, as the prevalence of heavy episodic drinking in Europe, Australia, and South America approximates that of American instances of binge drinking (Karam, Kypri, & Salamoun, 2007). Emerging Adulthood Dale A. Masi and Suzie Foster-Sanda 387 Emerging adulthood is proposed as a new conception of development for the period from the late teens through the 20s, with a focus on ages 18 to 25. Although a pattern of maturing out of alcohol use has been documented among some individuals in their late 20s, research indicates that individuals between ages 21 to 25 years, as compared to the general adult population, demonstrate the highest alcohol use rates. Thus, many young adults continue to engage in frequent binge drinking upon graduating from college and entering the work force (Arnett, 2000; Jackson, Sher, Gotham, & Wood, 2001). THE ROLE OF NIAAA As a result of Call to Action (NIAAA, 2002), NIAAA designed a massive effort to study various approaches to the problem of binge

8 388 JOURNAL OF WORKPLACE BEHAVIORAL HEALTH drinking. Called Rapid Response to College Binge Drinking, 15 grants were awarded to different universities, each with a different approach to resolving the problem. The Northeastern University (NU) grant is the only grant with specific applications to the EAP field, as it adapted EAP concepts to the problem of college binge drinking. Although the other grant recipients chose different methodologies, their programs and research are important. One of these programs had as its goal to reduce alcohol consumption and its associate negative consequences among first-year students and students turning age 21 (North Dakota State University). Many grant recipients chose to focus much of their research toward incoming first-year student (Clemson University, Loyola Marymount University, and University of San Diego). The University of Michigan took its first-year student initiative one step further by examining the role of segregated housing, where students did not have easy access to alcohol, and comparing that to alcohol misuse in first-year students living in traditional residence hall settings. The University of Virginia chose to focus its efforts on reducing the number of alcohol-related negative consequences experienced by the members of fraternities and sororities. These examples show the range of research that was done through the grants given and deserve mention as most of the issues being investigated are problems at colleges and universities across the country. KEY ASPECTS OF THE NORTHEASTERN UNIVERSITY (NU) PROGRAM RELATED TO EAPS In designing the grant proposal the project director (Masi) deliberately took the EAP essential ingredients and applied them to the university setting. Role of the Advisory Board The Advisory Board s responsibility was to provide guidance and oversight for the entire effort, and to meet monthly to review and approve implementation, progress plans, and actions that were to be taken. The board was assembled to manage and oversee the University Assistance Program (UAP) and was chaired by the principal investigator=senior vice president of Enrollment and Student Life.

9 The board included members of various stakeholder groups on and off campus, Student Affairs, Public Safety, the center for Health and Counseling, Student Government, and Resident Assistants. The mayor s office is also represented. The committee was organized as follows: (1) prevention services and outreach, (2) policy=disciplinary, (3) clinical services, (4) community relations, (5) research, and (6) student representatives. Alcohol Policy Although NU previously had an alcohol policy, it was found that it needed revision in many aspects. Examples of recommendations were to expand the alcohol and drug policy with an increase in the severity of penalties for alcohol and drug violations, and a strengthening for the substance abuse and date rape education in the larger NU community. Strategic planning efforts for proactive prevention had already begun at NU. For example, the first-year student orientation curriculum (now attended by students and parents) had been revised to reflect a greater emphasis on the negative impact of drinking on the academic environment, the student code of behavior, and the expectations of students to exhibit behavior in keeping with NU s status as an asset to the neighborhood. Required completion of an alcohol education course was expanded from undergraduates with alcohol-related violations to a mandatory education requirement for all incoming first-year students. A major change in the alcohol policy worth noting has been the implementation of an amnesty policy for students who call for help during an emergency induced by binge drinking. Previously, students would receive a violation if they were around a binge drinking emergency, even if they called for help. This policy of giving violations to all parties led to students not wanting to call for help if another student needed medical attention. The amnesty policy has made it so the student who calls about the emergency will not receive a violation, therefore allowing for more emergencies to be reported and for the overall health and safety of the student population to be better maintained. Training for Faculty and Staff Dale A. Masi and Suzie Foster-Sanda 389 In the same way managers and supervisors maintain a critical role in identifying and providing assistance to employees with substance

10 390 JOURNAL OF WORKPLACE BEHAVIORAL HEALTH abuse problems in the university setting, resident assistants, deans, faculty, and other administrative personnel provide a key ingredient to identifying students with alcohol problems, reaching out to them and offering help. The training has been extremely successful, with 100% faculty attendance from various departments having already been trained. These trained faculty members include all faculty of the College of Business Administration, College of Computer and Information Science, College of Criminal Justice, Bouve College of Health Sciences, and the College of Arts and Sciences. Handbooks were given during the training, which covers the following topics: (1) being informed of what the substance abuse policy is at NU, (2) being provided information of possible performance problems that may identify a student with an alcohol problem, and (3) the referral process. The resident assistant training program has included guest speakers being brought in to lecture, and attendance is required. Program Promotion A clearly defined campus-wide program promotion strategy was implemented with a clear emphasis on clear communication of the appropriate messages. This was done through group meetings with students, health fairs, and appropriate flyers and posters. The most important aspect of the promotion was to involve the students in the process of selecting the various approaches. The student representatives on the Advisory Board, from the Greek system, Athletic Department, and Student Government were solicited to help promote various approaches. Student Education Eleven focus groups were conducted to obtain students thoughts and ideas about what causes binge drinking and how the problem can be handled. During the first year, three programs were implemented where speakers came in to lecture and interact with the students. This failed, as the students were not interested. The failed approach was used as a learning tool as to what does not work. A different approach was taken during the second year, where the HBO film Addiction was shown to all incoming first-year students in a classroom setting. After this was shown, surveys were distributed asking

11 students what worked and to what other types of education they would respond. Toll-Free Telephone Access A new program has been implemented that offers students access to the after-hours counseling service in case of emergencies. Formerly, there was no way to get in touch with counselors after hours. Students were forced to call the campus police, which they were apprehensive to do in some cases. The telephone line allows for students to be in touch with counseling service personnel 24 hours a day. Evaluation of Clinical Cases Dale A. Masi and Suzie Foster-Sanda 391 Two peer reviews were implemented to evaluate the effectiveness of the clinical process. As peer reviews are important to the EAP to ensure the delivery of quality services, so were they important to evaluate the NU program. Peer reviews serve as an ongoing process of assessment and evaluation. It ensures the quality and efficiency of services. The two peer reviews were done 6 months apart from each other; the first being done by a social worker (MSW) with an EAP background and a substance abuse background, and the second being done by a psychologist (PhD) with a background of working with college students. RELEVANCE TO EAPS Almost every campus in the United States has a Faculty-Staff Assistance Program (FSAP). The expertise in alcohol-related problems is found among their staffs. Many campuses struggle with the problem of binge drinking while the resource of the FSAP is not tapped. Such programs should reach out to college administrators who could benefit from their knowledge. The external EAP providers who deliver FSAPs should also reach out to university officials. This provides a new area for EAPs to broaden the delivery of their services. EAPs need to be alert to the problem of the young workers who bring their binge drinking habits into the workplace. These former students have been binge drinking from Thursdays to Sundays, some for 4 years. This havoc does not necessarily stop upon entering the workplace. EAP professionals need to be sensitive to this and train

12 392 JOURNAL OF WORKPLACE BEHAVIORAL HEALTH supervisors to refer young workers who are showing signs of binge drinking early on. An additional reason why this is a critical subject for EAP professionals is because the parents of the binge drinkers are in the workplace. Many are experiencing tragedies from their children s behavior. Most important, parents are often ignorant of the nature and extent of binge drinking. Studies from NIAAA have shown that college students do listen to their parents, and parents need to be educated enough to speak with their children about this subject. Finally, educational programs on these phenomena should be developed for managers, occupational physicians and nurses, and human resource directors. REFERENCES Arnett, J. J. (2000). Emerging adulthood: A theory of development from the late teens through the twenties. American Psychologist, 55, Baer, J. S. (2002). Student factors: Understanding individual variations in college drinking. Journal of Studies on Alcohol, Suppl., 13, Bon, S. R., Hittner, J. B., & Lawandales, J. P. (2001). Normative perceptions in relations to substance use and HIV-related sexual behaviors of college students. Journal of Psychology, 135(2), Capraro, R. L. (2000). Why college men drink: Alcohol, adventure, and the paradox of masculinity. Journal of American College Health, 48, Comeau, M. N., Stewart, S. H., & Loba, P. (2001). The relations of trait anxiety, anxiety sensitivity, and sensation seeking to adolescents motivations for alcohol, cigarette, and marijuana use. Addictive Behaviors, 26, Conrod, P. J., Stewart, S. H., Comeau, N., & Maclean, A. M. (2006). Preventative efficacy of cognitive behavioral strategies matched to the motivational bases of alcohol misuse in at-risk youth. Journal of Clinical Child and Adolescent Psychology, 35, Cooper, M. L., Frone, M. R., Russell, M., & Mudar, P. (1995). Drinking to regulate positive and negative emotions: A motivational model of alcohol use. Journal of Personality and Social Psychology, 69, Dawson, D. A., Grant, B. F., Stinson, F. S., & Chou, P. S. (2004). Another look at heavy episodic drinking and alcohol use disorders among college and noncollege youth. Journal of Studies on Alcohol, 65, Fillmore, K. M. (1984). When angels fall : Women s drinking as cultural preoccupation and as reality. In S. C. Wilsnack & L. J. Beckman (Eds.), Alcohol problems in women (pp. 7 36). New York: Guilford Press. Gill, J. S. (2002). Reported levels of alcohol consumption and binge drinking within the UK undergraduate student population over the last 25 years. Alcohol and Alcoholism, 37,

13 Dale A. Masi and Suzie Foster-Sanda 393 Grant, B. F. (1997). Prevalence and correlates of alcohol use and DSM-IV alcohol dependence in the United States: Results of the National Longitudinal Alcohol Epidemiologic Survey. Journal of Studies on Alcohol, 58(5), Ham, L. S., & Hope, D. A. (2003). College students and problematic drinking: A review of the literature. Clinical Psychology Review, 23, Hingson, R., Heeren, T., Winter, M., & Wechsler, H. (2005). Magnitude of alcoholrelated mortality and morbidity among U.S. college students ages 18 24: Changes from 1998 to Annual Review of Public Health, 26, Hildebrand, K., Johnson, D., & Bogle, K. (2001). Comparison of patterns of alcohol use between high school and college athletes and non-athletes. College Student Journal, 35, Jackson, K. M., Sher, K. J., Gotham, H. J., & Wood, P. K. (2001). Transitioning into and out of large-effect drinking in young adulthood. Journal of Abnormal Psychology, 110, Johnson, R. A., & Gerstein, D. R. (1998). Initiation of use of alcohol, cigarettes, marijuana, cocaine, and other substances in US birth cohorts since American Journal of Public Health, 88(1), Karam, E. G., Kypri, K., & Salamoun, M. (2007). Alcohol use among college students: An international perspective. Current Opinion in Psychiatry, 20(3), Kypri, K., Paschall, M. J., Maclennan, B., & Langley, J. D. (2007). Reducing alcohol consumption in university students. Addictive Behaviors, 32(11), Larimer, M. E., Anderson, B. K., Baer, J. S., & Marlatt, G. A. (2000). An individual in context: Predictors of alcohol use and drinking problems among Greek and residence hall students. Journal of Substance Abuse, 11, Meilman, P. W., Leichliter, M. A., & Presley, C. A. (1999). Greeks and athletes: Who drinks more? Journal of American College Health, 47, Naimi, T. S., Brewer, R. D., Mokdad, A., Denny, C., Serdula, M. K., & Marks, J. S. (2003). Binge drinking among US adults. Journal of the American Medical Association, 289, National Center on Addiction and Substance Abuse (CASA) at Columbia University. (2007). CASA analysis of data obtained from the Campus Security Data Analysis Cutting Tool website provided by the U.S. Department of Education, Office of Postsecondary Education. Retrieved January 12, 2008, from security/ National Institute on Alcohol Abuse and Alcoholism. (2002). A call to action: Changing the culture of drinking at U.S. colleges. Bethesda, MD: Author. National Institute on Alcohol Abuse and Alcoholism. (2004). Helping patients with alcohol problems: A health practitioner s guide. Bethesda, MD: Author. Nezlek, J. B., Pilkington, C. J., & Bilbro, K. G. (1994). Moderation in excess: Binge drinking among college students. Journal of Studies on Alcohol, 55, O Malley, P. M., & Johnston, L. D. (2002). Epidemiology of alcohol and other drug use among American college students. Journal of Studies on Alcohol, Suppl., 14,

14 394 JOURNAL OF WORKPLACE BEHAVIORAL HEALTH Perkins, H. W. (2002). Surveying the damage: A review of research on consequences of alcohol misuse in college populations. Journal of Studies on Alcohol, Suppl., 14, Popova, S., Rehm, J., Patra, J., & Zatonski, W. (2007). Comparing alcohol consumption in central and Eastern Europe to other European countries. Alcohol and Alcoholism, 42(5), Pridemore, W. A., & Kim, S. W. (2006). Patterns of alcohol-related mortality in Russia. Journal of Drug Issues, 35, Sher, K. J., Bartholow, B. D., & Wood, M. D. (2000). Personality and substance use disorders: A prospective study. Journal of Consulting and Clinical Psychology, 68, Sher, K. J., & Rutledge, P. (2007). Heavy drinking across the transition to college: Predicting first-semester heavy drinking from precollege variables. Addictive Behavior, 32, U.S. Department of Agriculture=U. S. Department of Health and Human Services. (1995). Nutrition and your health: Dietary considerations for Americans (4th ed.). Washington, DC: Author. Valencia-Martin, J. L., Galan, I., & Rodriguez-Artalejo, F. (2007). Binge drinking in Madrid, Spain. Alcoholism: Clinical and Experimental Research, 31(10), Webb, C. P. M., Bromet, E. J., Gluzman, S., Tintle, N. L., Schwartz, J. E., Kostyuchenko, S., et al. (2005). Epidemiology of heavy alcohol use in Ukraine: Findings from the world mental health survey. Alcohol and Alcoholism, 40, Wechsler, H. (1996). Alcohol and the American college campus: A report from the Harvard School of Public Health. Change, 28(4), Wechsler, H., Davenport, A., Dowdall, G., Moeykens, B., & Castillo, S. (1994). Health and behavioral consequences of binge drinking in college: A national survey of students at 140 campuses. Journal of the American Medical Association, 272, Wechsler, H., Dowdall, G., Maenner, G., Gledhill-Hoyt, J., & Hang L. (1998). Changes in binge drinking and related problems among American college students between 1993 and 1997: Results of the Harvard School of Public Health College Alcohol Study. Journal of American College Health, 47(2), Wechsler, H., & Isaac, N. (1992). Binge drinkers at Massachusetts colleges: Prevalence, drinking style, time trends, and associated problems. Journal of the American Medical Association, 267, Wechsler, H., Kuo, M., Lee, H., & Dowdall, G. W. (2000). Environmental correlates of underage alcohol use and related problems of college students. American Journal of Preventative Medicine, 19(1), Wechsler, H., Lee, J. E., Kuo, M., Seibring, M., Nelson, T. F., & Lee, H. (2002). Trends in college binge drinking during a period of increased prevention efforts: Findings from 4 Harvard School of Public Health college alcohol study surveys: Journal of American College Health, 50(5), White, A. M., Kraus, C. L., Kestenbaum, L. A., Mitchell, J. R., Shah, K., & Swartzwelder, H. S. (2005). College students lack knowledge of standard drink volumes: Implications for definitions of risky drinking behavior based on survey data. Alcoholism: Clinical and Experimental Research, 29(4),