Social norms information for alcohol misuse in university and college students

Effects of experimental, network-based social circle norm feedback on studying behavior and alcohol consumption

Misrepresentation of peer behavior has often been observed in college students and may lead to over-expression of alcohol consumption and under-expression of studying. While social norm feedback approaches have had mixed success in addressing these misrepresentations and altering behavior, they may have been too unspecific to be effective and did not directly assess individual perception accuracy. We thus investigated how specific, one-time feedback on the behavioral distribution of alcohol consumption or study time of a clearly defined, individually-adjusted social circle would affect the respective norm estimations and behavior of a class of Psychology students (n = 89 in January) across their first year of study. Students overestimated alcohol consumption and partially underestimated studying norms. While social circle feedback on alcohol consumption did not clearly affect both individual estimation accuracy and alcohol consumption, feedback on peers' studying time increased studying with no clear effect on estimation accuracy. This indicates that social circle norm feedback may be suitable to evoke behavioral effects. The correction of the detected inaccuracies did not appear to be a precondition for the feedback to be effective.

Persuasive communication, financial incentives, and social norms: Interactions and effects on behaviors

Social norms and financial incentives are both known to shape the decisions people make about prosocial actions. This paper reviews the financial incentives in normative systems (FINS) model, which integrates theories of social norms from communication, social psychology, and behavioral economics to predict relationships among incentives, norms, and behaviors. It addresses how incentives can affect norms and how they change the effects of norms on behaviors. The model shows how strategic communication (framing) of social norms and incentives can shape the way people respond to incentives, minimizing unwanted outcomes and even enhancing the effectiveness of behavioral incentive payments. These insights can guide hypothesis testing and application to real-world use of incentives for behavior change.

Breaking the endometriosis silence: a social norm approach to reducing menstrual stigma and policy resistance among young adults

OBJECTIVE

Endometriosis is a menstrual disorder that affects one in ten women. Diagnosis often takes several years due to low awareness and menstrual stigma. In this study, we employed a social norm approach (SNA) to investigate the effects of an educational leaflet on endometriosis knowledge, menstrual stigma, and acceptance of paid menstrual leave among women and men.

METHODS

The 3 × 2 online experiment tested the influence of either descriptive norm messages or both descriptive and injunctive norm messages (compared to a control group, factor 1) in an educational leaflet by taking the role of addressee's sex into account (quasi-experimental factor 2). The study included 796 German participants aged 16-35.

RESULTS

Men exhibited significantly poorer knowledge, stronger menstrual stigma, and weaker policy acceptance compared to women. No significant main effect of the social norm messages on menstrual stigma was found. In contrast, the combined norm messages seem to be beneficial when addressing policy acceptance. Moreover, compared to the control group, the intervention material indirectly influenced stigma and policy acceptance through increased knowledge.

CONCLUSIONS

Providing information about social norms appears to be an effective strategy for educating not only women but especially men about menstrual disorders like endometriosis.

Socializing social sampling models: The limits of explaining norm perceptions and biases with sampling from social circles

People often overestimate the prevalence of unfavorable behavior. To explain these misperceptions, social sampling models propose that individuals infer the social norm from the behavior of their own social circle. We investigated this idea by asking a friendship network of college freshmen to report their own behavior and norm perceptions across eight domains at two timepoints (N = 104). Assessing this complete social network allows to directly test if sampling from the social circle shapes norm perception. Replicating previous findings, freshmen systematically misperceived the average social norm within their cohort. Yet, these misperceptions persisted even when individuals judged their own social circle, indicating that sampling from social circles does not fully explain normative biases. Moreover, cognitive modelling of norm perceptions suggested that individuals unlikely limited their search to their own social circle.

Mobile App-Based Coaching for Alcohol Prevention among Adolescents: Pre-Post Study on the Acceptance and Effectiveness of the Program "MobileCoach Alcohol"

BACKGROUND

At-risk alcohol use, particularly binge drinking, is widespread among adolescents and young adults in most Western countries. MobileCoach Alcohol is a mobile app-based program for alcohol prevention that provides individualized coaching using a conversational agent. The current study tested the acceptance, use, and evaluation of this newly developed program and explored its potential effectiveness.

METHODS

Longitudinal pre-post study among upper secondary and vocational school students in Switzerland. Within the MobileCoach Alcohol prevention program, a virtual coach motivated participants to deal with alcohol sensitively, and provided feedback on alcohol use and strategies to resist alcohol for a period of 10 weeks. Information was provided in weekly dialogs, within contests with other participants, and interactive challenges. By means of a follow-up survey after the end of the 10-week program, indicators of the use, acceptance, and effectiveness of the program were examined.

RESULTS

Between October 2020 and July 2022, the program was advertised in upper secondary and vocational schools. Recruiting schools and school classes was difficult due to the COVID-19 containment measures in place during this period. Nevertheless, the program could be implemented in 61 upper secondary and vocational school classes with a total of 954 participating students. Three out of four students who were present in the school classes participated in the MobileCoach Alcohol program and the associated study. Online follow up assessment at week 10 was completed by 272 program participants (28.4%). Based on program use and evaluations by the participants, the overall acceptance of the intervention was good. The proportion of students who engaged in binge drinking was significantly reduced from 32.7% at baseline to 24.3% at follow up. Furthermore, the longitudinal analyses revealed decreases in the maximum number of alcoholic drinks consumed on an occasion and the mean number of standard drinks per month, whereas self-efficacy to resist alcohol increased between baseline and follow up.

CONCLUSIONS

The mobile app-based MobileCoach Alcohol program proved to be an attractive intervention, in which the majority of students were interested when proactively recruited at school classes. It allows for individualized coaching in large groups of adolescents and young adults and is promising for reducing at-risk alcohol use.

The effectiveness of a mobile intervention to reduce young adults' alcohol consumption to not exceed low-risk drinking guidelines

Background

Young adults' drinking habits often exceed low-risk drinking guidelines. As young adults show increased access, use, and interest in personalized content related to physical and mental well-being, mobile applications might be a suitable tool to reach this target group. This study investigates the effectiveness of "Boozebuster", a self-guided mobile application incorporating various therapeutic principles to reduce young adults' alcohol consumption to not exceeding low-risk drinking guideline levels, compared to an educational website condition.

Method

Young adults aged 18-30 wanting to reduce their alcohol consumption entered a two-arm, parallel-group RCT. There were no minimum drinking severity inclusion criteria. Primary outcomes included alcohol consumption quantity and frequency. Secondary outcomes included binge drinking frequency and alcohol-related problem severity. Baseline, 6-week postbaseline, and 3-month post-baseline assessments were analyzed using linear mixed model analyses. Sex, treatment adherence, experienced engagement and motivation to change alcohol use behavior were investigated as moderators. Sub-group analyses contained problem drinkers and binge drinkers.

Results

503 participants were randomized to the intervention or control condition. Results showed no intervention effects on primary or secondary outcomes compared to the control group. Both groups showed within-group reductions on all outcomes. Sub-group analyses in problem drinkers or binge drinkers showed similar results. Motivation to change drinking behavior and experienced engagement with the application significantly moderated the intervention effect regarding the quantity or frequency of alcohol consumption, respectively. Exploratory analyses showed that participants who indicated they wanted to change their drinking patterns during the initial PNF/MI module showed a significantly greater reduction in drinking quantity compared to those who indicated not wanting to change their drinking patterns.

Conclusion

The intervention group did not show a greater reduction in alcohol-related outcomes compared to the control group, but both groups showed a similar decrease. Potential explanations include similar effectiveness of both condition due to using a minimal active control in participants predominantly in the action stage of motivation to change. Future research should further explore the effectiveness of using mobile application to reduce young adults' drinking behavior to not exceed low-risk drinking guideline levels and identify factors that motivate participants to engage with such an intervention.

A vignette-based approach to understanding social norms around family planning in three Nigerian cities

Understanding the mechanisms through which social norms shape contraceptive use can help prevent unintended pregnancies in low-income countries. The Nigerian Urban Reproductive Health Initiative (NURHI) aimed to increase contraceptive uptake through advocacy, service delivery, and demand generation. Using data from focus group discussions, we examined whether social norms around family planning (FP), and specifically use of modern contraception (MC), varied among women and girls of reproductive age exposed to varying levels of the programme in three Nigerian cities. Injunctive social norms were generally unfavourable of unmarried adolescent girls' use of MC, though participants often shared exceptions for certain types of adolescents whose use of MC would be acceptable. There was greater acceptability for MC use by women who wanted to space or limit pregnancies. Participants reported that norms around FP and MC use have become more accepting in their communities over time. Normative differences between cities were identified. Participants' perceptions of religious leaders' support for FP use may have contributed to positively influencing social norms.

Substance Use Descriptive Norms and Behaviors among US College Students: Findings from the Healthy Minds Study

BACKGROUND

Social norms have been associated with alcohol use in college populations; however, more research is needed to confirm the associations between social norms and a range of substance use behaviors during the COVID-19 pandemic.

METHODS

We analyzed data from the Healthy Minds Study (September 2020-December 2020), a non-probability sample administered online to college students. We used multivariable logistic regression to test for associations between respondents' perceptions of substance use behaviors in their respective colleges and their own substance use behaviors, adjusting for age, gender, race/ethnicity, and international student status.

RESULTS

We found that those who overestimated the prevalence of alcohol use, cigarette use, cannabis use, and vaping were significantly more likely to use these substances when compared with those who did not overestimate. These associations persisted even when using different prevalence estimates of substance use, though some associations lost statistical significance when applying the survey weights to account for non-response.

CONCLUSION

College students overestimated the prevalence of substance use in their respective colleges, even during the early stages of the pandemic when social interactions were limited, and these beliefs were associated with substance use. Future studies may test the utility of campaigns to alter perceptions of social norms and interventions that use personalized normative feedback to reduce substance use during pandemics.

Factors That Influence the Effectiveness of Primary Prevention of Substance Use: A Review of Reviews

Context: The fact that substance use may result in dependence and severe harm to the user and the community has led to serious and extensive endeavors to design and implement preventive interventions. Prevention programs, however, have been shown to have different effects, and that should not be taken for granted. Systematic reviews and meta-analyses in the field have tried to reveal the effects of different types of substance use prevention programs and to identify the influencing factors. Objectives: The purpose of the current review was to more accurately identify factors associated with the effectiveness of interventions or reversal of desired effects. Evidence Acquisition: We systematically reviewed systematic review and meta-analyses studies within the period of 2009 - 2019 that reported the effectiveness of substance use prevention programs. After the systematic screening of 1586 articles, 43 articles were finally reviewed. Results: In preparation for extracting our data, we designed a structural model for analyzing the results of research on the effectiveness of substance use prevention programs. In general, universal types of prevention programs were reported as more effective than the two other types of selective and indicated programs. Regarding the context of programs, the school setting was more effective than others. In the case of interventions performed in the family setting, selective programs were more effective. Interventions provided by specialists were more effective than those provided by laypeople and / or peers. Interventions provided by more than one person and from more than one discipline showed higher effectiveness. Conclusions: Based on our structural design, we feel that further studies are needed to extend our knowledge regarding the effectiveness of substance use prevention programs.

Finding the Right Balance: A Social Norms Intervention to Reduce Heavy Drinking in University Students

Introduction: Heavy alcohol consumption constitutes a major health risk among University students. Social relationships with peers strongly affect University students' perception of the drinking behavior of others, which in turn plays a crucial role in determining their own alcohol intake. University students tend to overestimate their peers' alcohol consumption – a belief that is associated with an increase in an individual's own consumption. Therefore, we implemented a social norms intervention with personalized normative feedback at a major University in Germany to reduce and prevent excessive drinking among University students.

Methods: Our intervention was part of a regular health monitoring survey. We invited all enrolled University students to take part in this survey on two occasions. A total of 862 University students completed the questionnaire, 563 (65.3%) of which received e-mail-based feedback upon request concerning their peers' and their own alcohol consumption. For the intervention group (n = 190) as well as the control group (no feedback requested; n = 101), we included only University students in the evaluation who overestimated their peers' alcohol use and indicated above average consumption of the peers. We applied analyses of variance to assess intervention effects with regard to the correction of overestimated group norms as well as University students' drinking behavior.

Results: Within the intervention group, we observed a significantly larger reduction of the previously overestimated behavioral norms compared to the control group (p < 0.001; ηp2 = 0.06). With regard to behavioral outcomes the intervention group showed a significantly larger reduction in the AUDIT-C score (p = 0.020; ηp2 = 0.03).

Discussion: Our study confirms previous research whereupon personalized, gender-specific and selective normative feedback is effective for alcohol prevention among University students. However, University students still overestimated their peers' alcohol intake after the intervention. Furthermore, we did not reach high-risk groups (University students with the highest alcohol intake) since no feedback was requested. Future studies should address factors influencing the impact of the intervention and reachability of selective groups.

A Mobile Intervention to Promote Low-Risk Drinking Habits in Young Adults: Protocol for a Randomized Controlled Trial

BACKGROUND

Young adults' drinking habits commonly exceed recommendations for low-risk drinking, which may have a negative effect on their mental, social, and physical health. As smartphones are highly accessible to young adults, mobile apps could be used to support young adults to develop low-risk drinking habits and improve their general health.

OBJECTIVE

The objective of this study is to evaluate the effectiveness of Boozebuster, a self-guided mobile app based on healthy lifestyle-related components that aim to develop and maintain low-risk drinking habits among young adults.

METHODS

This two-arm, parallel-group randomized controlled trial will investigate whether a 6-week self-guided mobile intervention (Boozebuster) targeting drinking behavior is more effective than a minimal intervention consisting of an educational website on alcohol use and its consequences for young adults. We will recruit 506 young adults (aged 18-30 years) from the Netherlands via an open recruitment strategy by using an open access website. All outcomes will be self-assessed through questionnaires. The primary outcome is the quantity and frequency of alcohol consumption in standard drinks (10 g ethanol per standard drink) per month (timeline follow-back [TLFB]). Secondary outcomes include binge-drinking sessions per month, alcohol-related problem severity (Rutgers Alcohol Problem Index), cannabis use frequency and quantity in grams (TLFB), depressive symptoms (Center for Epidemiological Studies Depression Scale), perceived stress (Perceived Stress Scale), engagement (Twente Engagement with eHealth Technologies Scale), readiness to change (Readiness to Change Questionnaire), mental well-being (Warwick-Edinburgh Mental Wellbeing Scale), trauma and COVID-19-related trauma (Short-Form Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), impulsivity (Urgency, Premeditation, Perseverance, Sensation Seeking, Positive Urgency Impulsive Behavior Scale), study or work performance (Individual Work Performance Questionnaire), and treatment adherence. Baseline (T0), 6-week postbaseline (T1), and 3-month postbaseline (T2) assessments will be conducted and analyzed on the basis of the intention-to-treat principle using multilevel mixed modeling analyses.

RESULTS

Recruitment began in September 2020. We received 933 registrations via our study information website; 506 participants have completed the T0 assessment, 336 participants have completed the T1 assessment, and 308 participants have completed the T2 assessment as of May 2021. The study is still in progress, and results will be reported in 2021 and 2022.

CONCLUSIONS

Self-guided mobile interventions based on a lifestyle approach might be an attractive approach for young adults due to their preference on self-reliance, healthy living, and increased perceived anonymity. Such interventions are yet understudied, and it is known that interventions addressing solely problem drinking are less appealing to young adults. We hypothesize that the Boozebuster mobile app will effectively reduce drinking levels compared to an alcohol educational website (control condition). If effective, our intervention could be an inexpensive and scalable public health intervention to improve drinking habits in young adults.

TRIAL REGISTRATION

Netherlands Trial Register NL8828; https://www.trialregister.nl/trial/8828.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/29750.

The efficacy of Personalized Normative Feedback interventions across addictions: A systematic review and meta-analysis

Personalized Normative Feedback (PNF) may help address addictive disorders. PNF highlights discrepancies between perceived and actual peer norms, juxtaposed against self-reported behavior. PNF can be self-directed and cost-efficient. Our study estimates the efficacy of PNF alone, and in combination with other self-directed interventions, to address frequency and symptom severity of hazardous alcohol use, problem gambling, illicit drug and tobacco use. We searched electronic databases, grey literature, and reference lists of included articles, for randomized controlled trials published in English (January 2000-August 2019). We assessed study quality using the Cochrane Risk of Bias tool. Thirty-four studies met inclusion criteria (k = 28 alcohol, k = 3 gambling, k = 3 cannabis, k = 0 tobacco). Thirty studies provided suitable data for meta-analyses. PNF alone, and with additional interventions, reduced short-term alcohol frequency and symptom severity. PNF with additional interventions reduced short-term gambling symptom severity. Effect sizes were small. PNF did not alter illicit drug use. Findings highlight the efficacy of PNF to address alcohol frequency and symptom severity. The limited number of studies suggest further research is needed to ascertain the efficacy of PNF for gambling and illicit drug use. Cost-effectiveness analyses are required to determine the scale of PNF needed to justify its use in various settings.

Understanding further education as a context for public health intervention: qualitative findings from a study process evaluation

BACKGROUND

Over 1.2 million 16-18 year-olds are enrolled in further education (FE-advanced secondary education) in England. Life course transitions provide opportunities to change, establish or reinforce health behaviours. FE presents an opportunity for public health improvement, yet few interventions target this setting. Using a smoking prevention intervention, we explore how young people were viewed in FE and how this affected intervention acceptability.

METHODS

Eleven student and five staff focus groups were conducted in three intervention institutions (two colleges, one school sixth-form), as part of the process evaluation of a smoking prevention feasibility study. FE managers in intervention and control institutions were also interviewed (n = 5). Data were analysed using thematic analysis.

RESULTS

In both colleges and the sixth-form, students were viewed as emergent adults and treated differently from 'school-children', in practice if not in policy. Colleges permitted smoking in designated areas; in the school sixth-form smoking was unofficially tolerated but concealed from younger students. Using staff to deliver anti-smoking messages reintroduced an unwanted power dynamic which disrupted perceptions of students as young adults.

CONCLUSIONS

FE is an important setting for young people's health. Understanding the culture and context of FE is critical in designing acceptable and effective public health interventions.

A Systematic Umbrella Review on the Epidemiology of Modifiable Health Influencing Factors and on Health Promoting Interventions Among University Students

Background: Universities represent an important setting for health promotion. The unique collective of university students is of particular relevance since they are the leaders, decision-makers, and parents of tomorrow. In this context, modifiable health influencing factors as well as interventions to prevent these, play a crucial role. Therefore, the present umbrella review aims to (i) provide an overview of review articles addressing epidemiological issues (prevalence and determinants) of modifiable health influencing factors in university students and (ii) to provide an overview of review articles addressing the evidence of interventions to promote/enhance modifiable health influencing factors in university students. Methods: A systematic literature search was performed in the databases PubMed, Cochrane Reviews Library und Web of Science according to the PRISMA guidelines. Only systematic reviews and meta-analyses were included. The AMSTAR-2-Tool was used for the quality assessment. Result: The initial search resulted in 10,726 records of which 81 fulfilled the inclusion criteria, with a further distinction in articles with an epidemiological focus (n = 39) and in articles with interventional approaches (n = 42). Topics of the different review articles ranged from physical activity over mental health, substance use, sleep, diet and nutrition, and media consumption. Many review articles had a specific focus on medical and nursing students and originated from the U.S.A., U.K., or China. Discussion: This umbrella review provides an overview of review articles on the epidemiology of modifiable health influencing factors and on the evidence of interventions targeting these factors among university students. Thereby, experts as well as stakeholders in the field could gain insights into crucial target points for health promotion. It identifies research gaps in terms of study region and groups of students.

Cluster Analysis of Health-Related Lifestyles in University Students

Health-related lifestyles in young adults are a public health concern because they affect the risk for developing noncommunicable diseases. Although unhealthy lifestyles tend to cluster together, most studies have analyzed their effects as independent factors. This study assessed the prevalence, association, and clustering of health-related lifestyles (smoking, alcohol consumption, physical activity, and quality of diet) among university students. This cross-sectional study examined a sample of student participants from the University of the Balearic Islands (n = 444; 67.8% females; mean age: 23.1 years). A self-reported questionnaire was used to assess health-related lifestyles. Men that consumed more alcohol, had less healthy diets, were more likely to be overweight, and performed more physical activity. Women had a higher prevalence of low weight and performed less physical activity. Physical activity had a negative association with time using a computer (OR: 0.85; 95% CI: 0.76, 0.95) and a positive association with adherence to the Mediterranean diet (OR: 1.16; 95% CI: 1.02, 1.32). Adherence to the Mediterranean diet had a negative association with tobacco consumption (OR: 0.52; 95% CI: 0.30, 0.91), and positive associations with having breakfast every day (OR: 1.70; 95% CI: 1.05, 2.76) and consuming more daily meals (OR: 1.43; 95% CI: 1.10, 1.87). Cluster analysis indicated the presence of three distinct groups: Unhealthy lifestyles with moderate risk; unhealthy lifestyles with high risk; and healthy lifestyles with low risk. Health promotion interventions in the university environment that focus on multiple lifestyles could have a greater effect than interventions that target any single lifestyle.

Alcohol consumption among university students in the night-time economy in the UK: A three-wave longitudinal study

BACKGROUND

Excessive alcohol consumption is commonly reported in university/college students, and contributes to emerging peer-group relations.

PURPOSE

This study aimed to provide up-to-date longitudinal data on students' alcohol consumption patterns, and predictors of this, across a single academic year.

METHODS

A 3-wave study was conducted at a university in the UK. Participants reported their alcohol consumption patterns, along with perceptions of the social norms and behavioral expectations associated with attending licensed venues where alcohol is sold (the "night time economy"). Participants also reported their social identification with this environment.

RESULTS

Around half of participants overall fell into the three higher alcohol-risk categories (moderate, high or hazardous drinking). A modest reduction in consumption was observed across the study. At each assessment point, males reported greater alcohol consumption in the preceding two months than females, while Year 4 students and those on graduate-entry programs reported the lowest consumption. Excessive alcohol consumption was regarded as largely normative within the night time economy, both descriptively ("what others do") and injunctively ("what others approve of"). Social identification and norm perceptions, along with gender, year group, and intoxication and socialising expectations, were significantly associated with higher alcohol consumption at baseline. However, baseline consumption was the only variable significantly associated with alcohol use at the end of the academic year.

CONCLUSIONS

Many students drink alcohol at potentially harmful levels, and norms and expectations supporting this consumption are prominent and stable. The findings support a targeted approach to intervention that accounts for heterogeneity in the student population.

Ideal, expected and perceived descriptive norm drunkenness in UK nightlife environments: a cross-sectional study

Background

Drunkenness is common in nightlife environments and studies suggest it can be considered both desirable and normal by nightlife users. We aimed to compare UK nightlife users’ ideal levels of drunkenness to their expected drunkenness on a night out and their perceptions of descriptive nightlife norms.

Methods

A cross-sectional survey with nightlife patrons (n = 408, aged 18–35) in three cities. Using a scale from 1 (completely sober) to 10 (very drunk), participants rated: personal drunkenness at survey; expected drunkenness on leaving nightlife; perceived descriptive drunkenness norm in the city’s nightlife; and ideal personal drunkenness. Analyses were limited to those who had or were intending to consume alcohol.

Results

Almost half of participants (46.8%) expected to get drunker than their reported ideal level on the night of survey, rising to four fifths of those with the highest levels of expected drunkenness. 77.9% rated typical nightlife drunkenness ≥8 but only 40.9% expected to reach this level themselves and only 23.1% reported their ideal drunkenness as ≥8. Higher expected drunkenness was associated with higher ideal drunkenness, higher perceived drunkenness norm and later expected home time.

Conclusions

Nightlife users’ perceptions of typical drunkenness in nightlife settings may be elevated and many of the heaviest drinkers are likely to drink beyond their ideal level of drunkenness. Findings can support emerging work to address cultures of intoxication in nightlife environments and suggest that interventions to correct misperceptions of normal levels of nightlife drunkenness may be of benefit.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6802-5) contains supplementary material, which is available to authorized users.

Mass media to communicate public health messages in six health topic areas: a systematic review and other reviews of the evidence

Background

Mass media campaigns can be used to communicate public health messages at the population level. Although previous research has shown that they can influence health behaviours in some contexts, there have been few attempts to synthesise evidence across multiple health behaviours.

Objectives

To (1) review evidence on the effective use of mass media in six health topic areas (alcohol, diet, illicit drugs, physical activity, sexual and reproductive health and tobacco), (2) examine whether or not effectiveness varies with different target populations, (3) identify characteristics of mass media campaigns associated with effectiveness and (4) identify key research gaps.

Design

The study comprised (1) a systematic review of reviews, (2) a review of primary studies examining alcohol mass media campaigns, (3) a review of cost-effectiveness evidence and (4) a review of recent primary studies of mass media campaigns conducted in the UK. A logic model was developed to inform the reviews. Public engagement activities were conducted with policy, practitioner and academic stakeholders and with young people.

Results

The amount and strength of evidence varies across the six topics, and there was little evidence regarding diet campaigns. There was moderate evidence that mass media campaigns can reduce sedentary behaviour and influence sexual health-related behaviours and treatment-seeking behaviours (e.g. use of smoking quitlines and sexual health services). The impact on tobacco use and physical activity was mixed, there was limited evidence of impact on alcohol use and there was no impact on illicit drug behaviours. Mass media campaigns were found to increase knowledge and awareness across several topics, and to influence intentions regarding physical activity and smoking. Tobacco and illicit drug campaigns appeared to be more effective for young people and children but there was no or inconsistent evidence regarding effectiveness by sex, ethnicity or socioeconomic status. There was moderate evidence that tobacco mass media campaigns are cost-effective, but there was weak or limited evidence in other topic areas. Although there was limited evidence on characteristics associated with effectiveness, longer or greater intensity campaigns were found to be more effective, and messages were important, with positive and negative messages and social norms messages affecting smoking behaviour. The evidence suggested that targeting messages to target audiences can be effective. There was little evidence regarding the role that theory or media channels may play in campaign effectiveness, and also limited evidence on new media.

Limitations

Statistical synthesis was not possible owing to considerable heterogeneity across reviews and studies. The focus on review-level evidence limited our ability to examine intervention characteristics in detail.

Conclusions

Overall, the evidence is mixed but suggests that (1) campaigns can reduce sedentary behaviour, improve sexual health and contribute to smoking cessation, (2) tobacco control campaigns can be cost-effective, (3) longer and more intensive campaigns are likely to be more effective and (4) message design and targeting campaigns to particular population groups can be effective.

Future work

Future work could fill evidence gaps regarding diet mass media campaigns and new-media campaigns, examine cost-effectiveness in areas other than tobacco and explore the specific contribution of mass media campaigns to multicomponent interventions and how local, regional and national campaigns can work together.

Study registration

This study is registered as PROSPERO CRD42015029205 and PROSPERO CRD42017054999.

Funding

The National Institute for Health Research Public Health Research programme.

A Control-Theoretic Assessment of Interventions During Drinking Events

This paper employs control-theoretic tools to provide guidelines for in-situ interventions aimed at reducing high-risk alcohol consumption at drinking events. A dynamical directed network model of a drinking event with external intervention, suitable for mathematical analysis and parameter estimation using field data is proposed, with insights from pharmacokinetics and psychology. Later, a characterization of a bound on blood alcohol content (BAC) trajectories is obtained via Lyapunov stability analysis, and structural controllability guarantees are obtained via a graph-theoretic method. We use the degree of controllability, given to be the trace of the system's controllability Gramian, as a metric to compare the viability of network nodes for intervention based on theoretic and heuristic centrality measures. Results of numerical examples of bars and parties, informed by field data, and the stability and controllability results, suggest that intervening in the environment in wet bars, while targeting influential individuals with high alcohol consumption motivations in private parties efficiently yield lower peak BAC levels in individuals at the drinking events.

Predicting College Student Drinking and Smoking Intentions With Cognitively Accessible Attitudes and Norms

Understanding the factors that make college students more likely to drink alcohol and smoke cigarettes is key to developing effective interventions in order to reduce these behaviors. This study sought to understand entering college students' intentions to engage in smoking and drinking behavior by examining the cognitive accessibility (ease of retrieval from memory) of attitudes and norms for drinking. A sample of 413 first-year college students living in on-campus residence halls participated in the study in the first 2 weeks of their first semester of college. Reaction time measures of attitudes and norms assessed the cognitive accessibility of these constructs. Hierarchical linear regression analysis was conducted. Results indicated that the cognitive accessibility of both attitudes and peer injunctive norms predicted behavioral intentions to drink and smoke. Our findings indicate that when injunctive peer norms are accessible from memory, they are better predictors of drinking and smoking intentions than descriptive norms or injunctive family norms. Our work provides important guidance for interventions to reduce risky behavior in college students and suggests that emphasizing social costs of these behaviors may be a promising strategy.

A Critical Appraisal of the Social Norms Approach as an Interventional Strategy for Health-Related Behavior and Attitude Change

The Social Norms Approach is a widely used intervention strategy for promoting positive health-related behaviors. The Approach operates on the premise that individuals misperceive their peers' behaviors and attitudes, with evidence of under- and over-estimations of behaviors and peer approval for a range of positive and negative behaviors respectively. The greater these misperceptions, the more likely an individual is to engage in negative behaviors such as consuming heavier amounts of alcohol and other substances and reduce positive behaviors such as eating healthily and using sun protection. However, there are many complexities associated with the use of social norms feedback in interventions and empirical studies. Many social norms interventions do not attempt to change misperceptions of social norms or measure changes in normative perceptions pre- and post-intervention. This has led to a conflation of generic social norms interventions with those that are explicitly testing the Approach's assumptions that it is misperceptions of peer norms which drive behavior. The aim of the present review was to provide a critical appraisal of the use of the Social Norms Approach as an intervention strategy for health-related behaviors, identify the current issues with its evidence base, highlight key opportunities and challenges facing the approach, and make recommendations for good practice when using the approach. There are three core challenges and areas for improved practice when using the Social Norms Approach. Firstly, improvements in the methodological rigor and clarity of reporting of 'social norms' research, ensuring that studies are testing the approach's assumption of the role of misperceptions on behaviors are differentiated from studies investigating other forms of 'social norms.' Secondly, the need for a more explicit, unified and testable theoretical model outlining the development of normative misperceptions which can be translated into interventional studies. Finally, a need for a more robust evaluation of social norms interventions in addition to randomized controlled trials, such as the inclusion of process evaluations, qualitative studies of participant experiences of social norms feedback, and alternative study designs better suited for real-world public health settings. Such improvements are required to ensure that the Social Norms Approach is adequately tested and evaluated.

Student and staff perceptions of alcohol as part of student life in Denmark: A Q methodology study

INTRODUCTION

Intervening effectively to prevent students' harmful use of alcohol remains a challenge. Harmful alcohol use has been noted as the most dominant public health problem facing universities today. This study sought to investigate the diversity in staff and student perceptions of the contribution alcohol makes to student life in a Danish university setting. Increasing understanding of staff and students' perceptions of how alcohol fits into student life is required to amend future public health intervention for this population.

MATERIALS AND METHODS

This Q methodology study included 38 staff members and 105 students from Aarhus University, Denmark. Participants used online Q sorting software, to rank 40 statements about the contribution alcohol makes to the university student experience from strongly agree to disagree. To support the interpretation of the factors, self-reported alcohol consumption and demographic data were collected. In addition qualitative data was collected on the participant's reasons for the ranking of the items they most strongly agreed or disagreed with.

RESULTS AND DISCUSSION

Using principal components analysis, five statistically independent viewpoints for students and four for staff were identified. The findings provide evidence to inform approaches to prevent harmful alcohol use. Some viewpoints suggest a need for tailored secondary and tertiary prevention and intervention that focusses on individuals and/or sub-groups who are at risk of consuming alcohol at harmful levels. Other viewpoints suggest the need for primary universal prevention to support the maintenance of healthy norms which can prevent harmful alcohol behaviour. Public health campaigns need to ensure that interventions targeting harmful alcohol use at universities challenge problematic perceptions and attitudes while also bolstering exposure to positive norms.

From awareness to behaviour: Testing a hierarchy of effects model on the Australian Make Healthy Normal campaign using mediation analysis

The Make Healthy Normal mass media campaign was a three-year campaign launched in 2015 in New South Wales (NSW), Australia to address community norms around overweight and obesity. It was underpinned by a hierarchy of effects model; a commonly used framework in campaigns but one that has rarely been tested. The campaign evaluation included a cohort study of NSW adults, surveyed three times over 12 months (n = 939 at Wave 3). This study tested the campaign's hierarchy of effects model, which theorized that participants would move from recognition to behaviour change via understanding, knowledge, attitude, social norms, self-efficacy, and intention, using these data. We used the moderation and mediation of effects method proposed by Baron and Kenny, adjusting for age and sex, to test for progression through the hierarchy of effects for two outcomes: physical activity and fast food consumption. We found a clear progression through the theorized model, from recognition through to behaviour change, via the intermediate variables for both outcomes. We also found several effects not predicted by the theorized model, with consistently strong associations between understanding and attitude, understanding and self-efficacy, attitude and self-efficacy, and self-efficacy and behaviour change in both outcome models. Our study provides support for the hierarchy of effects as a conceptual model in campaign planning and evaluation of social marketing campaigns. To our knowledge, this is the first study to compare the hierarchy between two behavioural outcomes and the consistency observed between the models adds to the potential usefulness of the hierarchy of effects.

Effectiveness of Mass Media Campaigns to Reduce Alcohol Consumption and Harm: A Systematic Review

AIMS

To assess the effectiveness of mass media messages to reduce alcohol consumption and related harms using a systematic literature review.

METHODS

Eight databases were searched along with reference lists of eligible studies. Studies of any design in any country were included, provided that they evaluated a mass media intervention targeting alcohol consumption or related behavioural, social cognitive or clinical outcomes. Drink driving interventions and college campus campaigns were ineligible. Studies quality were assessed, data were extracted and a narrative synthesis conducted.

RESULTS

Searches produced 10,212 results and 24 studies were included in the review. Most campaigns used TV or radio in combination with other media channels were conducted in developed countries and were of weak quality. There was little evidence of reductions in alcohol consumption associated with exposure to campaigns based on 13 studies which measured consumption, although most did not state this as a specific aim of the campaign. There were some increases in treatment seeking and information seeking and mixed evidence of changes in intentions, motivation, beliefs and attitudes about alcohol. Campaigns were associated with increases in knowledge about alcohol consumption, especially where levels had initially been low. Recall of campaigns was high.

CONCLUSION

Mass media health campaigns about alcohol are often recalled by individuals, have achieved changes in knowledge, attitudes and beliefs about alcohol but there is little evidence of reductions in alcohol consumption.

SHORT SUMMARY

There is little evidence that mass media campaigns have reduced alcohol consumption although most did not state that they aimed to do so. Studies show recall of campaigns is high and that they can have an impact on knowledge, attitudes and beliefs about alcohol consumption.

Moving alcohol prevention research forward-Part I: introducing a complex systems paradigm

BACKGROUND AND AIMS

The drinking environment is a complex system consisting of a number of heterogeneous, evolving and interacting components, which exhibit circular causality and emergent properties. These characteristics reduce the efficacy of commonly used research approaches, which typically do not account for the underlying dynamic complexity of alcohol consumption and the interdependent nature of diverse factors influencing misuse over time. We use alcohol misuse among college students in the United States as an example for framing our argument for a complex systems paradigm.

METHODS

A complex systems paradigm, grounded in socio-ecological and complex systems theories and computational modeling and simulation, is introduced. Theoretical, conceptual, methodological and analytical underpinnings of this paradigm are described in the context of college drinking prevention research.

RESULTS

The proposed complex systems paradigm can transcend limitations of traditional approaches, thereby fostering new directions in alcohol prevention research. By conceptualizing student alcohol misuse as a complex adaptive system, computational modeling and simulation methodologies and analytical techniques can be used. Moreover, use of participatory model-building approaches to generate simulation models can further increase stakeholder buy-in, understanding and policymaking.

CONCLUSIONS

A complex systems paradigm for research into alcohol misuse can provide a holistic understanding of the underlying drinking environment and its long-term trajectory, which can elucidate high-leverage preventive interventions.

Effectiveness of a web-based intervention in reducing binge drinking among nightclub patrons

OBJECTIVE

To evaluate the effectiveness of a web-based intervention in reducing binge drinking among nightclub patrons after six months.

METHODS

We carried out a website survey with probabilistic sample in 31 nightclubs in the city of São Paulo, Brazil, which originated a randomized controlled trial with 1,057 participants. Those classified as problem drinkers (n = 465) using the Alcohol Use Disorders Identification Test were randomized into two study groups – intervention and control. The web-based intervention consisted of exposing the participants to a normative feedback screen about their alcohol consumption, characterizing the risks associated with amount consumed, money spent on drinks, drinking and driving, risk classification of Alcohol Use Disorders Identification Test, and tips to reduce damage.

RESULTS

There was a significant reduction in the practice of binge drinking in the week estimated at 38% among participants in the intervention group after six months (p < 0.05). However, there was no significant reduction in the outcomes when we analyzed the intervention and control groups and at baseline and after sixth months, simultaneously.

CONCLUSIONS

We cannot conclude that digital tools reduce the pattern of binge drinking among party goers in São Paulo. More studies are needed with this methodology because of its attractiveness to this type of group, given the privacy and speed that personalized information is transmitted.

A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective

This paper reviews the evidence for the effectiveness and cost-effectiveness of policies to reduce alcohol-related harm. Policies focus on price, marketing, availability, information and education, the drinking environment, drink-driving, and brief interventions and treatment. Although there is variability in research design and measured outcomes, evidence supports the effectiveness and cost-effectiveness of policies that address affordability and marketing. An adequate reduction in temporal availability, particularly late night on-sale availability, is effective and cost-effective. Individually-directed interventions delivered to at-risk drinkers and enforced legislative measures are also effective. Providing information and education increases awareness, but is not sufficient to produce long-lasting changes in behaviour. At best, interventions enacted in and around the drinking environment lead to small reductions in acute alcohol-related harm. Overall, there is a rich evidence base to support the decisions of policy makers in implementing the most effective and cost-effective policies to reduce alcohol-related harm.

Media as a "Super Peer": How Adolescents Interpret Media Messages Predicts Their Perception of Alcohol and Tobacco Use Norms

Adolescents' media environment offers information about who uses substances and what happens as a result-how youth interpret these messages likely determines their impact on normative beliefs about alcohol and tobacco use. The Message Interpretation Processing (MIP) theory predicts that substance use norms are influenced by cognitions associated with the interpretation of media messages. This cross-sectional study examined whether high school adolescents' (n = 817, 48 % female, 64 % white) media-related cognitions (i.e., similarity, realism, desirability, identification) were related to their perceptions of substance use norms. Results revealed that adolescents' media-related cognitions explained a significant amount of variance in perceived social approval for and estimated prevalence of peer alcohol and tobacco use, above and beyond previous use and demographic covariates. Compared to prevalence norms, social approval norms were more closely related to adolescents' media-related cognitions. Results suggest that critical thinking about media messages can inhibit normative perceptions that are likely to increase adolescents' interest in alcohol and tobacco use.

Prevention, early intervention, and harm reduction of substance use in adolescents

This paper presents a systematic review on the effectiveness of prevention, early intervention, and harm reduction including treatment of substance abuse among adolescents for tobacco, alcohol and illicit drugs. Taxation, public consumption bans, restriction on advertisements, and minimum legal age for consumption, are effective measures to reduce the use of tobacco and alcohol. School-based prevention and skill-training interventions are effective tools to reduce substance use among adolescents. Social norms and intervention to reduce substance use in adolescents do not have strong evidence of effectiveness. Road-side testing and reduction of injection related harm are effective. However, further research is needed to support it. Moreover, the available research evidence comes from the Western countries with questionable applicability in Indian setting. Research is needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in adolescents in India.

Are young men who overestimate drinking by others more likely to respond to an electronic normative feedback brief intervention for unhealthy alcohol use?

AIM

To tested whether the efficacy of an internet-based brief intervention that included normative drinking feedback varied with estimations of the drinking of others.

METHODS

This study is a secondary analysis of a randomized controlled trial showing an intervention effect on weekly drinking. Participants were males with unhealthy alcohol use (mean age [SD]=20.8 [1.1]). Before the trial, participants were asked to estimate the percentage of men their age who drink more than they do. Using their self-reported drinking data, the "perceived" percentage of people their age and gender who drink more than they do, and data from Swiss statistics, we classified participants as overestimating (>+10%), accurately (-10% to +10%) or underestimating (<-10%) drinking by others.

RESULTS

Of 734 participants with complete data, 427 overestimated, 205 accurately estimated and 102 underestimated the drinking of others. The mean (SD) number of drinks per week was 9.8 (7.9) and AUDIT score was 10.6 (4.2). In stratified negative binomial regression models predicting drinks per week, at 6months, and controlling for baseline drinks per week, the intervention was effective among those overestimating (IRR[95%CI]=0.86[0.74;0.98]), but showed no effect among those accurately estimating (IRR[95%CI]=0.83[0.66;1.03]) or underestimating IRR[95%CI]=1.21[0.92;1.60]) the drinking of others.

CONCLUSIONS

Perception of drinking by others appears to be a moderator of effect of an electronic feedback intervention among hazardous drinkers. This finding is consistent with the hypothesis that correcting the perceptions of others' drinking is a potential mechanism of action in normative feedback paradigms.

Text Message-Based Intervention Targeting Alcohol Consumption Among University Students: Findings From a Formative Development Study

Background

Drinking of alcohol among university students is a global phenomenon; heavy episodic drinking is accepted despite several potential negative consequences. There is emerging evidence that short message service (SMS) text messaging interventions are effective to promote behavior change among students. However, it is still unclear how effectiveness can be optimized through intervention design or how user interest and adherence can be maximized.

Objective

The objective of this study was to develop an SMS text message-based intervention targeting alcohol drinking among university students using formative research.

Methods

A formative research design was used including an iterative revision process based on input from end users and experts. Data were collected via seven focus groups with students and a panel evaluation involving students (n=15) and experts (n=5). Student participants were recruited from five universities in Sweden. A semistructured interview guide was used in the focus groups and included questions on alcohol culture, message content, and intervention format. The panel evaluation asked participants to rate to what degree preliminary messages were understandable, usable, and had a good tone on a scale from 1 (very low degree) to 4 (very high degree). Participants could also write their own comments for each message. Qualitative data were analyzed using qualitative descriptive analysis. Quantitative data were analyzed using descriptive statistics. The SMS text messages and the intervention format were revised continuously in parallel with data collection. A behavior change technique (BCT) analysis was conducted on the final version of the program.

Results

Overall, students were positive toward the SMS text message intervention. Messages that were neutral, motivated, clear, and tangible engaged students. Students expressed that they preferred short, concise messages and confirmed that a 6-week intervention was an appropriate duration. However, there was limited consensus regarding SMS text message frequency, personalization of messages, and timing. Overall, messages scored high on understanding (mean 3.86, SD 0.43), usability (mean 3.70, SD 0.61), and tone (mean 3.78, SD 0.53). Participants added comments to 67 of 70 messages, including suggestions for change in wording, order of messages, and feedback on why a message was unclear or needed major revision. Comments also included positive feedback that confirmed the value of the messages. Twenty-three BCTs aimed at addressing self-regulatory skills, for example, were identified in the final program.

Conclusions

The formative research design was valuable and resulted in significant changes to the intervention. All the original SMS text messages were changed and new messages were added. Overall, the findings showed that students were positive toward receiving support through SMS text message and that neutral, motivated, clear, and tangible messages promoted engagement. However, limited consensus was found on the timing, frequency, and tailoring of messages.

Self-Other Differences in Student Drinking Norms Research: The Role of Impression Management, Self-Deception, and Measurement Methodology

BACKGROUND

Data-driven student drinking norms interventions are based on reported normative overestimation of the extent and approval of an average student's drinking. Self-reported differences between personal and perceived normative drinking behaviors and attitudes are taken at face value as evidence of actual levels of overestimation. This study investigates whether commonly used data collection methods and socially desirable responding (SDR) may inadvertently impede establishing "objective" drinking norms.

METHODS

U.K. students (N = 421; 69% female; mean age 20.22 years [SD = 2.5]) were randomly assigned to 1 of 3 versions of a drinking norms questionnaire: The standard multi-target questionnaire assessed respondents' drinking attitudes and behaviors (frequency of consumption, heavy drinking, units on a typical occasion) as well as drinking attitudes and behaviors for an "average student." Two deconstructed versions of this questionnaire assessed identical behaviors and attitudes for participants themselves or an "average student." The Balanced Inventory of Desirable Responding was also administered.

RESULTS

Students who answered questions about themselves and peers reported more extreme perceived drinking attitudes for the average student compared with those reporting solely on the "average student." Personal and perceived reports of drinking behaviors did not differ between multitarget and single-target versions of the questionnaire. Among those who completed the multitarget questionnaire, after controlling for demographics and weekly drinking, SDR was related positively with the magnitude of difference between students' own reported behaviors/attitudes and those perceived for the average student.

CONCLUSIONS

Standard methodological practices and socially desirable responding may be sources of bias in peer norm overestimation research.

Perception of High Alcohol Use of Peers Is Associated With High Personal Alcohol Use in First-Year University Students in Three Central and Eastern European Countries

OBJECTIVES

The objectives of this study were to assess discrepancies between estimated peer and personal drinking behavior and to determine associations between perceptions of peer and personal drinking behavior among university students from Hungary (HU), Lithuania (LT), and the Slovak Republic (SK).

METHODS

2,554 freshman university students completed an online questionnaire on the frequency of their personal alcohol use, the number of heavy drinking occasions and on their perception concerning the corresponding drinking behavior of a typical student. Associations between perceived peer and personal use were analyzed by means of logistic regression, adjusting for sex.

RESULTS

The majority of students across all countries thought their peers drink more frequently and are more often involved in heavy drinking occasions than themselves. Students who perceived the frequency of peer alcohol use to be higher were more likely to drink alcohol twice a week or more often (SR: OR = 3.81, 95% CI = 2.51-5.79; LT: OR = 3.16, 95% CI = 2.11-4.75; HU: OR = 2.10, 95% CI = 1.53-2.87) compared with students who drink alcohol monthly or less. Those who perceived the number of peer heavy drinking occasions as high were more likely to report heavy drinking weekly or more often (SR: OR = 3.16, 95% CI = 1.92-5.20; LT:OR = 3.56, 95% CI = 2.14-5.94; HU:OR = 1.41, 95% CI = 0.79-2.51) compared with students who report heavy drinking less than monthly.

CONCLUSIONS/IMPORTANCE

University students perceived peer alcohol use to be higher than their personal use. Given the association between perceptions and personal alcohol use, future research should investigate if targeting perceptions in the surveyed countries may have an impact on alcohol use.

An exploratory pilot study of mechanisms of action within normative feedback for adult drinkers

Background. Normative feedback (NF), or receiving information about one’s drinking compared to peer drinking norms, is one of the most widely used brief interventions for prevention and intervention for hazardous alcohol use. NF has demonstrated predominantly small but significant effect sizes for intention to change and other drinking related outcomes. Identifying mechanisms of action may improve the effectiveness of NF; however, few studies have examined NF’s mechanisms of action, particularly among adults.

Objective. This study is an exploratory analysis of two theorized mechanisms of NF: discrepancy (specifically personal dissonance—the affective response to feedback) and belief in the accuracy of feedback.

Method. Using Amazon’s Mechanical Turk, 87 men (n = 56) and women (n = 31) completed an online survey during which they were asked about their perceptions about their drinking and actual drinking behaviors. Then participants were provided tailored NF and evaluated for their reactions. Severity of discrepancy was measured by the difference between one’s estimated percentile ranking of drinking compared to peers and actual percentile ranking. Surprise and worry reported due to the discrepancy were proxies for personal dissonance. Participants were also asked if they believed the feedback and if they had any plans to change their drinking. Mediation analyses were implemented, exploring whether surprise, worry, or belief in the accuracy of feedback mediated severity of discrepancy’s impact on plan for change.

Results. Among this sample of adult drinkers, severity of discrepancy did not predict plan for change, and personal dissonance did not mediate severity of discrepancy. Severity of discrepancy was mediated by belief in the accuracy of feedback. In addition, viewing one’s drinking as a problem prior to feedback and post-NF worry both predicted plan for change independently.

Conclusions. Results revealed that NF may not work to create personal dissonance through discrepancy, but belief in the accuracy of feedback may be important. It appears the more one believes the feedback, the more one makes a plan for change, suggesting practitioners should be mindful of how information within feedback is presented. Findings also indicate NF may work by validating a preexisting perception that drinking is a problem instead of creating concern related to discrepancy where none existed. Limitations regarding generalizability are discussed.

Reverse engineering a 'responsible drinking' campaign to assess strategic intent

BACKGROUND AND AIMS

The alcohol industry produces 'responsible drinking' advertising campaigns. There is concern that these may promote drinking while persuading governments and the general public that the industry is acting responsibly. This paper examined young people's thoughts and feelings in response to one of these campaigns in Australia.

DESIGN

A qualitative analysis of introspection data provided by young drinkers after exposure to a responsible drinking advertisement produced by DrinkWise called 'How to Drink Properly'.

SETTING

Perth, Western Australia.

PARTICIPANTS

Forty-eight 18-21-year-old drinkers.

MEASUREMENTS

The qualitative data were imported into NVivo10 and coded according to the various stages of advertising effects frameworks. A thematic analysis approach was used to identify patterns in the data relating to (i) perceptions of the source and purpose of the advertisement and (ii) any resulting attitudinal or behavioural outcomes.

FINDINGS

Despite the sample comprising mainly high-risk drinkers, participants were generally unable to relate to the heavy drinkers depicted in the DrinkWise advertisement. This disassociation resulted in a perceived lack of need to modify their own drinking behaviours. Instead, the study participants found the advertisement to be entertaining and supportive of existing social norms relating to heavy drinking among members of this age group.

CONCLUSIONS

The 'How to Drink Properly' advertisement by Drinkwise in Australia may reinforce existing drinking attitudes and behaviours among young drinkers.

Effectiveness of a Web-Based Screening and Fully Automated Brief Motivational Intervention for Adolescent Substance Use: A Randomized Controlled Trial

Background

Mid-to-late adolescence is a critical period for initiation of alcohol and drug problems, which can be reduced by targeted brief motivational interventions. Web-based brief interventions have advantages in terms of acceptability and accessibility and have shown significant reductions of substance use among college students. However, the evidence is sparse among adolescents with at-risk use of alcohol and other drugs.

Objective

This study evaluated the effectiveness of a targeted and fully automated Web-based brief motivational intervention with no face-to-face components on substance use among adolescents screened for at-risk substance use in four European countries.

Methods

In an open-access, purely Web-based randomized controlled trial, a convenience sample of adolescents aged 16-18 years from Sweden, Germany, Belgium, and the Czech Republic was recruited using online and offline methods and screened online for at-risk substance use using the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) screening instrument. Participants were randomized to a single session brief motivational intervention group or an assessment-only control group but not blinded. Primary outcome was differences in past month drinking measured by a self-reported AUDIT-C-based index score for drinking frequency, quantity, and frequency of binge drinking with measures collected online at baseline and after 3 months. Secondary outcomes were the AUDIT-C-based separate drinking indicators, illegal drug use, and polydrug use. All outcome analyses were conducted with and without Expectation Maximization (EM) imputation of missing follow-up data.

Results

In total, 2673 adolescents were screened and 1449 (54.2%) participants were randomized to the intervention or control group. After 3 months, 211 adolescents (14.5%) provided follow-up data. Compared to the control group, results from linear mixed models revealed significant reductions in self-reported past-month drinking in favor of the intervention group in both the non-imputed (P=.010) and the EM-imputed sample (P=.022). Secondary analyses revealed a significant effect on drinking frequency (P=.037) and frequency of binge drinking (P=.044) in the non-imputation-based analyses and drinking quantity (P=.021) when missing data were imputed. Analyses for illegal drug use and polydrug use revealed no significant differences between the study groups (Ps>.05).

Conclusions

Although the study is limited by a large drop-out, significant between-group effects for alcohol use indicate that targeted brief motivational intervention in a fully automated Web-based format can be effective to reduce drinking and lessen existing substance use service barriers for at-risk drinking European adolescents.

Trial Registration

International Standard Randomized Controlled Trial Registry: ISRCTN95538913; http://www.isrctn.com/ISRCTN95538913 (Archived by WebCite at http://www.webcitation.org/6XkuUEwBx)

Prevention, early intervention, harm reduction, and treatment of substance use in young people

We did a systematic review of reviews with evidence on the effectiveness of prevention, early intervention, harm reduction, and treatment of problem use in young people for tobacco, alcohol, and illicit drugs (eg, cannabis, opioids, amphetamines, or cocaine). Taxation, public consumption bans, advertising restrictions, and minimum legal age are effective measures to reduce alcohol and tobacco use, but are not available to target illicit drugs. Interpretation of the available evidence for school-based prevention is affected by methodological issues; interventions that incorporate skills training are more likely to be effective than information provision-which is ineffective. Social norms and brief interventions to reduce substance use in young people do not have strong evidence of effectiveness. Roadside drug testing and interventions to reduce injection-related harms have a moderate-to-large effect, but additional research with young people is needed. Scarce availability of research on interventions for problematic substance use in young people indicates the need to test interventions that are effective with adults in young people. Existing evidence is from high-income countries, with uncertain applicability in other countries and cultures and in subpopulations differing in sex, age, and risk status. Concerted efforts are needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in young people.

Interventions in sports settings to reduce risky alcohol consumption and alcohol-related harm: a systematic review

BACKGROUND

Elevated levels of risky alcohol consumption and alcohol-related harm have been reported for sportspeople and supporters compared to non-sporting populations. Limited systematic reviews have been conducted to assess the effect of interventions targeting such behaviours.

METHODS

A review was undertaken to determine if interventions implemented in sports settings decreased alcohol consumption and related harms. Studies were included that implemented interventions within sports settings; measured alcohol consumption or alcohol-related injury or violence and were either randomised controlled trials, staggered enrollment trials, stepped-wedged trials, quasi-randomised trials, quasi-experimental trials or natural experiments. Studies without a parallel comparison group were excluded. Studies from both published and grey literature were included. Two authors independently screened potential studies against the eligibility criteria, and two authors independently extracted data from included studies and assessed risk of bias. The results of included studies were synthesised narratively.

RESULTS

The title and abstract of 6382 papers and the full text of 45 of these papers were screened for eligibility. Three studies met the inclusion criteria for the review. One of the included studies was a randomised controlled trial (RCT) of a cognitive-behavioural intervention with athletes within an Olympic training facility in the USA. The study reported a significant change in alcohol use between pre-test and follow-up between intervention and control groups. The other two studies were RCTs in community sports clubs in Ireland and Australia. The Australian study found a significant intervention effect for both risky alcohol consumption at sports clubs and overall risk of alcohol-related harm. The Irish study found no significant intervention effect.

CONCLUSIONS

A limited number of studies have been conducted to assess the effect of interventions implemented in sports settings on alcohol consumption and related harms. While two of the three studies found significant intervention effects, it is difficult to determine the extent to which such effects are generalisable. Further controlled trials are required in this setting.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014001739.

Stand-Alone Personalized Normative Feedback for College Student Drinkers: A Meta-Analytic Review, 2004 to 2014

Background

Norms clarification has been identified as an effective component of college student drinking interventions, prompting research on norms clarification as a single-component intervention known as Personalized Normative Feedback (PNF). Previous reviews have examined PNF in combination with other components but not as a stand-alone intervention.

Objectives

To investigate the degree to which computer-delivered stand-alone personalized normative feedback interventions reduce alcohol consumption and alcohol-related harms among college students and to compare gender-neutral and gender-specific PNF.

Data Sources

Electronic databases were searched systematically through November 2014. Reference lists were reviewed manually and forward and backward searches were conducted.

Selection Criteria

Outcome studies that compared computer-delivered, stand-alone PNF intervention with an assessment only, attention-matched, or active treatment control and reported alcohol use and harms among college students.

Methods

Between-group effect sizes were calculated as the standardized mean difference in change scores between treatment and control groups divided by pooled standard deviation. Within-group effect sizes were calculated as the raw mean difference between baseline and follow-up divided by pooled within-groups standard deviation.

Results

Eight studies (13 interventions) with a total of 2,050 participants were included. Compared to control participants, students who received gender-neutral (d_between = 0.291, 95% CI [0.159, 0.423]) and gender-specific PNF (d_between = 0.284, 95% CI [0.117, 0.451]) reported greater reductions in drinking from baseline to follow-up. Students who received gender-neutral PNF reported 3.027 (95% CI [2.171, 3.882]) fewer drinks per week at first follow-up and gender-specific PNF reported 3.089 (95% CI [0.992, 5.186]) fewer drinks. Intervention effects were small for harms (d_between = 0.157, 95% CI [0.037, 0.278]).

Conclusions

Computer-delivered PNF is an effective stand-alone approach for reducing college student drinking and has a small impact on alcohol-related harms. Effects are small but clinically relevant when considered from a public health perspective. Additional research is needed to examine computer-delivered, stand-alone PNF as a population-level prevention program.

Identification of Behavior Change Techniques and Engagement Strategies to Design a Smartphone App to Reduce Alcohol Consumption Using a Formal Consensus Method

Background

Digital interventions to reduce excessive alcohol consumption have the potential to have a broader reach and be more cost-effective than traditional brief interventions. However, there is not yet strong evidence for their ability to engage users or their effectiveness.

Objective

This study aimed to identify the behavior change techniques (BCTs) and engagement strategies most worthy of further study by inclusion in a smartphone app to reduce alcohol consumption, using formal expert consensus methods.

Methods

The first phase of the study consisted of a Delphi exercise with three rounds. It was conducted with 7 international experts in the field of alcohol and/or behavior change. In the first round, experts identified BCTs most likely to be effective at reducing alcohol consumption and strategies most likely to engage users with an app; these were rated in the second round; and those rated as effective by at least four out of seven participants were ranked in the third round. The rankings were analyzed using Kendall’s W coefficient of concordance, which indicates consensus between participants. The second phase consisted of a new, independent group of experts (n=43) ranking the BCTs that were identified in the first phase. The correlation between the rankings of the two groups was assessed using Spearman’s rank correlation coefficient.

Results

Twelve BCTs were identified as likely to be effective. There was moderate agreement among the experts over their ranking (W=.465, χ²₁₁=35.8, P<.001) and the BCTs receiving the highest mean rankings were self-monitoring, goal-setting, action planning, and feedback in relation to goals. There was a significant correlation between the ranking of the BCTs by the group of experts who identified them and a second independent group of experts (Spearman’s rho=.690, P=.01). Seventeen responses were generated for strategies likely to engage users. There was moderate agreement among experts on the ranking of these engagement strategies (W=.563, χ²₁₅=59.2, P<.001) and those with the highest mean rankings were ease of use, design – aesthetic, feedback, function, design – ability to change design to suit own preferences, tailored information, and unique smartphone features.

Conclusions

The BCTs with greatest potential to include in a smartphone app to reduce alcohol consumption were judged by experts to be self-monitoring, goal-setting, action planning, and feedback in relation to goals. The strategies most likely to engage users were ease of use, design, tailoring of design and information, and unique smartphone features.