Hookah Tobacco Smoking During the Transition to College: Prevalence of Other Substance Use and Predictors of Initiation.

INTRODUCTION: The prevalence of hookah tobacco smoking is increasing, and the transition to college is a vulnerable time for initiation. Hookah use is associated with other forms of substance use, but most research has been cross-sectional, thus limiting our understanding of temporal patterns of use. The goals of this longitudinal study were to assess the prevalence of hookah use and initiation, as well as other forms of substance use among hookah users, and identify which forms of substance use predicted hookah initiation during the first 30 days of college. METHODS: Incoming students (N = 936, 50% female) reported on past 30-day substance use prior to the start of the Fall 2011 semester and again 30 days later (n = 817). Substances included hookah, cigarettes, other forms of tobacco, alcohol, marijuana, and other illegal drugs. RESULTS: Current prevalence of hookah use increased from 9.0% before college to 13.1% during the first month of college. At baseline and follow-up, current hookah users were more likely than nonusers to report current use of cigarettes, cigars/little cigars/clove cigarettes, smokeless tobacco, marijuana, and alcohol. Among pre-college hookah never users, 13.8% initiated hookah use in the first month of college. Alcohol (adjusted odds ratio [AOR] 1.11, 95% confidence interval [CI] 1.05, 1.17) and marijuana (AOR 1.30, 95% CI 1.03, 1.65) were the only substances predictive of hookah initiation. CONCLUSIONS: Findings indicate that hookah prevention and intervention is needed during the transition to college, and interventions may need to address comorbid alcohol, marijuana, and hookah use. IMPLICATIONS: To our knowledge this is the first longitudinal study examining predictors of hookah initiation among male and female incoming first-year college students. While hookah users were more likely than nonusers to use all other substances before and during the first month of college, pre-college marijuana and alcohol use were the only two predictors of hookah initiation during the first 30 days of college. Collectively, these findings provide additional support for the need for efficacious hookah prevention and intervention programs. The transition to college appears to be an ideal time to deliver prevention programs given the increased prevalence of hookah use during the first 30 days of college. In addition to prevention, former users may benefit from targeted relapse prevention as one-fifth of former hookah smokers resumed use during the first 30 days of college.

Drinking Location and Pregaming as Predictors of Alcohol Intoxication Among Mandated College Students.

BACKGROUND: Both drinking location and pregaming have been associated with heavy alcohol use among college students, yet the manner by which they uniquely contribute to alcohol intoxication remains unclear. OBJECTIVE: The current study examined the unique utility of drinking location and pregaming in predicting alcohol intoxication among college students who violated campus alcohol policy. METHOD: Between 2011 and 2012, mandated college students who reported drinking prior to their referral events (N = 212, 41% female, 80% White, Mage = 19.4 y) completed a computerized assessment of drinking location and related behaviors as part of larger research trial. Chi-squared statistics, t-tests, one-way analyses of covariance, and regression were used to examine study aims. RESULTS: Participants were most likely (44%) to report drinking in off-campus housing prior to the referral event, and approximately half (47%) reported pregaming. Alcohol intoxication on the night of the referral event differed significantly as a function of both drinking location and pregaming, but pregaming did not moderate the association between drinking location and alcohol intoxication among mandated students. Female birth sex, pregaming, and drinking at either fraternities or off-campus housing predicted greater levels of alcohol intoxication on the night of the referral incident, while drinking in a residence hall/dorm predicted lower intoxication. CONCLUSIONS/IMPORTANCE: Drinking location and pregaming are distinct predictors of alcohol intoxication among mandated college students. Future interventions may benefit from targeting both where and how college students consume alcohol.

Drinking games, tailgating, and pregaming: precollege predictors of risky college drinking.

BACKGROUND: The transition from high school to college is a critical period for developing college drinking habits. Hazardous alcohol consumption increases during this period, as well as participation in drinking games, pregaming, and tailgating. All of these risky drinking practices are associated with higher levels of intoxication as well as an increased risk of alcohol-related problems. OBJECTIVE: The current study aimed to evaluate pre-college predictors (personality, social norms, and beliefs reflecting the internalization of the college drinking culture [ICDC]) of estimated peak BAC (pBAC) reached during drinking games, pregaming, and tailgating, as well as pBAC and alcohol-related problems during the first 30 days of college. METHODS: Participants (n = 936) were incoming freshmen at a large university who completed a baseline assessment prior to college matriculation and a follow-up assessment after they had been on campus for 30 days. RESULTS: Using path analysis, ICDC was significantly associated with pBAC reached during the three risky drinking practices. ICDC had an indirect effect on both pBAC and alcohol-related problems via pBAC from drinking games, pregaming, and tailgating. Hopelessness and sensation seeking were significantly related to alcohol use outcomes. CONCLUSION: Precollege perceptions of the college drinking culture are a stronger predictor of subsequent alcohol use than social norms. Interventions that target these beliefs may reduce peak intoxication and associated harms experienced during the first 30 days of college.

Tailgating and pregaming by college students with alcohol offenses: patterns of alcohol use and beliefs.

Research indicates that pregaming (drinking before a social event) and tailgating (drinking before a sporting event) are two culturally ingrained alcohol use behaviors by college students. We examined the prevalence of these two activities in a sample of college students (N = 354) who violated campus alcohol policy and were mandated to receive an alcohol intervention in fall 2010. Results indicated that alcohol consumption and other risk factors were related to pregaming and tailgating. These findings are discussed in the context of clinical implications and future directions for research. This study was funded in part by the National Institutes of Health.

Personality, marijuana norms, and marijuana outcomes among college students.

Based on the high prevalence of marijuana use among college students, we examined distal and proximal antecedents to marijuana-related outcomes in this population. Specifically, we examined three marijuana-related perceptions (descriptive norms, injunctive norms, and internalization of college marijuana use culture) as potential mediators of the associations between four personality traits (impulsivity, sensation seeking, hopelessness, and anxiety sensitivity) and marijuana-related outcomes (marijuana use, negative marijuana-related consequences). In a large sample of college student marijuana users (n=2129), our path analysis revealed marijuana-related perceptions to significantly mediate the associations between personality and marijuana-related outcomes. Specifically, internalization of college marijuana use culture mediated the effects of both impulsivity and sensation seeking on marijuana-related outcomes. Not only do our findings suggest the importance of distinct types of marijuana-related norms in predicting marijuana involvement, but also the possibility that such normative beliefs could be targeted as part of personality-tailored interventions.

Drinking before drinking: pregaming and drinking games in mandated students.

Pregaming, the practice of consuming alcohol before attending a social function, has not received as much research attention as drinking games among college students. This study investigated the prevalence of both pregaming and drinking game participation in a sample of mandated students (N=334) who had been referred for an alcohol violation. Approximately one-third (31%) of the sample reported pregaming on the night of their referral event. Pregaming was associated with higher estimated blood alcohol content on that night, along with a greater history of pregaming and taking greater responsibility for the incident. A higher proportion of the students (49%) reported playing drinking games on the event night and reported the event to be less aversive than non-players. Neither drinking games nor pregaming was consistently related to recent alcohol consumption or problems, nor did they frequently occur together on the event night. Pregaming was a unique predictor of intoxication on the night of the referral, and drinking games were not. Therefore, pregaming and drinking games appear to be distinct activities. This research suggests methods of prevention for both activities as well as promising research directions for future research.

Mandated college students' response to sequentially administered alcohol interventions in a randomized clinical trial using stepped care.

OBJECTIVE: Students referred to school administration for alcohol policies violations currently receive a wide variety of interventions. This study examined predictors of response to 2 interventions delivered to mandated college students (N = 598) using a stepped care approach incorporating a peer-delivered 15-min brief advice (BA) session (Step 1) and a 60- to 90-min brief motivational intervention (BMI) delivered by trained interventionists (Step 2). METHOD: Analyses were completed in 2 stages. First, 3 types of variables (screening variables, alcohol-related cognitions, mandated student profile) were examined in a logistic regression model as putative predictors of lower risk drinking (defined as 3 or fewer heavy episodic drinking [HED] episodes and/or 4 or fewer alcohol-related consequences in the past month) 6 weeks following the BA session. Second, we used generalized estimating equations to examine putative moderators of BMI effects on HED and peak blood alcohol content compared with assessment only (AO) control over the 3-, 6-, and 9-month follow-ups. RESULTS: Participants reporting lower scores on the Alcohol Use Disorders Identification Test, more benefits to changing alcohol use, and those who fit the "Bad Incident" profile at baseline were more likely to report lower risk drinking 6 weeks after the BA session. Moderation analyses revealed that Bad Incident students who received the BMI reported more HED at 9-month follow-up than those who received AO. CONCLUSION: Current alcohol use as well as personal reaction to the referral event may have clinical utility in identifying which mandated students benefit from treatments of varying content and intensity.

Using calculations to estimate blood alcohol concentrations for naturally occurring drinking episodes: a validity study.

OBJECTIVE: The purpose of this study is to determine the accuracy of retrospective estimated blood alcohol concentrations (eBACs) for re-creating intoxication resulting from a naturally occurring drinking event. This study identified five eBAC equations, applied them to self-report data and compared the results to actual blood alcohol concentration obtained by a breath test. METHOD: A convenience sample of 109 drinkers was recruited near drinking establishments and asked to provide breath alcohol concentration (BrAC) samples. Participants were contacted by telephone on the next waking day to gather data required for five algorithms that determine eBAC. BrAC and eBAC obtained from each equation were compared to determine the level of agreement between the two approaches. RESULTS: eBACs correlated highly with each other (r > or = 0.99); R2 for all algorithms ranged from 0.54 to 0.55 with BrAC as the criterion. On average, eBAC equations overestimated BrAC. Regression analysis identified the amount of time spent drinking, number of standard drinks, weight and year in school as factors related to discrepancy. CONCLUSIONS: These data indicate that, although all equations produce eBACs that are highly related, their relationship to BrAC does vary across equations. Using the best fitting equation, eBAC is more strongly correlated with BrAC when intoxication is less than 0.08 g/210 L of breath, and the magnitude of the relationship decreases as intoxication rises.

It's all fun and games...or is it? Collegiate sporting events and celebratory drinking.

OBJECTIVE: Heavy drinking is prevalent on college campuses, and collegiate sporting events may precipitate heavy drinking. Despite this, relatively few studies have examined student drinking on the days of sporting events. In 2003, Syracuse University won the men's National College Athletic Association basketball championship; ongoing data collection allowed an investigation of alcohol consumption at Syracuse University during the two Final Four game days, when the semifinals and championship games are played. The goals of the study were to examine the level of alcohol use on these days and to examine factors related to game-day consumption. METHOD: As a part of an ongoing study, 206 undergraduate students completed several questionnaires, then returned daily drinking diaries at 1-week intervals for 4 consecutive weeks. RESULTS: Alcohol consumption levels on the two game days exceeded what is typical on campus. Further analyses conducted using zero-inflated negative binomial regression modeling demonstrated that heavier drinkers were more likely to drink alcohol, and drink alcohol heavily, on both game days. Furthermore, lack of impulse control was independently associated with an increased likelihood of drinking on both days. CONCLUSIONS: Although results from this study should be considered preliminary, these data document heavier drinking associated with high-profile athletic events. Sporting events may be a particularly opportune time and venue for collegiate risk-reduction programs.

Descriptive norms and expectancies as mediators of a brief motivational intervention for mandated college students receiving stepped care for alcohol use.

Stepped care approaches for mandated college students provide individual brief motivational interventions (BMI) only for individuals who do not respond to an initial, low-intensity level of treatment such as Brief Advice (BA). However, how BMIs facilitate change in this higher-risk group of mandated students remains unclear. Perceived descriptive norms and alcohol-related expectancies are the most commonly examined mediators of BMI efficacy but have yet to be examined in the context of stepped care. Participants were mandated college students (N = 598) participating in a stepped care trial in which mandated students first received BA. Those who reported continued risky drinking 6 weeks following a BA session were randomized to either a single-session BMI (N = 163) or an assessment-only comparison condition (AO; N = 165). BMI participants reduced alcohol-related problems at the 9 month follow up significantly more than AO participants. Multiple mediation analyses using bootstrapping techniques examined whether perceived descriptive norms and alcohol-related expectancies mediated the observed outcomes. Reductions in perceptions of average student drinking (B = -.24; 95% CI [-.61, -.04]) and negative expectancies (B = -.13; 95% CI [-.38, -.01]) mediated the BMI effects. Furthermore, perceived average student norms were reduced after the BMI to levels approximating those of students who had exhibited lower risk drinking following the BA session. Findings highlight the utility of addressing perceived norms and expectancies in BMIs, especially for students who have not responded to less intensive prevention efforts.

Are retrospectively reconstructed blood alcohol concentrations accurate? Preliminary results from a field study.

OBJECTIVE: The purpose of this study was to evaluate the relationship between blood alcohol concentration (BAC) derived from an in vivo breath test and retrospective estimates of BAC (eBAC) for the same drinking event. The relationship was expected to be lower at higher levels of BAC as a result of inaccuracies in the recall of self-report data. METHOD: The sample consisted of 44 persons (64% male) who were walking away from a bar district adjacent to a university campus. After giving informed consent, participants provided a breath sample and contact information. The next day a research assistant telephoned the participants and conducted a brief interview, using the equation prescribed by the National Highway Traffic Safety Administration, to obtain the self-report data necessary to calculate the eBAC for the previous evening. RESULTS: The actual BACs and eBACs were not significantly different, and they were highly correlated (r = 0.84, n = 43). BAC did predict the magnitude of discrepancy between the two, and at BACs over 0.08, the relationship was nonsignificant. CONCLUSIONS: Although self-report data can be used to approximate the BAC obtained during a naturally occurring drinking event the relationship is moderated by measured level of intoxication. Retrospective calculations are less accurate when estimating higher BACs.

Personality and alcohol-related outcomes among mandated college students: descriptive norms, injunctive norms, and college-related alcohol beliefs as mediators.

The present study examined three alcohol-perception variables (descriptive norms, injunctive norms, and college-related alcohol beliefs) as mediators of the predictive effects of four personality traits (impulsivity, sensation seeking, anxiety sensitivity, and hopelessness) on alcohol use and alcohol-related consequences in a sample of mandated college students (n=875). Our findings replicated several findings of a previous study of incoming freshman college students (Hustad et al., in press) in that impulsivity and hopelessness had direct effects on alcohol-related problems, sensation seeking and impulsivity had indirect effects on alcohol-related outcomes via college-related alcohol beliefs, and college-related alcohol beliefs predicted both alcohol use and alcohol-related problems. We discuss the implications of our findings for global college student interventions as well as personality-targeted interventions.

The role of alcohol perceptions as mediators between personality and alcohol-related outcomes among incoming college-student drinkers.

After high school, college students escalate their drinking at a faster rate than their noncollege-attending peers, and alcohol use in high school is one of the strongest predictors of alcohol use in college. Therefore, an improved understanding of the role of predictors of alcohol use during the critical developmental period when individuals transition to college has direct clinical implications to reduce alcohol-related harms. We used path analysis in the present study to examine the predictive effects of personality (e.g., impulsivity, sensation seeking, hopelessness, and anxiety sensitivity) and three measures of alcohol perception: descriptive norms, injunctive norms, and perceptions regarding the perceived role of drinking in college on alcohol-related outcomes. Participants were 490 incoming freshmen college students. Results indicated that descriptive norms, injunctive norms, and the role of drinking largely mediated the effects of personality on alcohol outcomes. In contrast, both impulsivity and hopelessness exhibited direct effects on alcohol-related problems. The perceived role of drinking was a particularly robust predictor of outcomes and mediator of the effects of personality traits, including sensation seeking and impulsivity on alcohol outcomes. The intertwined relationships observed in this study between personality factors, descriptive norms, injunctive norms, and the role of drinking highlight the importance of investigating these predictors simultaneously. Findings support the implementation of interventions that target these specific perceptions about the role of drinking in college.

Predictors of motivation to change in mandated college students following a referral incident.

The purpose of present study was to understand factors that are related to a desire or motivation to change (MTC) alcohol use in a sample of college students mandated to receive an alcohol intervention. We examined characteristics of and reactions to the referral event, typical alcohol use involvement, and alcohol beliefs about the perceived importance of drinking in college assessed by the College Life Alcohol Salience Scale (CLASS; Osberg et al., 2010) as predictors of MTC following referral to an alcohol intervention. College students (N = 932) who presented for a mandatory alcohol intervention following a referral event (e.g., citation for underage drinking, medical attention for an alcohol-related incident, or driving under the influence) completed an assessment prior to receiving an alcohol intervention. Higher perceived aversiveness of the referral event and higher personal responsibility one felt for the occurrence of the event were positively related to higher MTC. Although alcohol beliefs about the role of drinking in college were not significantly related to either event aversiveness or responsibility, it was negatively related to MTC even after controlling for alcohol use involvement variables. Alcohol beliefs about the role of drinking in college represent an important construct that is related to increased alcohol use and alcohol-related problems and decreased MTC in a sample of college students. Interventions aimed at reducing alcohol beliefs about the role of drinking in college may be an effective strategy to reduce alcohol use and alcohol-related problems by college students.

Hospitalizations for students with an alcohol-related sanction: gender and pregaming as risk factors.

OBJECTIVE: The purpose of this study is to investigate whether pregaming (ie, drinking prior to a social event) is a risk factor for hospitalization. PARTICIPANTS: Participants (N = 516) were undergraduate students with an alcohol-related sanction. METHODS: Participants completed a survey about alcohol use, as well as behaviors and experiences, prior to and during the referral event. The dependent variable was whether participants received medical attention at an emergency department during the sanction event. RESULTS: Results indicated that older students, females who pregame, students with higher alcohol use screening scores, lighter drinkers, and higher numbers of drinks before the referral event all increased the odds of receiving medical attention. Pregaming alone was not significantly related to receiving medical attention in the multivariate analysis. CONCLUSIONS: Female students who pregame appear to be at risk for requiring hospitalization after drinking when controlling for the number of drinks consumed.

Phone-delivered brief motivational interventions for mandated college students delivered during the summer months.

OBJECTIVE: Across the United States, tens of thousands of college students are mandated to receive an alcohol intervention following an alcohol policy violation. Telephone interventions may be an efficient method to provide mandated students with an intervention, especially when they are away from campus during summer vacation. However, little is known about the utility of telephone-delivered brief motivational interventions. METHOD: Participants in the study (N=57) were college students mandated to attend an alcohol program following a campus-based alcohol citation. Participants were randomized to a brief motivational phone intervention (pBMI) (n=36) or assessment only (n=21). Ten participants (27.8%) randomized to the pBMI did not complete the intervention. Follow-up assessments were conducted 3, 6, and 9 months post-intervention. RESULTS: Results indicated the pBMI significantly reduced the number of alcohol-related problems compared to the assessment-only group. Participants who did not complete the pBMI appeared to be lighter drinkers at baseline and randomization, suggesting the presence of alternate influences on alcohol-related problems. CONCLUSION: Phone BMIs may be an efficient and cost-effective method to reduce harms associated with alcohol use by heavy-drinking mandated students during the summer months.

The comparative effectiveness of individual and group brief motivational interventions for mandated college students.

Individual brief motivational intervention (iBMI) is an efficacious strategy to reduce heavy drinking by students who are mandated to receive an alcohol intervention following an alcohol-related event. However, despite the strong empirical support for iBMI, it is unknown if the results from rigorously controlled research on iBMI translate to real-world settings. Furthermore, many colleges lack the resources to provide iBMI to mandated students. Therefore, group-delivered BMI (gBMI) might be a cost-effective alternative that can be delivered to a large number of individuals. The purpose of this study was to conduct a comparative effectiveness evaluation of iBMI and gBMI as delivered by staff at a university health services center. Participants (N = 278) were college students who were mandated to receive an alcohol intervention following an alcohol-related incident. Participants were randomized to receive an individual (iBMI; n = 133) or a Group BMI (gBMI; n = 145). Results indicated that both iBMI and gBMI participants reduced their peak estimated blood alcohol concentration (BAC) and the number of negative alcohol-related consequences at 1-, 3-, and 6-months postintervention. The iBMI and gBMI conditions were not significantly different at follow-up. These findings provide preliminary support for the use of iBMI and gBMIs for college students in real-world settings.

Addressing alcohol use and problems in mandated college students: a randomized clinical trial using stepped care.

OBJECTIVE: Over the past 2 decades, colleges and universities have seen a large increase in the number of students referred to the administration for alcohol policies violations. However, a substantial portion of mandated students may not require extensive treatment. Stepped care may maximize treatment efficiency and greatly reduce the demands on campus alcohol programs. METHOD: Participants in the study (N = 598) were college students mandated to attend an alcohol program following a campus-based alcohol citation. All participants received Step 1: a 15-min brief advice session that included the provision of a booklet containing advice to reduce drinking. Participants were assessed 6 weeks after receiving the brief advice, and those who continued to exhibit risky alcohol use (n = 405) were randomized to Step 2, a 60- to 90-min brief motivational intervention (n = 211), or an assessment-only control (n = 194). Follow-up assessments were conducted 3, 6, and 9 months after Step 2. RESULTS: Results indicated that the participants who received a brief motivational intervention showed a significantly reduced number of alcohol-related problems compared to those who received assessment only, despite no significant group differences in alcohol use. In addition, low-risk drinkers (n = 102; who reported low alcohol use and related harms at 6-week follow-up and were not randomized to stepped care) showed a stable alcohol use pattern throughout the follow-up period, indicating they required no additional intervention. CONCLUSION: Stepped care is an efficient and cost-effective method to reduce harms associated with alcohol use by mandated students.

Does clinician continuity over two brief motivational sessions improve outcomes in college students?

Previous research has shown that brief motivational interventions (BMIs) are an effective treatment approach for reducing college student alcohol use and associated negative consequences. The purpose of this study was to determine whether clinician continuity (having the same vs. a different clinician) across an initial BMI and follow-up booster session was related to differences in session satisfaction, self-reported alcohol use, and alcohol-related negative consequences. Participants included 358 undergraduate students who were part of a larger randomized clinical trial. Results revealed no significant differences in alcohol use and associated consequences at follow-up between participants who met with the same versus a different clinician. Clinician continuity was not significantly related to intervention fidelity in terms of BMI-consistent qualities, relevance of information presented, or session satisfaction. These findings suggest that clinician continuity across BMIs for college students is not related to participant satisfaction or intervention effectiveness, especially if the clinicians adhere to empirically supported techniques.