laws restricting underage and high-volume drinking were less likely to drink and to binge drink (Wechlser et al., 2002b). These comprehensive sets of laws were also associated with less drinking and driving among college students (Wechsler et al., 2003).
Clearly, many malleable social, structural, and policy factors influence patterns of heavy and abusive drinking among college youth. Whether society chooses to act to alter these factors hinges on the levels of social and political will available for addressing competing interests, ideologies, and inertia (WHO 2005). Mustering sufficient will also depends on how we understand adolescence versus young adult- hood. Arguably, society is reasonably comfortable enacting strong social policies aimed at limiting hazardous exposures for youth insofar as there is a good fit between normative understandings about youth and societal commitment to protecting the vulnerable. By contrast, society tends toward allowing people greater discretion to make their own mistakes by young adulthood, given the fit between norma- tive understandings about adulthood and societal encouragement of independence and autonomy for adults. Finally, willingness to manipulate social, structural, and policy levers to affect behavior change may hinge on society’s understanding of individual and population risks for harm as they relate to different levels of alcohol consumption.
Controlling Misuse of Alcohol by College Youth n 165 still a period of active development and maturation, even though the social construc- tion of adolescence may deem otherwise.
Understanding of associations between developing neurologic structures and risk-taking is only just beginning. However, this work is sparking debate about the importance for young people’s behavior of biologic structures and the implica- tions for policy and prevention of observed associations. In the context of a quickly developing science, it seems that brain structure and development are important considerations with respect to health risk behavior. Moreover it seems that ado- lescence lasts longer than many people thought—roughly from 13 to 25 years of age. From a policy perspective this age span is notable because it encompasses ages when society permits young people to make decisions with far-reaching implica- tions for their health, including decisions to drive (at 16), vote and enlist in the military (at 18), and purchase and use tobacco and alcohol (at 21). This age span is also when young people may be most likely to live in peer dense settings—as they do in college. It is the time when many young people experience disruption or loss of familiar adult supports and supervisory controls that serve to protect or buffer them including from parents, family primary care providers, teachers, and neigh- bors. Perhaps not surprisingly, this period of life may be one in which people are most heavily targeted by industries seeking to develop markets, such as the tobacco, alcohol, and food industries.
Findings that young people may be vulnerable to health risk behaviors as a result of their incomplete neurologic development give us pause about the types of influences and opportunities that surround them. Are we overly optimistic about young people’s abilities to regulate their own choices and behaviors in the con- text of powerful influences to drink, smoke, and eat poorly? How do we balance young people’s needs and desire for autonomy with societal obligations to practi- cally and frankly consider their vulnerabilities and perhaps need for protection a little later into life than we may have thought? Colleges are one of the institutions most directly confronted with the need to resolve this issue.
A second scientific discussion reflects questions about the magnitude of harm generated by various levels of alcohol consumption and drinking style—and the implication of these patterns for setting prevention priorities and strategies. Epi- demiologists have been exploring whether harms from drinking are most likely to reflect patterns of intensive heavy drinking and intoxication—patterns which call for secondary and tertiary prevention approaches (i.e., screening and treatment);
or, whether harms disproportionately reflect lower levels of consumption typical of large segments of the general population—patterns not generally considered haz- ardous and that call for primary prevention approaches (i.e., policy changes target- ing supply and availability of alcohol-, media-, and communication-based efforts to change knowledge, attitudes, and beliefs).
Studies suggest that the bulk of all harms may in fact disproportionately arise from patterns of low to moderate consumption in a phenomenon termed the “pre- vention paradox” (Rose 1992), first investigated with respect to alcohol by Kreitman
(1986). A number of investigators using different methods and approaches have found that the burden of alcohol-related harms experienced by communities dis- proportionately reflects low to moderate levels of consumption (i.e., two to three drinks per occasion). This pattern exists despite findings that a given individual’s risk for experiencing drinking-related harm increases with the amount of alcohol consumed. The paradoxical nature of this finding reflects the distribution of con- sumption patterns in a community. Because the bulk of drinkers consume at low to moderate levels but experience a non-zero risk for harm from their drinking, the majority of drinking-related harms in a community derive from their drinking behaviors. Studies by Spurling and Vinson (2005) using case control methods and hospital emergency room data, and Weitzman and Nelson (2004) analyzing four panels of a nationally representative survey (approximately 50,000 college youth) both found that the magnitude of drinking harms arising from persons drink- ing at low to moderate levels outweighed harms arising from persons drinking at heavier and extreme levels. Gruenwald et al. (2003) came to similar conclusions when modeling survey data describing patterns of alcohol consumption and harm among college youth using a dose-response framework. Finally, Stockwell and col- leagues (2004) concluded that the prevention paradox applies to measures of alco- hol and tobacco but not illicit drug use among adolescents in Victoria, Australia.
Examining cross-sectional and longitudinal patterning of substance use by social and developmental risk factors, they found that even across intensities of use, the vast majority of substance use was found among youth with low/average risk.
These findings turn what may feel like common sense on its head and suggest that as a society we focus attention on social and policy factors that incrementally reduce low and moderate consumption among the majority to maximally improve public health. Primary prevention strategies focused on moderating consumption among the majority stand in contrast to tertiary prevention strategies (i.e., treat- ment). The latter are designed to affect large changes in behavior for the minority of drinkers who consume at extreme levels. Despite the public health logic of targeting prevention resources toward incrementally changing behavior among the majority of drinkers given they account for the largest share of drinking-related morbidity and mortality, considerable challenges exist in affecting these changes. Generat- ing strong support for enacting environmental strategies that foster moderation in consumption requires educating lay people, policy makers, and clinicians about the relationship between consumption and harms and the “prevention paradox.” As stated by Weitzman and Nelson (2004, p. 249):
…these types of prevention strategies may be both controversial—by seeking to incrementally change the behavior of a majority who may correctly perceive they are at low individual risk of harm—and coun- terintuitive—by investing prevention resources and attention toward changing the upstream determinants of behaviors that may appear
Controlling Misuse of Alcohol by College Youth n 167 benign individually while seemingly ignoring the easily identified problems of persons with more acute symptoms or disease.
Despite ample evidence supporting environmental strategies for reducing consump- tion and harms (SAMHSA 1999; NIAAA 2002; Bonnie and O’Connell 2003), there appears to be resistance globally to making use of these strategies (Room et al., 2003). An example of leadership trying to focus attention on environmental (as opposed to mostly individual) exposures is evident in the World Health Orga- nization’s “Declaration on Young People and Alcohol, 2001” (WHO 2001). This call to action intentionally draws attention to societal factors influencing heavy and problem drinking among young people, including the marketing and promotion of alcohol. Additionally, the Declaration highlights links between alcohol, tobacco, and other substances, urging protection of young people within school and univer- sity settings.