Along with a growing understanding of risk and protective factors for heavy and harmful drinking among young people, the latter 20th century has seen a parallel movement toward applying a developmental perspective toward drinking issues (Schulenberg et al., 2001). The developmental perspective recognizes that patterns of health risk behaviors and influences on their expression may differ across the lifespan. An integrated social development perspective goes further and recognizes both the developmental and multifactorial nature of drinking in which myriad risk and protective can be located at individual, family, peer, neighborhood, and macro- social levels (Weitzman 2004). This perspective acknowledges that issues related to life stage, social role, and setting may be important considerations in understanding young adult health status, health risk behaviors, and outcomes. The developmental perspective may offer a particularly compelling motivation to intervene. Because young adulthood is a time during which young people learn to establish indepen- dent social ties and connections, participate in higher education, and begin work and career paths, heavy drinking poses substantial risks for longer term problems.
Reflecting on the opportunity costs of heavy drinking in adolescence and young adulthood, Koren Zailckas wrote:
Nine years after I took my first drink it occurs to me that I haven’t grown up. I am missing so much of the equipment that adults should have, like the ability to sustain eye contact without flinching or letting my gaze roll slantwise to the floor. At this point in time, I should be able to hear my own unwavering voice rise in public without feeling my heart flutter like it’s trying to take flight. I should be able to locate a point of conversation with the people I deeply long to know as my friends. …For me abstinence has been nothing but growing pains. It has meant starting from scratch, reliving my awkward phase, and learn- ing all over again what it means to be an adult. (2005: xvii–xx)
A focus on life course patterns for young adults coincides with a trend toward formal conceptualization of “emergent adulthood” as a developmental stage bridging later adolescence and adulthood (Arnett 2000). Emergent adulthood, in fact, appears to encompass three separate but related developmental challenges: existential chal- lenges centered on meaning-making as one becomes an adult; economic challenges centered on moving toward financial independence from financial dependence on parents and caretakers; and epidemiologic challenges centered on moving healthily through a period of peak behavioral and psychological risk.
The net result of this growing awareness about the ways that social developmen- tal issues may affect heavy and harmful drinking among young people may be: 1) growing acceptance of the need for comprehensive prevention programs that target multiple risk and protective factors spanning individual and community levels and
2) a move toward developmentally oriented programs that target risk and protec- tive factors thought to be most salient for young people in a given time, place, and setting. As Schulenberg and Maggs wrote:
The task now for scientists is to understand more fully how risk and protective factors are linked with substance use within individuals over time and across contexts. (2002: 57)
An excellent case for advancing this more nuanced approached to prevention is made by considering heavy and problem drinking by youth in college in the United States, a group at particular risk for drinking problems who are undergoing dra- matic developmental change. In going to college, young people are transitioning from adolescence to young adulthood, often in a new place. As such, they need to repopulate their social networks and supports, assume new roles and responsibili- ties, and move away from familiar and established supervisory controls and settings.
The cumulative effect of these transitions on health behaviors is only beginning to be addressed and may be evident in the very high risks for alcohol misuse and abuse seen among them.
Among young people, college students drink more heavily than their non–col- lege attending peers (O’Malley and Johnston 2002). About two in five students attending college in the United States engage in heavy episodic, or “binge” drink- ing—defined as consumption of five or more drinks in a row for males and four or more drinks for females on one or more occasion during a two-week period.
This rate has been consistent across multiple national surveys employing differing methods and was stable during the 1990s (CDC 1997; Douglas et al., 1997; Pre- sley et al., 1999; SAMHSA 2000; Johnston et al., 2001; O’Malley and Johnston 2002; Wechsler et al., 2002), a period of concentrated research activity on this topic (Dowdall and Wechsler 2002).
In college, about one third of college students and three in five frequent binge drinkers qualify for a diagnosis of alcohol abuse, whereas 1 in 17 (one in five fre- quent binge drinkers) could be diagnosed as alcohol dependent (Knight et al., 2002) based on clinical criteria (American Psychiatric Association 1994). It is esti- mated that approximately 1,700 U.S. college students died in unintentional injuries related to alcohol in 2001. During that year, about 2.8 million college youth drove a motor vehicle under the influence of alcohol. Nearly 600,000 college youth were unintentionally injured while under the influence of alcohol and 696,000 were assaulted by another student who was under the influence (Hingson et al., 2005).
These problems worsened significantly over the period 1998–2001 (Hingson et al.). Despite their evident problems with alcohol, few college students who drink heavily perceive that they are heavy or problem drinkers and even fewer report that they have sought treatment or counseling for their drinking (Knight et al., 2002;
Wechsler et al., 2002).
Controlling Misuse of Alcohol by College Youth n 163 A growing body of evidence links high risks for misuse and abuse of alcohol in college to environmental exposures. This is significant because environmental exposures can be changed to affect large numbers of youth in a presumably last- ing fashion. In contrast, individual characteristics, including patterns of knowl- edge, attitude, and belief about alcohol must be addressed on an ongoing basis.
This is because within the college setting different cohorts of youth enter and cycle through a college annually. Unfortunately for public health, individually oriented preventive interventions have a poor track record of working in college settings (see Larimer and Cronce 2002, for a comprehensive review). In light of the need to repeat them regularly, they may also be deemed inefficient.
The movement toward supporting exploration of environmental prevention pro- grams reflects not only theory and practicality but findings about social patterning of heavy drinking among college youth. For example, researchers found that rates of heavy episodic or “binge” drinking vary dramatically by college (ranging from 1 to 76 percent), by region of the country (lower in the Western states), and by the sets of policies and laws governing alcohol sale and use (Wechsler et al., 1998, 2002a, 2002b, 2003; Presley et al., 2002). The pricing and promotion of alcoholic beverages have been linked to consumption among college students (Chaloupka and Wechsler 1996), for whom low prices and easy access promote underage alco- hol use (Wechsler et al., 2000b). Similarly, lower rates of heavy episodic drinking have been observed among students attending colleges where no alcohol outlets exist within a mile of campus (Wechsler et al., 1994). High alcohol outlet den- sity is associated with higher levels of frequent and heavy drinking and drinking- related problems (Weitzman et al., 2003a). Moreover, perceptions about alcohol’s accessibility and availability strongly predict the acquisition in college of binge drinking in a national study examining factors that contributed to binge uptake among underage freshmen who reported they did not binge drink in high school (Weitzman et al., 2003b). In fact, the impact of these factors on binge uptake in college far exceeds the impact of other factors related to exposure to educational messages about alcohol, family characteristics, and individual social-demographic characteristics.
Campus policies that target alcohol use are associated with less binge drinking among college students. Substance-free residences, in which students are prohibited from using alcohol and tobacco products, are associated with less alcohol use and fewer secondhand effects of alcohol (Wechsler et al., 2001b). Among underage stu- dents who reside on campus, those who live in substance-free housing (i.e., alcohol and tobacco use prohibited) have the lowest rates of binge drinking (Wechsler et al., 2002b). State and local alcohol policies are also associated with drinking behavior among college students. Strong state and local drunk-driving policies targeting youths and young adults are associated with lower levels of drinking (Williams, Chaloupka, and Wechsler 2002). The National Minimum Legal Drinking Age law in the United States appears to be an effective deterrent (Toomey and Wagonaar 2002; Wagonaar and Toomey 2002). Underage students in states with extensive
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.