Beyond CollegeAIM: Lessons Learned in Alcohol and Other Drug Prevention

Beyond CollegeAIM: Lessons Learned in Alcohol and Other Drug Prevention

- Jessica Cronce, Ph.D., Jason Kilmer, Ph.D., and Toben Nelson, Sc.D.

Jessica Cronce, Jason Kilmer, and Toben Nelson, three of the six scientific contributors to the National Institute on Alcohol Abuse and Alcoholism's College Alcohol Intervention Matrix (CollegeAIM), presented a "fireside chat" at the 2023 NASPA Strategies Conference, in which they were asked to identify up to three observations or "lessons learned" about policy, prevention, or intervention efforts and up to three suggestions for campuses in their strategic planning. In this "View from the Field," they are answering those same questions, passing on observations, and making suggestions with the hope these are helpful for readers, partners, and collaborators in prevention.

Jessica Cronce
I'm excited to be able to collaborate, once again, with Jason and Toben. I also feel privileged to have worked closely for multiple years with campus prevention personnel who are the ones implementing our collective work with students every day. I've learned so much from these collaborations and relationships that informs my research and clinical practice with students (and the views I will express in this piece). I believe each of us is doing our very best every day to reduce the harms that students experience and, as students continue to experience harm despite these efforts, we all also need to do better. As I thought about the ways in which the field of alcohol prevention and intervention and all of us who work in myriad roles within that field can try to do "better," a few key observations came to mind.

Observation #1: "College students" and "campus contexts" are very heterogenous, yet they are often treated as homogenous when considering best practices for individual intervention.

The individuals that comprise a given college's or university's student body likely reflect the full compass of human diversity including, but not exclusively with respect to, varying racial and ethnic identity, nationality, culture, language(s), gender, sex assigned at birth, social class, socioeconomic status (and related factors, such as housing and food stability), familial and occupational obligations, mental and physical health and (dis)abilities, experiences of trauma and discrimination, and, of course, substance use. Though the ways in which the effect of existing interventions tend to differ based on some of these factors has been explored (e.g., the impact of group gender composition on the effectiveness of alcohol expectancy challenge interventions), far more is unknown than is known at this point. A particular gap exists with respect to understanding how different gender-affirming hormone therapies may impact blood alcohol concentration levels and attendant risk for alcohol-related consequences. Additionally, most existing brief alcohol interventions do not address how experiences of (or worries about experiencing) discrimination may shape alcohol use, often contributing to lower levels of overall alcohol use with disproportionate experiences of alcohol-related harm, and how alcohol interventions can inadvertently reinforce stigma by essentializing alcohol "misuse" as a characteristic of individuals with identities that are marginalized by society without acknowledging their resilience and the role of social stigma in shaping alcohol use. Of course, another current gap relates to the field's understanding of how the intersections of students' different identities (and therefore how they may experience interlocking systems of oppression) may shape or be associated with the effectiveness of alcohol interventions.

Campus contexts in which interventions are applied are also heterogeneous and may not match the context in which an intervention was initially developed or evaluated in terms of composition of the student body, resources available to students, alcohol policies on campus, alcohol density immediately adjacent to campus, rural/urban setting, the composition of the populace in which the campus is located, and the political milieu, to name a few. Such contextual differences shape students' individual experiences, access to intervention, access to other (potentially more intensive) forms of care, and perceptions of the likely helpfulness/outcomes of seeking care (e.g., students who have been marginalized within systems designed to offer "help" may be less likely to seek help when needed).

Collectively, these differences point to the need for ongoing program evaluation and future larger-scale research to ensure that effective alcohol interventions exist for all students, which may require adaptation of existing interventions (in light of individual or contextual differences) or new yet-to-be developed interventions.

Suggestion #1: Critical next steps for the field include increasing our understanding of (a) which interventions work for whom and in what context(s) and (b) when and what adaptation may be needed to maximize effectiveness in reducing alcohol-related harms.

Observation #2: Individual interventions that work for alcohol use may not work equally well for cannabis or other substance use or non-substance-based addictive behaviors.

One goal of nomothetic scientific traditions is generalizability of findings. Something that works as a solution for one problem (e.g., alcohol misuse) is applied to other "similar" problems (e.g., cannabis misuse) in the hopes that the solution will work as effectively in reducing or protecting against the development of the "similar" problems, too. Though some unique interventions exist for certain substances (e.g., needle exchange programs for substances that are injected), generalizing strategies is a very common approach to substance misuse prevention and intervention, especially for substances for which few (if any) substance-specific, effective interventions exist. Such has largely been the case on college campuses with respect to cannabis intervention, where "cannabis" is sometimes simply swapped for "alcohol" in existing programming. This move is both understandable from a scientific standpoint (i.e., sometimes things do generalize; in the absence of clear best practices, using something with some evidence is better than using something with no evidence) and a resource management standpoint (i.e., it is far more cost effective for staff who are already trained in one intervention to extend that intervention to incorporate a new focus than it is to train staff in a new intervention; the vast majority of students who use cannabis also use alcohol and some use both substances at the same time). However, what we know about cannabis is that the motivations for (or their association with cannabis use) and consequences of cannabis use are often different than for alcohol (e.g., cannabis is used by some students to expand their awareness, which is not true for alcohol; while social motives are positively associated with frequency of alcohol use, social motives are negatively associated with frequency of cannabis use, but may be predictive of greater consequences on days when cannabis is used simultaneously with alcohol). Additionally, historically, most measures of cannabis-related behaviors and consequences were directly adapted from alcohol measures (by swapping in "cannabis" or "alcohol"), which missed consequences that are unique to cannabis (e.g., the "munchies").

As campuses consider how best to deploy their resources to prevent harm associated with student substance use (and non-substance-related addictive behaviors, like gambling), beyond meeting regulatory requirements, there is value in conducting routine needs assessments to identify what behaviors are contributing most to individual and collective harms and then seeking interventions with evidence of reducing those harms. Of course, measures designed specifically to assess consequences/harms associated with a given behavior are best (when feasible) rather than using a general measure of harms that is meant to apply equally to all behaviors.

Suggestion #2: Consider what student behavior(s) you are trying to shift on your campus and look for interventions that specifically show evidence for reducing harms associated with that(those) behavior(s). Also consider if measures used for evaluation were developed specifically for a given behavior vs. merely adapted from alcohol.

Observation #3: Intervention development ideally considers adoption and implementation during the development process.

I frequently talk with campus prevention personnel who say they have a metaphorical mountain of program evaluation data that they haven't had the resources to analyze. I often speak with researchers on the same or nearby campuses who may be developing or refining interventions that could be informed by that program evaluation data. Going back to "Observation #1," I think one way the field can better understand how campus context (inclusive of campus resources devoted to prevention) shapes intervention response is by looking at existing program evaluation data and inquiring about implementation-related factors. Were effective programs adapted in one or more ways to fit within a campus's available resources? The answer is often "yes." Most frequently, I hear campuses describe that they took an intervention that was originally designed to be delivered to students individually (which was shown to be effective in that format) and they adapted it to be delivered in a group format instead. This action is often taken when there is an imbalance between the availability of interventionists/time and demand for the intervention, usually because students are mandated to participate in the intervention following violation of a campus alcohol policy. The question then becomes, "Did these adaptations change how effective the program was, either increasing or decreasing effectiveness?" One potential unintended consequence of such adaptations can be that the intervention is less effective than expected, which, understandably, can undermine various campus administrators' commitment to devoting resources to support continued delivery of the intervention. Considering implementation factors during intervention development is key (e.g., using approaches that involve stakeholders in the development process). However, research that compares the effect of various adaptations across different college contexts may also point to more feasible, equally (or more) effective means of intervention, especially when campuses assess and document things that facilitated or created a barrier to delivery of the intervention as designed. Partnering with researchers, in particular students who may be looking for data to analyze to meet program research requirements, to disseminate this information to other researchers and campus prevention personnel will help advance the field.

Suggestion #3: Consider assessing/documenting adoption and implementation facilitators and barriers as part of intervention evaluation activities and partnering with others (if/as needed) to publish this information.

Jason Kilmer
It's great to reunite with these two amazing people, even in a written "View from the Field."

I would fear the person that claims they have all the answers - that's not me, and I know Jess and Toben feel the same way (i.e., that I, Jason, don't have all the answers.ha!). Joking aside, you know your own campus best, and you know any one student or student group that you're working with best.

In my professional work, I have been lucky enough to always have had a foot in the research side of things (as we try to develop, implement, and evaluate prevention and intervention efforts) as well as in the direct provision of prevention and intervention programs to college students. When I considered observations and suggestions, they all seem interrelated and based on these experiences:

Observation #1: When you look at how interconnected policies, prevention, and intervention are on college campuses, res life and RAs are among your most important partners.

RAs are, for many incoming students, the first student leader they see and meet. And they are unbelievably influential. Pat Fabiano, an amazing norms-based practitioner and researcher who worked at Western Washington University until she retired, always pointed out that what students believe "most" students do related to alcohol use (or what the "typical student" does) certainly matters in what they choose to do themselves, but what they think student leaders do matters even more. When an RA sets a tone about the importance of alcohol and other drug prevention, that matters. When an RA talks about students in recovery with respect, that matters. When an RA enforces policy, and consistently enforces policy, that matters. Several years ago, Earl Rubington conducted some great studies with RAs to document the impact of their consistent policy enforcement - RAs that were too "laid back" lost control of their residents that becomes really hard to reclaim; ones that were too strict just pushed it elsewhere. Thus.

Suggestion #1: Share with RAs the data on how influential they are as carriers of normative messages, and the role they have in consistent enforcement. Especially if you have evidence-based prevention programs for mandated students, their consistent enforcement helps connect students to those programs.

Observation #2: When you have senior level administrators that are "all in" on alcohol prevention, it makes all the difference.

Prevention professionals are amazing. I always point out that no one calls a prevention professional and says, "Good news.nothing bad happened last night!" Instead, when there is an incident of any kind, the focus goes to "what are we doing about this?"

The bottom line is this. Prevention matters. So much. We have so much research showing that the more students drink alcohol, the lower their grades are and the less engaged they are with their coursework. The more students use cannabis, the lower their grades are and the less likely they are to graduate on time, if they make it to graduation.

If an administrator is all about student success and student outcomes (including retention and graduation rates), then that same administrator should be all about supporting alcohol and other drug prevention. What we do about alcohol and other drug prevention pays dividends in the classroom, and is directly related to the mission of the campus.

Suggestion #2: Do all you can to make sure senior level administrators understand the value of AOD prevention. If that is not a role you can personally play, find a champion for prevention on your campus who can be that voice they will listen to. If the narrative is that "we can't afford" to invest in a new prevention effort or support program, make the case that the campus can't afford not to - show what the impact could be on student success (and retaining students who might not otherwise stay enrolled) through what you do. In fact, as an example, I think we've seen an amazing model in what can be done to support investments in Collegiate Recovery Communities, and I always point to the Center for Collegiate Recovery Communities at Texas Tech University. Years ago, their campus released a guidebook on building a Collegiate Recovery Community that included a formula for estimating the financial impact of retaining students who might otherwise not be retained if services were not available on campus. If the issue is finances, estimates like this can be a step toward reducing (or eliminating) that barrier.

Observation #3: On the one hand, it's great when lots of people are talking about alcohol prevention on campus. On the other hand, sometimes people throw terms around or have insufficient buy in that can be a step backwards in the direction of what the science really says.

"We do BASICS." "We do social norming." "It's an evidence-based program." A lot goes into declaring something an evidence-based program - it's great when people recognize the value of empirically supported prevention efforts, but if this term gets used across the board for everything being done, people might stop thinking critically about what's actually being offered on campus. If you are selecting an evidence-based program (e.g., something from NIAAA's CollegeAIM), be sure it's being done the way it was meant to be done - if a program gets altered too much, it might no longer have the expected impact.

Suggestion #3: Fidelity and dosing matter. If you're going to do something, do it well and as true to the science as possible.

We really are all in this together. And I'm proud to be alongside all of you working so hard to make a difference on college campuses - all of your efforts absolutely matter.

Toben Nelson
I feel very privileged to have had the opportunity to work with Jessica and Jason over the years. It is an honor to share our reflections on our work with readers. Support of our collective work from NIAAA and practice organizations like the National Association of Student Personnel Administrators has been critical to advancing our understanding of the factors that promote safe and healthy environments with respect to alcohol use.

As someone who currently has children on campus (one in graduate school and one undergraduate), those issues are even more personal for me than when I started working in this area more than 25 years ago. Over that time there has been both tremendous progress made in some areas and maddeningly little movement in others. Continued vigilance and hard work are needed to create and sustain environments where our young people can grow, be healthy and safe, and be free from the consequences of alcohol misuse.

Observation #1: The thing I am most often aware of when I work with groups on alcohol-related issues is that most members of communities do not want to experience the negative consequences of excessive alcohol use. These include things ranging from the truly awful and devastating alcohol-involved motor vehicle crashes and incidents of interpersonal violence to more mundane nuisances such as noise disturbances, litter, and vandalism.

A few years ago, a student in one of my classes wondered why my colleagues and I cared so much about alcohol. This student said, "It's fun and frivolous." And I suppose that is true to some extent. It is also true that alcohol can be a very dangerous product, especially when consumed in excess. It has the potential to create havoc, harm people, ruin lives, and even end lives. The Centers for Disease Control and Prevention estimate that every year more than 100,000 people in the United States die as a result of excessive alcohol use. That is way too much power to give alcohol.

We can shape health and safety-promoting environments. We can create communities that are consistent with our values. We can give alcohol as much or as little power in our communities as we collectively decide. Social environments are created by people and we have the power to limit the role that alcohol has in our communities.

I used to do presentations where we would share data on excessive drinking and how much some groups seemed to be drinking compared with others. The basic message was "Alcohol is bad." And by extension, lots of student groups got the message that they are bad for being such heavy drinkers. Somehow the audiences did not like these presentations and we did not see much change. At some point, we simply started engaging the audiences with what they wanted for their own community. Sometimes they needed help connecting the environmental conditions with behaviors with the consequences, but the approach seemed to work much better and was certainly more engaging and empowering.

Suggestion #1: Listen to the values and hopes and aspirations of people who choose to be part of your community and shape the environment accordingly. Consider the role that alcohol plays in your community and decide what is acceptable and what is not. Make a clear connection between the environment and the consequences of excessive drinking and work to shape the environment to be consistent with community values.

Observation #2: While the experience and consequences of excessive drinking can be deeply personal and individual, it seems to me that the most effective solutions are interpersonal and collective.

When excessive alcohol use and its negative consequences are viewed solely as a problem of individuals, the onus of responsibility falls to the individual. Sometimes that can extend to blaming the individual for their misfortune. I think this is often mistaken for accountability. There is frequent accountability for individuals who experience negative consequences from excessive alcohol use. From public health and harm reduction perspectives, we want to avoid those consequences. There is too infrequently accountability for creating the social and environmental conditions that facilitate excessive drinking or silently supporting those harmful environments.

Suggestion #2: I would like to see a reframing of accountability to where we all accept more responsibility for creating safe and healthy environments that limit the negative effects of excessive alcohol use.

This is not to absolve individuals from being accountable for their own behavior but to expand our definition of responsibility and accountability. Social systems are needed to get effective help for those who need it. Positive ways of establishing and maintaining vital social connections are needed. Those social connections are basic human needs and we should recognize them as such. College students are in the process of establishing lots of new social connections. They can be facilitated without the potential harm from alcohol. Policies about how alcohol is made available to people in our communities shape how alcohol is used. Those policies should be consistent with our community values.

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Jessica M. Cronce, Ph.D.
Dr. Cronce is an Associate Professor within the Department of Counseling Psychology and Human Services at the University of Oregon. She is also Director of the Counseling Psychology Ph.D. Program, Director of the Counseling Psychology Center within the HEDCO Clinic, and a licensed psychologist in Oregon state. Dr. Cronce is best known for her research on the prevention of high-risk drinking and associated consequences among college students and other young adults, including developing and evaluating brief interventions that utilize motivational interviewing. Dr. Cronce's most recent research has focused on developing and adapting preventive alcohol interventions to better serve transgender and gender diverse college students.

Jason R. Kilmer, Ph.D.               
Dr. Jason Kilmer is an Associate Professor in Psychiatry and Behavioral Sciences at the University of Washington School of Medicine and an Adjunct Associate Professor in Psychology at UW. Jason serves as an investigator on several studies evaluating prevention and intervention efforts for alcohol, cannabis, and other drug use by college students. In addition to research and teaching, he has worked extensively with college students and student groups around alcohol and other drug prevention programming and presentations throughout his career. Dr. Kilmer serves as the chairperson of Washington state's College Coalition on Substance Misuse, Advocacy, and Prevention.

Toben F. Nelson, Sc.D.
Dr. Nelson is a Professor in the Division of Epidemiology and Community Health at the University of Minnesota School of Public Health. He directs the Robert Wood Johnson Foundation Interdisciplinary Research Leaders program, and is a faculty member in the Alcohol Epidemiology Program and the Minnesota Population Center. Dr. Nelson is a nationally recognized expert on alcohol policy and the prevention of alcohol use and alcohol-attribute harm, injury, and violence.