Screening and Brief Alcohol Counseling of College Students and Persons Not in School

Associated with the top 3 causes of adolescent death (unintentional injuries, homicides, and suicides), underage drinking is annually responsible for 4000 to 5000 deaths and contributes to unprotected sex, social problems, and poor academic performance.¹ A substantial body of experimental research indicates screening and brief intervention for risky alcohol use conducted in adult primary care settings is effective in reducing alcohol misuse and related problems.² Evidence concerning effectiveness among young adults and adolescents is also accumulating.^3,4 Unfortunately, screening and brief alcohol counseling for adolescents and college-aged emerging adults is not routine.⁵

College students more often drink 5 or more drinks on an occasion and drive under the influence of alcohol more than same-age, noncollege peers.⁶ Important unanswered questions are whether college students are (1) more or less likely than same-age peers to be asked about their substance use, (2) given advice about related health risks, and (3) encouraged to reduce or stop substance use.

The NEXT Generation Health Study used a 3-stage stratified design to select a sample representative of 10th graders enrolled in public, private, and parochial high schools in the United States. Details of the sample and data collection are provided in Hingson et al.⁵ The survey was conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, whose institutional review board reviewed and approved the protocol. Parents and/or participants provided written consent. Of the national sample of 2519 10th graders (average age 16 years) surveyed in school in 2009,⁵ 2140 (84%) were resurveyed annually through 1 year past high school in 2012 and 2013. Respondents were asked if they had seen a physician in the past year and been asked and counseled about their drinking, smoking, and drug use.

As detailed in the Table, of respondents, 42% were enrolled in a 4-year college, 25% in community college, and 33% were not enrolled. Four-year and community college students were more likely than those not enrolled to have seen a physician. Of them, three-quarters in each group were asked about drinking, smoking, and drug use. Less than half of college students (fewer than same-age peers) were advised about health risks linked to substance use, and significantly fewer college students, less than one-third who frequently drank, used drugs, or smoked, were advised to reduce or stop. Fewer received advice about substance use than exercise, diet, and risky sexual behavior.

Most young adults saw a physician in the past year and the majority were asked about substance abuse. However, deplorably low proportions were advised about related health risks and encouraged to reduce or stop drinking, drug use, or smoking. The lack of routine screening combined with counseling to reduce or stop alcohol use among college students is worrisome in light of their higher rates of heavy episodic drinking and driving under the influence of alcohol.

Many barriers exist to screening and brief intervention for substance use among adolescents and young adults. It takes time to ask and to counsel patients about substance use, and some youth may fear confidentiality of their responses, particularly if their use prompts referral to treatment, for which their parents may ultimately pay. The lack of physician training and reimbursement for screening is an issue. The National Institute on Alcohol Abuse and Alcoholism has prepared and published guides on how to screen for alcohol misuse among adults and adolescents and some reliable screening tools like the CRAFFT assess both alcohol and drug use. Finally, while reimbursement issues could be addressed by the Affordable Care Act, this may vary according to how each state implements the act. Efforts are needed to remove these barriers to screening for all substances and particularly for alcohol misuse because it is the most widely used substance by youth and is the leading contributor to injuries, the leading cause of death in that age group.

Corresponding Author: Ralph Hingson, ScD, MPH, Division of Epidemiology and Prevention Research, National Institute on Alcohol Abuse and Alcoholism, 5635 Fishers Ln, Room 2074, Bethesda, MD 20892 (rhingson@mail.nih.gov).

Published Online: September 28, 2015. doi:10.1001/jamapediatrics.2015.2231.

Author Contributions: Drs Simons-Morton and Zha had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Hingson, Simons-Morton.

Acquisition, analysis, or interpretation of data: Hingson, Zha, White.

Drafting of the manuscript: Hingson.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hingson, Zha.

Obtained funding: Simons-Morton.

Administrative, technical, or material support: Hingson, White.

Study supervision: Hingson.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Heart, Lung, and Blood Institute, the National Institute on Alcohol Abuse and Alcoholism, and Maternal and Child Health Bureau of the Health Resources and Services Administration, with supplemental support from the National Institute on Drug Abuse (contract HHSN267200800009C).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.