Challenging Dogma - Spring 2011

Sunday, May 15, 2011

The Failure of School-Based Alcohol Education Programs to Bring About Long-Term Changes in Adolescent Drinking Habits – Ankura Singh

Binge drinking, defined as consumption of 5 or more alcoholic drinks within a couple of hours, is associated with an increased risk of injuries, academic problems and illegal behavior among youth (1). This type of excessive alcohol consumption early in life is also linked to several long-term adverse health effects, such as liver disease, cancer, and several psychiatric problems. According to the 2009 CDC national youth risk behavior survey, 41.8% of high school students reported drinking alcohol during the 30 days before the survey was taken, and 24.2% of the students reported binge drinking during this same period of time. The survey results show that current high school students are more likely to engage in binge drinking than smoking marijuana or cigarettes (1).

Many interactive and non-interactive school-based health education programs have not proven to have lasting effects of preventing and reducing alcohol use among adolescents (2). While non-interactive didactic programs have failed to achieve even short-term success, interventions with an interactive approach have shown some immediate positive changes in behavior. According to follow-up surveys taken when the study subjects were in 12th grade, however, interactive school programs such as the Michigan Model for Comprehensive School Health Education and the Preventative Health Education Program did not result in a significant difference in alcohol usage between the control and intervention groups in the long term (3). These types of interventions all managed to improve adolescent knowledge regarding the health risks related to substance abuse, but effective school programs cannot rely solely on increasing knowledge as a means to prevent binge drinking (4). School-based interventions have not seen enduring success in changing adolescent attitudes toward excessive alcohol consumption partly because of their tendency to focus on future problems and negative health consequences (2). Adolescents have high levels of optimistic bias and therefore may not be influenced by purely educational methods of changing behavior that reflect the Health Belief Model. Another reason why interventions based off of this model will have difficulty achieving the desired outcome of preventing teen alcohol abuse is that they operate with the underlying assumption that decisions related to drinking are the result of a rational thought process, even though adolescents are prone to irrational and/or spontaneous behavior (5). These types of interventions may also incite psychological reactance in their target group, since they are being carried out by authority figures who deliver a message that threatens the subjects’ freedom of choice (6). In order for a school-based program to have lasting consequences of curbing binge drinking among students, it should focus less on the severity of future alcohol-related problems and instead establish a social norm of avoiding excessive drinking, in addition to conveying messages in a manner that will minimize reactance.

School-based Interventions Fail to Consider Adolescents’ Optimistic Bias

Health education programs in middle schools have had less success in reducing alcohol consumption than cigarette smoking and drug use (7). The difficult in preventing alcohol use among adolescents stems from the fact that current societal norms promote excessive drinking while showing less tolerance toward use of cigarettes and illegal drugs (8). Both traditional and contemporary classroom-based alcohol prevention efforts have some basis in the Health Belief Model, an individual-level health behavior model that has been used to explain one’s reasons for adopting or rejecting a particular behavior. The model takes into account four constructs that are said to predict a person’s health-related actions: the perceived threat to his own well-being, the level of severity that he associates with a specific health problem, and his understanding of the benefits and costs of taking action to prevent this problem (9). Educational interventions are designed to increase students’ perceived severity of the negative effects of alcohol and persuade them that they are susceptible to these types of problems. Although contemporary alcohol education programs tend to use more interactive methods than simply relaying information, many of these interventions still employ the main ideas of the Health Belief Model when delivering relevant messages (3).

One of the major obstacles in applying this model to the issue of adolescent binge drinking is the high level of optimistic bias that is present in people within this age group. Optimistic bias, defined as the tendency of individuals to have unrealistic optimism about future life events, is especially likely to be present if people believe that they have some control over the outcome of the event in question (10). This type of bias can lead individuals to engage in detrimental behaviors such as unprotected sex and cigarette smoking even when they are aware of the associated health risks (11). Studies on this topic that involved college student participants have demonstrated that the inclination to believe one’s own chance of experiencing an undesirable event is lower than that of one’s peers is particularly strong among young people (11). One study examined levels of optimistic bias in college students who professed to be regular drinkers, and its results showed that the students underestimated the possibility of alcohol-related problems occurring in their future (11).

The high prevalence of optimistic bias that exists within the target group can explain why non-interactive school-based interventions based on the Health Belief Model have not been effective, and why similar interactive ones have not led to sustained changes in adolescent attitudes toward alcohol usage. If people do not believe themselves to be personally susceptible to a particular health problem, it is unlikely that they will take steps to avoid this problem (9). Since adolescents tend to have unrealistic optimism about the likelihood of negative events happening to them as a result of alcohol usage, they may believe that interventions that emphasize the severity of alcohol-related problems do not apply to them.

School-based Interventions do not Adequately Address Irrational Behavior

Since the Health Belief Model assumes that the intention to change or adopt a particular behavior will always result in action, given that the individual in question has enough self-efficacy, it does not account for spontaneous or irrational decision-making (9). Alcohol education programs in schools operate under the notion that given adequate information, high self-esteem and strong decision-making skills, adolescents will make a rational choice not to drink excessively (8). Since adolescence is a period of time during which individuals are prone to irrational or unplanned behavior (5), it is unlikely that their decision to drink or abstain from alcohol is the result of a rational thought process that involved weighing the costs and benefits of alcohol use. Although an alcohol prevention program may provide an adolescent with the information and skills required to engage in rational decision-making, these tools will not be sufficient to affect student drinking practices, which have been linked to external factors such as familial relationships and perceived alcohol use of peers (8). Even if an adolescent initially plans to refuse alcohol after being repeatedly exposed to an intervention at school, she might consent to drinking in a situation where heightened emotions are a factor.

When individuals are in a state in which emotions are intensified, they become prone to making irrational or spontaneous decisions that they would otherwise not support (12). Adolescents are unlikely to be in this emotional state while in a classroom setting, and therefore may not be able to accurately visualize a scenario in which they would feel pressured to drink alcohol. When faced with a situation outside of school that involves alcohol and socializing with peers, the behavior of an adolescent may be dictated by his emotions and he will be more likely to yield to temptation. Since the Health Belief Model states that “cues to action” are necessary for one to adopt a healthy behavior, it does not apply to behaviors that must be maintained by everyday choices, as it is improbable to assume that an individual will experience a trigger to action on a daily basis (9). Choosing to avoid binge drinking is not a one-time decision; as many adolescents are frequently pressured to consume alcohol by their peers, application of the Health Belief Model to this type of behavior is not appropriate.

Perceived Threats to Personal Freedom will induce Psychological Reactance

In addition to facing difficulties in altering adolescent attitudes and actions regarding excessive alcohol use, school-based interventions are likely to incite psychological reactance among members of their target group. Reactance theory, developed by Jack Brehm in 1966, predicts how a person will respond when her behavioral freedom has been limited or eliminated. When an individual perceives a threat to her freedom to choose from multiple behavior options, she enters a state of psychological reactance and will be motivated to take action to restore that freedom by pursuing the forbidden behavior (13). The likelihood of triggering reactance in an individual is related to the level of perceived threat. Studies have found that statements that sound coercive or use controlling language have a greater chance of causing reactance than similar messages that seem to have a low threat level; the use of low threat messages increased the study participant’s tendency to agree with the communicator (14, 15). College students who were exposed to high threat anti-drinking messages were more likely to consume alcohol than students who saw versions of the messages that used less threatening language (15).

Although campaigns that encourage adolescents to abstain from alcohol can employ less coercive messages, it will be difficult for prevention programs to completely avoid generating reactance within their target group. The mere fact that the legal drinking age is 21 elicits psychological reactance in teenagers, as they are explicitly prohibited from the freedom to choose this particular behavior. An increase in heavy alcohol consumption among underage college students was reported after the minimum drinking age was raised in 1987, and it coincided with a decrease in the percentage of college students that abstained from alcohol use (16). Interventions that do not portray underage alcohol use as a choice and instead emphasize the fact that it is illegal are likely to have the unintended effect of motivating adolescents to exert their freedom by carrying out the prohibited behavior.

Low levels of similarity between the communicator and receiver of a message has also been associated with reactance in the recipient (14). If members of the target audience of a message do not believe that they have much in common with the communicator, they are more likely to perceive that the message is being delivered by an authority figure and may act to restore the threatened freedom (15). This poses another problem for school-based interventions that use teachers and health workers to deliver anti-drinking messages, as both of these groups do not share many similarities with the students they are addressing.

Proposed Intervention: The Our Choice Program

In order for school-based alcohol prevention programs to avoid generating reactance and account for adolescent optimistic bias and spontaneous behavior, they must improve their strategies of delivering relevant messages and focus on the main concerns of their target population. Although the interactive classroom interventions involve activities that may prevent or reduce binge drinking in the immediate future, follow up studies show that the effects of these programs tend to decrease over time. The Our Choice program will be an alternative to current school-based interventions that takes components of the interactive approach, such as self-esteem building and development of refusal skills, and improves upon them by using messages that the students can relate to. Since this new intervention will aim to prevent students from beginning to abuse alcohol, it should be implemented mainly in middle schools, for high-risk health behaviors are often initiated during early adolescence (17).

One of the main features of the Our Choice program will be the participation of high school volunteers who are willing to serve as mentors for the target group. Since small-scale interactive interventions have been more effective than those that attempt to address a large number of students all at once (3), each mentor will be assigned to a small group of students and they will be required to engage their group members in a variety of activities outside of the classroom. The existence of positive relationships with one’s peers and participation in peer programs are both associated with reduced alcohol consumption among teenagers (4). The nature of peer group activities will partly depend on the interests of group members, but they can range from games and exercise to creating and presenting skits to other groups that are taking part in the program.

In addition to increasing the students’ self-esteem and levels of interaction with their peers, this intervention will employ the basic ideas behind Social Cognitive Theory and Social Network Theory to create a social environment in which more students will choose not to drink. Social Cognitive Theory states that an individual’s cognition, environmental influences, and level of self-efficacy are all factors in determining whether or not he will adopt a particular behavior. According to Albert Bandura, who developed the theory by expanding upon the constructs of Social Learning Theory, social norms will influence an individual’s perception of the outcome related to a behavior; if the action in question falls in line with these norms, a positive social outcome will be expected (18). Adolescents tend to overestimate the percentage of their peers that are using alcohol, and so a perceived norm of excessive drinking is established (19). The proposed intervention will utilize the concept of modeling outlined in this theory to adopt a social norm of abstaining from alcohol use. Bandura stated that people learn behaviors by observing social models; in the Our Choice program, the non-drinking behavior modeled by the high school mentors will be reenacted by members of their assigned peer group. Since Social Network Theory asserts that health behaviors are spread among contacts within a social network (20), this intervention will build new connections between students and make use of the networks that are already present within the school to spread the behavior exhibited by the peer group leaders. It may be beneficial for the program to especially target those students who have central positions within the social network and therefore many connections, such as members of sports teams.

Addressing Optimistic Bias

In order to take into consideration the unrealistic optimism about future events that is especially prevalent among young people, the Our Choice program will refrain from placing too much of an emphasis on detailing the most severe consequences of alcohol use, such as accidents while driving under the influence and long-term adverse health effects. Although these alcohol-related problems will be discussed, they will not be employed as scare tactics to increase students’ perceived susceptibility and severity. As studies have demonstrated that young people are particularly optimistic about their low chances of ever experiencing problems this severe (11), the program will instead focus on how binge drinking can have a negative impact on the daily lives of adolescents.

Since individuals are less likely to have unrealistic optimism about negative events that they have personally experienced (10), communicators will emphasize how alcohol consumption can adversely affect outcomes that are relevant to middle school students, such as athletic ability, grades, physical appearance and popularity. The older teens that are to assume mentorship roles in their respective peer groups will also serve to project a positive image of non-drinkers who have managed to achieve the desired outcomes. Interventions that linked abstaining from excessive drinking with these types of outcomes reported a significant reduction in the alcohol usage of the adolescent populations that they were targeting (21). Focusing on life events that students do not perceive themselves to be in complete control of will also help reduce optimistic bias, as studies have demonstrated that an individual’s unrealistic optimism is strongly correlated to their perceived level of control (10). Although optimistic bias will continue to be an obstacle to preventing the development of high-risk drinking habits during adolescence, the proposed alternatives to traditional scare tactics will associate alcohol use with outcomes that young people are concerned about.

Accounting for Irrational Behavior

Since adolescents will be required to choose whether or not to drink alcohol several times throughout their teenage years, it is probable that at least some of these decisions will not be the result of a rational thought process. Programs that simply educate students about the dangers of alcohol and teach them refusal skills will not prevent against alcohol use in situations where emotions are highly involved in decision-making. As the Our Choice program seeks to establish a social norm of refusing alcohol within school populations, it should succeed in reducing the number of instances when students feel pressured by their peers to engage in heavy drinking. These scenarios are likely to arise while the students are high school, however, and so the intervention must account for the possibility of irrational actions by having mentors develop techniques to aid students in avoiding tempting situations. Staying clear of circumstances that incite temptation can better guarantee abstinence from risky behavior than planning to refuse to do the behavior when these situations arise. When individuals are in their normal, rational state, they greatly underestimate their ability to behave rationally when in a state in which emotions are heightened (12). To protect subjects of the intervention from falling into this pattern and eventually making an irrational decision regarding alcohol use, mentors must reenact group situations where teens would feel pressured to drink and develop their skills to resist pursuing this behavior when among their peers.

Avoid Generating Psychological Reactance

Increasing the legal drinking age to 21 years has had the unintended consequence of producing psychological reactance in adolescents, provoking them to adopt high-risk drinking habits in order to maintain their behavioral freedom (16). A major goal of the Our Choice program will be to communicate to adolescents that this particular behavior is a personal choice that many of their peers decide not to pursue. Messages will emphasize that teens are free to choose whether or not to drink, so that students will understand that most of their peers decide on their own to refrain from excessive drinking rather than being ordered to do so. This idea of having the freedom to choose between behaviors is summed up in the program title; rather than using a threatening message such as “Don’t Drink”, it is called “Our Choice” to represent the fact that the majority of adolescents have chosen not to be regular drinkers (1).

The concept of freedom of choice must be reinforced by both educators and high school mentors, who must avoid using controlling language when communicating with the students and try not to highlight the fact that underage drinking is an illegal activity. Since anti-drinking messages will primarily be delivered by other adolescents who are similar to the middle school students, they are not likely to be viewed as threatening and will encourage compliance among the target population. High similarity between the recipient and communicator of a message is associated with an increase in the recipient’s positive feelings and likelihood of agreement (14). By matching mentors to specific groups of students based on gender, hobbies and interests, this program will ensure that reactance is not brought about by the individuals’ perception that they are being told not to pursue a behavior by a person who has little in common with them.


The Our Choice program has been designed with the intention of addressing some of the main flaws that exist in current classroom-based alcohol prevention efforts. Excessive drinking continues to be a problem among youth in the United States, and school-based interventions must compete with external influences from peers, family members and societal norms in their attempts to dissuade adolescents from using alcohol. The fact that many of these programs have been unsuccessful in changing adolescent drinking habits and attitudes toward alcohol indicates that the strategies they employ fail to account for several of the factors that determine adolescent behavior. The proposed intervention will take steps to ensure that its messages and methods of delivery do not invoke psychological reactance in its adolescent audience. It addresses the problem of optimistic bias by focusing on outcomes that are pertinent to adolescent daily life rather than long-term or severe problems, and will establish and propagate an anti-drinking social norm within a school’s population. By taking into consideration the issues of unrealistic optimism, irrational behavior and reactance in adolescents, this intervention improves upon the interactive programs that are currently used and will prove to have lasting success in changing alcohol consumption behaviors among adolescents.


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