Elsevier

Clinical Psychology Review

Volume 33, Issue 8, December 2013, Pages 1025-1040
Clinical Psychology Review

Use of alcohol protective behavioral strategies among college students: A critical review

https://doi.org/10.1016/j.cpr.2013.08.006Get rights and content

Highlights

  • Reviews studies on protective behavioral strategies (PBS) among college students

  • Measurement of alcohol PBS is inconsistent across studies.

  • Alcohol PBS is consistently negatively correlated with alcohol-related problems.

  • It is less clear what the antecedents to PBS are and moderators of its effects.

  • Gaps in the literature are identified to provide suggestions for future research.

Abstract

Protective behavioral strategies (PBS) are specific behaviors one can utilize to minimize the harmful consequences of alcohol consumption. Recently, there has been an increasing amount of interest in use of PBS among college students, especially as an intervention target. The purpose of the present comprehensive review of the PBS literature was to examine the measurement of PBS and summarize the quantitative relationships between PBS use and other variables. The review found inconsistency across studies in terms of how the use of PBS is operationalized and found only two PBS measures with good psychometric properties that have been replicated. Although several antecedents to PBS use were identified, most were only examined in single studies. Moderators of the predictive effects of PBS use on outcomes have similarly suffered from lack of replication in the literature. Of all 62 published reports reviewed, 80% reported only cross-sectional data, which is unfortunate given that PBS use may change over time and in different contexts. In addition, only two attempted to minimize potential recall biases associated with retrospective assessment of PBS use, and only two used an approach that allowed the examination of both within-subject and between-subject effects. In terms of the gaps in the literature, there is a dearth of longitudinal studies of PBS use, especially intensive longitudinal studies, which are integral to identifying more specifically how, when, and for whom use of PBS can be protective.

Introduction

Among college students, alcohol use contributes to a wide range of negative consequences ranging in severity from social/interpersonal problems to injury and death (Hingson, Zha, & Weitzman, 2009). Behavioral strategies that can be used to minimize the harm associated with alcohol use have received an increasing amount of attention in the past few decades. Although the measurement of these strategies initially emerged based on self-control theory and self-help manuals (Merbaum and Rosenbaum, 1980, Miller and Muñoz, 1982, Vogler and Bartz, 1982; Werch, 1986), the emergence and acceptance of the harm reduction approach to treatment of alcohol misuse (Dimeff, Baer, Kivlahan, & Marlatt, 1999; Marlatt & Witkiewitz, 2002, 2010) has led to increased interest in these behavioral strategies. As PBS use has been shown to mediate intervention effects (Barnett et al., 2007, Larimer et al., 2007, Murphy et al., 2012), increasing the use of these behavioral strategies among college students seems to be a progressively more common intervention target. Given this trend, it is important to conduct a comprehensive review of the literature to determine gaps in our knowledge regarding the use of these strategies.

Section snippets

Protective behavioral strategies

Broadly defined, protective behavioral strategies (PBS) are behaviors that reduce the negative consequences experienced from drinking (Martens, Pederson, LaBrie, Ferrier, & Cimini, 2007). They have also been referred to as behavioral self-control strategies (Werch and Gorman, 1986, Werch and Gorman, 1988), drinking control strategies (Sugarman & Carey, 2007) and alcohol reduction strategies (Bonar et al., 2011). Although there is significant variability in how PBS are operationalized, most PBS

Purpose of the present review

Overall, there is strong support for the fact that multiple types of self-reported PBS use are negatively correlated with self-reported alcohol use/problems. The present review addresses two important issues that are essential to moving research on PBS forward. First, the present review examines the measurement of PBS to resolve inconsistencies regarding the operational definition of PBS, develop a more precise definition of PBS, and compare different measures of PBS use in terms of their

Identification of studies

In the present review, multiple databases (APA PsycNet, Web of Science, and Google Scholar) were used to conduct online searches for relevant published studies using terms known to the author to describe PBS (‘protective behavior strategies’ OR ‘protective behavioral strategies’ OR ‘drinking control strategies’, AND ‘alcohol OR drinking’). Then, additional studies were found from searching the reference lists for relevant studies. Finally, a search through all studies that cite any of the

Measurement of PBS

PBS were defined previously as behaviors that reduce the negative consequences experienced from drinking. The problem with this conceptual definition is that PBS are defined entirely by an outcome that they are presumed to effect. In this sense, the definition is tautological. If a particular protective behavioral strategy is found to be unrelated to negative consequences from drinking, is it still a protective behavioral strategy? The trouble in providing a more precise definition is that the

Summarizing the nomological network

Summaries of the PBS-related findings of the 62 studies included in the present review are included in Appendix A. It is important to note that PBS use was not a primary focus of all of these studies, so these summaries are not aimed to summarize the most important or significant findings from each study; rather, an attempt was made to describe the most unique, significant findings regarding the relationship between PBS use and other variables.

Although the relationship between PBS use and

Gender

Of all variables examined as a predictor of PBS use, the most evidence exists for the effect of gender. Specifically, women have been found to use more PBS when examined as a single factor (Benton et al., 2006, Benton et al., 2008, Benton et al., 2004, Borden et al., 2011, D'Lima et al., 2012, Ehret et al., 2013, Frank et al., 2012, Palmer et al., 2010b;), multiple factors (Nguyen et al., 2011) including all PSQ subscales (DeMartini et al., 2013), all PBSS subscales (LaBrie et al., 2011, Lewis

Moderators of the relationships between PBS use and alcohol-related outcomes

In addition to identifying antecedents to PBS use, it is important to identify factors that may moderate the relationship between PBS use and alcohol-related outcomes. Moderation analyses, which are essentially tests of interactions, can provide a better understanding of the boundary conditions associated with an effect. In other words, these interaction tests can suggest when and for whom the use of PBS is strongly related (or unrelated) to alcohol-related outcomes.

Randomized controlled trials

Not only are PBS proposed to be a proximal antecedent to alcohol-related outcomes, they are presumed to be a mechanism of change in alcohol use (Kazdin, 2007), thus it should mediate intervention effects that are expected to manipulate PBS use. Currently, at least three RCTs with college students have been shown to have significant effects on alcohol-related outcomes that were significantly mediated by PBS use. Larimer et al. (2007) found that the effect of a mailed personalized feedback

Identifying gaps in knowledge

In the review of the different PBS measures and a brief, yet broad, review of antecedents, moderators, and consequences of PBS use, many of the important gaps in the literature have already been identified. Additional knowledge gaps are considered here. Despite the benefits of finding converging effects using alternative operationalizations of a construct, inconsistency in the assessment of PBS has limited the degree to which PBS research has moved forward in a cumulative fashion. Although

Conclusion

In the present review, the literature on PBS use in the college student population was summarized. The review of various PBS measures demonstrates that the vast majority of studies have operationally defined PBS to include behaviors that are used immediately prior to, during, and/or after drinking that reduce alcohol use, intoxication, and/or alcohol-related harm. Although some studies have also included alcohol avoidance strategies (i.e., avoiding alcohol use altogether), this author

Acknowledgments

No official funding was provided to conduct the present review; however, Dr. Pearson is supported by a National Institute on Alcohol Abuse and Alcoholism (NIAAA) training grant T32-AA018108.

I would like to thank the attendants of the Spring 2013 Addictions Seminar at the University of New Mexico, Mandy Owens, Kylee Hagler, Samara Rice, Megan Kirouac, Benjamin Kite, Gabrielle D'Lima, and especially Katie Witkiewitz for their helpful comments on previous drafts of this manuscript. This research

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