There have been substantial increases in alcohol use, heavy episodic drinking (≥ 4/5 drinks on one occasion for females/males, respectively), alcohol use disorders (AUD), and alcohol-related deaths in the United States over the past decade, particularly among vulnerable subpopulations, including individuals with minoritized racial/ethnic identities as well as individuals with lower educational attainment and family income (Grant et al., 2017; White et al., 2020). Emerging adults (EAs; ages 18–29) have higher levels of recent heavy-episodic drinking (35.6%) and AUD (26.7%) than other age groups (Grant et al., 2017). This is not surprising because EAs display a neuro-developmentally mediated tendency towards elevated reward-seeking, impulsivity, and negative affect (Casey & Jones, 2010; Kenney et al., 2015). Patterns of frequent heavy episodic drinking often lead to significant acute and chronic health and social consequences that can disrupt critical developmental tasks including educational attainment and career advancement and can result in elevated alcohol use across the lifespan (Lee et al., 2018; Tapper & Parikh, 2018). Results from the 2023 Monitoring the Future study suggest that an increasing number of Americans display persistent risky drinking throughout their 30s and 40s (Patrick et al., 2022), which highlights the importance of disseminating targeted alcohol harm prevention interventions to emerging adults who engage in risky drinking.
Approximately 18.3 million EAs (59% of EAs) in the United States are not current college students (McFarland et al., 2019) and only 41% of EAs will ultimately earn a 4-year college degree. The college environment is protective against many alcohol-related consequences (e.g., driving while intoxicated, arrests; Quinn & Fromme, 2011), and non-student EAs typically work and live in less enriched and more stressful psychosocial environments than college students. Moreover, failure to earn a 4-year college degree reduces lifetime job stability, status, and salary, which in turn limits the availability of alternative reinforcers and may reduce constraints against drinking throughout adulthood (Acuff et al., 2019; U.S.Bureau of Labor Statistics, 2021). An analysis of data from the National Survey on Drug Use and Health indicated that non-student EAs report slightly higher levels of heavy episodic drinking than same-age EAs who are college students (40% vs. 37%; Hingson et al., 2017). Other epidemiological data suggest that, relative to college graduates, adults without a college degree consume more drinks per occasion and have elevated lifetime risk for AUD/SUD (Rosoff et al., 2021).
College student EAs have shown recent population-level reductions in drinking, which may be due in part to steadily increasing university-based prevention efforts over the past two decades, including brief alcohol interventions (BAIs; Larimer et al., 2022; Tanner-Smith et al., 2022). BAIs are delivered using a motivational interviewing style (MI; Miller & Rollnick, 2013) and typically include peer-referenced normative comparisons, personalized feedback on drinking patterns and associated risks, and harm reduction strategies. BAIs have led to significant reductions in drinking across numerous clinical trials with college students and are a Tier 1 prevention approach for college student drinking, resulting in wide dissemination in university settings (Larimer et al., 2022). The efficacy of these prevention efforts is encouraging (Mun et al., 2022), but the disproportionate focus on 4-year college students may inadvertently exacerbate existing health and economic disparities between them and individuals without bachelor’s degrees (Case & Deaton, 2017; James & Jordan, 2018). Thus, it is critically important to provide BAIs for non-student EAs.
To date, most of the BAI trials with non-student EAs have been conducted in medical or employment settings. Reviews of BAIs in EA drinkers suggest that these interventions are more efficacious than no treatment or minimal treatment control conditions (Mun et al., 2022; Tanner-Smith et al., 2022) and a meta-analysis of BAIs for non-student EAs found that studies implementing counselor-administered MI had statistically significant, though small, effects on alcohol use (d = .20 [.04, .36]) relative to active controls (Davis et al., 2017). Although these are important settings, many EAs do not present in these settings for treatment. Thus, in order to increase generalizability and potential for widespread dissemination across other settings, there is a need to evaluate the efficacy of BAIs among diverse samples of EAs recruited from the community. Moreover, it is essential to evaluate interventions that address the unique risk factors experienced by EAs, including increased negative affect and limited access to substance-free activities (Davis et al., 2017; Murphy et al., 2022).
Two recent trials have examined BAIs that were adapted for non-student EAs recruited from communities in the USA. One study evaluated a single-session BAI that included personalized drinking feedback along with strategies for coping with stress and a discussion about participants’ vocational and educational aspirations (N = 164, ages 18–25; Lau-Barraco et al., 2018). There were significant treatment effects on drinking but not alcohol problems at a 3-month follow-up and no drinking reductions at the 6- or 9-month follow-ups. Another study examined the short-term effects of a BAI for non-student EAs recruited from the community who did not plan to attend college (N = 167, ages 17–20; Colby et al., 2018). The single-session intervention included standard BAI content (personalized alcohol feedback delivered in a MI style) enhanced with a discussion of vocational and personal goals along with personalized feedback on time allocation to alcohol vs. other activity categories (cf. Murphy et al., 2019). One- and three-month follow-up assessments revealed significant reductions in alcohol use and problems relative to a relaxation training control session. Treatment effects were partially mediated by increases in seeking alternatives to drinking (Magill et al., 2017).
Despite the promise of single session BAIs, effect sizes are generally small and there is a need to enhance these interventions with novel content to increase their efficacy with higher-risk EAs (DeMartini et al., 2015; Murphy et al., 2022). The modest overall response may be due in part to the limited focus of BAIs, which generally target motivation to reduce drinking without addressing reasons for drinking (e.g., boredom, stress, lack of goals or future orientation) or providing alternative means of experiencing reward or reducing negative affect. Indeed, predictors of poor response to BAI include low levels of substance-free reinforcement, poor self-regulation/impulsivity, low future time orientation, and anxiety or depressive symptoms (Carey et al., 2007; Murphy et al., 2005, 2012, 2019; Soltis et al., 2018).
Furthermore, help-seeking for alcohol-related interventions in EAs is low. One study found that only 23% of EAs were interested in responsible alcohol use, whereas > 45% expressed interest in programs focused on improving mood and planning for the future (careers, money, health, life balance; Cadigan et al., 2019). Thus, programs that address alcohol use indirectly in the context of an overall focus on wellness and enhancing mood and goal setting might have greater appeal and potential for dissemination than traditional brief alcohol interventions (Ash et al., 2020; Murphy et al., 2022).
A recent daily diary study with non-student EA drinkers indicated that engagement in alternative enjoyable activities was the most frequently endorsed strategy to avoid drinking (Lau-Barraco & Linden-Carmichael, 2019). The Substance-Free Activity Session (SFAS) was developed to supplement alcohol-focused BAIs and uses MI, personalized normative feedback, goal setting, and an episodic future thinking exercise to target the behavioral economic mechanisms of substance-free reinforcement and delayed reward discounting (Acuff et al., 2023). The SFAS encourages EAs to identify and discuss the long-term benefits associated with their life goals and to consider how their current patterns of time allocation and drinking (which are aggregated as personalized feedback) might impact those valued goals (Murphy et al., 2019) (Gex et al., 2023; Meshesha et al., 2020).
The two-session BAI + SFAS approach has demonstrated efficacy for reducing both alcohol use/problems and depressive symptoms in two randomized controlled trials with college EAs and may be a more promising approach than single-session BAIs for higher-risk non-student EAs. Our first trial (Murphy et al., 2012) found that a two-session (BAI + SFAS) intervention resulted in larger reductions in heavy drinking and alcohol problems than a two-session (BAI + RT) at 6-month follow-up in a sample of 82 college students who reported recent heavy drinking.
A subsequent two-site randomized controlled clinical trial compared BAI + SFAS and BAI + RT to an assessment control condition (Murphy et al., 2019). The combination of a BAI plus either the SFAS or RT was associated with significant reductions in alcohol use and problems across the 16-month follow-up compared with assessment only. Increases in proportional reinforcement from substance-free activities and protective behavioral strategies mediated treatment effects. Both active treatments were also associated with more global benefits, including significant increases in self-regulation and reductions in depression and anxiety (Murphy et al., 2019). There were no overall group differences between BAI + SFAS and BAI + RT, although a secondary analysis indicated an advantage for BAI + SFAS for participants with low levels of environmental reward at baseline (Murphy et al., 2021). Thus, the primary results provide support for both SFAS and RT as potentially efficacious supplements to BAI that may contribute to both drinking reductions and increased overall wellness.
The Present Study
The primary goal of the proposed study is to establish the efficacy of the BAI + SFAS and BAI + RT approaches, relative to an education only control condition, among high-risk community-dwelling EAs. The primary hypothesis is that at 1, 3, 6, and 12-month follow-ups both BAI + SFAS and RT + SFAS participants will report significantly greater reductions in alcohol use and alcohol problems relative to education control participants, with no differences in outcomes between the two active treatment conditions. A secondary hypothesis is that the predicted advantage for BAI + SFAS and RT + SFAS, relative to education control, will be mediated by changes in alcohol reinforcing efficacy, negative affective symptoms, and proportionate substance-related reinforcement. An additional secondary hypothesis is that the BAI + SFAS and the RT + SFAS conditions will be associated with greater reductions in alcohol demand, proportionate substance-related reinforcement, drug use, and negative affect than the control condition, with no differences in outcomes between the two active treatments.