Alcohol 44% of females drank over the recommend

Alcohol use is very common, in 2016 29 million people in Great Britain over the age of 16 drank alcohol and on their heaviest day of drinking, 7.8 million people ‘binged’ (Office of National Statistics, 2016).  Alcohol is popular with all age ranges, and although young people (aged 16-24 years old) are the least likely to drink than any other age group, on their heaviest drinking day, consumption tends to be higher than other ages (Office of National Statistics, 2016).  This is reflected in the increase in ‘binge drinking’, especially common in University students.

One unit of is 8g or 10ml of pure alcohol and binge drinking can be defined as drinking more than 6 units of alcohol in a single session (“Binge drinking- Live Well- NHS Choices”, 2017).  Research from an East Midlands University recorded that 30% of males and 44% of females drank over the recommend daily limit of 5-6 units and 3-4 units respectively (Penny and Armstrong-Hallam, 2010), and that 1/5 binge drink weekly (defined as more than 6 units on one occasion).  Furthermore, their scores on the Alcohol Use Disorders Identification Test (AUDIT) showed that 51.9% of students drank at levels that are considered ‘hazardous’.  This is concerning as binge drinking carries significant risk of adverse consequences such as poor academic performance, aggression, sexually transmitted diseases, unplanned pregnancy, accidents and injury (Gill, 2002; Windle, 2003; Gmel, Rehm & Kuntsche, 2003).  Furthermore, the cost of these consequences was estimated to cost £4.86 billion per year for the UK government in 2014 (James & Francesconi, 2015).  For these reasons, it is necessary to not only look at the pattern and prevalence of alcohol use, but also to understand the factors that predict this drinking behaviour in order to try and prevent problematic drinking from occurring.

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Alcohol expectancies are cognitive representations of the learned connections between the positive and negative effects resulting from the consumption of alcohol which in turn affects the decision to drink (Goldman, Brown & Christiansen, 1987).  Expectancies may or may not be motivating, one individuals may choose to drink to ‘let loose’ based on the expectation that alcohol leads to disinhibition, yet another individual may choose to avoid alcohol for the same expectation.  Whereas, motives suggest that individuals engage in drinking specifically for the purpose of obtaining a desired outcome (Cox & Klinger, 1988).  Simply, motives refer to “I drink to achieve” and expectancies refer to “I drink to expect” (Kuntsche, Wiers, Janssen & Gmel, 2010).  This review will be focusing on the role of drinking motives as it has been shown that they fully mediate the relationship between alcohol expectancies and alcohol consumption, whereas alcohol expectancies only partially mediate the relationship between motives and consumption (Kuntsche et al., 2010) suggesting motives are the stronger predictor. 

Emotion regulation is the monitoring and evaluating of emotional reactions, via intrinsic and extrinsic processes, to accomplish one’s goals (Thompson, 1994).  It involves the study of how individuals influence the emotions they feel, when they feel them and how they both experience and then expresses them (Gross, 1998).  Research has shown that college students who employ maladaptive regulation strategies are subsequently drink alcohol to escape from increased levels of emotional dysregulation (Gottfredson & Hussong, 2013).

The aim of this review is to investigate if there is a relationship between drinking motives and emotional dysregulation and the alcohol consumed by university students.  It will also look at alcohol related problems resulting from harmful alcohol use such as blackouts and alcohol-related injuries as identified in the AUDIT (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001).

Drinking Motives

Cox and Klinger (1988) believed the common pathway to alcohol consumption is motivational.  They proposed drinking motives can be characterized by two underlying dimensions; valence (positive or negative) and source (internal or external).  Thus, individuals drink to attain a positive outcome from drinking or to avoid a negative outcome of not drinking.  Moreover, drinking may be in order to gain internal rewards such as regulations one’s emotional state, or to gain external rewards such as social approval. 

Crossing over these two dimensions results in four classes of motives which Cooper (1994) labelled as enhancement (positive, internal), social (positive, external), coping (negative, internal) and conformity (negative, external), leading to Cooper’s Four-Factor Model. This Four- Factor Model has been shown to be most appropriate when investigating college drinking (MacLean & Lecci, 2000) compared to the previously suggested Two-Factor Model (Farber, Khavari & Douglass, 1980), which only included coping and social reasons and the Three-Factor Model (Cooper, Russel, Skinner, & Windle, 1992), which added the enhancement motive.

Positive Reinforcement Motives

            Social and enhancement motives are both positive reinforcement motives, they involve increasing the desired outcome, meaning individuals may drink to obtain positive social rewards or drink to enhance positive mood (Cooper, 1994).  It has been shown that university students endorse enhancement and social motives most strongly (Kuntsche, Stewart, Cooper, 2008). 

            Social. Cooper (1994) found a positive association between social motives and the quantity and frequency of consumption, but consumption still remained at a moderate level and social motives were not directly associated with problem drinking.  Moreover, Karwacki and Bradley (1996) found that students who drank for social reasons are less likely to drink excessively than coping or enhancement reasons.  This could be due to external motives being associated with social environments which have less inimical effects than drinking in solitary environments.

 However, recent research has found a lack of consensus with these ideas.  White, Anderson, Ray and Mun (2016) found that social motives strongly relate to extreme binge drinking, which they defined as drinking double the amount classified as binge drinking.  The longitudinal study found that at a 6-month follow up, students who had become extreme drinkers showed increases in social motives compared to those who remained non-extreme.  Furthermore, the more social motive items reported, the more at risk of problematic drinking the individual was (Van Damme et al., 2013) and were also predictive of alcohol consequences (LaBrie, Hummer, & Pedersen, 2007).  Therefore, social motives should not be underestimated in their relationship with excessive binge drinking and related consequences, especially as social influence factors were shown to have both direct and indirect associations (through social motives) with alcohol use and problems, suggesting college drinking is strongly influenced by social environment (Read, Wood, Kahler, Maddock & Palfai, 2003).

            Enhancement. There is positive relationship between drinking to get ‘high’ and being at risk of problematic drinking (Van Damme et al., 2013).  This can be seen as enhancement motives are positively associated with heavy drinking (Cooper, 1994) and light/moderate drinkers scored significantly lower on drinking to enhance pleasant emotions than heavy drinkers (> seven drinks; Carey, 1993).  Similarly, to social motives, extreme drinkers were more likely to endorse enhancement motives and increases in enhancement motives were associated with becoming an extreme drinker at the 6-month follow up (White et al., 2016).  Kuntsche and Cooper (2010) also found that enhancement motives predicted weekend drinking above usual consumption levels and individuals who drank for mainly enhancement consumed, on average, six drinks more than those who drank for coping, social or conformity motives.  This study highlighted a drinking culture of young people that involves binge drinking on the weekend to seek fun and excitement which appears to be very similar to the drinking cultures found at universities (Penny and Armstrong-Hallam, 2010).

Negative Reinforcement Motives

            Coping and conformity motives are both negative reinforcement motives, they involve reliving undesired outcomes, meaning individuals drink to reduce negative affect or to avoid social rejection (Cooper, 1994).  Coping and conformity are the lowest endorsed motives of university students (Kuntsche et al., 2008) however, Carey and Correia (1997) found that negative reason for drinking were much stronger predictors of both heavy drinking and alcohol-related problems.

Coping.  It has been shown that drinking to reduce negative affect predicted drinking problems via consumption (Cooper, 1994).  Students who drink to cope have higher odds of drinking alcohol more than weekly, binge drinking more than once a month and have higher a risk of problematic drinking (Van Damme et al., 2013).  Furthermore, extreme drinkers expressed higher coping motives than non-extreme drinkers and a cessation of extreme drinking behaviour over the 6-month follow up period was related to reductions in coping motives (White et al., 2016).  This extreme drinking behaviour was also found by Goldstein and Flett (2009), coping motivated drinkers reported more binge drinking episodes than that of social or conformity.  These findings are consistent with literature that suggests internally motived affect-related drinking tends to lead to riskier drinking behaviours such as excessive consumption and greater consequences (Rutledge & Sher, 2001).  This pattern of heavy drinking relating to coping motives may be explained by the outcomes desired by affect related drinking, that is individuals who drink to ‘forget worries’ or ‘to reduce anxiety’ may feel higher doses are necessary to achieve an appropriate affective change, which is less relevant to externally motivated drinkers who drink for social or conformity reasons. 

Grant, Stewart, O’Connor, Blackwell, & Conrod (2007) suggested a Five- Factor Model may be more appropriate, splitting coping into two separate factors; coping-anxiety and coping-depression.  This model provided a superior fit to the data compared to Cooper’s (1994) Four-Factor Model which only has one generic coping factor.  Coping- depression were predicted of above typical quantities of drinks consumed, whereas this was not found for coping- anxiety motives.  Moreover, coping- anxiety was found to be directly related to alcohol-related problems which is inconsistent with Cooper’s (1994), however coping-depression was found to be indirectly associated with drinking problems via the higher level of consumption, which is consistent with Cooper’s (1994) findings.  This highlights the importance of separating the coping motive as both coping for anxiety and depression lead to different patterns of alcohol consumption and problems.

Conformity. Unlike Carey and Correia’s (1997) suggestion, drinking to avoid social rejection is the only motive negatively associated with frequency, quantity of usual consumption and heavy drinking (Cooper, 1994).  This could be due to non-internal motives being related to lower alcohol us as individuals are less likely to drink in solitary unlike those who endorse coping motives (Goldstein & Flett, 2009; Cooper, 1994).  Furthermore, conformity was the only motive that was unrelated to extreme drinking in White et al.’s (2016) longitudinal study, which is supported by the finding of a negative relationship between problematic drinking and drinking to ‘fit in’ (Van Damme et al., 2013).  The consensus of literature reviewed is that conformity motives are typically unrelated to both college alcohol use and problems (Merrill & Read, 2010; Karwacki & Bradley, 1996).  However, drinking to ‘fit in’ is positively associated with alcohol use at parties where the pressure to conform is most salient and despite a pattern of infrequent and light drinking, Cooper (1994) found that conformity motives directly predicted drinking problems, suggesting an increased risk relative to those who endorse social or enhancement motives.

Developmental Trajectories of Drinking Motives

Student drinking behaviour shows a normative shift that is quite remarkable, heavy/excessive alcohol consumption and associated problems peak during university years, where there is an abundance of opportunities and expectations to drink, and then subside as students move into adulthood roles (Schulenberg & Maggs, 2002).  Drinking motives also follow a developmental trajectory of endorsement and their related pattern of alcohol use.  Anderson, Briggs and White’s (2013) longitudinal analysis demonstrates the importance of alcohol motives during adolescence.  They found that baseline drinking (aged 15) account for 75% of the final effect on alcohol consumption when participants were evaluated from 21 to 35 years old, whereas when aged 25 only 6% of drinking was predicted by baseline drinking.  This suggests that motives of alcohol use have the largest impact on consumption across adolescence and young adulthood but are less influential as drinking behaviour stabilise in adulthood. 

            Kuntsche and Müller’s (2011) findings suggest that most adolescents (aged between 10 and 13 years old) initiated drinking for social motives (to have fun a parties) or enhancement motives (find out about the effect of alcohol).  The indication of social motives for first time drinking motives is consistent with previous research that the positive social consequences that are expected from alcohol consumption also predicted drinking initiation in other adolescent samples (Gunn and Smith, 2010).  Interestingly only some aspects of enhancement and social motives related to risky drinking behaviours such as drunkenness and drink more than 5 drinks, for example having fun at parties (social) and personal excitement (enhancement), whereas drinking to toast and curiosity of effects showed no relation.

This result is partially supported by Webb, Getz, Baer, & McKelvey (1999) findings that 6th graders began to distinguish coping and social motives as separate (conformity and enhancement motives were not included in the study).  Both these motives were related to 6th graders intentions of drinking in junior high school, but social was more strongly related than coping.  However, they found these motives were correlated and two items conceptualised as relating to social motives also loaded onto the coping factor.  These reflected social situations that could arouse anxiety suggesting pre-adolescents could view alcohol as a way of managing the negative affect that arises from these stressful situations.  Furthermore, social motives may be most strongly endorsed for the initiation of alcohol consumption as alcohol may only be available to adolescences exclusively in social situations such as parties.  However, the same pattern was not found by Webb et al. (1999) for 5th graders, results showed that 5th graders did not perceive social and coping motives as separate as they remained highly intercorrelated.  This highlights a potentially critical period from the ages of 10-13 where motives for drinking alcohol begin to develop and separate into distinct motives.

Although, social reasons are the most indicated for first time drinking (Kuntsche and Müller, 2011), a cross-sectional analysis showed that alcohol misuse was also predicted by social motives during later adolescence (16 to 22 years old; Bradizza, Reifman, & Barnes, 1999).  This follows the developmental trajectory suggested by Schulenberg and Magg’s (2002), that heavy drinking is more normative among university aged students and the proportion who are misusing alcohol to meet social needs increases.

The results from Kuntsche and Müller’s (2011) study highlighted coping motives were the least indicated for initiation of drinking, this is contradictory of Webb et al.’s (1999) results, however the overlapping of social and coping motives in the study could be the reason for this result as previous research supports coping being the least frequently indicated (Cooper, 1994).  Coping was found to related more strongly to consuming five or more drinks than to the feeling of drunkenness, endorsing coping motives towards alcohol at such young ages is likely to relate to the individuals having experienced traumatic life events or being predisposed to heavy drinking through personality (Sartor, Lynskey, Heath, Jacob, & True, 2007).  Similarly, Bradizza et al.’s (1999) findings showed that alcohol misuse was significantly predicted by coping motives in younger adolescents.  This is due to heavy drinking being less normative of 15 to 19 year olds so individuals who are drinking heavily are more likely to be doing so to cope than for social reasons.  Although those indicating first time drinking motives as coping was few in number, this group is highlighted as a risk group due to coping motives being linked to alcohol problems in later adolescence (Van Damme et al., 2013).  This risk to alcohol problems later in adolescence is supported by Patrick and Schulenberg’s (2011) findings that individuals who continue to use alcohol for coping reasons after the age of 22, were less likely to reduce binge drinking behaviours during young adulthood.

Lastly, conformity was very rarely indicated as a motive of first time drinking (Kuntsche and Müller, 2011), it was unrelated to both drunkenness and consuming five or more drinks, this is due to conformity motives being typical of a pattern that involves infrequent and low-level drinking which is not possible to interpret from individuals who have only just started drinking.

Emotion Regulation

Gratz and Roemer (2004) recognised emotional regulation is a multifaceted process that involves a) awareness and understanding of emotions, b) the acceptance of emotions, c) ability to control behaviour, even when experiencing negative emotions, in order to achieve desired goals and d) ability to use appropriate emotion regulation strategies.  From this they developed The Difficulties in Emotion Regulation Scale (DERS) in order to assess individual’s ability to regulate their emotions, which has been shown to be reliable and valid when using to measure emotion regulation in adolescents (Weinberg & Klonsky, 2009).  Hustad, Carey, Carey and Maisto (2009) found that students with lower self-regulation abilities made smaller reductions in both their alcohol consumption and the related consequences over the year follow up than individuals with higher self-regulation abilities.   This is supported by Brister (2012) findings that individuals who participated in Emotion Regulation Skills Training reported greater reductions in heavy drinking and related consequences post intervention and at a 1 month follow up. 

Dvorak et al. (2014) highlighted specific facets of the DERS that were found to relate to increase use and frequency of alcohol-related consequences.  Specifically, impulse control difficulties were the only facet found to relate to both frequency of use and consequences, whereas lack of emotional clarity, difficulties in goal-directed behaviour and non-acceptance of emotions were all only significantly associated with the frequency of consequences.  Furthermore, Carey, Neal and Collins (2004) also found increases in alcohol consequences were related to lower self-regulation scores even when alcohol consumption was controlled, suggesting college students who have emotion regulation deficits experience a higher frequency of consequences regardless of consumption levels, even when impairment was mild (Chandley, Luebbe, Messman-Moore & Ward, 2014).

Emotion Regulation and Drinking Motives

            Drinking motives have been shown to mediate the relationship between alcohol use and emotional dysregulation, resulting in specific alcohol use and related consequences patterns.  Simons, Hahn, Simons and Murase (2017) found that both anxiety and depression coping motives were predicted by the limited access to emotional regulation strategies of the DERS in undergraduates.  Moreover, having limited access to strategies was indirectly related to alcohol problems via coping motives, but was not associated with alcohol use.  This indirect association was also found by Messman-Moore and Ward’s (2014) for the facets of difficulties attaining goals and impulsive behaviour difficulties, however they found that these facets did predict heavy drinking via coping motives, this association is possible as coping motives have been shown to predicted alcohol problems via heavy consumption (Cooper, 1994; Rutledge & Sher, 2001).  Furthermore, coping was found to be a full mediator of the relationship between emotional dysregulation and problem drinking in college students further supporting previous that emotional dysregulation is related to coping motives which predicted problem drinking (Aurora & Klanecky, 2016).  These findings suggest that emotional dysregulation may increase the likelihood of an individual drinking to cope.

            Similarly, emotional dysregulation was also found to predict enhancement motives specifically difficulty in goal directed behaviours (Simons et al., 2017), and was found to have an indirect association with alcohol consumption via enhancement.  This suggests that individuals may be able to drink more to feel better if they get distracted when upset.  Furthermore, enhancement motives were also found to partially mediate the relationship between emotional dysregulation and problem drinking, neither social or conformity motives were shown to mediate this relationship (Aurora & Klanecky, 2016).  These findings are consistent with previous literature that suggests drinking to enhance affective experiences is related to greater problematic drinking (Van Damme et al., 2013; Kuntsche, Knibbe, Gmel & Engels, 2005).

 Drinking to enhance or cope with emotional experiences are two motives that drinking alcohol is directly aimed at changing these emotions, either by increasing positive affect or decreasing negative effect (Cooper, Frone, Russell & Mudar, 1995).  Therefore, when an individual has emotional dysregulation deficits alcohol is relied on more strongly to regulate emotional experiences, which results in higher consumption and problematic drinking.  Whereas, no mediation effects were found of social and conformity motives as they work to directly change the environment or situation an individual is drinking in, and therefore indirectly changing emotional experience (Gross, 2015).

Given the substantial evidence that drinking motives mediate the relationship between emotional dysregulation and alcohol consumption and related problems, it is likely emotional dysregulation is also relevant to alcohol use trajectories of adolescences/young adults.  Hustad et al.’s (2009) findings that self-regulation deficits in an individual’s ability to plan and attain outcomes through goal-directed behaviours, predicted the rate of change in consumption over the one year follow up, demonstrate this potential relationship.  Although, there have been studies identifying trajectories of drinking among adolescences/young adults (Schulenberg & Maggs, 2002), no study has ever examined the emotional regulation as a potential correlate despite the evidence of the relationship with both drinking motives and alcohol use and consequences.

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