Article

Protective Behavioral Strategies and Alcohol Use Outcomes Among College Women Drinkers: Does Disordered Eating and Race Moderate This Association?

Journal of Drug Education: Substance Abuse Research and Prevention 2014, Vol. 44(3-4) 95–115 ! The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0047237915573525 dre.sagepub.com

Alicia S. Landry1, Kayla D. Moorer1, Michael B. Madson1, and Virgil Zeigler-Hill2

Abstract The current study examined the degree to which associations that protective behavioral strategy use had with alcohol consumption and alcohol-related negative consequences were moderated by disordered eating and race. Participants were 382 female undergraduates (ages 18–25) who had consumed alcohol at least once within the previous month. Participants completed online self-report measures concerning their use of protective behavioral strategies, disordered eating, weekly alcohol consumption, harmful drinking patterns, and alcohol-related negative consequences. White non-Hispanic women who used the fewest protective behavioral strategies reported the highest levels of alcohol consumption and harmful drinking patterns. Protective behavioral strategy use was associated with lower levels of alcohol-related negative consequences except for African American women with low levels of disordered eating behaviors. For interventions targeting drinking among college women, disordered eating behaviors may increase risky behaviors and qualify relationships between protective behavioral 1

The University of Southern Mississippi, Hattiesburg, MS, USA Oakland University, Rochester, MI, USA

2

Corresponding Author: Alicia S. Landry, The University of Southern Mississippi, Hattiesburg, MS, USA. Email: [email protected]

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strategies and alcohol-related negative consequences. Thus, assessment of disordered eating behavior as part of drinking interventions may be helpful. Keywords protective behavioral strategies, disordered eating, college women, hazardous drinking, African American

Although overall rates of alcohol consumption among college students have remained stable over recent decades, college women are beginning to drink more like their male peers (Hoeppner, Paskausky, Jackson, & Barnett, 2013; Johnston, O’Malley, Bachman, & Schulenberg, 2013). In fact, males report only a slightly higher prevalence of getting drunk in the past 30 days than females (42% vs. 39%, respectively; Hoeppner et al., 2013; Johnston et al., 2013). Consequently, with college women engaging in increasingly harmful drinking patterns, they are more at risk of experiencing a greater number of and more severe alcohol-related negative consequences (Ham & Hope, 2003; National Institute on Alcohol Abuse and Alcoholism, 2013). Numerous alcohol-related negative consequences are associated with hazardous drinking among college students, including death, injury, physical or sexual assault, unsafe sex, academic and health problems, and drunken driving (National Institute on Alcohol Abuse and Alcoholism, 2013), and college women tend to report more personal consequences than do men (Ham & Hope, 2003). Additionally, there is increasing evidence of the co-occurrence of harmful alcohol use and mental health problems such as anxiety, depression, and disordered eating among college students (Krahn, Kurth, Gomberg, & Drewnoswski, 2005; Linden, Lau-Barraco, & Milletich, 2013; Substance Abuse and Mental Health Services Administration, 2010). As a result, much research has focused on ways to prevent harmful drinking and the associated negative consequences (e.g., poor mental health and disordered eating) among college drinkers, and the use of protective behavioral strategies [PBS]) as a harm reduction approach has gained much support in recent years. PBS are cognitive–behavioral self-regulatory strategies that students can use to limit their consumption of alcohol as well as alcohol-related negative consequences (D’Lima, Pearson, & Kelley, 2012; Martens, Martin, Littlefield, Murphy, & Cimini, 2011). These strategies include behaviors aimed at directly managing intake of alcohol or controlling consumption such as avoiding drinking games, having a set number of drinks, and alternating alcoholic and nonalcoholic drinks as well as indirect behaviors such as using a designated driver, knowing what is in your drink and going home with a friend (DeMartini et al., 2013; Pearson, D’Lima, & Kelley, 2013). The value of PBS as a harm reduction approach with college students has been demonstrated through findings that increased use of PBS is linked with fewer general alcohol-related negative

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consequences (Borden et al., 2011; Madson, Moorer, Zeigler-Hill, Bonnell, & Villarosa, 2013b; Martens et al., 2011; Pearson, 2013), as well as specific consequences like unwanted sexual experiences (Moorer, Madson, Mohn, & Nicholson, 2013) and that addressing PBS as part of brief alcohol interventions with college students contributes to their effectiveness (Barnett, Murphy, Colby, & Monti, 2007; Larimer et al., 2007; Murphy et al., 2012). Moreover, evidence is emerging that the efficacy of PBS may vary depending on students’ mental and social health status (LaBrie, Kenny, Lac, Garcia, & Ferriaiolo, 2009). For instance, LaBrie, Kenny, and Lac (2010) found that while increased PBS use was associated with fewer alcohol-related negative consequences among all college students, the link was particularly strong for students with poorer mental health. Moreover, students with poorer mental health may be inclined to consume alcohol as a way to alleviate their distress (e.g., self-medication hypothesis; Strahan, Panayiotou, Clements, & Scott, 2011) and, therefore, may be less likely to implement PBS. For example, increased symptoms of anxiety and social anxiety symptoms were directly related to fewer PBS use among college drinkers (Linden et al., 2013; Villarosa, Madson, Zeigler-Hill, Nobel, & Mohn, 2014a). Thus, even though students with relatively poor mental health may greatly benefit from implementing PBS when they choose to drink (LaBrie et al., 2010; Villarosa et al., 2014a), it appears that mental health problems may mitigate the efficacy of PBS. Race and gender have been shown to be important variables related to PBS use (Kenny & LaBrie, 2013; Madson & Zeigler-Hill, 2013). For example, Kenny and LaBrie (2013) found that Asian men who had poorer mental health experienced greater benefit from more PBS use than those with better mental health, whereas White non-Hispanic women received benefits from PBS regardless of level of mental health. This pattern suggests that race and gender may be important variables to consider when evaluating the links between PBS, mental health concerns, and alcohol-related negative consequences. Additionally, Madson and Zeigler-Hill (2013) found that increased use of PBS was associated with more reductions in alcohol consumption, harmful drinking, and alcohol-related negative consequences for White non-Hispanic than African American students. Given the recent increase in alcohol consumption among college women, it is important to develop a better understanding of the links that PBS have with alcohol consumption, harmful drinking, and alcohol-related negative consequences, as well as factors that may moderate these associations. Disordered eating behaviors have been associated with more harmful drinking patterns among White non-Hispanic and African American college women (Granner, Abood, & Black, 2001) and are related to less use of PBS (Dams-O’Connor, Martens, & Anderson, 2006). However, the degree to which disordered eating moderates the links that PBS use has with alcohol consumption, harmful drinking, and alcohol-related negative consequences has yet to be examined. In addition, Lo, Monge, Howell, and Cheng (2013) found the link between alcohol use

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and mental health problems to be stronger in college females than males. For example, depressive symptoms and disordered eating behaviors—especially binge eating and purging—have been linked to problematic alcohol use among college women (see Harrell, Slane, & Klump, 2009, for a review). In an effort to curb the potential dangers associated with increased alcohol consumption among college women, university administrators, prevention or intervention specialists, and researchers have sought to better understand various factors—such as mental health problems—that are linked with safe and harmful drinking behaviors (Harrell & Karim, 2008; Harrell et al., 2009). Disordered eating is a common problem among college women as evidenced by significant increases in the total number of female undergraduates practicing these behaviors from 23.6% in 2002, and 32.6% in 2008 (White, ReynoldsMalear, & Cordero, 2011). The link between disordered eating and alcoholrelated negative consequences among college women has also been established (Anderson, Martens, & Cimini, 2005; Dams-O’Connor et al., 2006; Dunn, Neighbors, Fosso, & Larimer, 2009), and there appears to be a strong cooccurrence between disordered eating and harmful drinking patterns. For instance, Grilo, Sinha, and O’Malley (2002) found that almost 50% of those with disordered eating also abused alcohol. More recently, Heidelberg and Correia (2009) found that college students who consumed more alcohol and engaged in dieting behavior reported experiencing a greater number and severity of alcohol-related negative consequences than those who did not engage in dieting behavior. Although racial differences in disordered eating symptoms and eating attitudes appear to exist between White non-Hispanic and African American women (Kelly, Lydecker, & Mazzeo, 2012), the link between disordered eating and alcohol use appears to be similar among these two racial groups (Granner et al., 2001). However, little is known about whether disordered eating may moderate the association that PBS has with drinking behaviors among college women.

Overview and Predictions The purpose of the present study was to better understand the degree to which PBS are linked with alcohol use, harmful drinking patterns, and alcohol-related negative consequences, as well as to assess whether these links are moderated by disordered eating and race among college women. As such, we aimed to respond to three specific research questions: (a) How are PBS related to alcohol use, harmful drinking patterns, and alcohol-related consequences? (b) To what extent are the relationships between PBS and alcohol use, harmful drinking patterns, and alcohol-related consequences qualified by disordered eating? (c) Does the racial or ethnic background of participants further moderate the associations that exist between PBS, alcohol-related outcomes, and disordered eating in a sample of college women? In this nonrandom, convenience sample—which

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was representative of the academic institution in which the research was conducted—we hypothesized that increased use of PBS would be associated with less alcohol use, less harmful drinking patterns, and less alcohol-related negative consequences for all students. Additionally, we suspected that problematic eating attitudes—which are indicative of disordered eating—would significantly qualify the associations between PBS and alcohol-related outcomes (e.g., alcohol use, harmful drinking patterns, and negative consequences). More specifically, we hypothesized that PBS would have stronger associations with alcohol-related outcomes among those with higher levels of disordered eating than it would for those with lower levels of disordered eating. The rationale for this prediction is derived from recent work showing that the link between PBS and alcohol-related negative consequences is particularly strong for college students with relatively poor mental health (LaBrie et al., 2009, 2010). We hypothesized that this association would be further moderated by race because racial differences have been observed for disordered eating symptoms (Kelly et al., 2012), amount of alcohol consumed (Borsari, Murphy, & Barnett, 2007; Paschall, Bersamin, & Flewelling, 2005; Strada & Donahue, 2006), and the strength of the association between PBS and alcohol-related outcomes (Madson & Zeigler-Hill, 2013). These previous results led us to hypothesize that there would be a strong association between PBS and alcohol-related outcomes for White non-Hispanic women regardless of their eating attitudes. This prediction is consistent with the results of Kenny and LaBrie (2013) which found that White women received benefits from PBS regardless of their mental health status. In contrast, we believed that the association between PBS and alcoholrelated outcomes may be stronger for African American women when they reported higher levels of disordered eating symptoms because their relatively poor mental health status may put them at greater risk for alcohol-related negative consequences.

Method Participants and Procedure Participants were 382 female undergraduates at a university in the southern region of the United States who were enrolled in psychology courses and participated as an option to satisfy partial fulfillment of a research requirement. Participants completed measures concerning PBS, eating attitudes, amount of alcohol consumed, harmful drinking patterns, and alcohol-related negative consequences via a secure website. Potential participants had to (a) be between the ages of 18 and 25, (b) have consumed alcohol within the past 30 days, and (c) self-identify as either White non-Hispanic or African American in order to participate in the study. The average age of the participants was 19.46 years (SD ¼ 1.63), and the racial or ethnic composition was 55% White non-Hispanic

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and 45% African American. This study was approved by the University of Southern Mississippi’s institutional review board. Protective behavioral strategies. The use of PBS was assessed by using the 18-item Protective Behavioral Strategies Scale-revised (PBSS-r; Madson, Arnau, & Lambert, 2013a). The PBSS-r asks participants to “indicate the degree to which you engage in the following behaviors to keep yourself safe when using alcohol or partying.” Participants responded to each item using scales that ranged from 1 (never) to 6 (always) for behaviors such as using a designated driver or alternating between alcoholic and nonalcoholic drinks. Scores range from 18 to 108 with higher scores indicating greater use of PBS. The reliability and validity of scores on the PBSS-r has been demonstrated among college student drinkers (Madson et al., 2013a). Specifically, increased PBS use has been found to be associated with decreases in alcohol consumption, harmful drinking, and alcohol-related negative consequences (Madson et al., 2013a; Moorer, et al., 2013; Villarosa et al., 2014a; Villarosa, et al., 2014b) For the present sample, the internal consistency was excellent (a ¼ .92) Disordered eating. Symptoms of disordered eating were assessed using the Eating Attitudes Test-26 (EAT-26; Garner, Olmsted, Bohr, & Garfinkel, 1982). Participants respond to items such as “I am terrified about being overweight” and “I feel extremely guilty after eating” using 6-point Likert-type scales that ranged from always to never. Total scores that are greater than 20 may be indicative of an eating disorder (Garner et al., 1982). Originally, the EAT-26 was normed on women and it is intended to detect characteristic symptoms of eating disorders in nonclinical samples. The scale has demonstrated good internal consistency among women (a ¼ 83) and has been shown to be effective for identifying individuals with eating disorders (Garner et al., 1982). The internal consistency for the present sample was a ¼ .92. Alcohol consumption. Weekly alcohol consumption was assessed using the Daily Drinking Questionnaire (Collins, Parks, & Marlatt, 1985). Participants were asked to estimate the number of standard drinks they consumed on each day of a typical week for the past month. Total drinks per week was calculated by summing the number of drinks each day. Harmful drinking patterns. The Alcohol Use Disorders and Identification Test (AUDIT; Saunders, Aasland, Babor, De La Fuente, & Grant, 1993) is a 10item instrument that assesses harmful drinking patterns (e.g., “How often do you have 6 or more drinks on one occasion?”). Participants responded to each question using a scale ranging from 0 (never) to 4 (4 or more times per week). Total scores ranged from 0 to 40 with higher scores representing more harmful drinking. The AUDIT is the leading instrument for the detection of early-phase

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risky drinking patterns across different cultures and age groups (e.g., Reinert & Allen, 2002) including college students (e.g., Kokotailo et al., 2004). The internal consistency estimate for the AUDIT was a ¼ .81 for the present study. Alcohol-related negative consequences. The negative consequences of alcohol consumption were measured using the brief version of the Rutgers Alcohol Problem Index (RAPI; Earleywine, LaBrie, & Pedersen, 2008). The RAPI is a 23-item measure designed to assess alcohol-related negative consequences. Participants rate how often they have experienced a specific negative consequence such as “neglected your responsibilities” and “missed a day, or part of a day, of school or work” within the past year using scales ranging from 0 (never) to 4 (more than 10 times). The total score ranged from 0 to 92 with higher scores indicating more negative consequences. The RAPI has been shown to be a reliable and valid measure with college students (Neal, Corbin, & Fromme, 2006). The internal consistency for this sample was a ¼ .94.

Results The means, standard deviations, and intercorrelations for the measures in the present study are presented in Table 1. Moderational analyses were conducted to determine whether disordered eating qualified the association between PBS and alcohol-related outcomes. This was accomplished by conducting a series of hierarchical multiple regression analyses in which each alcohol-related outcome was regressed onto PBS, disordered eating, and racial or ethnic background (0¼African American, 1 ¼ White non-Hispanic). We included racial or ethnic background in these analyses because it has been found to be a moderator of PBS use (Kenny & LaBrie, 2013; Madson & Zeigler-Hill, 2013). The main effect terms for PBS, disordered eating, and racial or ethnic background were entered on Step 1. The two-way interactions of the main effect terms were entered on Step 2, and the three-way interaction was entered on Step 3. The continuous predictor variables were centered for the purpose of testing interactions (Aiken & West, 1991). The results of these analyses are presented in Table 2. These regression analyses were followed by the simple slopes tests recommended by Aiken and West (1991) to describe the interaction of continuous variables. These simple slopes were conducted using values that were one standard deviation above the mean to represent those with high levels of eating attitudes and one standard deviation below the mean to represent those with low levels of eating attitudes.

Alcohol Consumption The results of the analysis concerning alcohol consumption found main effects for PBS (b ¼ .35, t[378] ¼ 6.75, p < .001), disordered eating (b ¼ .18,

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Table 1. Intercorrelations and Descriptive Statistics for PBS, Eating Attitudes, and AlcoholRelated Outcomes. 1 1. PBS

–

2

3

4

5

.26**

.35***

.25**

.35***

2. Eating attitudes

.18*

.45***

3. Alcohol consumption

.43***

.12

4. Harmful drinking patterns

.52***

.14

–

.18*

.42***

.43***

– .54***

.35*** .52***

–

5. Alcohol-related negative consequences

.37***

MAfrican American SDAfrican American

75.67 21.58

12.08 15.60

7.47 7.55

6.17 6.17

11.26 16.80

MWhite

80.05

15.41

9.28

6.96

10.63

20.35

12.45

9.02

5.09

12.55

SDWhite

non-Hispanic non-Hispanic

.33***

.14

.67***

–

Note. PBS ¼ protective behavioral strategies. Correlations for African American participants are presented above the diagonal and correlations for the White non-Hispanic participants are presented below the diagonal. *p < .05. **p < .01. ***p < .001.

Table 2. Regressions of Alcohol-Related Outcomes on PBS, Eating Attitudes, and Racial or Ethnic Background. Alcohol consumption R2 Step 1

***

.19

R2

Alcohol-related negative consequences

Harmful drinking patterns R2

b

***

***

.19

.14

R2

R2

b

***

***

.14

.17

PBS

.35***

EAT

***

.09

*

.09

Racial or Ethnic background (Race) Step 2

.11 .05***

.17***

.03*

***

PBS  EAT

.17

.30*** .23*** .01 .21***

.04* .13*

.03

.18

*

b

***

.35***

.18

.24***

R2

***

PBS  Race

.16

.23

.05

EAT  Race

.12

.08

.17*

Step 3 PBS  EAT  Race

.24***

.17***

.00 .02

.23***

.00 .01

Note. PBS ¼ protective behavioral strategy; EAT ¼ eating attitudes test. * p < .05. **p < .01. ***p < .001.

.02* .11*

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t[378] ¼ 3.51, p < .001), and racial or ethnic background (b ¼ .11, t[378] ¼ 2.27, p ¼ .02). These main effects were qualified by the two-way interactions of PBSDisordered Eating (b ¼ .18, t[375] ¼ 3.52, p < .001) and PBS  Racial or Ethnic Background (b ¼ .16, t[375] ¼ 2.15, p ¼ .03). The predicted values for the interaction of PBS  Disordered Eating are presented in Figure 1. Simple slopes tests found that the slope of the line representing the association between PBS and alcohol consumption was significant for those with high levels of disordered eating (b ¼ .32, t[375] ¼ 4.05, p < .001) but that the association was not significant for those with low levels of disordered eating (b ¼ .07, t[375] ¼ 0.78, p ¼ .44). These results show that individuals with high levels of disordered eating who fail to employ PBS report the highest levels of alcohol consumption. The predicted values for the interaction of PBS  Racial or Ethnic Background are presented in Figure 2. Simple slopes tests found that the slope of the line representing the association between PBS and alcohol consumption was significant for African American individuals (b ¼ .23, t[375] ¼ 3.01, p ¼ .003) but that this association was even stronger for White non-Hispanic individuals (b ¼ .37, t[375] ¼ 5.43, p < .001). These results show that the highest levels of alcohol consumption were reported by White non-Hispanic individuals who failed to employ PBS.

Harmful Drinking Patterns The results of the analysis concerning harmful drinking patterns revealed a main effect for PBS (b ¼ .35, t[378] ¼ 6.45, p < .001) that was qualified by its twoway interaction with racial or ethnic background (b ¼ .23, t[375] ¼ 2.91, p ¼ .004). The predicted values for this interaction are presented in Figure 3. Simple slopes tests found that the slope of the line representing the association between PBS and harmful drinking patterns was significant for White nonHispanic individuals (b ¼ .52, t[375] ¼ 7.84, p < .001) but not for African American individuals (b ¼ .17, t[375] ¼ 1.91, p ¼ .06). These results show that the highest levels of harmful drinking patterns were reported by White non-Hispanic individuals who failed to employ PBS.

Alcohol-Related Negative Consequences The results of the analysis concerning alcohol-related negative consequences found main effects for PBS (b ¼ .30, t[378] ¼ 5.84, p < .001) and eating attitudes (b ¼ .23, t[378] ¼ 4.32, p < .001). However, these main effects were qualified by the three-way interaction of PBS  Disordered Eating  Racial or Ethnic Background (b ¼ .11, t[374] ¼ 2.14, p ¼ .03). The predicted values for this interaction are presented in Figure 4.

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Figure 1. Predicted values for alcohol consumption illustrating the interaction between PBS and disordered eating attitudes at values that are one standard deviation above and below their respective means. PBS ¼ protective behavioral strategy.

Figure 2. Predicted values for alcohol consumption illustrating the interaction between PBS and racial or ethnic background at values that are one standard deviation above and below their respective means. PBS ¼ protective behavioral strategy.

As suggested by Cohen, Cohen, West, and Aiken (2003), this interaction was probed by first examining whether the two-way interaction of PBS and eating attitudes was significant for African American and White non-Hispanic participants separately. These analyses found that this two-way interaction emerged for the African American participants (b ¼ .22, t[168] ¼ 2.83, p ¼ .005) but not the White non-Hispanic participants (b ¼ .02, t[206] ¼ 0.21, p ¼ .83). Simple

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Figure 3. Predicted values for harmful drinking patterns illustrating the interaction between PBS and racial or ethnic background at values that are one standard deviation above and below their respective means. PBS ¼ protective behavioral strategy.

Figure 4. Predicted values for alcohol-related negative consequences illustrating the interaction between PBS and disordered eating attitudes for White non-Hispanic participants (left panel) and African American participants (right panel) at values that are one standard deviation above and below their respective means. PBS ¼ protective behavioral strategy.

slopes tests were then conducted for the African American participants which found that the slope of the line representing the association between PBS and alcohol-related negative consequences was significant for those with high levels of disordered eating (b ¼ .34, t[168] ¼ 3.98, p < .001) but the slope of the line representing the association between PBS and alcohol-related negative

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consequences was not significant for those with low levels of disordered eating (b ¼ .09, t[168] ¼ 0.90, p ¼ .37). Taken together, these results show that the use of PBS was generally associated with lower levels of alcohol-related negative consequences. The exception to this pattern emerged for African American participants with low levels of eating attitudes because they reported low levels of alcohol-related negative consequences even when they failed to employ PBS.

Discussion The purpose of this study was to explore the degree to which the relationships that PBS had with alcohol use, harmful drinking, and alcohol-related negative consequences were moderated by disordered eating and race. We believe the present study is the first to examine how disordered eating and race may qualify the relationships between PBS and alcohol use outcomes, and this is an important issue due to increasing evidence that mental health problems among college students attenuate their use of PBS (Kenny & LaBrie, 2013; LaBrie et al., 2009, 2010). Consistent with previous findings, increased use of PBS was associated with less alcohol use, less harmful drinking, and fewer alcohol-related negative consequences among all participants. Also consistent with previous findings, higher levels of disordered eating were associated with less PBS use (Krahn et al., 2005). Further, disordered eating was associated with higher levels of alcohol consumption, harmful drinking, and alcohol-related negative consequences (e.g., Krahn et al., 2005). Thus, our findings are consistent with research that found a link between disordered eating and more harmful drinking patterns and fewer safe drinking behaviors among college drinkers. Our results suggest that the highest levels of alcohol consumption existed among participants who had higher levels of disordered eating and employed the fewest PBS. Accordingly, PBS use was particularly important in reducing alcohol consumption among individuals with higher disordered eating and is consistent with other findings of PBS and specific mental health problems (Kenney & LaBrie, 2013). Specifically, D’Lima, Pearson, and Kelley (2012) found that PBS appear to be most effective in limiting alcohol-related harm for students with low levels of self-regulation, and it is plausible that students with high levels of disordered eating might also exhibit low self-regulation, thus making PBS especially valuable for these students. The results of the present study are consistent with other studies showing that the use of PBS is especially important for college students with mental health concerns (e.g., Harrell et al., 2009; Villarosa et al., 2014a). As a result, Villarosa and colleagues (2014a) have emphasized the importance of examining PBS use within subgroups of college students at risk for alcohol use and related problems because of their mental health issues. Given that PBS appear to be differentially effective for certain subgroups of students, perhaps exploring specific types of mental health problems in relation to the value of PBS can help further our understanding of how

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the association between PBS and alcohol consumption may be mitigated by mental health problems. We also found that the highest levels of alcohol consumption were among White non-Hispanic females who employed the fewest PBS. Similarly, we found that the highest levels of harmful drinking were among White nonHispanic females who implemented the fewest PBS. The fact that White nonHispanic women engaged in more alcohol consumption and more harmful drinking supports other findings related to these racial differences (Borsari et al., 2007; Paschall et al., 2005; Strada & Donahue, 2006). These findings are also consistent with similar research concerning racial differences in PBS use among African Americans and White non-Hispanic college students (Madson & Zeigler-Hill, 2013). For instance, Madson and Zeigler-Hill (2013) found that African American students utilized more PBS directly related to limiting their consumption, which may help explain our findings of greater consumption and harmful drinking patterns among White non-Hispanic women. While our findings are in line with previous research, it is important to note the brevity of existent literature examining potential mechanisms that might explain these racial differences. Factors such as racial differences in attitudes toward alcohol use (Cooper et al., 2008), perceptions of normative drinking behavior (Rice, 2006), and experiences and evaluations of alcohol-related negative consequences (Skidmore, Murphy, Martens, & Dennhardt, 2012) may help to explain these differences. We also found racial distinctions in the potential effectiveness of PBS in reducing alcohol-related negative consequences for women with disordered eating. More specifically, increased use of PBS was associated with fewer alcohol-related negative consequences for African American women who reported more disordered eating symptoms and White non-Hispanic women regardless of their disordered eating symptoms. Research findings have suggested that the rates of disordered eating among African American and White non-Hispanic college women have become more similar in recent years (Marques et al., 2011); however, factors such as the experience of negative affect, acculturation, and oppression may lead to somewhat unique characteristics of disordered eating among African Americans (Napolitano & Himes, 2011). For example, negative affect—as seen in anxiety, depression, and low self-esteem—has been linked with a drive for thinness, fear of fatness, and dietary restraint among African American college students, but it has not been found to be associated with binge eating (Abrams, Allen, & Gray, 1993). Similarly, Blue and Berkel (2010) suggested that African American college students may internalize the dominant culture’s views of body type and thinness, which may lead them to experience greater body dissatisfaction and disordered eating patterns. Previous research has also shown that self-esteem and acculturation moderate the association between alcohol use and body image perception for African Americans (Abdullah & Brown, 2012). Thus, there may be acculturation and assimilation issues that may lead to psychological distress (e.g., anxiety, low self-esteem, poor

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body image; Blue & Berkel, 2010), and this psychological distress may then be exhibited in disordered eating behaviors, alcohol use, or other risky behaviors among African American college women. However, scarce existent literature has sought to understand the intersection of race, acculturation, mental health, and risky behaviors among African American college students, and it may be especially beneficial to explore these associations among first-year college students (i.e., during a time when potential acculturation effects would likely be strongest). Overall, screening and brief interventions that incorporate PBS and screen for mental health problems among African Americans may be important to implement on campuses especially given the low rates of help seeking among this minority group (Masuda, Anderson, & Edmonds, 2012). Our results have several implications for prevention and intervention efforts on college campuses. Considering the increasing rates of alcohol consumption among college women (Hoeppner et al., 2013) in combination with the prevalence of disordered eating on college campuses (White et al., 2011), prevention and intervention efforts aimed at reducing harm on college campuses may be enhanced by including an assessment of eating attitudes or disordered eating behaviors among student drinkers. Current harm reduction approaches such as the Brief Alcohol Screening and Intervention for College Students programs operate from a skills-based curriculum that provides specific cognitive– behavioral strategies to college student drinkers (Dimeff, Baer, Kivlahan, & Marlatt, 1999). Accordingly, these brief interventions—which could be implemented as part of key activities on campus such as freshman orientations or College Alcohol Awareness Week—would benefit from detecting problematic eating attitudes and adopting a culturally congruent approach to help students engage in safe drinking behaviors. However, it is important to note that students with disordered eating or harmful alcohol use patterns may not always seek help from campus health services; therefore, health professionals—as well as other student affairs personnel—are encouraged to develop culturally competent outreach programs that teach and promote the use of PBS among all college students. For instance, given the findings that proximal reference groups may have more influence on drinking behaviors than distal groups, group-specific educational and social norming campaigns may include within group information about alcohol consumption, harmful drinking, PBS use, and disordered eating (Neighbors et al., 2008). In other words, those providing prevention and intervention might individualize or tailor information based on the group with whom they are working to make these interventions more meaningful (Madson, Villarosa, Moorer, & Zeigler-Hill, in press). Our findings help to advance the understanding of PBS and a specific mental health problem—disordered eating—among African American and White nonHispanic college women; however, potential limitations of the present work call for caution in interpreting the results. First, the study was cross sectional and, therefore, causal inferences cannot be made. Future research may address this

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limitation by using longitudinal research designs. For instance, daily diary methods of assessing eating and alcohol use behaviors, including PBS use, may provide a more comprehensive assessment of these behaviors than a single assessment (O’Grady, Cullum, Armeli, & Tennen, 2011; Pearson, 2013). Second, the present study used a convenience sample from a single university in the southern United States, and there may be regional differences in eating attitudes and behaviors as well as alcohol consumption that could limit generalizability of the current findings. To address this limitation, future research should attempt to include students from multiple regions of the country. Finally, this study focused only on female college students so it may be important for future studies of this sort to include male participants in order to gain an understanding of these processes among men. Overall, our results demonstrate that disordered eating and race qualifies the effectiveness of PBS in reducing alcohol-related harm. PBS were generally linked with less alcohol consumption, less harmful drinking, and fewer alcohol-related negative consequences. Disordered eating was generally linked with more alcohol consumption, more harmful drinking, and more alcohol-related negative consequences. PBS appear to be particularly effective at limiting alcohol-related harm for White non-Hispanic women, regardless of level of disordered eating, and African American women with high levels of disordered eating. These results highlight the importance of developing culturally relevant prevention and intervention programs for college student drinkers and contribute to the literature by identifying the significant impact of disordered eating on increasing alcohol-related harm among college women drinkers. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

Note 1. Additional analyses were conducted using the subscales of the PBSS-r (i.e., controlled consumption [CC] and serious harm reduction [SHR]). For alcohol consumption, main effects emerged for CC (b ¼ .23, t ¼ 3.44, p < .001) and SHR (b ¼ .16, t ¼ 2.30, p ¼ .02) as did the following interactions: CC  racial or ethnic background (b ¼ .25, t ¼ 2.33, p ¼ .02) and SHR  eating attitudes (b ¼ .30, t ¼ 2.64, p ¼ .01). In both cases, the predicted values and simple slopes tests were similar to those that emerged for the composite PBS score. For harmful drinking patterns, main effects emerged for CC (b ¼ .15, t ¼ 2.16, p ¼ .03) and SHR (b ¼ .26, t ¼ 3.63, p < .001) but the main effect of CC was qualified by its two-way interaction with racial

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or ethnic background (b ¼ .25, t ¼ 2.25, p ¼ .03). The predicted values and simple slopes tests were similar to those that emerged for the composite PBS score. For alcohol-related negative consequences, the main effect of SHR emerged (b ¼ .38, t ¼ 5.70, p < .001) but it was not qualified by eating attitudes or racial or ethnic background.

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Author Biographies Alicia S. Landry is an assistant professor in the Department of Nutrition and Food Systems at the University of Southern Mississippi (USM). Her research interests are community-based participatory interventions to reduce chronic disease risk in health disparate populations, especially with child nutrition programs, including farm to school and community gardens.

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Kayla D. Moorer is currently a fourth-year doctoral student at the University of Southern Mississippi’s Counseling Psychology Program. She earned a bachelor of science degree in psychology, with a minor in child and family studies and a master of arts degree in counseling psychology from the same institution. Her professional interests include harm reduction approaches to college student drinking, gendered social learning, and the impact of trauma on overall wellbeing. Michael B. Madson, an associate professor of psychology at the University of Southern Mississippi, received his PhD in counseling psychology from Marquette University. His research interests have focused on motivational interviewing and harm reduction for college student drinking. Virgil Zeigler-Hill is an associate professor of psychology at Oakland University. His primary research interests are in three interrelated areas: (a) dark personality features (e.g., narcissism, spitefulness), (b) self-esteem, and (c) interpersonal relationships. He has written more than 120 journal articles and book chapters that focus on these topics. Dr. Zeigler-Hill has edited three books: Self-Esteem, Evolutionary Perspectives on Social Psychology, and The Dark Side of Personality. He is currently an associate editor for Self and Identity, Journal of Personality Assessment, and Evolutionary Psychology.