Alcohol protective behavioral strategies for young adults: A content analysis across drinking contexts and gender

Abstract

Background:

Protective behavioral strategies (PBS) are specific harm reduction behaviors which mitigate alcohol-related consequences among young adults. Prior work indicates PBS utilization varies according to drinking context and gender, suggesting a need for further research assessing whether young adults employ unidentified PBS according to such factors.

Objectives:

This study examined alcohol PBS young adults suggest using across drinking contexts and gender to inform alcohol-related harm reduction interventions.

Methods:

An online survey with 514 young adult heavy drinkers (n = 269 female, M_age = 22.36 years) assessed PBS use generally, and across twelve physical and social contexts. We utilized qualitative content analysis methods to code and derive themes from open-ended responses from a prompt asking participants to state additional PBS used per context. The frequency of each theme’s appearance was calculated across the overall sample, by gender, and within each context.

Results:

PBS endorsement varied across context and gender within each theme. Young adults who reported PBS use most frequently endorsed utilizing strategies related to drink content (18.30%), social support (12.36%), and engaging in other activities (10.34%). Participants infrequently endorsed strategies related to awareness of time (0.23%), standards of behavior (0.78%) and avoiding environments (0.87%).

Conclusions:

Young adults endorse utilizing additional PBS in varying frequency according to drinking context and gender. Given PBS are often a key component of alcohol harm reduction interventions, monitoring trends in young adult PBS use is crucial to ensure continued relevance and efficacy of such interventions to minimize harms associated with young adult heavy alcohol use.

Introduction

Harms associated with alcohol use are exacerbated as the level of consumption increases. Young adults (aged 18-25) engage in heavy episodic drinking (HED), defined as four or more standard drinks per drinking occasion for women and five or more for men, more often and with more sustained intensity than any other age group (1). Further, approximately 10.30% of young adults engage in high-intensity drinking (HID), which is defined as drinking at two or more times the threshold of HED (2). Engaging in excessive alcohol consumption contributes to unique negative health impacts, ranging from immediate harms, such as unintentional injury, to long-term consequences, including the development of alcohol use disorder (3,4). The wide range of consequences associated with young adult heavy alcohol use necessitates the development of practical approaches to limit such harms.

Protective behavioral strategies (PBS) are individual-level harm reduction approaches which aim to reduce alcohol-related consequences when employed by young adults before, during, or after drinking events (5). PBS can range from behaviors which target manner of drinking (e.g., drink slowly) and stopping or limiting alcohol consumption (e.g., stop drinking at a predetermined time) to serious harm reduction (e.g., use a designated driver; 6). While the most widely utilized PBS scales (e.g., 7) have been updated in the past decade (6,8), emerging technologies and shifting patterns of alcohol use necessitate ongoing assessment of existing PBS to ensure continued applicability for young adults. Available technologies such as ridesharing apps and location-sharing options on mobile phones are increasingly utilized by young adults to limit their risk of immediate alcohol-related consequences (9). Notably, the COVID-19 pandemic led to a greater number of young adults reporting solitary drinking and drinking at home (10,11). Consequently, it is reasonable to assume that young adults’ PBS use has evolved alongside such changes.

Young adult alcohol use behaviors are shaped by person-level and contextual factors. At the individual-level, alcohol consumption and consequent harms experienced vary across young adults of different genders. Men have historically consumed alcohol in greater quantities than women and are more likely to experience direct alcohol-related harm, such as being arrested for driving under the influence (12), while women are more likely to experience harms due to another person’s drinking (13). Variation in PBS use by gender has been documented, with previous research indicating greater PBS uptake among women compared to men (14,15). Additionally, drinking behaviors and alcohol-related consequences have been shown to be related to the physical and social contexts in which drinking occurs (16,17). Drinking at a party or with others who are intoxicated is associated with greater levels of alcohol consumption, whereas drinking at home is protective for risky drinking (18). Similarly, a greater risk of alcohol-related harms is evident when drinking in public, social settings as compared to private settings (19). Given differences in alcohol use behaviors and consequences according to drinking context, it is reasonable to assume that PBS use varies according to context. Some PBS are inherently dependent upon the drinking context; for example, make your own drink may only be relevant when one is at home. Few studies have examined differences in PBS use by physical and social context, but initial findings suggest young adults employ PBS to varying degrees depending upon their environment (20). Expanding our understanding of PBS use by gender and drinking context is necessary to ensure the relevance and utility of interventions in which PBS are an integral component.

The present study examines the protective behavioral strategies young adults report utilizing across drinking contexts and by gender. First, we identified strategies suggested by young adults that differed in content or structure from selected existing PBS measures (7,21,22). Second, we examined how identified PBS varied by gender. Third, we sought to describe how strategies varied across social (e.g., in a large group) and physical (e.g., at a bar/club) contexts. Describing the breadth of strategies young adults endorse utilizing for alcohol-related harm reduction is essential for the development of innovative interventions aimed at reducing associated consequences.

Method

Participants and procedures

We recruited participants via Qualtrics’ panels for social science research in December 2021. Previous work has found Qualtrics panels to reflect community samples and offer a valid means of recruiting participants for addictive behaviors survey research (23). Throughout the data collection process, Qualtrics removed and replaced responses deemed to be duplicates, bots, or otherwise poor quality due to completion speed that was less than one half the median completion time. Of the 610 responses received from Qualtrics, 514 passed a second quality inspection and were retained in analyses (84.26%). Participants provided informed consent prior to completing the survey. Eligible participants were (a) 18-25 years old, (b) not currently enrolled in high school, (c) residing in the United States, (d) able to speak English, and (e) reported engaging in at least two episodes of HED (4+/5+ drinks for females/males in one event) or one episode of HID (8+/10+ drinks for females/makes in one event) in the past 30 days. Eligible participants were sent a link to complete the survey online. Following survey completion, Qualtrics distributed a one-time incentive to consenting eligible participants. Procedures were approved by the university’s Institutional Review Board (IRB#21-2612).

The mean age of the total sample (N=514) was 22.36 years old, and 52% participants self-identified as female. The most frequently endorsed racial category was White (57%), and 30.35% of participants identified as Hispanic/Latino(a). In the past month, participants reported HED an average of 6.22 (SD=4.85) days, of which 4.88 (SD=4.63) were HID days. Table 1 presents results of key demographic and behavioral attributes of the sample.

Table 1.

Demographic and behavioral characteristics of the sample.

Characteristic	All Participants (n = 514)			Males (n = 235)			Females (n = 269)
	n	%	M (SD)	n	%	M (SD)	n	%	M (SD)
Gender
Male-identifying	235	45.81
Female-identifying	269	52.44
Genderqueer/Gender non-conforming	7	1.36
Other identity	2	0.39
Missing	1	0.19
Age			22.36 (2.01)			22.55 (1.99)			22.24 (2.00)
Self-reported race
White	293	57.00		127	54.04		161	59.85
Black or African American	111	21.60		64	27.23		45	16.73
Asian	27	5.25		12	5.11		14	5.20
American Indian or Alaskan Native	10	1.95		6	2.55		3	1.12
Native Hawaiian or other Pacific Islander	5	0.97		0	0.00		5	1.86
Other/mixed	54	10.51		21	8.95		32	11.89
Prefer not to answer	14	2.72		5	2.13		9	3.35
Hispanic or Latino(a)(x) ethnicity	156	30.35		66	28.09		87	32.34
Past 30-day any drinking frequency			9.52 (6.59)			10.38 (6.82)			8.91 (6.36)
Past 30-day drinking amount			5.99 (3.56)			6.27 (3.64)			5.83 (3.53)
Past 30-day binge frequency			6.22 (4.85)			6.78 (5.16)			5.81 (4.57)
Past 30-day high intensity drinking frequency			4.48 (4.63)			4.88 (4.79)			4.20 (4.54)
Past 30-day maximum drinks			7.43 (3.88)			8.22 (4.01)			6.76 (3.65)
Past 30-day alcohol use at home	388	75.49		178	75.54		204	78.84
Past 30-day alcohol use at a friend’s house	328	63.81		153	65.11		170	63.20
Past 30-day alcohol use at a party	283	55.06		144	61.28		132	49.07
Past 30-day alcohol use at a bar or club	244	47.47		119	50.64		121	44.98
Past 30-day alcohol use at a concert or sporting event	90	17.51		48	20.43		42	15.61
Past 30-day alcohol use in a dark and/or loud space	81	15.76		35	14.89		43	15.99
Past 30-day alcohol use with a close peer(s)	203	39.49		83	35.32		115	42.75
Past 30-day alcohol use with others you feel safe with when drinking alcohol	203	39.49		80	34.04		118	43.87
Past 30-day alcohol use with other people who are intoxicated themselves	108	21.01		45	19.15		61	22.68
Past 30-day alcohol use in a group of people of mixed genders	165	32.10		68	28.94		92	34.20
Past 30-day alcohol use in a group of people mostly the same gender	78	15.18		29	12.34		46	17.10

N = 514 participants.

Measures

First, participants quantitatively rated their likelihood of engaging in 26 PBS identified from three validated scales: the Protective Behavioral Strategies Survey (PBSS), the Strategy Questionnaire, and the Protective Behavioral Strategies Measure (7,21,22). Participants were then asked to provide a text response to the open-ended item, “What other strategies or behaviors would you use to reduce your level of intoxication or lessen the likelihood of experiencing negative side effects or consequences of alcohol?”. This item was asked for general PBS use (i.e., no specific context), and repeated across six physical contexts (home, friend’s house, party, bar or club, concert or sporting event, dark/loud space) and six social contexts (with close friends, with people they feel safe or comfortable with when drinking alcohol, at an event with a large number of people, with others who are intoxicated, with a group who are mixed genders, and with a group who are the same gender as them).

Data analysis

We used qualitative content analysis methods (24) to code and thematically analyze PBS reported by young adults generally, then across the distinct social and physical contexts. Participant responses (n = 4,996) were first coded within each context, and then further grouped by self-reported gender within each context. Responses from participants who did not identify as male or female were not retained due to the small number of respondents within this category (n = 9). Three deductive codes were preemptively created to apply across all responses which were not retained in analyses: “No/Not Applicable” (n = 1,768) and “Unsure” (n = 319) were used for responses that did not suggest any PBS and “Previously Listed PBS” (n = 605) was used for responses specifying strategies which appeared in the 26 PBS items included in the survey.

We inductively generated codes from all responses retained in the analyses (n = 2,186). Each open-ended response was read and coded (by M.R.) according to the strategy listed by the participant. For example, if a participant responded, “Stay the night,” then the newly created code was spend the night; however, if that code was already documented in the codebook, then the response was counted toward the previously generated code. Where relevant, several codes were applied to a single response. Responses were excluded if they were (a) incomprehensible, (b) not written in English, or (c) derogatory or inappropriate (n = 859).

Assessment of participant responses yielded 220 codes representing PBS which differed in content or structure from existing PBS measures utilized in this study (7,20,21). Two research assistants (M.R. and A.G.) independently reviewed the newly generated codes and grouped them according to conceptual similarity. Together, research assistants (M.R. and A.G.) compared independently generated themes and, upon determining conceptual similarity across individually derived themes, refined descriptions until 18 themes were finalized by consensus. These code groupings were assessed broadly (i.e., regardless of context) and defined as unique themes. During this process, some initial codes were deemed irrelevant and discarded after agreement by both reviewers (n = 32). The frequency of each theme, determined by the counts of each code within a theme, was calculated across the overall sample, for each gender, and within each context. Finally, two study team members (M.R. and A.G) grouped the 18 themes via consensus methods into six overall categories.

Results

Findings from participant open-ended responses were organized by overall categories and themes established from codes identified in conventional and directed content analyses. Data were best represented by six comprehensive categories: Avoidance, Social Influence, Limiting Consumption, Planning Ahead, Awareness, and Alternatives to Drinking. Avoidance included responses pertaining to avoiding specific social and environmental situations, as well as responses suggesting removing oneself from drinking situations after entering them. Social Influence was comprised of responses which highlighted relationships with other people. Limiting Consumption pertained to responses which offered strategies targeting beverage content and alcohol access as means of limiting alcohol consumption. Planning Ahead included strategies which incorporated an element of planning in advance of the drinking event to reduce future harms. Awareness highlighted responses that emphasized awareness of one’s drink, physical surroundings, and self, as well as the passage of time. Alternatives to Drinking encompassed strategies which suggested using another activity to distract oneself from drinking, which also involved other substance use.

Overall, participants most frequently suggested PBS related to drink content (18.30%), social support (12.36%), and engaging in other activities (10.34%). Codes that fell under the drink content theme (n = 7) were predominantly related to type of alcohol consumed (e.g., avoid hard alcohol) though also included responses regarding consuming nonalcoholic beverages (e.g., drink water). Importantly, the most frequently endorsed overall strategy (drink water; 15.96% of total responses) was included in this theme. Strategies encompassed by the social support theme (n = 29) incorporated involving others to reduce drinking-related harms. This included communicating one’s needs and feelings (e.g., ask for help), curating a drinking environment in which one feels safe (e.g., drink with trusted people), and relying on others to maintain personal safety (e.g., don’t walk to car alone). PBS related to personal safety highlighted opportunities to reflect on the content of existing items (e.g., tell friends when you leave compared to make sure that you go home with a friend from the PBSS; 7) as reported strategies appear to shift importance to communication with trusted people rather than continued immediate contact. Additionally, several strategies in this theme suggested relying on bar staff for support (e.g., tell the bartender you’re driving) which is a concept not found in scales assessed in this study (7,20,21). However, strategies were also shared which emphasized the role of the respondent in offering support to others in drinking situations (e.g., monitor your friends). Finally, codes categorized under engaging in other activities (n = 21) varied from activities that were specific to one’s location (e.g., wait in line) to activities that could be done in a variety of contexts (e.g., have conversations).

PBS endorsement varied across physical and social contexts. Participants suggested utilizing PBS in the dark/loud context most often; this context solely contained the greatest proportion of responses across four unique themes: awareness of time (60.00%), awareness of one’s drink (14.29%), remove self from situation (18.38%), and avoidance of environments (58.89%). Social contexts alone were more frequently endorsed in only four of the total 18 themes: avoidance of social situations (others intoxicated; 15.29%), substance use avoidance (others intoxicated; 12.71%), peer influence (close peer; 17.86%), and self-awareness (mixed genders; 11.42%). Multiple contexts were endorsed equally often in two themes: other substance use (other, friend’s house, and at a party; 13.33%) and awareness of physical surroundings (at a bar/club and with others who are intoxicated; 11.11%).

While the most frequently endorsed theme overall was drink content for both women and men (8.92% and 9.38% of total responses, respectively), there was little additional overlap in theme endorsement by gender. Across the total sample, the second and third most endorsed themes by women were social support (7.96%) and self-awareness (5.35%), while men endorsed engage in other activities (6.18%) and alcohol consumption behavior (5.31%). Comprehensive frequencies and counts of theme endorsement across contexts and by gender are provided in Tables 2, 3, and 4.

Table 2.

Frequency of endorsement of PBS by theme for the overall sample and by self-reported gender.

Category	Theme	Across Total Sample						Within Theme1
		Overall		Female		Male		Female	Male
		n	%	n	%	n	%	%	%
Avoidance	Substance use avoidance	181	8.28	105	4.80	76	3.48	58.01	41.99
	Remove self from situation	136	6.22	74	3.39	62	2.84	54.41	45.59
	Avoidance of social situations	85	3.89	51	2.33	34	1.56	60.00	40.00
	Avoidance of environments	19	0.87	9	0.41	10	0.46	47.37	52.63
Social Influence	Social support	268	12.26	174	7.96	94	4.30	64.93	35.07
	Peer influence	28	1.28	8	0.37	20	0.91	28.57	71.43
Limiting Alcohol Consumption	Drink content	400	18.30	195	8.92	205	9.38	48.75	51.25
	Alcohol consumption behavior	193	8.83	77	3.52	116	5.31	39.90	60.10
Planning Ahead	Predetermined action	98	4.48	42	1.92	56	2.56	42.86	57.14
	Limiting access to alcohol	91	4.16	30	1.37	61	2.79	32.97	67.03
	Reducing adverse health outcomes	36	1.65	21	0.96	15	0.69	58.33	41.67
Awareness	Self-awareness	219	10.02	117	5.35	102	4.67	53.42	46.58
	Awareness of one's physical surroundings	90	4.12	64	2.93	26	1.19	71.11	28.89
	Standard of behavior	17	0.78	5	0.23	12	0.55	29.41	70.59
	Awareness of one's drink	49	2.24	22	1.01	27	1.24	44.90	55.10
	Awareness of time	5	0.23	2	0.09	3	0.14	40.00	60.00
Alternatives to Drinking	Engage in other activities	226	10.34	91	4.16	135	6.18	40.27	59.73
	Other substance use	45	2.06	15	0.69	30	1.37	33.33	66.67

n = 2,186 responses suggesting different PBS. ¹Refers to participant endorsement of protective behavioral strategies included within a given theme across all physical and social contexts.

Table 3.

Frequency of theme endorsement across physical contexts.

Category	Theme	Context
		Home	Friend's House	Party	Bar/Club	Concert/ Sporting Event	Dark/ Loud	Other1
Avoidance	Substance use avoidance	4.97	8.84	8.84	6.63	11.60	7.18	8.29
	Remove self from situation	2.21	4.41	16.18	13.97	5.15	18.38	3.68
	Avoidance of social situations	3.53	3.53	12.94	14.12	7.06	12.94	7.06
	Avoidance of environments	5.26	0.00	0.00	21.05	5.26	57.89	0.00
Social Influence	Social support	6.34	10.45	9.70	8.96	2.99	7.09	7.84
	Peer influence	0.00	10.71	10.71	3.57	0.00	0.00	7.14
Limiting Alcohol Consumption	Drink content	9.75	9.00	7.50	7.25	7.00	5.50	17.00
	Alcohol consumption behavior	10.36	9.33	7.25	7.77	6.22	7.25	11.40
Planning Ahead	Predetermined action	9.18	19.39	6.12	7.14	2.04	3.06	17.35
	Limiting access to alcohol	26.37	9.89	10.99	7.69	7.69	3.30	6.59
	Reducing adverse health outcomes	8.33	11.11	2.78	8.33	2.78	2.78	27.78
Awareness	Self-awareness	5.94	5.02	6.85	6.85	5.02	10.50	10.05
	Awareness of one's physical surroundings	7.78	8.89	7.78	11.11	2.22	8.89	7.78
	Standard of behavior	23.53	11.76	0.00	0.00	11.76	0.00	0.00
	Awareness of one's drink	2.04	6.12	8.16	12.24	8.16	14.29	4.08
	Awareness of time	20.00	0.00	0.00	0.00	0.00	60.00	20.00
Alternatives to Drinking	Engage in other activities	20.35	11.06	7.08	4.42	9.73	7.08	6.19
	Other substance use	8.89	13.33	13.33	4.44	8.89	6.67	13.33

n = 2,186 responses suggesting different PBS. ¹Refers to participant responses regarding general PBS use (i.e., no specific context)

Table 4.

Frequency of theme endorsement across social contexts.

Category	Theme	Context
		Close Peer	Safe	Large Group	Others Intoxicated	Mixed Gender	Same Gender
Avoidance	Substance use avoidance	5.52	4.97	9.94	12.71	6.08	4.42
	Remove self from situation	2.21	5.15	10.29	8.09	5.88	4.41
	Avoidance of social situations	2.35	2.35	10.59	15.29	3.53	4.71
	Avoidance of environments	0.00	5.26	0.00	0.00	5.26	0.00
Social Influence	Social support	8.21	6.34	8.96	5.22	9.33	8.58
	Peer influence	17.86	14.29	7.14	10.71	10.71	7.14
Limiting Alcohol Consumption	Drink content	6.50	7.50	5.75	6.75	5.25	5.25
	Alcohol consumption behavior	5.18	5.70	9.33	9.84	4.15	6.22
Planning Ahead	Predetermined action	10.20	6.12	7.14	6.12	2.04	4.08
	Limiting access to alcohol	7.69	2.20	4.40	2.20	4.40	6.59
	Reducing adverse health outcomes	11.11	8.33	5.56	2.78	2.78	5.56
Awareness	Self-awareness	7.31	5.94	8.68	8.22	11.42	8.22
	Awareness of one's physical surroundings	2.22	5.56	10.00	11.11	8.89	7.78
	Standard of behavior	5.88	5.88	5.88	17.65	11.76	5.88
	Awareness of one's drink	6.12	8.16	10.20	2.04	12.24	6.12
	Awareness of time	0.00	0.00	0.00	0.00	0.00	0.00
Alternatives to Drinking	Engage in other activities	8.41	4.42	4.87	1.77	6.19	8.41
	Other substance use	4.44	2.22	6.67	8.89	4.44	4.44

n = 2,186 responses suggesting different PBS.

Discussion

This study sought to describe protective behavioral strategies to reduce alcohol-related harms that young adults currently report using across various contexts. Results identified PBS that differed in content, phrasing, or structure of PBS included in scales assessed in this study (7,21,22). Further, use of these strategies varied by gender and across social and physical drinking contexts which offer further insight into PBS utilization by young adults today.

Participants endorsed engagement in several strategies which diverged conceptually from PBS captured by scales assessed in this study (7,21,22). For example, participants identified strategies related to adhering to a personal code of conduct (e.g., have a personal standard of behavior) or tailoring one’s drinking habits to reflect present company (e.g., child present) highlight the importance of portraying positive outward appearances while consuming alcohol among some young adults. Further, suggested strategies to reduce alcohol-related consequences indicated shifts in young adults’ perceptions of harm reduction which may reflect broader social changes. For example, young adults endorse utilizing current technologies for PBS (e.g., watch event online; using Rideshare companies for safe transportation). Therefore, researchers and practitioners should consider adapting current PBS scales to reflect technological advancements that young adults regularly employ in their daily lives (25).

In alignment with previous work (20), many PBS were inherently tied to physical and social context. This ranged from examples where a physical context’s presence or absence was the strategy itself (e.g., stay home, leave location) to PBS which were reliant upon environment (e.g., don’t keep alcohol at home). Several bar-specific PBS encouraged involving the bartender in one’s drinking choices (e.g., tell bartender you’re driving). Such strategies support the utility of responsible beverage service training as a component of evidence-based interventions targeting the drinking environment (26,27). Several identified PBS highlight the importance of planned behaviors to reduce alcohol-related consequences in unanticipated physical contexts. Participants endorsed strategies such as have an exit plan and keep phone charged, indicating that young adults view planning for the drinking environment as a meaningful way to prevent future harms. This aligns with previous work demonstrating the relationship between drinking intentions, plans to engage in PBS, and actual PBS use (28-30).

Social context was also important as involving others in one’s use of PBS was a key theme in the data. Several strategies related to social support differed from existing PBS in their emphasis on the reciprocal nature of drinking-related support for harm reduction. Specifically, looking out for the safety of others was suggested as a means of protecting oneself from alcohol-related consequences (e.g., be the designated driver, ensure others are safe). This differs in the direction of support from current PBS (e.g., use a designated driver), and points to a more nuanced, bidirectional framing for these strategies. Respondents also endorsed willingness to engage in strategies which emphasized multiple dimensions of personal safety for various social contexts. Young adults suggested taking additional steps to minimize drink-related tampering (e.g., keep a lid on your drink) and cultivate feelings of safety (e.g., drink with trusted people). Such strategies were especially useful for women, who endorsed themes emphasizing personal safety (e.g., substance use avoidance, awareness of physical surroundings) more often than men. These findings are consistent with past research linking women’s elevated sexual assault risk in drinking settings (31) and their increased likelihood of utilizing PBS directed toward those harms (32). However, it is important to note that recent work has found women drink more when employing sexual assault risk reduction PBS in drinking settings (33), signaling a need for nuanced approaches when incorporating serious harm reduction PBS in prevention efforts aimed at women. Concerningly, some young adults endorsed strategies which reflect the social context in ways that may exacerbate alcohol-related consequences. Strategies related to peer influence (e.g., keep pace with friends) were popular among men, which is concerning given previous research suggesting greater conformity to male social norms leads to less PBS use (34). Given the differing ways alcohol impacts the body, making drinking decisions based on peers’ behaviors may not be protective for individuals. Further, some young adults endorsed other substance use as an alternative to drinking (e.g., smoke weed), particularly in social settings such as a party. While several studies have posited that substituting cannabis for alcohol may be useful as a harm reduction approach (35,36), other work has documented increased negative consequences associated with simultaneous alcohol and cannabis use (37) and adverse health effects of cannabis use in general (38). Thus, there is an ongoing need to counter or dispel such misperceptions about alcohol-related behaviors among young adults.

Several limitations of this research should be noted. The adapted 26-item list of PBS used in this study drew from widely utilized PBS scales (7,21,22); however, it is possible that strategies named here may be addressed in other existing harm reduction scales. Given the repeated nature of the open-ended question (i.e., once generally and across 12 distinct contexts), participants may have misunderstood question and provided a strategy mentioned in the survey, thus potentially causing differing strategies to go unreported. Thematic organization of final codes was assessed in the context of all included strategies; consequently, it is possible that some codes may apply across themes or categories. The cross-sectional study design necessitated asking participants to suggest additional strategies they would engage in, which may differ from the strategies they actually employ. Intensive longitudinal data, such as that collected by ecological momentary assessment (39), would be beneficial to more accurately capture specific strategies used by young adults in various physical and social drinking contexts.

Conclusions

This study described self-reported PBS employed by young adults across drinking contexts. We found that young adults use a wide range of strategies, some of which are conceptually distinct from currently used PBS measures. For other reported PBS that are related to current items, young adults report nuanced use that varies by gender and across physical and social contexts. Interventions that employ alcohol protective behavioral strategies should consider adaptations to reflect young adults’ current drinking patterns and environments.