Abstract
Purpose
The aim of the study was to determine the prevalence of hazardous alcohol consumption (HAC) according to gender among university students and associated factors.
Methods
This is a cross-sectional study conducted on undergraduate students. We used a stratified sampling technique to represent 26036 students from all grade levels and 11 faculties, and the survey was administered to 2349 undergraduate students. The prevalence of HAC was determined with the Alcohol Use Disorders Identification Test (AUDIT). HAC was defined as getting 8 points or more from the AUDIT. Multivariate logistic regression analyses were performed to examine HAC related factors in both genders.
Results
In this study, 53.2% of the participants were male. The prevalence of HAC in the study group was 13.5% and prevalence of lifetime drinker was 65.3%. In males; those whose fathers [OR = 1.72; 95% CI: (1.17-2.52)], mothers [1.49; (1.02-2.18)], close friends [2.42; (1.28-4.60)] drink alcohol and smoking [3.16; (2.09- 4.77)], use illicit substance [2.35; (1.66-3.34)], have mental health problems [1.65; (1.04-2.62)] were more likely to report HAC. Meanwhile in females, those whose fathers [OR = 1.92; 95%CI: (1.03-3.57)], close friends [5.81; (1.73-19.45)] drink alcohol and smoking [4.33; (2.31-8.15)], use illicit substance [4.34; (2.34-8.06)] have mental health problems [3.01; (1.67-5.43)] were more likely to report HAC.
Conclusions
HAC prevalence is high among university students. The risk of HAC increases with the use of alcohol in family and circle of friends, smoking, illicit substance use and mental health problems. The factors associated with the risk of HAC in both genders are similar.
Keywords: AUDIT, Epidemiology, Hazardous alcohol consumption, University students, Sociodemographic factors
Introduction
In many cultures, drinking alcohol is seen as a pleasurable activity that has numerous cultural and social aspects in addition to personal biological and psychological components [1, 2]. As it is legal, unlike other addictive substances, its negative effects are as widespread as its consumption, making it a serious public health problem [2]. The harmful use of alcohol has been linked to the risk of more than 200 diseases and injuries, including non-communicable diseases, some cancers, mental and behavioural disorders, accidents and violence [2, 3]. According to the World Health Organisation’s (WHO) Global Status Report on Alcohol and Health 2018, an estimated 5.3% of deaths worldwide (approximately 3 million deaths per year) and 5.1% of disability-adjusted life years (DALYs) are attributable to alcohol [2]. The proportion of all deaths caused by alcohol rises to up to 13.5% in the 20to 39 age group [4].
According to the WHO, 44.5% of the world’s population drank alcohol last year [2]. It is estimated that around 2.3 billion people in the world consume alcohol and that on average 6.4 L of pure alcohol are consumed per capita [4]. According to the WHO, Turkey, where 89.1% of the population does not drink alcohol, appears to be the country with the lowest alcohol consumption in the WHO European region, with an average per capita consumption of pure alcohol of around one third of the global average. Although this amount is far below the global average, the amount of pure alcohol per capita of alcohol drinkers in Turkey is estimated at 28.5 L, while the average amount of pure alcohol per capita in the European region, where alcohol consumption is highest, is 17.2 L [2]. According to the 2015 OECD (Organisation for Economic Co-operation and Development) report Tackling Harmful Alcohol Use Economics and Public Health Policy, alcohol is consumed intensively by the 20% of the population who drink the most [5]. This fact emphasises how important the patterns of alcohol drinking are in addition to the quantity of alcohol consumed.
Alcohol drinking patterns can occur in a spectrum ranging from hazardous and harmful alcohol consumption to heavy and intensive alcohol consumption and alcohol use disorders including alcohol dependence [6, 7]. The prevalence of alcohol use disorders in the European region for the general population aged 15 years and older was reported to be 8.8%, while in Turkey it is estimated to be 1.7% in women and 8.1% in men [2]. azardous alcohol consumption (HAC) is defined as a repetitive drinking pattern that does not fulfil the criteria for alcohol use disorder or dependence but carries the risk of causing harmful consequences for the drinker or others [6]. Epidemiological studies show that most physical, social and psychological problems associated with alcohol consumption occur in drinkers who are not defined as dependent [6].
The period between the ages of 18 and 25, also known as emerging adulthood, lies between adolescence and early adulthood and is a developmental transition period with unique characteristics [8]. During this period, which also includes the university education phase, different lifestyles and values are learnt and experienced. It is known that risky behaviours can be tolerated and even encouraged during this period as freedom and peer contact increase and social control decreases [9]. It is known that lifetime prevalence and related problems with alcohol drinking, smoking and illicit substance use peak in young adulthood [9, 10]. Epidemiological studies have shown that the frequency and quantity of alcohol drinking and HAC patterns are more common in university students than in their non-university peers [11–14]. Due to the social acceptance of alcohol drinking among university students as part of the university culture, HAC patterns among university students may be underestimated and overlooked [15].
Although patterns of alcohol drinking vary from country to country and from culture to culture, gender is one of the most important sources of heterogeneity within populations in terms of alcohol drinking and related problems [16, 17]. It is known worldwide that men are more prone to alcohol consumption, consume more alcohol than women and are more affected by the subsequent negative consequences [1, 2, 16]. However, it has been reported that the gender gap in indicators of alcohol drinking and associated harms tends to narrow significantly, especially in the young adult age group [18]. Although the same situation was observed in studies conducted among university students, it is noteworthy that high levels of alcohol consumption were found in both genders [19, 20]. In many countries, hazardous or harmful alcohol consumption patterns remain the biggest problem of substance misuse during university life [20, 21].
The aim of the study was to determine the prevalence of hazardous alcohol consumption (HAC) according to gender among university students and associated factors.
Methods
This study is a cross-sectional study performed on undergraduate students at a university in Eskisehir, a province in the north-west of Turkey in the Central Anatolia region, during the 2019–2020 academic year, i.e. before the COVID-19 pandemic. The province of Eskisehir is home to over 70 thousand students from three universities.
Eskisehir Osmangazi University (ESOGU) was founded in 1970 and today has 12 faculties, 2 colleges, 5 vocational schools, 4 institutes and 32 application and research centres. The research population consists of 26,036 students receiving formal education in undergraduate programmes of 4 or more years [22, 23]. The sample size was calculated with a 95% confidence interval and a 2% margin of error to 2,198 individuals, assuming a 50% prevalence of HAC. Each faculty was considered as a stratum and the number of students to be included in the sample from each faculty was determined taking into account the weights of the strata. To account for loss of data due to incomplete forms and inappropriate responses, it was planned to include 2,400 students in the study.
Administrative and ethical approval (E122483, 22.10.2019) was obtained to conduct the study. Appropriate days and times for data collection were determined together with the faculty administrators, and students were required to assemble in their classrooms prior to data collection. The prepared questionnaires were completed by the students under observation in about 10–15 min. The study group consisted of 2349 students who agreed to participate in the study and answer the questionnaires.
A questionnaire was created for data collection in the study using the literature [20, 24, 25]. The questionnaire consisted of two parts. The first part included some sociodemographic characteristics (age, gender, place of residence, income situation, etc.) and some factors thought to be related to HAC (alcohol consumption by parents or close friends, smoking and illicit substance use, etc.). The second part of the questionnaire consisted of the Alcohol Use Disorder Identification Test (AUDIT).
The AUDIT, developed by WHO and Babor et al., consists of 10 questions including alcohol drinking habits, alcohol consumption and problems caused by alcohol drinking [26]. The scores achievable with the scale range from 0 to 40, and scores of 8 and above are defined as “HAC” [27]. The scale was adapted into Turkish by Saatcioglu et al. in 2002 [28].
In the study, the alcohol consumption status of the individuals was categorized as follows; those who have experienced alcohol at least once in their lives were classified as “lifetime drinkers”, those who had never consumed alcohol were classified as “lifetime abstainers”, ”, those who stated that they had drunk alcohol at least once in the past year were classified as “current drinkers” and those who stated that they had consumed alcohol but had stopped in the past year were classified as “former drinkers” [29]. .
Students who regularly smoked at least 1 conventional cigarette and heated tobacco products per day were considered as"smokers” [30]. Smoking status was categorized into three groups (never, former or current smoker) based on participants’ responses. Illicit substance use status was categorized into three groups (never, former, or current user) based on participiants’ response on illicit substance. The academic achievement status of the students was evaluated as “lower than average”, “average” and “higher than average” according to their own perceptions. In order to obtain realistic results in the evaluation of illicit substance use, a fake substance named “relactin” was added and 17 individuals who stated that they used this substance were not included in the study [31].
The data were then transferred to the computer and analysed using the SPSS 15.0 (Statistical Program in Social Sciences, SPSS Inc., Chicago, IL, USA). The students were divided into two groups according to their HAC for both genders. In the statistical evaluation of the data, descriptive data were given as number, percentage, mean and standard deviation. In the first step in the statistical evaluation of the data, the relationships between sociodemographic and related factors and HAC were evaluated using Chi-square analysis. The relationships found to be significant in the univariate analyses were then re-evaluated using the Multivariate Logistic Regression model for both gender groups. p values < 0.05 were considered statistically significant.
Results
Of the 2,349 students who participated in the study, 1,250 (53.2%) were male and 1099 (46.8%) were female. The age of the study group ranged from 18 to 35 years, with a mean (SD) of 21.04 (2.07) years. While 1,147 (48.8%) of the students participating in the study were studying in Natural/Engineering Sciences, 682 (29.0%) were in fourth grade and above. The distribution of the sample by gender and some socio-demographic characteristics is presented in Table 1.
Table 1.
Sociodemographic Characteristics of the study group
| % (n) | Male % (n) | Female % (n) | ||
|---|---|---|---|---|
| Gender | ||||
| Male | 53.2 (1,250) | |||
| Female | 46.8 (1,099) | |||
| Age | ||||
| ≤ 19 | 22.4 (526) | 18.3 (229) | 27.0 (297) | |
| 20–21 | 42.7 (1,002) | 41.5 (519) | 43.9 (483) | |
| ≥ 22 | 35.0 (821) | 40.2 (502) | 29.0 (319) | |
| Faculty | ||||
| Education Sciences | 16.9 (397) | 11.0 (137) | 23.7 (260) | |
| Natural / Engineering Sciences | 48.8 (1,147) | 56.1 (701) | 40.6 (446) | |
| Health Sciences | 14.0 (330) | 10.6 (133) | 17.9 (197) | |
| Social/Humanities | 20.2 (475) | 22.3 (279) | 17.8 (196) | |
| Year of study | ||||
| 1th | 23.9 (561) | 22.8 (285) | 25.1 (276) | |
| 2th | 23.3 (546) | 22.6 (283) | 23.9 (263) | |
| 3th | 23.8 (560) | 23.6 (295) | 24.1 (265) | |
| 4th and above | 29.0 (682) | 31.0 (387) | 26.8 (295) | |
| Status of residence | ||||
| With the family | 19.7 (463) | 18.5 (231) | 21.1 (232) | |
| With his friend | 62.0 (1,456) | 58.3 (729) | 66.2 (727) | |
| Alone | 18.3 (430) | 23.2 (290) | 12.7 (140) | |
| Academic achievement status | ||||
| Lower than average | 11.1 (261) | 13.0 (162) | 9.0 (99) | |
| Average | 63.4 (1,490) | 61.3 (767) | 65.8 (723) | |
| Higher than average | 25.5 (598) | 25.7 (321) | 25.2 (277) | |
| Income situation | ||||
| Low | 8.9 (210) | 11.5 (144) | 6.0 (66) | |
| Medium | 57.5 (1,350) | 56.2 (702) | 59.0 (648) | |
| High | 33.6 (789) | 32.3 (404) | 35.0 (385) | |
| Smoking | ||||
| Never smoker | 49.2 (1,155) | 39.7 (496) | 60.0 (659) | |
| Current and former smoker | 50.8 (1,194) | 60.3 (754) | 40.0 (440) | |
| Illicit substance use | ||||
| Never used | 87.5 (2,055) | 81.9 (1,024) | 93.8 (1,031) | |
| Current and former user | 12.5 (294) | 18.1 (226) | 6.2 (68) | |
| Physician diagnosed any mental health problem | ||||
| None | 90.0 (2,114) | 90.7 (1,134) | 89.2 (980) | |
| Present | 10.0 (235) | 9.3 (116) | 10.8 (119) | |
In the study group, 53.2% of female students and 69.8% of male students stated that they current drinkers (p < 0.001). While 25.5% of male students reported a lifetime abstinence form alcohol consumption, this prevalence was 45.2% for female students (p < 0.001). The distribution of the alcohol drinking status of the students in the study group according by gender is presented in Graph 1.
Graph 1.
Distribution of alcohol consumption status of the research group by gender
HAC was detected in 317 (13.5%) students in the study group. The prevalence of HAC was 18.8% in male students and 8.2% in female students. The prevalence of HAC was significantly higher in male and female students who lived alone at home, smokers, used illicit substances, and had any mental health problems. The prevalence of HAC was higher in both gender among those whose mother, father and close friend consumed alcohol. The prevalence of HAC was lower among those with medium income in terms of both genders. Among male students, the prevalence of HAC was higher among those studying in Social/Humanities than those studying in Natural/Engineering and Education Sciences. Among female students, the prevalence of HAC was lower among those studying in Educational Sciences compared to those studying in other faculties. The distribution of the prevalence of HAC according to the socio-demographic characteristics and lifestyle factors of the students is presented in Table 2.
Table 2.
Distribution of frequency of HAC according to sociodemographic characteristics and lifestyle factors of students
| Male n = 1250 (53.2%) | p | Female n = 1099 (46.8%) | p | ||
|---|---|---|---|---|---|
| HAC | |||||
| Present | 227 (18.2) | < 0.001 | 90 (8.2) | < 0.001 | |
| Age | |||||
| ≤ 19 | 34 (14.8) | 0.051 | 20 (6.7) | 0.225 | |
| 20–21 | 86 (16.6) | 37 (7.7) | |||
| ≥ 22 | 107 (21.3) | 33 (10.3) | |||
| Faculty | |||||
| Education Sciences | 17 (12.4) | 5 (1.9) | |||
| Natural / Engineering Sciences | 115 (16.4) | 0.009 | 46 (10.3) | p < 0.001 | |
| Health Sciences | 28 (21.1) | 20 (10.2) | |||
| Social/Humanities | 67 (24.0) | 19 (9.7) | |||
| Year of study | |||||
| 1th | 47 (16.5) | 0.788 | 18 (6.5) | 0.219 | |
| 2th | 56 (19.8) | 18 (6.8) | |||
| 3th | 53 (18.0) | 22 (8.3) | |||
| 4th and above | 71 (18.3) | 32 (10.8) | |||
| Status of residence | |||||
| With the family | 34 (14.7) | p < 0.001 | 15 (6.5) | p < 0.001 | |
| With his friend | 127 (17.4) | 49 (6.7) | |||
| Alone | 66 (22.8) | 26 (18.6) | |||
| Academic achievement status | |||||
| Lower than average | 37 (22.8) | 0.223 | 10 (10.1) | 0.247 | |
| Average | 131 (17.1) | 52 (7.2) | |||
| Higher than average | 59 (18.4) | 28 (10.1) | |||
| Income situation | |||||
| Low | 33 (22.9) | 0.021 | 9 (13.6) | 0.030 | |
| Medium | 109 (15.5) | 42 (6.5) | |||
| High | 85 (21.0) | 39 (10.1) | |||
| Smoking | |||||
| Never smoker | 33 (6.7) | p < 0.001 | 14 (2.1) | p < 0.001 | |
| Current and former smoker | 194 (25.7) | 76 (17.3) | |||
| Illicit substance use | |||||
| Never used | 139 (13.6) | p < 0.001 | 61 (5.9) | p < 0.001 | |
| Current and former user | 88 (38.9) | 29 (42.6) | |||
| Physician diagnosed any mental health problem | |||||
| None | 187 (16.5) | p < 0.001 | 64 (6.5) | p < 0.001 | |
| Present | 40 (34.5) | 26 (21.8) | |||
| Alcohol consumption by the mother | |||||
| None | 142 (14.6) | p < 0.001 | 50 (5.8) | p < 0.001 | |
| Present | 85 (30.4) | 40 (17.1) | |||
| Alcohol consumption by the father | |||||
| None | 62 (10.5) | p < 0.001 | 20 (3.6) | p < 0.001 | |
| Present | 165 (25.0) | 70 (12.8) | |||
| Alcohol consumption by the close friends | |||||
| None | 12 (4.8) | p < 0.001 | 3 (0.7) | p < 0.001 | |
| Present | 215 (21.5) | 87 (12.7) | |||
A multivariate logistic regression model was constructed with the factors influencing HAC in terms of both genders (faculty of education, status of residence, income situation, smoking, illicit substance use status, physician diagnosed any mental health problem, alcohol consumption of mother, father and close friend) in the study group.
According to the results of the logistic model, the risk of HAC among male students increased 3.16 times for smoking [OR = 3.16; 95%CI: (2.09–4.77)], 2.35 times for illicit substance use [2.35; (1.66–3.34)], 1.65 times for any mental health problem diagnosed by a physician [1.65; (1.04–2.62)], 1.72 times for father’s alcohol consumption [1.72; (1.17–2.52)] and 2.42 times for close friend’s alcohol consumption [2.42; (1.28–4.60)]. The risk of HAC among female students was 4.33 times higher for smoking [4.33; (2.31–8.15)], 4.34 times higher for illicit substance use [4.34; (2.34–8.06)], 3.01 times higher for any mental health problem diagnosed by a physician [3.01; (1.67–5.43)], 1.92 times higher for father’s alcohol consumption [1.92; (1.03–3.57)] and 5.81 times higher for close friend’s alcohol consumption [5.81; (1.73–19.45)]. Mother’s alcohol consumption did not show a significant association with HAC in female students, whereas the risk of HAC increased 1.49 times in male students [1.49; (1.02–2.18)]. Faculty of study, status of residence and income situation were found to be unrelated to HAC in both genders. The multivariate logistic regression model analysis of the risk factors associated with HAC in male and female students is presented in Table 3.
Table 3.
Multivariate logistic regression analysis of risk factors associated with students’ HAC
| Male | Female | |||||||
|---|---|---|---|---|---|---|---|---|
| HAC % | OR | 95% CI | p | HAC % | OR | 95% CI | p | |
| Faculty | ||||||||
| Education Sciences | 12.4 | 1.00 | 0.063 | 1.9 | 1.00 | 0.192 | ||
| Natural / Engineering Sciences | 16.4 | 1.19 | 0.66–2.15 | 10.3 | 2.75 | 1.02–7.45 | ||
| Health Sciences | 21.1 | 1.73 | 0.85–3.54 | 10.2 | 3.21 | 1.10–9.42 | ||
| Social/Humanities | 24.0 | 1.82 | 0.98–3.40 | 9.7 | 2.71 | 0.93–7.89 | ||
| Status of residence | ||||||||
| With the family | 14.7 | 1.00 | 6.5 | 1.00 | 0.478 | |||
| With his friend | 17.4 | 1.23 | 0.79–1.93 | 0.557 | 6.7 | 1.04 | 0.53–2.05 | |
| Alone | 22.8 | 1.30 | 0.79–2.14 | 18.6 | 1.48 | 0.67–3.27 | ||
| Income situation | ||||||||
| Low | 22.9 | 1.00 | 13.6 | 1.00 | ||||
| Medium | 15.5 | 0.76 | 0.47–1.23 | 0.490 | 6.5 | 0.71 | 0.28–1.76 | 0.463 |
| High | 21.0 | 0.87 | 0.53–1.44 | 10.1 | 0.96 | 0.38–2.45 | ||
| Smoking | ||||||||
| Never smoker | 6.7 | 1.00 | < 0.001 | 2.1 | 1.00 | < 0.001 | ||
| Current and former smoker | 25.7 | 3.16 | 2.09–4.77 | 17.3 | 4.33 | 2.31–8.15 | ||
| Illicit substance use | ||||||||
| Never used | 13.6 | 1.00 | < 0.001 | 5.9 | 1.00 | < 0.001 | ||
| Current and former user | 38.9 | 2.35 | 1.66–3.34 | 42.6 | 4.34 | 2.34–8.06 | ||
| Physician diagnosed any mental health problem | ||||||||
| None | 16.5 | 1.00 | 0.032 | 6.5 | 1.00 | < 0.001 | ||
| Present | 34.5 | 1.65 | 1.04–2.62 | 21.8 | 3.01 | 1.67–5.43 | ||
| Alcohol consumption by the mother | ||||||||
| None | 14.6 | 1.00 | 0.037 | 5.8 | 1.00 | 0.858 | ||
| Present | 30.4 | 1.49 | 1.02–2.18 | 17.1 | 0.95 | 0.54–1.67 | ||
| Alcohol consumptionb by the father | ||||||||
| None | 10.5 | 1.00 | 0.006 | 3.6 | 1.00 | 0.038 | ||
| Present | 25.0 | 1.72 | 1.17–2.52 | 12.8 | 1.92 | 1.03–3.57 | ||
| Alcohol consumption by the close friends | ||||||||
| None | 4.8 | 1.00 | 0.007 | 0.7 | 1.00 | 0.004 | ||
| Present | 21.5 | 2.42 | 1.28–4.60 | 12.7 | 5.81 | 1.73–19.45 | ||
Discussion
In the study, while most of the university students in the study were current drinkers, the prevalence among male students reached worrying levels. While HAC is found in one in five students who current drinker, the gender gap remains. Similar factors had an influence on the HAC of male and female students. Students’ mental health status, smoking and illicit substance use habits, and the drinking habits of their social and close circle were associated with the prevalence of HAC among students.
In the study, about three out of five students (61.6%) were current drinkers. While the prevalence among men was 69.8%, 52.3% of women were current drinkers. An international study on the alcohol use of university students from 21 countries found that, despite large differences between countries, the prevalence of current drinkers ranged between 29 and 95%, with a higher prevalence among men [32]. In various studies, the prevalence of current alcohol consumption among university students; while it is 77.6% in the USA [33], 90% in Australia [34], 92% in the UK [35] and it rises to 95% in Northern European countries in particular [32]. It is also reported that the gender gap in the prevalence and amount of alcohol consumption in Northern European countries and the United Kingdom have narrowed or even disappeared [36]. Stock et al. in their study of university students from various European countries, it was reported that the frequency of occasionally or not drink alcohol was highest among Turkish students [37]. Various studies conducted in Turkey have shown that the prevalence of current drinkers among university students varies between 34.1 and 59.9%, with a higher prevalence among men [38–42]. The lifetime prevalence of alcohol among Turkish university students has been reported to vary between 46.1 and 76.2/63.3% [38, 40, 43–45] and in our study it was found to be 65.3%. In Turkey, where cultural diversity is high, alcohol drinking is more common among university students in the west of the country due to the influence of socio-economic and socio-cultural regional differences [43, 46], although the prevalence of current drinkers in the west is over 50% [41, 42]. The regional characteristics of the city in which the study was conducted, the socialisation opportunities for students and the social acceptance of alcohol drinking may have affected the prevalence of drinking among the students in the study.
Although most students in the study were current drinkers, HAC was found in 13.5% of students, and the prevalence increased to 22% among students who were current drinkers. HAC was more common among male students (18.2%) than female students (8.2%). Although difficult to compare the results obtained in this study with previous studies due to the different definitions of risky/hazardous alcohol consumption, the Cut-down, Annoyed, Guilty and Eye-opener (CAGE) questionniare and the AUDIT screening tool are the two most commonly used standardised measurement instruments used in the screening of problematic alcohol consumption (risky or hazardous patterns of alcohol consumption) [20]. In the study conducted by Cooke et al. among university students from various European countries, it was found that 37% of students were positive on AUDIT (8 or more), with a higher prevalence in men [47]. While a gender gap was found in various studies [34, 48, 49] using the AUDIT, HAC is 11.4% in Ethiopian university students [50], 16.9% in Spanish university students [49] and 34% in Australian university students [34], while reaches 60% in university students form UK [35, 47] and Northern European countries [19, 47]. However, some studies using the AUDIT have reported that HAC is much more common among university students in Northern European countries and UK and that the gender gap is closing [20, 51].
In various studies using the AUDIT in Turkey, the prevalence of HAC among university students, although higher in the west, varies from 4.5 to 22.2%, and it has been reported to be more common in males [39, 42, 44, 52]. In studies in which problematic alcohol consumption among Turkish university students is assessed with CAGE (2 or more), the prevalence of risky alcohol consumption/drinking varies between 7.4% and 15.3% [38, 40, 43, 45]. In the study by Sebena et al. in which risky consumption was assessed with CAGE (+ 2 points) among university students from various European countries, it was reported that the prevalence was between 11.8% and 22.1% [53]; while in another international study the lowest prevalence of risky alcohol consumption was found among Turkish female students (8%) [37]. Although the prevalence in the study did not reach the level of European and US university students, around one in five students who consumed alcohol met the HAC threshold. But even though problematic alcohol consumption such as HAC is not widespread among university students, it is known that the majority of students are harmed by their own consumption or that of other students [34, 54]. Gender differences in risky/hazardous alcohol consumption are expected to be greatest in countries where there are restrictions on women’s behaviour and gender inequalities in daily life [55]. The gender gap in HAC among the students in the study could be due to socio-cultural factors, such as the fact that alcohol consumption by women in Turkey is less socially accepted compared to men, that women are more sensitive to social acceptance and that men are more competitive in risky behaviour.
Although adolescence and emerging adulthood are risky phases for starting substance use, smoking and alcohol use generally begin before the use of illicit substances [56]. In our study, around one in two students stated that they smoker and one in ten students reported that they had experience with illicit substances use. While smoker was the factor that increased HAC among male students the most (3.2 times), smoking and illicit substance use increased HAC among female students more than four times. It is known that there is a complex relationship between tobacco and alcohol use which depends on both social and pharmacological factors [57] and that smoking in emerging adulthood is also prospectively associated with higher alcohol consumption [58]. It has also been shown that the co-occurence of smoking and drinking [59] and even non-daily smoking increases the risk of HAC [60]. In a systematic review of studies conducted on university students from various European countries, a strong association was found between the frequency and quantity of alcohol drinking and smoking, while students with high alcohol consumption were reported to be more likely to use illicit substances [36]. Various studies have shown that the prevalence of HAC is higher among university students who smoking and/or illicit substance use [19, 35, 50, 61]. A similar relationship was found in various studies among university students in Turkey [42, 44, 52]. Although risky behaviours are common among emerging adulthood, it is known that smoking and alcohol, which are legal and easily accessible substances, increase the risk of abuse of each other and other illicit substances. The possibility of other substance use problems in students with HAC should not be ignored.
Young adults are similar to their close friends or peers in terms of alcohol use, and it is known that peer norms have a strong influence on risky behaviours such as alcohol drinking [62]. In the study, although alcohol drinking by close friends is one of the factors influencing HAC among students of both genders, it is the factor that increases the risk of HAC the most among female students (5.8 times). University students are more influenced by the alcohol drinking they perceive among their close friends than by the drinking of their other peers at the university [63]. Our result is in line with various studies that show that the alcohol drinking of close friends or the circle of friends has an influence on the risky/hazardous alcohol consumption of students [36, 44, 45, 50, 54]. Furthermore, emerging evidence suggests that the influence of peers on an individual’s alcohol drinking in a socio-cultural context can become the norm not only in adolescence and young adulthood, but also in adult [64]. Given the homogeneity of peer groups of university students, it is likely that students have close friends with similar alcohol drinking patterns, which may make the social environment conducive to alcohol drinking. In the study, however it is not possible to make a statement about whether the students’ HAC is influenced by the alcohol drinking of their close friends or whether they choose their close friends based on similarities in their alcohol drinking paterns.
Emerging evidence shows that the alcohol drinking patterns of parents has less influence on the problematic alcohol consumption of adolescents and young adults compared to the influence of peers [62, 65]. In the study found that parental alcohol drinking increases the risk of HAC in students. While the alcohol drinking of both parents has an influence on HAC of male students, the relationship between HAC of female students and the alcohol drinking of the mother disappeared in the multivariate logistic model. It is to be expected that the attitudes and behaviours of parents in relation to alcohol will serve as a reference for the alcohol drinking patterns of university students who take on the role of adults [16, 66]. Although various studies conducted among university students have shown the opposite [38, 43, 50], many studies have reported that parents’ alcohol drinking pattern has an influence on students’ risky/hazardous alcohol consumption [44, 67, 68]. Carey et al. emphasised in their meta-analysis that although the presence of a family history has a minimal influence on alcohol drinking among students, the presence of a family history can increase the risk of students developing alcohol-related problems [67]. Although the result of our study is consistent with the literature, the fact that we could not find any influence of maternal alcohol drinking on the HAC of the female students could be due to the small number of drinker mothers who, according to the students in the sample.
Finally, another important variable that increases the risk of HAC among the students in the study is the presence of a diagnosed mental health problem. Our study found that HAC was 1.6 times more common in male students with mental health problems and 3.0 times more common in female students. In addition to emerging adulthood a risk period for mental health problems [69], but starting university can also pose a risk to people’s mental health during this time [70]. Poor mental health is known to fueling the risk of drinking and problematic alcohol consumption [71], and the emphasis on the prevalence and severity of mental health problems among university students should also be considered in this regard [72, 73]. Various studies conducted among university students also support our conclusion by showing a link between mental health problems and risky/hazardous alcohol consumption [42, 48, 52, 53, 61]. Among university students, the fact that health-risk behaviours tend to cluster among students with poor mental health [74] may explain the association in our study.
Strengths and weaknesses
The strengths of the study are the use of an internationally recognised screening tool whose validity and reliability have been previously verified to objectively detect HAC among university students and the use of a large sample of university students with a stratified sampling method. Although the variations in the definition of risky/hazardous alcohol consumption in studies conducted among university students in Turkey and worldwide lead to differences in prevalence, the results can be considered comparable in terms of the factors that may be related to it. In our study, when defining HAC in the AUDIT screening tool, we favoured the threshold of AUDIT 8 points and above, which has been frequently reported in previous studies, to facilitate the comparability of our results. However, the interpretation of our results could have changed if we had chosen to define HAC using other thresholds. The cross-sectional design of the study does not show a causal relationship, and the fact that the sample is limited to a single university makes it impossible to generalise the results. Another limitation of the study is the fact that the information provided by the students is based on recall and self-reporting. The fact that students who did not agree to participate in the study and absent students were not included in the sample may have led to a slight underestimation of HAC. We also have no reason to believe that those who were not in class on the day of the survey and did not respond to the survey had less HAC. This study is one of the rare studies to examine risky/hazardous alcohol consumption among university students, which is a current issue in many countries, among Turkish university students using a large sample, although it is limited to a single university.
Conclusion and suggestions
In this study, age, years of study, income situation, status of residence, faculty, and academic achievement of students were found to be no significant difference to report HAC in both genders. In the study, the prevalence of HAC, which entails social, physical and psychological risks in the short and long term, did not reach the level of European and US students. However, while three in five university students are current drinkers, one in five students who drink have HAC, indicating that the prevalence is not low. While the prevalence among male students is more notable, the gender gap remains among Turkish students. However, similar factors had an impact on the HAC of male and female students. Students’ mental healths, smoking and illicit substance use habits, and the drinking habits of their social and close circle increased the risk of HAC among students. Given the negative consequences of alcohol drinking, screening for problematic alcohol consumption among university students, an at-risk group, is of great importance for planning effective prevention and education measures and for early detection. We emphasise that other substance use problems may also exist when planning interventions to address student alcohol use and that it is important not to ignore mental health and perceived alcohol drinking among peers. In addition, intervention programmes involving parents can be useful to prevent risky/hazardous alcohol consumption among university students and raise their awareness.
Acknowledgements
We are grateful to all participants for their contributions to this study.
Author contributions
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by A.A., C.Ç., A.K., M.F.Ö. and S.M. The first draft of the manuscript was written by A.A.and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
No funds, grants, or other support was received.
Open access funding provided by the Scientific and Technological Research Council of Türkiye (TÜBİTAK).
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.WHO (2021) Alcohol: Fact sheet. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/alcohol. Accessed 1 Feb 2022
- 2.WHO (2018) Global Status Report on Alcohol and Health. World Health Organization, Geneva. https://www.who.int/publications/i/item/9789241565639 [Google Scholar]
- 3.Griswold MG, Fullman N, Hawley C et al (2018) Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the global burden of Disease Study 2016. Lancet 392:1015–1035. 10.1016/S0140-6736(18)31310-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Murray CJL, Aravkin AY, Zheng P et al (2020) Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of Disease Study 2019. Lancet 396:1223–1249. 10.1016/S0140-6736(20)30752-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.OECD (2015) Tackling Harmful Alcohol Use Economics and Public Health Policy. OECD publishing. https://www.oecd-ilibrary.org/social-issues-migration-health/tackling-harmful-alcohol-use_9789264181069-en
- 6.Saunders JB, Lee NK (2000) Hazardous alcohol use: its delineation as a subthreshold disorder, and approaches to its diagnosis and management. Compr Psychiatry 41:95–103. 10.1016/S0010-440X(00)80015-2 [DOI] [PubMed] [Google Scholar]
- 7.Babor TF, Higgins-Biddle JC (2001) Brief intervention for hazardous and harmful drinking: a manual for use in primary care. World Health Organization Geneva
- 8.Arnett JJ (2000) Emerging adulthood: a theory of development from the late teens through the twenties. Am Psychol 55:469. 10.1037/0003-066X.55.5.469 [PubMed] [Google Scholar]
- 9.Stone AL, Becker LG, Huber AM, Catalano RF (2012) Review of risk and protective factors of substance use and problem use in emerging adulthood. Addict Behav 37:747–775. 10.1016/j.addbeh.2012.02.014 [DOI] [PubMed] [Google Scholar]
- 10.SAMHSA (2020) Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health. https://www.samhsa.gov/data/
- 11.Slutske WS, Hunt-Carter EE, Nabors-Oberg RE et al (2004) Do College Students drink more Than their Non-college-attending peers? Evidence from a Population-based longitudinal female twin study. J Abnorm Psychol 113:530–540. 10.1037/0021-843X.113.4.530 [DOI] [PubMed] [Google Scholar]
- 12.Hingson R, Heeren T, Winter M, Wechsler H (2005) Magnitude of alcohol-related mortality and morbidity among US college students ages 18–24. Annu Rev Public Health 26:259–279. 10.1146/annurev.publhealth.26.021304.144652 [DOI] [PubMed] [Google Scholar]
- 13.Slutske WS (2005) Alcohol use disorders among US college students and their non–college-attending peers. Arch Gen Psychiatry 62:321–327. 10.1001/archpsyc.62.3.321 [DOI] [PubMed] [Google Scholar]
- 14.Kypri KYP, Cronin M, Wright CS (2005) Do university students drink more hazardously than their non-student peers? Addiction 100:713–714. 10.1111/j.1360-0443.2005.01116.x [DOI] [PubMed] [Google Scholar]
- 15.NİAAA (2022) College Drinking. In: Natl. Inst. Alcohol Abus. Alcohol. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/college-drinking. Accessed 1 Feb 2022
- 16.White A (2020) Gender differences in the Epidemiology of Alcohol Use and Related Harms in the United States. Alcohol Res Curr Rev. 10.35946/arcr.v40.2.01. 40: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Wilsnack RW, Wilsnack SC, Kristjanson AF et al (2009) Gender and alcohol consumption: patterns from the multinational GENACIS project. Addiction 104:1487–1500. 10.1111/j.1360-0443.2009.02696.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Slade T, Chapman C, Swift W et al (2016) Birth cohort trends in the global epidemiology of alcohol use and alcohol-related harms in men and women: systematic review and metaregression. BMJ Open 6:e011827. 10.1136/bmjopen-2016-011827 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Davoren MP, Shiely F, Byrne M, Perry IJ (2015) Hazardous alcohol consumption among university students in Ireland: a cross-sectional study. BMJ Open 5:e006045–e006045. 10.1136/bmjopen-2014-006045 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Davoren MP, Demant J, Shiely F, Perry IJ (2016) Alcohol consumption among university students in Ireland and the United Kingdom from 2002 to 2014: a systematic review. BMC Public Health 16:173. 10.1186/s12889-016-2843-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Järvinen M, Room R (2007) Youth drinking cultures: European experiences vol. 13. Ashgate Publishing, Ltd, Routledge, United Kingdom [Google Scholar]
- 22.Eskisehir Osmangazi University (2021) About The University. In: I.T. Dep. https://www.ogu.edu.tr/en/Icerik/Index/269/tarihce. Accessed 1 Feb 2022
- 23.Eskisehir Osmangazi University (2019) Current Student Enrollment. In: Dir. Student Aff. https://oidb.ogu.edu.tr/Sayfa/Index/25/ogrenci-sayilari. Accessed 1 Feb 2022
- 24.Akfert SK, Cakici E, Cakici M (2009) Cigarette and alcohol use among university students and its relationship with family problems. Anatol J Psychiatry 10:40–47 [Google Scholar]
- 25.Turhan E, İnandı T, Özer C, Akoğlu S (2015) Substance use, violence among university students and their some psychological characteristics. Türkiye Halk Sağlığı Derg 9:33–33. 10.20518/tjph.173053 [Google Scholar]
- 26.Babor TF, Grant M (1989) From clinical research to secondary prevention: International collaboration in the development of the Alcohol disorders Identification Test (AUDIT). Alcohol Health Res World 13:371–374 [Google Scholar]
- 27.Saunders JB, Aasland OG, Babor TF et al (1993) Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction 88:791–804. 10.1111/j.1360-0443.1993.tb02093.x [DOI] [PubMed] [Google Scholar]
- 28.Saatcioglu O, Evren C, Cakmak D (2002) Alcohol Use disorders Identification Test (AUDIT): validity and reliability. Türkiye’de Psikiyatr 4:107–113 [Google Scholar]
- 29.Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG (2001) The alcohol use disorders identification test. World Health Organization Geneva
- 30.Sulsky SI, Fuller WG, Van Landingham C et al (2014) Evaluating the association between menthol cigarette use and the likelihood of being a former versus current smoker. Regul Toxicol Pharmacol 70:231–241. 10.1016/j.yrtph.2014.07.009 [DOI] [PubMed] [Google Scholar]
- 31.Ögel K, Uğuz Ş, Sır A et al (2003) Cannabis Use Prevalence among primary and secondary School children in Turkey. J Depend 4:15–19 [Google Scholar]
- 32.Dantzer C, Wardle J, Fuller R et al (2006) International Study of Heavy drinking: attitudes and sociodemographic factors in University students. J Am Coll Heal 55:83–90. 10.3200/JACH.55.2.83-90 [DOI] [PubMed] [Google Scholar]
- 33.Schulenberg J, Johnston L, O’Malley P et al (2020) Monitoring the Future national survey results on drug use, 1975–2019: Volume II, college students and adults ages 19–60
- 34.Hallett J, Howat PM, Maycock BR et al (2012) Undergraduate student drinking and related harms at an Australian university: web-based survey of a large random sample. BMC Public Health 12:37. 10.1186/1471-2458-12-37 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.O’Neill G, Martin N, Birch J et al (2015) The Drinkers Degree: Risk Taking Behaviours amongst Undergraduate Student Drinkers. J Addict 2015:1–8. 10.1155/2015/965438 [DOI] [PMC free article] [PubMed]
- 36.Wicki M, Kuntsche E, Gmel G (2010) Drinking at European universities? A review of students’ alcohol use. Addict Behav 35:913–924. 10.1016/j.addbeh.2010.06.015 [DOI] [PubMed] [Google Scholar]
- 37.Stock C, Mikolajczyk R, Bloomfield K et al (2009) Alcohol consumption and attitudes towards banning alcohol sales on campus among European university students. Public Health 123:122–129. 10.1016/j.puhe.2008.12.009 [DOI] [PubMed] [Google Scholar]
- 38.Demirbas H (2015) Substance and alcohol use in young adults in Turkey as indicated by the CAGE Questionnaire and drinking frequency. Noro Psikiyatr Ars 52:29–35. 10.5152/npa.2015.6916 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Akpinar Aslan E, Batmaz S, Celikbas Z et al (2021) Prevalence of risk for substance-related and behavioral addictions among University students in Turkey. ADDICTA Turkish J Addict 8:35–44. 10.5152/ADDICTA.2021.21023 [Google Scholar]
- 40.Özgür İlhan İ, Yıldırım F, Demirbaş H, Doğan YB (2008) Alcohol use prevalence and sociodemographic correlates of alcohol use in a university student sample in Turkey. Soc Psychiatry Psychiatr Epidemiol 43:575–583. 10.1007/s00127-008-0335-z [DOI] [PubMed] [Google Scholar]
- 41.Dayi A, Gulec G, Mutlu F (2015) Prevalence of tobacco, alcohol and substance use among Eskisehir Osmangazi University students. Dusunen Adam J Psychiatry Neurol Sci 28:309–318. 10.5350/DAJPN2015280402 [Google Scholar]
- 42.Bahadırlı NB, Sönmez MB, Vardar ME (2018) Associations between energy drink consumption and alcohol use among college students. J Subst Use 23:162–168. 10.1080/14659891.2017.1378737 [Google Scholar]
- 43.Akvardar Y, Demiral Y, Ergör G et al (2003) Substance use in a sample of Turkish medical students. Drug Alcohol Depend 72:117–121. 10.1016/S0376-8716(03)00192-3 [DOI] [PubMed] [Google Scholar]
- 44.Havaçeliği Atlam D, Yüncü Z (2017) Relationship between cigarette, Alcohol, Substance Use disorders and Familial Drug Use in University students. J Clin Psychiatry 20:161–170. 10.5505/kpd.2017.88598 [Google Scholar]
- 45.Aldemir E, Çelikay H, Havaçeliği Atlam D et al (2018) Alcohol consumption and associated factors with alcohol consumption among university students. J Tepecik Educ Res Hosp. 10.5222/terh.2018.047 [Google Scholar]
- 46.Orhan M, Kaya MV, Sayar B (2023) Alcohol use among students in Turkey: a systematic review study. Türkiye Halk Sağlığı Derg 21:127–143. 10.20518/tjph.1168114 [Google Scholar]
- 47.Cooke R, Beccaria F, Demant J et al (2019) Patterns of alcohol consumption and alcohol-related harm among European university students. Eur J Public Health 29:1125–1129. 10.1093/eurpub/ckz067 [DOI] [PubMed] [Google Scholar]
- 48.Tembo C, Burns S, Kalembo F (2017) The association between levels of alcohol consumption and mental health problems and academic performance among young university students. PLoS ONE 12:e0178142. 10.1371/journal.pone.0178142 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Moure-Rodríguez L, Piñeiro M, Corral Varela M et al (2016) Identifying predictors and prevalence of Alcohol Consumption among University students: nine years of Follow-Up. PLoS ONE 11:e0165514. 10.1371/journal.pone.0165514 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Mekonen T, Fekadu W, Chane T, Bitew S (2017) Problematic Alcohol Use among University students. Front Psychiatry 8:86. 10.3389/fpsyt.2017.00086 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Beenstock J, Adams J, White M (2011) The association between time perspective and alcohol consumption in university students: cross-sectional study. Eur J Public Health 21:438–443. 10.1093/eurpub/ckp225 [DOI] [PubMed] [Google Scholar]
- 52.Eryılmaz D, Göğcegöz I, Eryılmaz G (2021) The Predictive Effect some effects of Risk Alcohol in University students. Curr Addict Res 4:1. 10.5455/car.105-1578571757 [Google Scholar]
- 53.Sebena R, El Ansari W, Stock C et al (2012) Are perceived stress, depressive symptoms and religiosity associated with alcohol consumption? A survey of freshmen university students across five European countries. Subst Abuse Treat Prev Policy 7:21. 10.1186/1747-597X-7-21 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 54.Hart E, Burns S (2016) The relationship between alcohol consumption and related harm among young university students. Heal Promot J Aust 27:15–20. 10.1071/HE15086 [DOI] [PubMed] [Google Scholar]
- 55.Bosque-Prous M, Espelt A, Borrell C et al (2015) Gender differences in hazardous drinking among middle-aged in Europe: the role of social context and women’s empowerment. Eur J Public Health 25:698–705. 10.1093/eurpub/cku234 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56.Degenhardt L, Stockings E, Patton G et al (2016) The increasing global health priority of substance use in young people. Lancet Psychiatry 3:251–264. 10.1016/S2215-0366(15)00508-8 [DOI] [PubMed] [Google Scholar]
- 57.McKee SA, Weinberger AH (2013) How can we use our knowledge of Alcohol-Tobacco interactions to reduce Alcohol use? Annu Rev Clin Psychol 9:649–674. 10.1146/annurev-clinpsy-050212-185549 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58.Cance JD, Talley AE, Morgan-Lopez A, Fromme K (2017) Longitudinal conjoint patterns of Alcohol and Tobacco Use throughout emerging Adulthood. Subst Use Misuse 52:373–382. 10.1080/10826084.2016.1228677 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 59.Weitzman ER, Chen Y-Y (2005) The co-occurrence of smoking and drinking among young adults in college: National survey results from the United States. Drug Alcohol Depend 80:377–386. 10.1016/j.drugalcdep.2005.05.008 [DOI] [PubMed] [Google Scholar]
- 60.Harrison ELR, Desai RA, McKee SA (2008) Nondaily Smoking and Alcohol Use, Hazardous drinking, and Alcohol diagnoses among Young adults: findings from the NESARC. Alcohol Clin Exp Res 32:2081–2087. 10.1111/j.1530-0277.2008.00796.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 61.Bogowicz P, Ferguson J, Gilvarry E et al (2018) Alcohol and other substance use among medical and law students at a UK university: a cross-sectional questionnaire survey. Postgrad Med J 94:131–136. 10.1136/postgradmedj-2017-135136 [DOI] [PubMed] [Google Scholar]
- 62.Perkins HW (2002) Social norms and the prevention of alcohol misuse in collegiate contexts. J Stud Alcohol 164–172. 10.15288/jsas.2002.s14.164 [DOI] [PubMed]
- 63.Walther CAP, Pedersen SL, Cheong J, Molina BSG (2017) The role of Alcohol expectancies in the associations between Close Friend, typical College Student, and Personal Alcohol Use. Subst Use Misuse 52:1656–1666. 10.1080/10826084.2017.1306561 [DOI] [PubMed] [Google Scholar]
- 64.Morris H, Larsen J, Catterall E et al (2020) Peer pressure and alcohol consumption in adults living in the UK: a systematic qualitative review. BMC Public Health 20:1014. 10.1186/s12889-020-09060-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 65.Scholte RHJ, Poelen EAP, Willemsen G et al (2008) Relative risks of adolescent and young adult alcohol use: the role of drinking fathers, mothers, siblings, and friends. Addict Behav 33:1–14. 10.1016/j.addbeh.2007.04.015 [DOI] [PubMed] [Google Scholar]
- 66.Borsari B, Murphy JG, Barnett NP (2007) Predictors of alcohol use during the first year of college: implications for prevention. Addict Behav 32:2062–2086. 10.1016/j.addbeh.2007.01.017 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 67.Carey KB, Scott-Sheldon LAJ, Carey MP, DeMartini KS (2007) Individual-level interventions to reduce college student drinking: a meta-analytic review. Addict Behav 32:2469–2494. 10.1016/j.addbeh.2007.05.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 68.Erevik EK, Pallesen S, Vedaa Ø et al (2017) Alcohol use among Norwegian students. Nord Stud Alcohol Drugs 34:415–429. 10.1177/1455072517709918 [Google Scholar]
- 69.McCloughen A, Foster K, Huws-Thomas M, Delgado C (2012) Physical health and wellbeing of emerging and young adults with mental illness: an integrative review of international literature. Int J Ment Health Nurs 21:274–288. 10.1111/j.1447-0349.2011.00796.x [DOI] [PubMed] [Google Scholar]
- 70.Hunt J, Eisenberg D (2010) Mental Health problems and help-seeking behavior among College Students. J Adolesc Heal 46:3–10. 10.1016/j.jadohealth.2009.08.008 [DOI] [PubMed] [Google Scholar]
- 71.Bell S, Britton A (2014) An exploration of the dynamic longitudinal relationship between mental health and alcohol consumption: a prospective cohort study. BMC Med 12:91. 10.1186/1741-7015-12-91 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 72.Stallman HM (2010) Psychological distress in university students: a comparison with general population data. Aust Psychol 45:249–257. 10.1080/00050067.2010.482109 [Google Scholar]
- 73.Auerbach RP, Mortier P, Bruffaerts R, WHO World Mental Health Surveys International College Student Project (2018) Prevalence and distribution of mental disorders. J Abnorm Psychol 127:623–638. 10.1037/abn0000362 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 74.Jao NC, Robinson LD, Kelly PJ et al (2019) Unhealthy behavior clustering and mental health status in United States college students. J Am Coll Heal 67:790–800. 10.1080/07448481.2018.1515744 [DOI] [PMC free article] [PubMed] [Google Scholar]