“Seems I’m Not Alone at Being Alone:” Potential Factors Contributing to Drinking Games in the College Setting

Abstract

Alcohol use among college students is prevalent and sometimes takes the form of drinking games, in which players are required to drink in accordance with a set of pre-defined rules. Drinking games are typically associated with elevated alcohol consumption and risk to the individual. This perspective piece considers the potential role of social anxiety in motivating participation in drinking games, perceived norms surrounding drinking games (including ways they are portrayed and discussed in popular media), and the role of competitiveness. Implications for skills training-based prevention and intervention efforts are discussed.

“Seems I’m Not Alone at Being Alone:” Contributing Factors and Interventions for Drinking Games in the College Setting

Cam: “I’m playing a new drinking game. It’s called ‘Every Time I’m Depressed, I Take a Drink.’”

Mitchell: “That game exists. It’s called alcoholism.”

Modern Family“Aunt Mommy,” aired February 15, 2012

Participation in drinking games is a routine activity for many college students, and the mere presence of drinking games at a social event has been shown to be predictive of high-risk (heavy episodic) drinking (1). In this perspective piece for this special issue on drinking games, we consider what contributes to this phenomenon and discuss future directions for interventions on college campuses.

Drinking games are not a new practice – efforts to describe them and their role in college life emerged in the scientific literature almost three decades ago. Douglas (2) reviewed drinking games throughout history (starting with the ancient Greeks), then categorized over 65 drinking games found in the college setting and documented that an “entire vocabulary” had developed for participants (in fact, this could be the first, and only, peer-reviewed article with the phrases “blow chow” and “blow groceries” provided to describe “getting sick to one’s stomach”) (p. 56).

A thorough review of the myriad factors that research has shown to relate to drinking game participation (e.g., motives, norms, expectancies) is beyond the scope of this perspective piece, but can be found elsewhere in this special issue. However, the potential for overlap in these factors and their influence on drinking games is noteworthy. For example, Nagoshi and colleagues (3) asked participants potential reasons for playing drinking games (all accounted for by two factors: getting drunk and social lubrication). They then examined correlations of drinking games with a range of measures, and illustrated that drinking game participation was associated with expectancies for both the positive and negative effects of alcohol. Further, drinking game participation was correlated with celebratory reasons for drinking. The authors suggested the visibility of drinking games could effectively raise the perceived norms related to heavy drinking on campus in addition to actual alcohol consumption by students.

The theme of socialization is certainly visible in the literature. In addition to motives for getting “drunk” (endorsed by 92% of participants), Newman and colleagues (4) documented that two-thirds of students played drinking games to socialize more easily. Likewise, Johnson, Hamilton and Sheets (5) noted that 38% of the variance in students’ reported motivations for drinking game play was accounted for by reasons related to relaxation and disinhibition (e.g."To feel more comfortable around others,” “To loosen up in a social situation”). Borsari, Bergen-Cico and Carey (6) demonstrated that over half of incoming students view drinking games as a way to socialize and suggest that making students aware of other socialization opportunities may reduce the need to play drinking games to meet others. This recommendation suggests that students may feel shy or alone, yet (ironically) are surrounded by others wanting to connect as well. Thus, in preparing this paper, we were reminded of the following lyrics (reflected in the title):

Seems I’m not alone at being alone

A hundred billion castaways

Looking for a home.

“Message in a Bottle,” The Police, 1979

If students are “not alone at being alone,” why might alternative means to meet friends be underutilized? In a webinar discussing research findings from interviews with college students, Vander Ven (7) explained that reasons associated with drinking heavily included lowering inhibitions, letting one’s guard down, and dealing with social anxiety. He described a tremendous amount of social awkwardness, shyness, and self-consciousness, and hypothesized that students today may be less equipped with problem-solving skills to deal with social anxiety than previous generations. When asked about the possible impact of social media, he questioned if using so much virtual interaction is “eroding the skills of young people to communicate [in person]” such that alcohol becomes a resource.

Consider this possibility further – for today’s students, many “friends” include social networking contacts whom they may have never met or have limited contact with outside of the virtual world. Emotions might be described with acronyms or emoticons instead of personally witnessed or expressed, communication may be limited to 140 characters (e.g., tweets on Twitter), and video games can be played with others online instead of in the same room. What do students say? Among undergraduates, 57% “felt very lonely” within the last year and 23.4% felt this way within the last 2 weeks (8). Students are indeed not alone at being alone.

Drinking games certainly seem to be perceived as a vehicle to promote social connections. There are a diverse number of drinking games, some based on chance occurrences (e.g., the roll of the dice) or tied to known events (e.g., phrases in television shows or movies), while other games test motor, verbal, or memory skills (9). Laboratory research indicates a single 20-min session of drinking-game play is associated with consumption of approximately 3–4 standard drinks, resulting in estimated blood alcohol concentrations (BACs) ranging from about 0.03% to over 0.08% (10). Outside of the laboratory, drinking-game participation often exceeds 20 minutes, increasing the likelihood of much higher BACs. In this study, water was consumed as a proxy for alcohol and individuals were allowed to not drink; in the “real world,” refusing to drink when game rules mandate it is not generally tolerated (or requires drinking even more). One’s ability to play skill-based games is also impaired by increasing intoxication, leading to decreased performance, which leads to more consumption and even greater intoxication. A cursory search reveals a host of websites devoted to explaining the rules of different drinking games. For example, drinkinggames.com arranges their games by level of intoxication, from For Designated Drivers to Last Day on Earth. The rules of one game in the latter category indicate the game is “guaranteed to make you pass out before you finish,” which, if true, would be associated for most people with BACs upward of 0.30%.

Drinking games may occur during “prepartying” (i.e., consumption of alcohol prior to departing for an intended destination/activity) (11), and game participation during prepartying increases risk and experience of unwanted consequences for women (12). However, many drinking games do not take place until the main event, either as an activity during a party to add fun and competition, or as the party itself (e.g. drinking establishments hosting “Beer Pong Tournaments”). Research has identified competition and social dominance as important motives for engaging in drinking games (13), and such motives may increase the risk among naturally competitive subpopulations of college student athletes (14). Given the various settings and goals of drinking games, it is important to evaluate the temporal relationship and function of participation.

Regardless of setting, misperceptions of norms could contribute to prevalence. Students grossly overestimate both how frequently the typical same-sex student plays drinking games (men averaged 3.04 times per month but perceived 8.09 times; women averaged 1.47 times but perceived 5.36) and the average number of drinks consumed per drinking game occasion (men consumed 2.94 per occasion but perceived 6.93 drinks; women averaged 1.84 drinks but perceived 5.36) (15). For men (but not women), perceptions were significantly associated with their own drinking game behavior. Future research should further explore gender differences in drinking game norm perception, evaluating attitudes and perceptions across various situations, opponents, and types of games.

Knowing the impact of norms, it is striking that in the past 3 years alone, drinking games feature prominently in the story lines of several popular television shows typically rated highly among college student (and college-bound) demographics. For example, in an episode of How I Met Your Mother (“The Naked Truth,” airdate September 19, 2011), a main character plays “Edward Forty Hands,” by duct-taping two 40-ounce bottles of malt liquor to his hands and consuming both. On New Girl, the characters play “True American” (introduced in “Normal,” airdate April 10, 2012), a drinking game created for the purposes of the show and described initially as “50% drinking game, 50% life-size Candy Land” and later as “90% drinking” with “a loose Candy Land-like structure to it.” On The Mindy Project (“The Other Dr. L.,” airdate September 24, 2013), Mindy (the OB/GYN lead character) challenges a rival male doctor she has identified as a “lightweight” to a “Doctor vs. Doctor Shots Off” and wins when her counterpart passes out. Future research should assess the potential impact of these portrayals of drinking games on norm perceptions and attitudes.

Thus, perhaps drinking games are providing that “thing to do,” that common goal that can break the ice or divert attention from discomfort (9). Not sure what to say? Back to the game! Awkward silence? Back to the game! The question becomes what can be done to develop or enhance increased comfort in social situations without the unwanted effects or outcomes associated with excessive drinking? Research evaluating interventions specifically targeting drinking games is nearly absent in the literature, though opportunities look promising for general intervention, specific intervention, and general skills approaches. Following an online education course for incoming first-year students, one study (16) found significant differences in drinking game participation, suggesting a small protective effect. However, an overall lack of intervention effectiveness and increased risks in other domains (e.g., higher likelihood of not using safe sex practices and, among those who drink, higher rates of choosing a drink with more alcohol) limit any conclusions about the impact or generalizability of this approach. Wood and colleagues (17) report in a footnote of their article that students receiving a brief motivational intervention (BMI) based on Brief Alcohol Screening and Intervention for College Students (BASICS; 18) were less likely than non-BMI participants to participate in drinking games over their first 2 years of college. Given this finding, one could hypothesize that already efficacious BMIs may impact drinking game involvement on their own or might be further tailored to target drinking game participation. This is particularly true if drinking game participation is a risk factor for problematic drinking (11) and a BMI can provide early intervention.

In fact, Borsari and colleagues (19) characterized high school drinking game players into three classes of “gamers” (lower risk, higher risk, and sexual regret groups), and suggest that BMIs could tailor feedback based on risks and include specific strategies to reduce drinking game-related harms. Certainly, the inclusion of drinking game-specific norms, expectancies and motives, and protective-behavioral strategies should be explored through future research. Other targeted interventions (20) have documented benefits of directly addressing high-risk events through event-specific prevention with norms and expectations that differ from “typical” drinking. While this approach is promising, a number of important differences exist between drinking games and event specific drinking, which tends to be scheduled and anticipated (e.g., birthdays, holidays) and/or time-limited (e.g., spring break). Regardless, the success of tailored intervention programs in reducing participation in drinking games and/or associated harm warrants further evaluation.

Another potential route of intervention is to address the social motives underlying participation in games. Kadden and Cooney (21) consider research from the early 1980s highlighting the positive impact of social skills training on relapse prevention, including strategies for handling criticism, relationship problems, and general social skills. Reviews of efficacious individual-focused strategies to reduce college student drinking and consequences have recognized cognitive behavioral skills as one component of effective programs (e.g., Marlatt’s Alcohol Skills Training Program) (22). Thus, future interventions should evaluate strategies for communication, reducing social anxiety, or general social skills training as part of existing skills-based programs or as stand-alone efforts in reducing drinking game participation.

In sum, the question of whether a general or targeted intervention might be effective in reducing drinking game participation is an empirical one, though we can (cautiously) extrapolate the findings above to support enthusiasm for their potential impact and stimulate further research. Actions can be taken on various levels, including individual (e.g., interventions described above), cohort (e.g., offering alternative activities for student groups to meet competitive or collaborative needs satisfied by drinking games), and campus (e.g., providing alternative socialization opportunities, along with other environmental strategies) to maximize impact and effectively change the drinking culture. Researchers, clinicians and campus and community partners are encouraged to continue to join efforts to understand, predict, and intervene with these behaviors. As with any effort to improve student health, changing the drinking game culture will require concerted and coordinated effort of key stakeholders, including students, and will likely not happen overnight. However, the efficacy of existing programs to reduce student drinking indicates optimism for the potential impact of drinking game interventions.