Recent Alcohol-Induced Blackouts among Heavy Drinking College Students: A Qualitative Examination of Intentions, Willingness, and Social Context

Abstract

One third to half of emerging adult drinkers report experiencing alcohol-induced blackouts in the past year, and blackouts increase risk for negative consequences. Qualitative methods provide valuable tools for scientific inquiry, allowing for in-depth understanding of lived experiences. The goal of the present study was to gain insight into emerging adults’ recent blackout experiences. One hundred heavy drinking, college students (age 18-20) completed a baseline survey, 28 days of ecological momentary assessment (EMA) of their alcohol use and consequences, and a follow-up interview. A subset of 37 (46% female, 13.5% Hispanic/Latinx. 54% non-Hispanic ethnicity/White race) endorsed a blackout (forgot what they did during or after drinking) and were interviewed regarding their recent blackout experience. A semi-structured interview guide focused on several key questions regarding intentions and/or willingness to blackout, how friends reacted to their blackout, and social norms for blacking out. A priori as well as emergent themes were generated from review of coded data. Qualitative themes included: blackouts are often unintentional, heavy drinking young adults express willingness to black out, friends react in a variety of ways to blackouts, and blackouts are perceived as common and acceptable. Data provide insight into the phenomenology of blackouts among college students, revealing that while college students may not intend to, they are often willing to black out. Future qualitative studies on blackouts among non-college-attending emerging adults are warranted. Such work can inform theory and future survey studies to better understand this high-risk behavior.

Alcohol-induced memory loss (i.e., blackout) is a period where an individual has an absence of memory for at least part of the drinking session (Wetherill & Fromme, 2016; White, 2003). Blackouts occur when a large amount of alcohol is consumed or alcohol is consumed quickly, as high blood alcohol concentration impairs the ability of the drinker to transfer short-term memory to long-term-memory. There is, however, some variation in the extent to which memory is lost during an alcohol-related blackout and researchers have found that blackouts range from a fragmentary blackout (also referred to as “brownout” by young adults; having fuzzy or incomplete memories of drinking events or remembering drinking events only after someone or something jogs their memory) to an en bloc blackout (where an individual is completely unable to remember events that happened while they were drinking, even if someone reminds them later) (Miller, Merrill, DiBello, et al., 2018; Rose & Grant, 2010).

Blackouts are a common alcohol-related consequence among young adult drinkers; depending on study eligibility criteria (e.g., lifetime vs recent consumption, any vs heavy consumption) one third to half of young adult drinkers report experiencing a blackout in the past year (Hingson et al., 2016; Jennison & Johnson, 1994; Wetherill & Fromme, 2016; White et al., 2016). Importantly, blackouts increase the risk for other negative consequences (Hingson et al., 2016; White et al., 2002), including embarrassing oneself (Merrill, Boyle, et al., 2019), injury, emergency department care (Mundt & Zakletskaia, 2012; Mundt et al., 2012) and sexual revictimization (Valenstein-Mah et al., 2015). Understanding the phenomenon of blackouts, including their proximal antecedents (e.g., intentions to blackout, willingness, social context), may help to inform ways to reduce blackouts via prevention and intervention efforts. The goal of the present study was to gather qualitative data on blackout intentions and willingness, as well as social factors that may influence blackout experiences.

Intentions and Willingness to Blackout

The Prototype Willingness model posits two routes that lead to risk-taking behaviors (Gerrard et al., 2008; Gibbons et al., 1998), such as drinking to the point of blackout – one involving willingness and one involving intentions. Specifically, the social reaction pathway suggests one’s willingness or openness to engage in risk behaviors may be influenced by descriptive norms, prototypes, and perceived vulnerability (Gerrard et al., 2008; Gibbons & Gerrard, 1995). If emerging adults believe that blackouts are common (descriptive norms), think that the prototypical young adult who blacks out is viewed favorably (prototypes), and/or perceive that that blacking out is unlikely to result in harm and/or other negative consequences (perceived vulnerability) then they may be more willing to black out, and thus more likely to engage in the level or type of drinking that results in a blackout. The reasoned pathway acknowledges that decisions to engage in a behavior may also be intentional, and influenced by attitudes and injunctive norms. Emerging adult’s intentions to engage in blackouts may vary as a function of how positive they view blacking out (attitudes) and how they perceive others to view blacking out (injunctive norms). In turn, stronger intentions to black out would be expected to predict higher likelihood of actually experiencing a blackout.

Although researchers view blackouts as a negative consequence of drinking, young adults may endorse intentions to experience alcohol-related blackouts. For example, Riordan et al. (2019) collected and analyzed posts on Twitter (i.e., Tweets) that referenced alcohol-related blackouts. They found that around 22% of Tweets about blackouts were written prior to a drinking session and that 51% of Tweets written before a blackout expressed an intention to black out. They also found that Tweets expressed various levels of intention to blackout prior to a drinking event (e.g., “I’m going to black out tonight” vs. “I might black out tonight”). Similarly, in a sample of 350 undergraduate students (age 18-29) reporting past-year blackouts, 39% indicated that they had intended to experience a blackout in the past 30 days, and 31% indicated that they intended to experience a blackout in the next 30 days (Miller et al., 2020). Importantly, a follow up of these participants one month later found that blackout intentions predicted subsequent blackouts (DiBello et al., 2020). Although this prior research has established that some individuals express intentions to black out, attempts to more deeply understand such intentions are lacking. Further, no research to date has explored the other key component of the Prototype Willingness model (i.e., willingness) in attempts to understand pathways to blackouts among young adult drinkers.

Social Norms and Blackouts

As noted above, the Prototype Willingness model highlights a role for social norms in the prediction of risk behavior; norms may exert indirect influence through both willingness and intentions. Recent evidence suggests that social norms are related to intentions to blackout and to actual (self-reported) blackouts. For example, in the sample of undergraduates with past year blackouts described above (Miller et al., 2020), on average, participants perceived that ~44% and 54% of college student drinkers of their same sex experienced a past-month en bloc and fragmentary blackout, respectively. Further, they rated perceived approval of en bloc and fragmentary blackouts among the typical college student drinker (without reference to sex/gender) as an average of 2.95 and 3.35 on a 5-point scale (1=strongly disapprove to 5=strongly approve). Finally, participants who endorsed intentions to experience blackouts (relative to those who did not) perceived that past-month blackouts were more prevalent among peers of their same sex, supporting links between norms and intentions purported by the prototype-willingness model. Again using this same data set, DiBello et al. (2020) found that blackout-specific norms, attitudes, and self-efficacy all influenced blackout intentions (which, as noted above, in turn predicted subsequent blackouts). Ward and Guo (2020) determined that beliefs about peers’ approval of drinking more generally (i.e., injunctive norms) related to higher likelihood of having a history of alcohol-induced blackouts. Specifically, perceived approval (i.e., injunctive norms) of the less severe behaviors assessed (e.g., drinking to have fun, drinking alcohol) related to previous experience of alcohol-induced blackouts. Moreover, perceived peer approval of drinking behaviors were associated with higher levels of intentions to blackout (Ward & Guo, 2020). Finally, Su et al. (2018) examined the effects of a social norms campaign on alcohol perceptions and alcohol-induced blackouts. Participants who engaged with the social norm marketing materials reported fewer alcohol-induced blackouts at follow up than those who did not engage with the materials. This provides additional evidence for the role that social norms may play in blackouts. However, perceived social norms about blackouts, including how heavy drinkers perceive those in their social circle react when they report alcohol-induced memory loss, remains understudied.

Friend Reactions to Blackouts

A more proximal indicator of social norms around blackouts may be the way one’s friends react when they see a drinker black out or hear about it later on. Friend reactions may influence not only one’s perceptions of the social norm, but also their subsequent behavior. If a young adult blacks out, and friends find it funny, the behavior may be perceived as acceptable and in turn may be reinforced. Alternatively, a friend who expresses concern following one’s blackout may make the drinker question whether blackouts are perceived acceptable by others and might think twice about drinking to similar levels in the future. One prior qualitative study suggested that discussing consequences of one’s drinking with friends the next day may indeed influence the extent to which those consequences are perceived to be normative and alleviate otherwise negative reactions to one’s own consequences (Merrill et al., 2018). However, the various ways in which friends may react to one’s blackout in particular have not been explored.

Qualitative Research on Blackouts

Qualitative methods provide researchers with valuable tools for scientific inquiry, allowing for in-depth understanding of lived experiences (Neale et al., 2005). Such methods are especially useful for experiences that cannot ethically be studied in the laboratory such as blackouts. Moreover, qualitative work allows researchers to obtain a level of depth in understanding individuals’ unique experiences with certain phenomena, which is not possible with quantitative methods such as surveys (Merriam, 2002). It also allows for the extraction of patterns and themes that are helpful for further conceptualizing how a range of people experience phenomena such as blackouts (Patton, 2005). To date, there have been few qualitative investigations of blackouts. In the first qualitative study of blackouts among college students (n = 50), a survey instrument was used to collect qualitative data about students’ general experiences with blackouts as well as a narrative of what happened during their most recent blackout (e.g., What’s the last thing you remember? How did you learn what happened during the blackout?). Key findings of this phenomenological study included that fragmentary blackouts are more common than en bloc, students remember some fragments of memory on their own and may also learn from their friends about events that occurred during memory loss, half of participants were scared by their blackout experience, and being scared was followed by at least short-term change in drinking behavior (White et al., 2004). These data also indicated that most (96%) had planned to get drunk on the occasions when they blacked out. Of note, while all participants in this sample endorsed lifetime blackouts, not all had a recent blackout.

More recently, Miller and colleagues used focus group data of 50 college students who experienced blackouts in the past six months to identify how well students understood risk factors for blackouts (Miller, Merrill, Singh, et al., 2018), how students distinguish between en bloc and fragmentary blackouts (Miller, Merrill, DiBello, et al., 2018), and how students subjectively evaluate their blackouts (Merrill, Miller, et al., 2019). Of relevance to the present study, one of the themes to emerge from this prior qualitative work suggested that the extent to which a blackout was perceived positively or negatively depended in part on normative perceptions and the social context of a blackout. This provides additional evidence for the potentially important role of social norms in the understanding of blackouts.

While this prior qualitative work provided important insight into some aspects of blackout experiences, all required participants to reflect upon prior experiences that may not necessarily have occurred recently (lifetime in one study, up to six months ago in others). Asking heavy drinkers to describe more recent experiences can reduce recall bias . Additionally, several key gaps in our understanding of blackout experiences remain. None of these prior examinations of blackouts centered on intentions and/or willingness to blackout, despite the importance placed on these constructs in the Prototype Willingness model as proximal predictors of risky behavior. Additionally, none of these studies specifically and thoroughly analyzed how students who black out describe the social norms of blacking out, including the ways in which their friends react to their blackouts and how common and/or acceptable alcohol-induced memory loss is among one’s peers. A more in-depth understanding of intentions, willingness, and social norms for blacking out may have important implications for theory refinement and intervention development (e.g., personalized normative feedback), and may help with hypothesis generation for future quantitative studies of the etiology of blackouts and the negative consequences that accompany them.

The Present Study

Previously, we conducted a quantitative, event-level analysis of predictors and consequences of blackouts in a sample of heavy drinking college students who endorsed a blackout over a 28-day assessment period (Merrill, Boyle, et al., 2019). All participants from that study also completed an individual interview following the 28-day protocol. The goal of the present study was to use these interview data to gain insight into college students’ recent blackout experiences in order to shape the direction and design of future studies on blackouts. In particular, we sought to gain a more in-depth understanding of (1) the extent to which heavy drinking students intend to and/or are willing to blackout, and (2) the social context of blacking out, including friend reactions and social norms.

Methods

Participants

One hundred participants enrolled in and completed a 28-day ecological momentary assessment (EMA) protocol, which was followed by an individual interview. To be eligible for this larger study, participants were 18-20 years of age, had no past 2-week illicit drug use (other than marijuana), were not currently in treatment for a substance use disorder, had access to a smartphone with a data plan, were enrolled in a local 4-year college or university, and reported, in the past two weeks, either (a) heavy drinking (4+/5+ for women and men respectively) twice or more or (b) experience of at least 1 negative alcohol-related consequence (of 10 assessed, e.g., hangover, blackout). The sample for the present study included only those who endorsed an alcohol-induced blackout, either during the EMA (n=29) or the interview portion of the study (n=8), and who were interviewed about their experience (n=37, 46% female).

Procedures

Recruitment and orientation.

All procedures were reviewed and approved by the Brown University Institutional Review Board. Flyers posted on and around local campuses and social media advertisements were used for recruitment. Interested volunteers completed a brief online screening survey, and those eligible were redirected to an online informed consent page. Upon consent, participants were then directed to an online baseline survey (~20 minutes). At the end of baseline, participants indicated availability to come into the lab for an orientation session. Group orientation sessions were conducted to describe the procedures and obtain consent for the longitudinal phase of the study. Participants were trained in reporting of standard drinks (1.5 oz liquor, 5 oz wine, 12 oz beer), downloaded the mobile application for EMA report delivery onto their smartphones and completed practice reports.

Baseline measures.

An online survey included assessment of demographics (age, gender, year in school, race, ethnicity, GPA, Greek involvement, and residence) and baseline drinking behavior, used for descriptive purposes in the present study. Specifically, participants reported their alcohol use during a typical week in the past 30 days using a grid modeled after the daily drinking questionnaire (DDQ) (Collins et al., 1985). They reported on experience of alcohol-related consequences with the Brief Young Adult Alcohol Consequences Questionnaire (Kahler et al., 2005). An additional single item asked, “During or after drinking, have you forgotten what you did?” (never; yes, but not in the last 30 days; yes, in the last 30 days).

EMA protocol.

Following orientation, participants began a 28-day EMA protocol (Merrill, Boyle, et al., 2019). Relevant to the present study, each day a morning report assessed prior day drinking. When prior day drinking was endorsed, participants were asked whether they had experienced a range of alcohol consequences, including whether they had a blackout (“forgot what you did”). Following drinking days (as per morning report), blackouts were again assessed at a 5 pm survey, in the event that a participant did not realize they had blacked out during the morning report. These data were used to identify the interview sample for the present study.

Follow-up interview.

Following the 28 days of EMA (M=10.01 days later, SD=6.88), all participants returned to the lab for an individual interview administered by the study principal investigator or a research assistant (RA). First, they completed the timeline follow-back interview (TLFB). For the same 28 days during which they participated in the EMA study, participants were asked to retrospectively indicate whether they consumed alcohol, and if so, how many standard drinks were consumed. Additionally, alcohol-related consequences, including blackouts, were also assessed for each drinking day. The interviewer encouraged participants to consider typical patterns and events to assist their memory of drinking behavior.

Next, for participants who endorsed a blackout during EMA or on this TLFB, the interviewer asked questions specific to recent blackout experiences. While 33 participants endorsed a blackout on EMA (having forgotten what they did), we conducted a total of 37 interviews. Of note, four participants who reported a blackout on EMA were not interviewed (due to lack of time or denying blackout at follow-up), while eight participants who did not report a blackout on EMA did endorse a blackout during the TLFB over the EMA period and/or during other parts of the qualitative interview, which prompted the interviewer to conduct the blackout portion of the interview. Participants were asked several questions about the key drinking event. If more than one blackout was endorsed over the 28-day period, depending on time, the interviewer was instructed to focus on the most recent and/or the one that stood out to the participant as “most significant.”

First, participants were asked to clarify whether their recent experience was an en bloc (being unable to remember events that happened while you were drinking, even if someone tries to remind you later) or fragmentary blackout (“brownout”; having fuzzy or incomplete memories of drinking events OR remembering drinking events only after someone or something jogged your memory). Next, key questions included: (1) To what extent, if any, did you intend to blackout/brownout that night? (2) Going into the drinking event, had you been willing to black/brown out? Tell me about that. (3) How did any of your friends react to the fact you had blacked out? and (4) How typical is alcohol-related memory loss among your friend group? How acceptable is it? While the majority of questioning focused on the recent black/brownout experience, general experiences with blackouts in these domains of interest were also queried.

Qualitative Data Analysis

Interviews were transcribed verbatim. The six-phase thematic analysis approach by Braun and Clarke (2006) was followed to code and analyze the interview data. First, a preliminary coding structure was derived from the interview script. Second, a team of coders (first author plus two RAs) independently coded transcripts. They then met to compare their codes, at which time the codebook was revised to include codes that emerged inductively during coding and to ensure that all final codes were relevant to the research questions and objectives of the study. At least two members of the research team coded each transcript, discussed differences and resolved discrepancies, bringing codes into 100% agreement. Master codes were then entered into NVivo10 (QSR International, 2008). In the third phase, summaries of the codes were generated from reviews of the coded passages to determine the most commonly reported experiences. Key codes used in this analysis are shown in Table 1. Next, for the fourth phase, both a priori as well as emergent themes were identified. Fifth, a total of 9 themes were named and defined. Lastly, a selection of quotes from each theme were selected.

Table 1.

Qualitative codes used in analysis

Code	Corresponding interview question and code description
Intention	Response to query “To what extent, if any, did you intend to blackout/brownout that night” as well as any follow-up queries on specifics of intention (e.g., specific motives for wanting to). Comments about whether (or not) a person ever intends to black out.
Willingness	Response to query “Going into the drinking event, had you been willing to black/brown out?” Comments regarding whether participant or friends are willing to have blackouts (in absence of intention - if they said they intended to, willingness may not have been queried)
Friend reactions	Response to query “How did any of your friends react?” Descriptions regarding how friends reacted to the participants recent or past blackout
Norms	Response to query “How typical is alcohol-related memory loss among your friend group? How acceptable?” Data on how normative blackouts are. May include both perceptions of how acceptable blackouts are among peers (injunctive norms) or how common they are (descriptive norms)

Results

Participant characteristics are summarized in Table 2. Participants (46% female, 13.5% Hispanic/Latinx, 54% non-Hispanic White) were relatively heavy drinkers by design, consuming close to six drinks per drinking day on a typical drinking event in the past month. Among the 29 participants who endorsed blackouts during EMA, most (n=17) reported only one, n=5 reported two, n=4 reported three, n=2 reported four, and n=1 reported five blackouts. During the interview, eighteen participants (49%) described their recent memory loss as an en bloc (vs fragmentary) blackout. Qualitative themes and representative verbatim quotes are shown in Table 3 and described below.

Table 2.

Participant characteristics

	Sample (n =37)
Age, M (SD; range)	18.7 (0.7; 18-20)
Sex, n (%)
Female	17 (45.9%)
Male	20 (54.1%)
Year in school, n (%)
Freshman	31 (83.8%)
Sophomore	5 (13.5%)
Junior	1 (2.7%)
Race, n (%) (check all that apply) a
White	27 (73.0%)
Black	2 (5.4%)
Asian	9 (24.3%)
Native American or Native Alaskan	1 (2.7%)
Hispanic/Latinx ethnicity, n (%)	5 (13.5%)
Drinking descriptive, M (SD; range)
Number of blackouts during 30-day EMAb	1.8 (1.1; 1-5)
Drinks per typical drinking day (past month)	5.7 (2.5; 0.2-12)
Drinks on peak drinking day (past month)	8.3 (3.3; 2-17)
Total cons in the past month (BYAACQ)	4.4 (3.7;0-15)

Note:

^aIn total, n=20 (54%) were non-Hispanic White and n=3 (8%) were multiracial.

^bbased on only n=29 because 8 participants who were interviewed (due to reporting blackout during the follow-up interview) did not report any blackouts during EMA

Table 3.

Themes from qualitative interview data with example quotes from both male and female participants

INTENTIONS
Memory loss is not typically intentional, but getting drunk often is.
382 (female, recent fragmentary and en bloc): Not really maybe like drink to the point when you just like your mood is a little better, but I think that's like my own intentions. I wouldn't want to go that far as to not remember events…but definitely it's not like an intention ever or something I'm going to report proudly.
304 (female, recent fragmentary and en bloc): Um, I think I intended to kind of maybe get slightly leaning toward brownout because, like, if I have nothing going on, I’m like this is a time for me, to like let loose and get, like be the drunkest I’ve been in several weeks, but I don’t think I intended like the extent of it.
303 (male, recent fragmentary): I've heard that a lot, but I don't see it as meaning I intend to lose my memory. I think it’s just like I want to drink a lot, like yeah.
373 (male, recent en bloc): Uh…I think part jokingly…because yeah, I like, not like blackout but like to like get pretty drunk, um yeah, I remember saying that.
WILLINGNESS
Heavy drinkers often express a willingness to black out.
358 (female, recent fragmentary and en bloc): Oh, um I don't think I ever go into the night intending to brownout. But I think I always know that it's a possibility.
393 (female, recent en bloc): I just sort of needed to like let loose I feel like and so I wasn’t trying to blackout or brownout but I was also like aware that it could happen as wasn’t trying to avoid it necessarily.
396 (male, recent fragmentary and en bloc): Um I guess I wasn’t like totally closed off to the idea of doing it um obviously I like did drink a lot so um maybe yeah, I guess I was like expecting a little bit more or less to be like more out of it um so I wasn’t necessarily I wasn’t planning on it but I definitely wasn’t avoiding it and knew it might be a possible consequence.
357 (male, recent fragmentary and en bloc): so I was like, the first few drinks are hard, but after that it’s like getting easier because it’s almost like you don’t even, like starting to taste even like better because you’re drunk, and then so like it was just like a slippery slope, and then like, and then once I’m down there I’m like ‘a few more drinks, it doesn’t matter if I blackout. Whatever.’ Like, so I kinda, yah. So yah.
Willingness to blackout is influenced by one’s environment and sense of safety.
314 (female, recent fragmentary and en bloc): I do like still being in control and I think that it’s a bit scary to go blackout but at a place like that where I know everyone there where it’s very contained and like no one else that’s from outside can get in and I feel a bit safer that and I’m with my really close friends.
312 (male, recent fragmentary): Um probably cause I trusted everyone around me um and I trust myself when I'm drunk.
370 (female, recent fragmentary and en bloc): Yeah, the thing is I always, I almost always feel pretty comfortable where I am because I'm always with my friends who I trust like so much. So yeah, I mean I guess if I had been…like if I hadn't…this doesn't really happen though ever but if I were going out like by myself or with people I don’t know that well I probably would be less likely to drink a lot.
325 (male, recent fragmentary and en bloc): Usually my friends um, react in a similar way, because as I said, more often than not, there are not lasting consequences that people view negatively because I think that I surround myself with friends that think like-minded to myself. So we all have kind of the expectation that there are inherent, I don’t want to say risk because I don’t know if these are all risks, but there is always the chance that you may not remember something the night before, and that’s something that we take readily, and we trust each other to look out for one another knowing that we’re not all going to, um, maybe forget everything that happened.
FRIEND REACTIONS
Friends sometimes react positively to one’s blackout.
357 (male, recent fragmentary and en bloc): Um, yah they kind of laughed about it, and they, they were like “yah,” I guess they were mostly just laughing about it, and like “oh, this is what you did. It was pretty funny.” I was like “oh yah, that is kinda funny.”
317 (female, recent en bloc): Um we just kind of laugh about it like it’s not a huge deal I think like the biggest thing is like if it does happen we all kind of like take care of each other so it’s like not a huge deal.
395 (female, recent fragmentary and en bloc): Yeah, they think it's funny.
325 (male, recent fragmentary and en bloc): Because the night they were reminding me of wasn’t very serious, it was amusing to both of us, and just had to with a funny moment that had happened, I don’t remember exactly what that was, I wasn’t very concerned about it. In fact, I thought that it was kind of funny.
Other friend responses to blackouts: surprised, expected, shared, neutral
355 (female, recent fragmentary and en bloc): Um…I guess she was surprised but not in like a not in like a judgy way, you know, she was just like "oh you usually don't do that" and I was like "yeah".
347 (female, recent en bloc): They were not surprised. They said I was acting differently, um a little just like out of it, um, yeah.
396 (male, recent fragmentary and en bloc): Um they were pretty like nonchalant about it I guess um or like kind of indifferent yeah for the most part I think like for better or worse a lot of the or some of the friends I have been out with have definitely experienced that before, so they were kind of just like “oh as long as you’re ok its fine”
352 (male, recent fragmentary): Um, it was, I mean, I just sort of initially just thought it was funny. I mean it wasn't like it was much talked like "oh [he] browned out" it wasn't like that it wasn’t, it wasn't a big deal really. It wasn't.
Friends sometimes reassure someone who has recently blacked out that they should not worry about it.
355 (female, recent fragmentary and en bloc): Uh, it was, it was, since it was a blackout, I was just like, I kinda, I asked him, I don’t know, I was like, “did I, I didn’t do anything like too crazy, right?” And they’re like “oh no, you were fine.”
358 (female, recent fragmentary and en bloc): I just want to make sure that nothing too terrible happened. And usually the answer's no, um the answer is…very much always been like "Oh you're good".
326 (male, recent fragmentary): Um, I mean they didn’t react negatively. So it was kinda just like if you feel bad about what you did, it’s not that big of a deal, so, yah.
304 (female, recent fragmentary and en bloc): My biggest thing was like “was I annoying?” Like, “was I like a hassle to you?” Or “were you guys helping take care of me?”…And they like, usually all of the times I ask, people are always like “no, you were just like funny,” like uh, and then I’m like “okay.”
Friends express concern following one’s blackout in specific situations.
314 (female, recent fragmentary and en bloc): Like my friend was very worried about me cause she was the one who found me and took care of me so she was, she was very worried about it um and then that night another one of my friends gave me a hard time about it.
398 (female, recent fragmentary): Um since I don't normally get that like I don't normally go that crazy um I like the next day a few of my friends uh were like asking me if it was ok which is weird for me because normally I'm the person who is like checking in on people.
387 (male, recent en bloc): Uh they were kind of like "no don't drink that much like it's not smart". And uh so they were all just kind of like telling me like don't do that.
377 (male, recent en bloc): Um, I think they were surprised but also disapproving but concerned.
SOCIAL NORMS
Generally, alcohol induced memory loss is perceived as both common and acceptable among heavy drinking college students.
370 (female, recent fragmentary and en bloc): We all kind of drink like the same amount so we usually all like will not remember some random…like the next morning we were talking about we're like yeah what did we…Oh god this sounds so bad! Usually like someone will be more sober than others or like some people won't even drink or some or like one person will be crazy blackout or whatever and we have to take care of them um or someone throwing up or something…like probably on any given night like maybe half of us will like not super remember everything.
390 (male, recent fragmentary): But it's not…too, too heavily condemned, especially not like past, like, the first the day after the drinking event…So like it's hardly memorable after that
393 (female, recent en bloc): I would say it accept- it's acceptable. Like it's not judged but it’s also not super like encouraged or like an end goal I guess. So, like if you say like "oh wow I cannot remember that" they’re like "oh really here's what happened" so it’s very, it’s like talking about anything else I guess.
389 (male, recent fragmentary): Um, usually whenever we go out someone browns-out.…Um, I don't think it's unacceptable like at all like I think it's pretty common in most drinkers.
Alcohol-induced memory loss is perceived as less acceptable under certain circumstances.
354 (female, recent en bloc): Yes. Like if they’re going home with someone. That’s not acceptable to be blacked. Um, especially like if you’re alone, if you don’t have anyone with you. And like that, those are my two main concerns I think.
351(male, recent fragmentary and en bloc): …I think um like if you have a problem where you're like kind of routinely like, like losing control or losing your memories like I like my friends will like sit you down.
382 (female, recent fragmentary and en bloc): If you have something like every week, a deadline or something really important the next day they would be more judgmental, but still.
390 (male, recent fragmentary): If that person was doing anything probably aggressive or like overly obnoxious then I guess like and they, they, they forgot about it, it definitely be something that the friend group uh wants to bring up again and like and make sure that it's corrected.

Blackout Intentions

Memory loss is not typically intentional, but getting drunk often is.

Most participants denied beginning a drinking event with the goal of losing memory. Instead, they indicated that, on the night of their recent blackout, they had indeed intended to drink a lot and/or get intoxicated. For example, participant 370 (female, recent fragmentary and en bloc) stated “I never intend to brownout but I did definitely intend to be drunk.” Participants noted that while they had heard others in their social groups express an intention to blackout, they did not believe that most others truly intended to lose memory, and that this was more of an expression of intent to get drunk.

Blackout Willingness

Heavy drinkers often express a willingness to black out.

A number of the participants described that while they did not typically intend to black out, they often went into a drinking event knowing that it may happen. They acknowledged that, by virtue of intending to get drunk, they were willing to experience a brownout or blackout, and “whatever happens, happens” (389, male, recent fragmentary). Many participants indicated that they were not taking any active steps to avoid blacking out, and were accepting of the potential for such an outcome. For example, one participant (312, male, recent fragmentary) stated “Um, I would say like I wasn't like trying to not do it.”

There were some notable exceptions to this theme, in which participants did not endorse any willingness to blackout. For example, when asked if they had been willing to blackout the night it recently occurred, some participants said no, “just cause like embarrassing stuff happens” (387, male, recent en bloc) and “because that's not something I'm trying to do ever cause it's like I love to remember what happened to me like the night prior, um so yeah no.” (341, male, recent fragmentary).

Willingness to blackout is influenced by one’s environment and sense of safety.

When asked why they were willing to blackout, a number of participants indicated that their sense of safety and/or being surrounded by friends that they know and trust played a role. They indicated a willingness to “let loose” (325, male, recent fragmentary and en bloc) in such situations. Accordingly, it was acknowledged that willingness may change from event to event, depending on the environment. For example, participant 358 (female, recent fragmentary and en bloc) reported “for myself I guess I just wouldn't want to blackout among people that I wasn't comfortable with, like, that would be unacceptable.”

Friend Reactions to Blackouts

Friends sometimes react positively to one’s blackout.

The most common positive reaction among friends to a recent blackout/brownout was finding humor in their experience. Comments reflected a mixture of laughing with the person who blacked out, and laughing at them (e.g., “Because my friends were like laughing at me like ‘you said this hahaha ’ whatever.” [382, female, recent fragmentary and en bloc]). The humor was found in what the person did during the blackout, rather than the memory loss itself. Additionally, friends were sometimes interested in learning more about the blackout experience, if they were not present when it occurred. It was typical for friend groups to re-hash the prior night in a social setting (e.g., “because then like there's like usually a story that comes with that where someone else is telling you about like what you did…” [373, male, recent en bloc]).

Friends sometimes reassure someone who has recently blacked out that they should not worry about it.

Reactions from friends seem to indicate that blacking out or browning out is not a big deal. For example, one participant indicated, “They would just be like… ‘ok like it’s a pretty typical thing. I don’t know why you’re telling me that you browned out’ ” [312, male, recent fragmentary]. Another participant reported, “I think that they didn’t give me any negative feedback but they did give me a little bit of positive feedback so, I wouldn’t say that it’s like encouraged, but I wouldn’t say it’s like…yah.” [357, (male, recent fragmentary and en bloc)].

Friends express concern following one’s blackout in specific situations.

Participants indicated that friends may express a negative reaction to one’s blackout in the event that it was a repeated experience, was out of character for someone, or were it to occur in what is perceived as an unsafe situation. For example, a participant reported, “Um, like, my boyfriend was taking care of me, my roommate was taking care of me, and then some of, I don’t think any of my friends were actually there. Um, they were just concerned” [354, female, recent en bloc]. In particular, the friend’s expressed concern by trying to stop the behavior (e.g., “Uh, they watched my drinks and made me, they tried to make me…stop drinking at parties” [377, male, recent en bloc]).

Other friend responses to blackouts: surprised, expected, shared, neutral.

In some cases, participants described that rather than any particularly negative or positive reaction, friends were sometimes surprised. In other cases, they indicated friends were not surprised, and instead may have expected it based on how much the participant had consumed or their prior behavior (e.g., “It doesn't seem too bad to them. Like it's not that surprising if they knew how much I was drinking the night prior” [390, male, recent fragmentary]. Additionally, some described that blackouts might be a shared experience, downplayed by friends who experienced it on the same drinking event.

Social Norms for Blacking Out

Generally, alcohol induced memory loss is perceived as both common and acceptable among heavy drinking college students.

Brownouts were described as more typical and more socially acceptable than blackouts (e.g., “Blackout is definitely more concerning, way more scary if they can’t remember. Um, brownouts, like Ifeel more normal” [354, female, recent en bloc]. Upon reflecting on their blackout experience, one participant stated, “So for example, last week my friend and I like both browned out. So, we like there are some parts of the night we're just like ‘oh we don't know what happened but it's fine’. Like, it's fine” [358, female, recent fragmentary and en bloc]. Another participant remarked that they thought it was accepted by their peers because the peers also had blackouts (e.g., “They didn't think much of it um because I'm sure, I'm pretty sure like they've had brownouts too” [389, male, recent fragmentary]).

Alcohol-induced memory loss is perceived as less acceptable under certain circumstances.

For example, participants perceived less approval of someone blacking out in a potentially unsafe situation, or with people they do not know well. Additionally, blackouts were described as unacceptable when there are consequences for others, such as having to take care of the intoxicated person (e.g., “Um I mean…I think…at like, I know like some of friends who are in Greek life at like mixers or like stuff where you do not want to get super sloppy, like there. Or if you have like a friend visiting or a someone there that you want to like um like that you are responsible for then blacking out there is not really acceptable. Not acceptable, yeah. Yeah because then you end up having to be taken care of by your other friends and then…” [393, (female, recent en bloc)]. Some described it as less acceptable if it becomes a pattern (e.g., “Because it would seem like a bad pattern for someone to be getting into that they are consistently making themselves, forgetting things from consistently drinking a lot” [313, female, recent fragmentary and en bloc]). Finally, if someone had responsibilities the next day, blacking out would more likely be frowned upon.

Discussion

This is the first qualitative study on blackouts that focused specifically on theory-based constructs of college students’ intentions/willingness to blackout, friends’ reactions to blackouts, and social norms for blacking out. Findings provide insight that willingness to black out is more typical than intentions to black out, and into the varying ways that friends may respond to one’s blackout and in turn shape one’s perceived social norms. These findings are further discussed below in the context of the Prototype Willingness model and prior research.

The fact that the students in our sample did not readily endorse intentions to black out, in light of prior work, is particularly interesting. Our findings contrast with a survey study showing that 39% of a college student sample reporting past year blackouts intended to experience a blackout in the past 30 days, and 31% intended to experience a blackout in the next 30 days (Miller et al., 2020). Lack of intentions to black out in this study are also inconsistent with examination of Twitter data wherein many people publicly expressed a desire to black out (Riordan et al., 2019). Of note, it is quite possible that when Twitter users describe a desire to “black out” they do not necessarily mean they intend to lose memory and instead just plan to drink heavily. In the present study, we explicitly defined blackout and brownout for participants, which helped frame their responses to be about blackouts specifically. Denial of intentions to engage in this high-risk behavior in the context of a one-on-one interview with a researcher might be related to social desirability (Grimm, 2010); participants may not have wanted to disclose blackout intentions to an interviewer whose stance on heavy drinking was unknown. Future studies on this topic might benefit from inclusion of measures of social desirability.

It is also possible that intentions are not a “yes or no” question, but that they exist on a continuum, which was not assessed well in the interviews conducted in this study. Notably, many of the participants in the present study reported hearing others express such intentions. Even then, they perceived that peers did not intend to lose their memory per se, but rather were expressing an intention to get intoxicated. Additionally, heavier drinkers reported that while they were not intending to black out, they often knew that it may happen, and may not take any active steps (i.e., protective behavioral strategies) to avoid the possibility of blacking out. It is important to note that like other psychological constructs, intentions may differ for en bloc vs fragmentary blackouts, which was not tested here. For example, Miller, Merrill, DiBello, et al. (2018) found that students with past year blackouts had more permissive attitudes toward fragmentary (M=2.33, SD=0.95) than en bloc blackouts (M=1.82, SD=0.94); similar differences might be expected for intentions.

The present study draws a distinction between intentions and willingness and suggests that expressing an intention to blackout may be more accurately expressing an intention to get drunk and/or a willingness to blackout. There were some exceptions to the general theme that heavy drinking students are willing to black out, with some participants denying any such willingness, but overall willingness seemed more relevant than intentions when it comes to blacking out. This suggests that the social reaction pathway (with a focus on willingness) of the Prototype Willingness Model may be more relevant to blackouts than the reasoned action pathway (with a focus on intentions).

Willingness appeared to vary not only between people, but also potentially within-person (from one occasion to another), influenced by participants environment and sense of safety. More specifically, participants reported that being surrounded by friends that they trust played an important role in their willingness to blackout. However, environmental changes across nights (or perhaps even throughout the night) sometimes meant changes in their willingness as well. With our findings in mind, one future direction for research might involve the use of real-time assessment to examine how willingness to drink to the point of memory loss may change both between drinking events but also over the course of a drinking event. Additionally, given women’s higher risk for blackouts despite men’s higher alcohol consumption (Sugarman et al., 2009), it would be fruitful to more explicitly examine sex differences in contexts in which it is deemed safe to blackout for men and women.

We also assessed for friends’ reactions to participants experiences of blacking out; friends reactions varied and there were several emergent themes, including positive reactions, reassurance, and expressions of concern. Overall, the most common positive reaction among friends was finding humor in the experience. However, some friends’ reactions were to provide participants with reassurance that blacking out is normal and common. This is particularly important, as such reassurance may serve to normalize the experience and potentially lessen a drinker’s concern about the problematic nature of blacking out. In turn, consistent with the processes of social reinforcement (Borsari & Carey, 2006), heavy drinking may persist in spite of blackouts.

These findings on how one’s friends respond to a drinker’s recent blackout are novel. Previous work with college students indicates that students often perceive their own blackouts to be negative, with some exceptions of students perceiving them as positive, neutral, or having mixed reactions (Merrill, Miller, et al., 2019). Thus, it is not surprising that participants reported that their friend’s reactions also varied. Concern was expressed in more extreme blackout situations, including when the experience was repeated (indicating a pattern of behavior), was out of character, or if the blackout occurred in an unsafe situation. The friends’ concern seemed to occur out of a place of concern for the participant’s well-being. This finding is consistent with prior work on students’ evaluations of blackouts as negative under certain conditions, such as when negative consequences occur following a blackout experience or when the social environment is unsafe (Merrill, Miller, et al., 2019). Future quantitative work could be used to better tease out the specific conditions under which friends do or do not express concern about one’s blackout.

Regarding social norms more generally, alcohol-induced memory loss was perceived by participants as both common and acceptable among other heavy drinking college students. However, alcohol-induced memory loss was perceived to be less acceptable by others if it occurred in an unsafe situation, or around people not known well to the participant. Additionally, blackouts were perceived less favorably if there were consequences for others such as having to take care of the participant (i.e., being a burden to others). These perceived social norms and the conditions under which they apply may be in part be influenced by friend reactions to recent blackouts described above. In turn, as per the Prototype Willingness Model, they may influence one’s own willingness/intentions to black out. Such possibilities could be more rigorously tested in future, quantitative studies.

Limitations

This study is not without limitations. First, the study focused primarily on college attending young adults and may not generalize to other alcohol drinking populations. Second, the sample was primarily Non-Hispanic White; study findings may not generalize to other racial/ethnic groups. Third, the friends’ reactions to the participants blackout experiences are only the participants perception of what other people said/did and may not be an accurate representation of what the friends actually think. Despite these limitations the study also had several strengths including that blackout events were recent (last month) and participants were encouraged to focus on the most recent and/or the event that stood out as “most significant” which is helpful in reducing recall bias. Additionally, our approach to qualitative coding and analysis was rigorous, and the focus of this investigation was novel, with great potential to inform future quantitative research.

Future Directions

Future qualitative and quantitative studies on blackouts among non-college-attending emerging adults are warranted, to inform theory, our understanding of this high-risk behavior, and ultimately intervention. For example, we did not qualitatively query participants regarding two additional constructs relevant to the Prototype Willingness model. These include prototypes (e.g., the extent to which the prototypical young adult who blacks out is viewed favorably) and perceived vulnerability (e.g., the extent to which one thinks that that blacking out is likely to result in some negative outcome). Future in-depth inquiries into these constructs as they relate to blackouts should be conducted. Additionally, future survey studies could be conducted to examine friends’ reactions and their long-term impacts on students’ drinking. Following from our findings, we might hypothesize friends’ reinforcement of one’s memory loss by using humor to defuse the situation may result in young adults continuing to drink in a way that leads to blackouts. On the other hand, friends who are disappointed and express concern, or who try to actively control aspects of the drinking situations to change behavior in the participants, may encourage risk reduction. This has yet to be rigorously tested. Additional work might also further assess whether intentions to black out are dynamic over time, even within a drinking event. It is possible that, when asked at the start of a drinking even or retrospectively, participants deny intentions to blackout, but that at some point during a drinking event their intentions change.

Understanding reactions and social norms for blackouts in more detail would also be helpful for tailoring a social norms intervention for college students who engage in heavy drinking behaviors. Students who have accurate perceptions of peers’ alcohol use report lower number of drinks per event and experiencing fewer blackouts relative to students who do not have accurate perceptions of peer alcohol use (Su et al., 2018), suggesting the importance of social norms in blackouts. Additional work in this area could involve altering the way friends react to recent blackouts (e.g., minimizing their positive feedback on this behavior), which may serve to reduce the extent to which heavy drinkers think this behavior is normative, and in turn reduce their willingness and/or intentions to engage in such behavior.

Conclusion

Key findings of this study included that while heavy drinking college students may not intend to black out, they often do intend to get drunk, and accordingly are often willing to blackout and anticipate that it may happen. In other words, when heavy drinking college students verbally express a plan to blackout what they actually intend to do is drink heavily and not necessarily experience memory loss. Moreover, while experiencing alcohol-related memory loss was largely considered a normal and common experience among heavy drinking college students, blacking out was not acceptable during some particular circumstances (i.e., when not safe, the night before next day responsibilities), suggesting that there are unspoken boundaries that college students place on other heavy drinkers’ behaviors. The apparent social influences on drinkers’ willingness to black out, including the range of ways that others in one’s social network react to blackouts, should be further explored in future quantitative studies with an eye toward whether social influence can be leveraged to reduce this high-risk behavior in the context of intervention.

Public Significance Statement:

Using a qualitative interview approach, this study provides initial insight into factors that may increase the likelihood of alcohol-induced memory loss (i.e., blackouts) among heavy-drinking college students. Findings suggest that while students do not typically intend to black out, they are often willing to do so, and that blackouts are sometimes seen as acceptable and/or normal among one’s friends. Findings may ultimately be used to inform ways to help decrease rates of blackouts among college students.