Journal of Studies on Alcohol

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ABSTRACT
Objective: The study was designed to assess current trends in studying, and emerging approaches to furthering understanding of, college drinking.
Method: A literature review was conducted of findings and methods highlighting conceptual and methodological issues that need to be addressed.
Results: Most studies address clinical, developmental and psychological variables and are conducted at single points in time on single campuses. Factors affecting college alcohol use and methods of studying them are discussed.
Conclusions: Most current studies of college drinking do not address the influence of the college and its alcohol environment. Our understanding of college drinking can be improved by expanding the scope of issues studied and choosing appropriate research designs. (J. Stud. Alcohol, Supplement No. 14: 14-22, 2002)

George W. Dowdall, Ph.D., Professor, Department of Sociology, St. Joseph’s University, and Henry Wechsler, Ph.D., Lecturer and Director of College Alcohol Studies, Department of Health and Social Behavior, Harvard School of Public Health

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ABSTRACT
Objective: This article provides information on the extent of alcohol use and other drug use among American college students.
Method: Five different sources of data are examined for estimating recent levels of alcohol (and other drug) use among college students: Harvard School of Public Health College Alcohol Study (CAS), the Core Institute (CORE), Monitoring the Future (MTF), National College Health Risk Behavior Survey (NCHRBS) and National Household Survey on Drug Abuse (NHSDA).
Results: Alcohol use rates are very high among college students. Approximately two of five American college students were heavy drinkers, defined as having had five or more drinks in a row in the past 2 weeks. Alcohol use is higher among male than female students. White students are highest in heavy drinking, black students are lowest and Hispanic students are intermediate. Use of alcohol—but not cigarettes, marijuana and cocaine—is higher among college students than among noncollege age-mates. Longitudinal data show that, while in high school, students who go on to attend college have lower rates of heavy drinking than do those who will not attend college. Both groups increase their heavy drinking after high school graduation, but the college students increase distinctly more and actually surpass their nonstudent age-mates. Trend data from 1980 to 1999 show some slight improvement in recent years.
Conclusions: Despite improvements in the past 20 years, colleges need to do more to reduce heavy alcohol use among students. (J. Stud. Alcohol, Supplement No. 14: 23- 39, 2002)

Patrick M. O’Malley, Ph.D., Senior Research Scientist, Institute for Social Research, University of Michigan, and Lloyd D. Johnston, Ph.D., Distinguished Research Scientist, Institute for Social Research, University of Michigan

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ABSTRACT
Objective: Research on individual differences in drinking rates and associated problems among college students is reviewed.
Method: Studies are included if completed within U.S. college and university samples and found in published scientific literature as identified by several searches of national databases.
Results: The resulting review suggests first that the extant literature is large and varied in quality, as most studies use questionnaire responses from samples of convenience in cross-sectional designs. Evidence from studies of college samples does consistently suggest that alcohol is consumed for several different purposes for different psychological effects in different contexts. A pattern of impulsivity/sensation seeking is strongly related to increased drinking among students. This pattern is supported by research into personality, drinking motives, alcohol expectancies and drinking contexts. A second pattern of drinking associated with negative emotional states is also documented. Some long-term consequences of this second pattern have been described. Social processes appear especially important for drinking in many college venues and may contribute to individual differences in drinking more than enduring personality differences.
Conclusions: Future research efforts should test interactive and mediating models of multiple risk factors and address developmental processes. (J. Stud. Alcohol, Supplement No. 14: 40-53, 2002)

John S. Baer, Ph.D., Research Associate Professor, Department of Psychology, University of Washington, and Coordinator of Education, Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System

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ABSTRACT
Objective: This article offers a developmental perspective on college drinking by focusing on broad developmental themes during adolescence and the transition to young adulthood.
Method: A literature review was conducted.
Results: The transition to college involves major individual and contextual change in every domain of life; at the same time, heavy drinking and associated problems increase during this transition. A developmental contextual perspective encourages the examination of alcohol use and heavy drinking in relation to normative developmental tasks and transitions and in the context of students' changing lives, focusing on interindividual variation in the course and consequences of drinking and on a wide range of proximal and distal influences. Links between developmental transitions and alcohol use and other health risks are discussed in light of five conceptual models: Overload, Developmental Mismatch, Increased Heterogeneity, Transition Catalyst and Heightened Vulnerability to Chance Events. We review normative developmental transitions of adolescence and young adulthood, focusing on the domains of physical and cognitive development, identity, affiliation and achievement.
Conclusions: As shown in a selective review of empirical studies, these transitions offer important vantage points for examining increasing (and decreasing) alcohol and other drug use during adolescence and young adulthood. We conclude with a consideration of research and intervention implications. (J. Stud. Alcohol, Supplement No. 14: 54-70, 2002)

John E. Schulenberg, Ph.D., Senior Research Scientist, Institute for Social Research, Professor, Department of Psychology, and Research Scientist, Center for Human Growth and Development, University of Michigan, and Jennifer L. Maggs, Ph.D., Associate Professor, Family Studies and Human Development, University of Arizona

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ABSTRACT
Objective: This article reviews the literature on adolescent brain development and considers the impact of these neural alterations on the propensity to use and misuse alcohol.
Method: Neural, behavioral and hormonal characteristics of adolescents across a variety of species were examined, along with a review of the ontogeny of ethanol responsiveness, tolerance development and stress/alcohol interactions.
Results: The adolescent brain is a brain in transition. Prominent among the brain regions undergoing developmental change during adolescence in a variety of species are the prefrontal cortex and other forebrain dopamine projection regions, stressor-sensitive areas that form part of the neural circuitry modulating the motivational value of alcohol and other reinforcing stimuli. Along with these characteristic brain features, adolescents also exhibit increased stressor responsivity and an altered sensitivity to a variety of ethanol effects. Findings are mixed to date as to whether exposure to ethanol during this time of rapid brain development alters neurocognitive function and later propensity for problematic ethanol use.
Conclusions: Developmental transformations of the adolescent brain may have been evolutionarily advantageous in promoting behavioral adaptations to avoid inbreeding and to facilitate the transition to independence. These brain transformations may also alter sensitivity of adolescents to a number of alcohol effects, leading perhaps in some cases to higher intakes to attain reinforcing effects. These features of the adolescent brain may also increase the sensitivity of adolescents to stressors, further escalating their propensity to initiate alcohol use. Additional investigations are needed to resolve whether ethanol use during adolescence disrupts maturational processes in ethanol-sensitive brain regions. (J. Stud. Alcohol, Supplement No. 14: 71-81, 2002)

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ABSTRACT
Objective: The purpose of this article is to examine the aspects of collegiate environments, rather than student characteristics, that influence drinking. Unfortunately, the existing literature is scant on this topic.
Method: A literature review of articles primarily published within the last 10 years, along with some earlier "landmark" studies of collegiate drinking in the United States, was conducted to determine institutional factors that influence the consumption of alcohol. In addition, a demonstration analysis of Core Alcohol and Drug Survey research findings was conducted to further elucidate the issues.
Results: Several factors have been shown to relate to drinking: (1) organizational property variables of campuses, including affiliations (historically black institutions, women's institutions), presence of a Greek system, athletics and 2- or 4-year designation; (2) physical and behavioral property variables of campuses, including type of residence, institution size, location and quantity of heavy episodic drinking; and (3) campus community property variables, including pricing and availability and outlet density. Studies, however, tend to look at individual variables one at a time rather than in combination (multivariate analyses). Some new analyses, using Core Alcohol and Drug Survey data sets, are presented as examples of promising approaches to future research.
Conclusions: Given the complexities of campus environments, it continues to be a challenge to the field to firmly establish the most compelling institutional and environmental factors relating to high-risk collegiate drinking. (J. Stud. Alcohol, Supplement No. 14: 82-90, 2002)

Cheryl A. Presley, Ph.D., Director, Student Health Programs and Assistant to the Vice Chancellor for Student Affairs for Research, Executive Director, Core Institute, Southern Illinois University; Philip W. Meilman, Ph.D., Director, Counseling and Psychological Services, Courtesy Professor of Human Development, Associate Professor of Psychology in Clinical Psychiatry, Cornell University; and Jami S. Leichliter, Ph.D., Behavioral Scientist, Division of STD Prevention, Centers for Disease Control and Preventiony

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ABSTRACT
This article provides a review and synthesis of professional research literature on the types, extent and patterns of negative consequences produced by student's misuse of alcohol in college populations based on survey research conducted during the last two decades. Considerable evidence is available documenting a wide range of damage by some student's drinking done to themselves as well as to other individuals, although some types of consequences remain speculative. Damage and costs to institutions are likely to be substantial, but this claim remains largely an inference based on current studies. Drinking by males compared with that of females produces more consequences for self and others that involve public deviance, whereas female's drinking contributes equally with males to consequences that are personal and relatively private. Research on racial/ethnic background, time trends and developmental stages reveals patterns in student data on consequences of drinking, but these data are very limited in the literature. Evidence suggests there is only a modest correlation between student's self-perception of having a drinking problem and the many negative consequences of drinking that are reported. (J. Stud. Alcohol, Supplement No. 14: 91-100, 2002)

H. Wesley Perkins, Ph.D., Professor of Sociology, Department of Anthropology and Sociology, Hobart and William Smith Colleges

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ABSTRACT
Objective: To evaluate the empirical associations between alcohol use and risky sex at two levels of analysis. Global associations test whether individuals who engage in one behavior are more likely to engage in the other, whereas event-specific associations test whether the likelihood of engaging in one behavior on a given occasion varies as a function of engaging in the other on that same occasion.
Method: Studies examining the association between drinking and risky sex in samples of college students and youth were reviewed. Those published in the past 10 years and using event-level methodology or random sampling were emphasized.
Results: Findings were generally consistent across levels of analysis, but differed across types of risky behaviors. Drinking was strongly related to the decision to have sex and to indiscriminate forms of risky sex (e.g., having multiple or casual sex partners), but was inconsistently related to protective behaviors (e.g., condom use). Moreover, the links among alcohol use, the decision to have sex and indiscriminate behaviors were found in both between-persons and within-persons analyses, suggesting that these relationships cannot be adequately explained by stable individual differences between people who do and do not drink. Analysis of event characteristics showed that drinking was more strongly associated with decreased protective behaviors among younger individuals, on first intercourse experiences and for events that occurred on average longer ago. Conclusions: Future efforts aimed at reducing alcohol use in potentially sexual situations may decrease some forms of risky sex, but are less likely to affect protective behaviors directly. (J. Stud. Alcohol, Supplement No. 14: 101-117, 2002)

M. Lynne Cooper, Ph.D., Professor of Psychology, Department of Psychology, University of Missouri at Columbia

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ABSTRACT
Objective: This article summarizes research on the role of alcohol in college students' sexual assault experiences. Sexual assault is extremely common among college students. At least half of these sexual assaults involve alcohol consumption by the perpetrator, the victim or both.
Method: Two research literatures were reviewed: the sexual assault literature and the literature that examines alcohol's effects on aggressive and sexual behavior.
Results: Research suggests that alcohol consumption by the perpetrator and/or the victim increases the likelihood of acquaintance sexual assault occurring through multiple pathways. Alcohol's psychological, cognitive and motor effects contribute to sexual assault.
Conclusions: Although existing research addresses some important questions, there are many gaps. Methodological limitations of past research are noted, and suggestions are made for future research. In addition, recommendations are made for college prevention programs and policy initiatives. (J. Stud. Alcohol, Supplement No. 14: 118-128, 2002)

Antonia Abbey, Ph.D., Associate Professor, Department of Community Medicine, Wayne State University

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ABSTRACT
Objective: The purpose of this article is to present an overview of the research literature on alcohol-related aggression with a focus on college students.
Method: Data from both survey studies and experimental laboratory investigations conducted on college students are reviewed. Various methodological approaches to studying the alcoholaggression relation, and their associated limitations, are then presented and discussed.
Results: The literature indicates that alcohol consumption facilitates aggressive behavior and increases the risk of being the victim of a violent act, particularly in heavy drinkers. Results from these studies are then placed into a context by reviewing 12 influential theories of aggression and alcohol-related aggression. On the basis of these theories and empirical data, a preliminary risk profile is presented to help identify which factors are likely to be important in predicting who will and who will not become aggressive after drinking alcohol.
Conclusions: Although much research is still needed to elucidate the intricate causes of alcohol-related aggression, current prevention efforts might focus on modifying key risk factors such as poor cognitive functioning and inaccurate expectations about the effects of alcohol. Other prevention efforts directed specifically at college students might focus on helping them to identify risky situations that might facilitate the expression of intoxicated aggression. (J. Stud. Alcohol, Supplement No. 14: 129-139, 2002)

Peter R. Giancola, Ph.D., Assistant Professor of Psychology, University of Kentucky

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ABSTRACT
Objective: This article outlines a typology of programs and policies for preventing and treating campus-based alcohol-related problems, reviews recent case studies showing the promise of campusbased environmental management strategies and reports findings from a national survey of U.S. colleges and universities about available resources for pursuing environmentally focused prevention.
Method: The typology is grounded in a social ecological framework, which recognizes that health-related behaviors are affected through multiple levels of influence: intrapersonal (individual) factors, interpersonal (group) processes, institutional factors, community factors and public policy. The survey on prevention resources and activities was mailed to senior administrators responsible for their school's institutional response to substance use problems. The study sample was an equal probability sample of 365 2- and 4-year U.S. campuses. The response rate was 76.9%.
Results: Recent case studies suggest the value of environmentally focused alcohol prevention approaches on campus, but more rigorous research is needed to establish their effectiveness. The administrators' survey showed that most U.S. colleges have not yet installed the basic infrastructure required for developing, implementing and evaluating environmental management strategies.
Conclusions: The typology of campus-based prevention options can be used to categorize current efforts and to inform strategic planning of multilevel interventions. Additional colleges and universities should establish a permanent campus task force that reports directly to the president, participate actively in a campus-community coalition that seeks to change the availability of alcohol in the local community and join a state-level association that speaks out on state and federal policy issues. (J. Stud. Alcohol, Supplement No. 14: 140-147, 2002)

William DeJong, Ph.D., Professor, Boston University School of Public Health, and Director, U.S. Department of Education's Higher Education Center for Alcohol and Other Drug Prevention, and Linda Langford, Sc.D., Associate Director of Evaluation and Assessment, U.S. Department of Education's Higher Education Center for Alcohol and Other Drug Prevention

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ABSTRACT
Objective: The purpose of this article is to review and assess the existing body of literature on individually focused prevention and treatment approaches for college student drinking.
Method: Studies that evaluate the overall efficacy of an approach by measuring behavioral outcomes such as reductions in alcohol use and associated negative consequences were included. All studies discussed utilized at least one outcome measure focused on behavioral change and included a control or comparison condition; however, not all trials were randomized.
Results: Consistent with the results of previous reviews, little evidence exists for the utility of educational or awareness programs. Cognitive-behavioral skills-based interventions and brief motivational feedback (including mailed graphic feedback) have consistently yielded greater support for their efficacy than have informational interventions.
Conclusions: There is mixed support for values clarification and normative reeducation approaches. Much of the research suffers from serious methodological limitations. The evidence from this review suggests that campuses would best serve the student population by implementing brief, motivational or skills-based interventions, targeting high-risk students identified either through brief screening in health care centers or other campus settings or through membership in an identified risk group (e.g., freshmen, Greek organization members, athletes, mandated students). More research is needed to determine effective strategies for identifying, recruiting and retaining students in efficacious individually focused prevention services, and research on mandated student prevention services is an urgent priority. Integration between campus policies and individually oriented prevention approaches is recommended. (J. Stud. Alcohol, Supplement No. 14: 148-163, 2002)

Mary Larimer, Ph.D., Assistant Professor of Psychiatry and Behavioral Sciences, Adjunct Assistant Professor of Psychology, Associate Director, Addictive Behaviors Research Center, University of Washington, and Jessica M. Cronce, B.S., Research Coordinator, Addictive Behaviors Research Center, Department of Psychology, University of Washington

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ABSTRACT
Objective: This article provides a review of conceptual and empirical studies on the role of social norms in college student alcohol use and in prevention strategies to counter misuse. The normative influences of various constituencies serving as reference groups for students are examined as possible factors influencing students' drinking behavior.
Method: A review of English language studies was conducted.
Results: Parental norms have only modest impact on students once they enter college beyond the residual effects of previously instilled drinking attitudes and religious traditions. Faculty could theoretically provide a positive influence on student drinking behavior, but there is little evidence in the literature that faculty norms and expectations about avoiding alcohol misuse are effectively communicated to students. Although the norms of resident advisers (RAs) should ideally provide a restraint on student alcohol misuse, the positive influence of RAs is limited by their negotiated compromises with students whom they oversee and by their misperceptions of student norms. Research reveals student peer norms to be the strongest influence on students' personal drinking behavior, with the more socially integrated students typically drinking most heavily. The widespread prevalence among students of dramatic misperceptions of peer norms regarding drinking attitudes and behaviors is also a consistent finding. Permissiveness and problem behaviors among peers are overestimated, even in environments where problem drinking rates are relatively high in actuality. These misperceived norms, in turn, have a significant negative effect promoting and exacerbating problem drinking.
Conclusions: Interventions to reduce these misperceptions have revealed a substantial positive effect in several pilot studies and campus experiments. (J. Stud. Alcohol, Supplement No. 14: 164- 172, 2002)

H. Wesley Perkins, Ph.D., Professor of Sociology, Department of Anthropology and Sociology, Hobart and William Smith Colleges

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ABSTRACT
Objective: The question addressed in this review is whether aggregate alcohol advertising increases alcohol consumption among college students. Both the level of alcohol-related problems on college campuses and the level of alcohol advertising are high. Some researchers have concluded that the cultural myths and symbols used in alcohol advertisements have powerful meanings for college students and affect intentions to drink. There is, however, very little empirical evidence that alcohol advertising has any effect on actual alcohol consumption.
Method: The methods used in this review include a theoretical framework for evaluating the effects of advertising. This theory suggests that the marginal effect of advertising diminishes at high levels of advertising. Many prior empirical studies measured the effect of advertising at high levels of advertising and found no effect. Those studies that measure advertising at lower, more disaggregated levels have found an effect on consumption.
Results: The results of this review suggest that advertising does increase consumption. However, advertising cannot be reduced with limited bans, which are likely to result in substitution to other available media. Comprehensive bans on all forms of advertising and promotion can eliminate options for substitution and be potentially more effective in reducing consumption. In addition, there is an increasing body of literature that suggests that alcohol counteradvertising is effective in reducing the alcohol consumption of teenagers and young adults.
Conclusions: These findings indicate that increased counteradvertising, rather than new advertising bans, appears to be the better choice for public policy. It is doubtful that the comprehensive advertising bans required to reduce advertising would ever receive much public support. New limited bans on alcohol advertising might also result in less alcohol counteradvertising. An important topic for future research is to identify the counteradvertising themes that are most effective with youth. (J. Stud. Alcohol, Supplement No. 14: 173-181, 2002)

Henry Saffer, Ph.D., Professor of Economics, Kean University, and Research Associate, National Bureau of Economic Research

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ABSTRACT
Objective: This article categorizes and describes current media campaigns to reduce college student drinking, reviews key principles of campaign design and outlines recommendations for future campaigns.
Method: The article describes three types of media campaigns on student drinking: information, social norms marketing, and advocacy. Key principles of campaign design are derived from work in commercial marketing, advertising, and public relations and from evaluations of past public health campaigns.
Results: Information campaigns on the dangers of high-risk drinking are common, but none has been rigorously evaluated. Quasi-experimental studies suggest that social norms marketing campaigns, which correct misperceptions of campus drinking norms, may be effective, but more rigorous research is needed. As of this writing, only one major media campaign has focused on policy advocacy to reduce college student drinking, but it is still being evaluated. Lessons for campaign design are organized as a series of steps for campaign development, implementation and assessment: launch a strategic planning process, select a strategic objective, select the target audience, develop a staged approach, define the key promise, avoid fear appeals, select the right message source, select a mix of media channels, maximize media exposure, conduct formative research, and conduct process and outcome evaluations.
Conclusions: Future campaigns should integrate information, social norms marketing, and advocacy approaches to create a climate of support for institutional, community and policy changes that will alter the environment in which students make decisions about their alcohol consumption. (J. Stud. Alcohol, Supplement No. 14: 182-192, 2002)

William DeJong, Ph.D., Professor, Boston University School of Public Health, and Director, U.S. Department of Education's Higher Education Center for Alcohol and Other Drug Prevention

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ABSTRACT
Objective: The goal of this article is to provide an overview of environmental strategies that may reduce college drinking. Drinking behavior is influenced by many environmental factors, including messages in the media, community norms and attitudes, public and institutional policies and practices and economic factors. College student drinking may be influenced by environmental factors on and off campus.
Method: A comprehensive search of MEDLINE, ETOH, Current Contents and Social Science Abstracts databases was conducted to identify research studies evaluating effects of environmental strategies on college and general populations.
Results: The identified environmental strategies fall into four categories: (1) increasing compliance with minimum legal drinking age laws, (2) reducing consumption and risky alcohol use, (3) decreasing specific types of alcohol-related problems and (4) deemphasizing the role of alcohol on campus and promoting academics and citizenship. Although the extant research indicates that many environmental strategies are promising for reducing alcohol-related problems among the general population, few of these strategies have been evaluated for effects on the college population.
Conclusions: Further research is needed to evaluate effects of alcohol control policies on alcohol consumption and its related problems among college students. (J. Stud. Alcohol, Supplement No. 14: 193-205, 2002)

Traci L. Toomey, Ph.D., Assistant Professor, School of Public Health, Division of Epidemiology, University of Minnesota, and Alexander C. Wagenaar, Ph.D., Professor and Director, Alcohol Epidemiology Program, School of Public Health, Division of Epidemiology, University of Minnesota

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ABSTRACT
Objective: The goal of this article is to review critically the extant minimum legal drinking age (MLDA) research literature and summarize the current state of knowledge regarding the effectiveness of this policy.
Method: Comprehensive searches of four databases were conducted to identify empirical studies of the MLDA published from 1960 to 1999. Three variables were coded for each study regarding methodological quality: (1) sampling design, (2) study design and (3) presence or absence of comparison group.
Results: We identified 241 empirical analyses of the MLDA. Fifty-six percent of the analyses met our criteria for high methodological quality. Of the 33 higher quality studies of MLDA and alcohol consumption, 11 (33%) found an inverse relationship; only 1 found the opposite. Similarly, of the 79 higher quality analyses of MLDA and traffic crashes, 46 (58%) found a higher MLDA related to decreased traffic crashes; none found the opposite. Eight of the 23 analyses of other problems found a higher MLDA associated with reduced problems; none found the opposite. Only 6 of the 64 college-specific studies (9%) were of high quality; none found a significant relationship between the MLDA and outcome measures.
Conclusions: The preponderance of evidence indicates there is an inverse relationship between the MLDA and two outcome measures: alcohol consumption and traffic crashes. The quality of the studies of specific populations such as college students is poor, preventing any conclusions that the effects of MLDA might differ for such special populations. (J. Stud. Alcohol, Supplement No. 14: 206-225, 2002)

Alexander C. Wagenaar, Ph.D., Professor and Director, Alcohol Epidemiology Program, School of Public Health, Division of Epidemiology, University of Minnesota, and Traci L. Toomey, Ph.D., Assistant Professor, School of Public Health, Division of Epidemiology, University of Minnesota

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ABSTRACT
Objective: This article reviews comprehensive community interventions that sought to reduce (1) cardiovascular disease risks; (2) smoking; (3) alcohol use disorders, alcohol-related injury and illicit drug use; or (4) sexual risk taking that could lead to HIV infection, sexually transmitted disease and pregnancy.
Method: Comprehensive community programs typically involve multiple city government agencies as well as private citizens and organizations and use multiple intervention strategies such as school-based and public education programs, media advocacy, community organizing, environmental policy changes and heightened enforcement of existing policies. This review focused on English-language papers published over the past several decades.
Results: Some programs in each of the four problem areas achieved their behavioral and health goals. The most consistent benefits were found in programs targeting behaviors with immediate health consequences such as alcohol misuse or sexual risk taking. Results were less consistent when consequences of targeted behaviors were more distant in time such as cardiovascular risks and smoking. Also, programs that targeted youth to prevent them from starting new health-compromising behaviors tended to be more successful than programs aimed at modifying preexisting habits among adults. Programs that combined environmental and institutional policy change with theory-based education programs were the most likely to be successful. Finally, programs tailored to local conditions by the communities themselves tended to achieve more behavior change than programs imported from the outside.
Conclusions:Comprehensive community intervention approaches may have considerable potential to reduce college-age drinking problems, especially given the success of these programs in reducing alcohol-related problems and in preventing health-compromising behaviors among youth. (J. Stud. Alcohol, Supplement No. 14: 226-240, 2002)

Ralph Hingson, Sc.D., Professor and Chair, Social and Behavioral Sciences Department, Boston University School of Public Health, and Jonathan Howland, Ph.D., M.P.H., Professor and Chair, Social and Behavioral Sciences Department, Boston University School of Public Health