Addictive Behaviors 29 (2004) 159 – 179
A cognitive model of binge drinking: The influence of
alcohol expectancies and drinking refusal self-efficacy
Tian P.S. Oei*, A. Morawska
School of Psychology, University of Queensland, Brisbane 4072, Australia
Abstract
While binge drinking—episodic or irregular consumption of excessive amounts of alcohol—is
recognised as a serious problem affecting our youth, to date there has been a lack of psychological
theory and thus theoretically driven research into this problem. The current paper develops a cognitive
model using the key constructs of alcohol expectancies (AEs) and drinking refusal self-efficacy
(DRSE) to explain the acquisition and maintenance of binge drinking. It is suggested that the four
combinations of the AE and DRSE can explain the four drinking styles. These are normal/social
drinkers, binge drinkers, regular heavy drinkers, and problem drinkers or alcoholics. Since AE and
DRSE are cognitive constructs and therefore modifiable, the cognitive model can thus facilitate the
design of intervention and prevention strategies for binge drinking.
D 2003 Elsevier Ltd. All rights reserved.
Keywords: Binge drinking; Alcohol expectancies; Drinking refusal self-efficacy
1. Introduction
Consumption of alcohol amongst adolescents and young adults is a widely recognised
problem, and often it is a problem without an apparent solution. The prevalence of drinking
amongst young people poses serious issues in terms of the consequences to the young people
involved, as well as to the family and society as a whole. It is often acknowledged that
alcohol abuse is one of the major causes of preventable morbidity and mortality, particularly
in Western societies (Weschler, Dowdall, Davenport, & Castillo, 1995), and alcohol has been
* Corresponding author. Tel.: +61-7-3365-6230.
E-mail address: [email protected] (T.P.S. Oei).
0306-4603/$ – see front matter D 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0306-4603(03)00076-5
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identified as the highest contributor to mortality and morbidity amongst young people in
Australia (Polkinghorne & Gill, 1995).
The hazardous consequences of binge drinking arise from the disabling effects of
consuming a large amount of alcohol over a short period. Adams, Barry, and Fleming
(1996) identified that while the number of drinks consumed per occasion was an important
risk factor for death from injury, frequency of consumption was not. While the various
ramifications of binge drinking are clear (Baron, Silberman, & D’Alonzo, 1998), effective
ways to prevent or intervene with binge drinking have yet to be demonstrated. This may be
due to a failure of previous research in this area to address the issue from a theoretical
perspective, instead conducting correlation studies examining a range of factors, which are
indicative of binge drinkers. The focus of the current review is to provide an overview of the
current literature on binge drinking and to propose a cognitive model as a theoretical
foundation from which to address the issue of binge drinking. This model is based on Alcohol
Expectancy Theory and describes cognitive motivations for binge drinking, thus enabling a
theoretical approach to the issue of binge drinking prevention and intervention. While the
model is a more general model, which applies to all forms of alcohol consumption patterns,
the aim of the current review is to focus in particular on binge drinking, as this is an area
which has not received much theoretical attention in the literature.
2. Definition of binge drinking
Although there is widespread consensus amongst researchers of the concept of binge
drinking and its distinctiveness from steady or moderate drinking, no generally accepted
definition of binge drinking exists. Different studies have used different definitions for both
quantity consumed in one session and the frequency with which this heavy consumption
occurs. In addition, various terms have been used to describe binge drinking, such as high risk
drinking and heavy episodic drinking, and this makes the issue of comparing across studies
particularly difficult. Similarly, some studies define different levels of binge drinking, for
example, high and low frequency binge drinkers. Finally, many studies use the same number
of drinks for defining both male and female binge drinkers, despite known gender differences
in metabolism and effects of alcohol (Weschler, Dowdall, Davenport, & Rimm, 1995).
Binge drinking has frequently been defined as drinking five or more standard drinks of
alcohol on one occasion (e.g., Syre, Martino-McAllister, & Vanada, 1997); however, various
other levels have also been used. For example, Moore, Smith, and Catford (1994) defined an
episode of binge drinking as the consumption of seven or more standard drinks for women
and 10 or more standard drinks for men. Nadeau, Guyon, and Bourgault (1998) used eight
standard drinks per day to define binge drinking. Lowe, James, and Willner (1998) created a
binge drinking index by multiplying the largest number of drinks consumed by the frequency
of this consumption and then formed a median split of bingers and nonbingers. Reilly et al.
(1998) defined different levels of binge drinking in terms of risk. Low risk drinking was
defined as 0–5 drinks for women and 0–6 drinks for men, hazardous drinking was defined as
6–12 drinks for women and 7–14 drinks for men, while harmful use was 13 or more drinks
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161
for women and 15 or more drinks for men. Weschler, Dowdall, Davenport, and Rimm (1995)
provided a lower standard defining binge drinking for women, showing that for 8 (out of 12)
alcohol-related problems, women who drank four or more standard drinks had a similar
likelihood of experiencing that problem as men who drank five or more standard drinks.
Thus, this definition makes alcohol-related risks associated with binge drinking equivalent for
males and females (Dowdall, Crawford, & Weschler, 1998). The Australian National Health
and Medical Research Council (NH&MRC) has defined binge drinking as four or more
standard drinks for women and six or more standard drinks for men per drinking period (Pols
& Hawks, 1992), and this definition is proposed here as a standard, particularly given recent
questions about the use of the four or five drinks definition (Lange & Voas, 2001; Perkins,
DeJong, & Linkenbach, 2001).
In terms of frequency of binge drinking, there appears to be more consensus in the
literature. Generally, binge drinking is defined as consuming more than the defined cut-off
level at least once in the 2 weeks prior to the survey or experiment (e.g., Syre et al., 1997;
Weschler, Dowdall, Maenner, Hill-Hoyt, & Lee, 1998). Nevertheless, differences between
studies are evident. For example, Ichiyama and Kruse (1998) defined frequent binge drinkers
as those who binged more than once in the 2 weeks prior to the questionnaire, while those
who binged once in those 2 weeks were classified as occasional binge drinkers. Moore et al.
(1994) defined binge drinkers as those who had binged at least once in the week prior to the
survey. Finally, Dowdall et al. (1998) used the term current binge drinkers as those who had
binged in the 2 weeks prior to the questionnaire. However, Vik, Tate, and Carrello (2000)
recently demonstrated that the 2-week time frame might not be sensitive enough for
discriminating student binge drinkers from nonbinge drinkers. Circumstances occurring
during the 2 weeks, such as exams, may prevent an individual from engaging in binge
drinking, despite this being a normal pattern of drinking for them. The study showed that
those individuals who indicated that they had binged in the 3 months, but not in the 2 weeks
prior to the survey, experienced the same level of negative consequences of alcohol use—
particularly severe consequences—as did those who had binged in the 2 weeks prior. Both
these binge drinking groups experienced significantly more negative alcohol-related consequences than a group of nonbinge drinkers.
In summary, research to date does not provide clear guidelines for the definition of binge
drinking. For the purposes of this review, the NH&MRC definition will be used and it is
suggested that this may be the most appropriate definition of binge drinking. In addition, the
2-week time frame will be used to define frequency. Nevertheless, this definition is essentially
arbitrary and may depend on cultural and social contexts. This definition may differentiate
more clearly between those who binge drink and those who do not and thus provide clearer
guidelines for research and risk assessment.
3. Binge drinking in adolescents and young adults
Adolescents and young adults often see binge drinking as a rite of passage into adulthood
(Schulenberg, O’Malley, Bachman, Wadsworth, & Johnston, 1996) and as such it is firmly
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embedded in Western culture (Broadbent, 1994). For example, White, Hill, and Segan (1997)
indicated that by age 18, most individuals have been exposed to alcohol and use it on a
regular basis, and that 80% of 12-year-olds had consumed some alcohol. In their sample of
Australian secondary school students, 30% of 16- and 17-year-olds were classified as binge
drinkers, and interestingly their study showed that slightly more girls than boys were drinking
at hazardous levels.
Binge drinking has also been found to be more prevalent in young people who attend
college or university than their peers who do not (Bennett, Miller, & Woodall, 1999;
Weschler, Dowdall, Davenport, & Castillo, 1995). This is consistent with findings that
alcohol is part of the culture of university life (Crundall, 1995) and that the prevalence of
alcohol use and associated problems has been shown to be higher in college populations than
in the general public (Evans & Dunn, 1995). In fact, binge drinking has been identified as the
number one substance abuse problem in American university life (Syre et al., 1997). In a
large-scale study of U.S. universities, 44% of students were classified as binge drinkers (50%
of men and 39% of women had binged at least once in the previous 2 weeks) (Weschler,
Dowdall, Davenport, & Castillo, 1995) and the rates have remained similar over time
(Weschler et al., 1998). One fifth of students were frequent binge drinkers, defined as three or
more binge drinking session in the previous 2 weeks (Weschler, Davenport, Dowdall,
Moeykens, & Castillo, 1994). Other studies have found even greater numbers of students
engaging in binge drinking; for example, in a survey by Syre et al. (1997), 55% of American
university students had consumed five or more drinks during a single occasion in the 2 weeks
prior to the questionnaire. Similarly, many students in Australia are drinking at levels in
excess of those recommended by the National Health and Medical Research Council
(O’Callaghan, Wilks, & Callan, 1990; Wilks, 1986) and a large proportion engage in binge
drinking sessions (Crundall, 1995).
Binge drinking is associated with unplanned and unsafe sex, assault and aggressive
behaviour, serious injury as a result of vehicle accidents, and various social and psychological
problems (Weschler, Dowdall, Davenport, & Castillo, 1995). In addition, binge drinking has
been associated with interpersonal problems, physical or cognitive impairment, and poor
academic performance (Weschler et. al., 1994). Weschler et al. (1994) showed that binge
drinkers, and particularly those who binged frequently, reported higher frequencies of
dangerous driving behaviours than nonbinge drinkers. Three out of five frequent male
drinkers drove after having some alcohol and two out of five drove after having five or more
drinks. Young adults who binge drink are more likely to damage property, have more trouble
with authorities, miss classes, have hangovers, and experience injuries (Bennett et al., 1999).
Amongst male students, binge drinking during college is related to later alcohol abuse
(Dowdall et al., 1998). Consequences also include increased risk of brain damage, antibody
suppression, memory loss, stroke, and there is a link between excessive use of alcohol and
illicit drug use and cigarette smoking (Ichiyama & Kruse, 1998).
Although research suggests that a large proportion of students are placing themselves at
risk by engaging in binge drinking, young people do not see this as a significant problem
(Broadbent, 1994; Crundall, 1995). For example, White et al. (1997) showed that the majority
of young people the researchers classified as binge drinkers or heavy drinkers defined
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themselves as party drinkers or occasional drinkers. Similarly, Crundall (1995) found that for
university students, hangovers were featured as the most negative aspect of binge drinking
while longer term risks were not mentioned at all.
Young people do not see the issue of alcohol use and abuse as an important one, perhaps
reflecting the acceptance of alcohol in Western culture and society. Young people surveyed by
Broadbent (1994) indicated that they drink for fun, to be happy, to gain confidence, to be
cool, and simply for something to do. In fact, these young people found alcohol such a
normal part of their life that one young woman indicated that the ‘‘only reason you didn’t get
totally ‘wasted’ when you were drinking is because you ran out of alcohol’’ (p. 33). Similarly,
in most situations, teens do not perceive themselves to be drunk, often erroneously so, and
consequently they do not perceive drinking as a problem (Turrisi & Wiersma, 1999).
University students identify sociability as the major benefit of alcohol (Crundall, 1995) and
perceive that binge drinking enhances social interaction and increases relaxation and arousal
(Turrisi, 1999). Davey and Clark (1991) found that not only was there an expectation, but also
tolerance on the part of organisers of student events that many students will get drunk.
Similarly, nonviolent drunken behaviour was accepted as the norm. When asked to quantify
their intent to drink, representative student responses were ‘‘10–14 drinks for the night’’ and
‘‘say after 14 or 15. . . if I feel like my head’s spinning, I’d go on to water or something till I
feel alright’’ (Davey & Clark, 1991, p. 33).
4. Variables associated with binge drinking
Although the negative effects of binge drinking are well documented, relatively few
studies have focused on factors influencing binge drinking. Of those studies that have
investigated binge drinking specifically, most have focused on demographic, personal, or
lifestyle characteristics that would characterise binge drinkers. Dowdall et al. (1998) found
that the strongest predictors of binge drinking amongst college students were residence in a
fraternity or sorority, engagement in a party-centred lifestyle, and participation in other risky
activities, such as use of cigarettes or marijuana and several sex partners. British binge
drinkers could be characterised as male, younger, involved in manual labour, without a
university degree, single, smokers, and overweight or obese (Moore et al., 1994). Similarly,
Bennett et al. (1999) found that binge drinkers tended to be younger and male. Caldwell,
Kivel, Smith, and Hayes (1998) indicated that adolescents and young adults who were
lesbian, gay, or bisexual were more likely to binge drink than those who were heterosexual.
However, a longitudinal study by Schulenberg, O’Malley, et al. (1996) indicated that
diverging trajectories of frequent binge drinking were not differentiated based on demographic and lifestyle characteristics at intake. Similarly, Weschler, Dowdall, Davenport, and
Castillo (1995) found that demographic variables were not important predictors of binge
drinking; however, the odds of binge drinking were much higher for students under 24 years
of age compared to older students.
Various lifestyle factors have also been linked to binge drinking. Valois, Dunham, Jackson,
and Waller (1999) showed that amongst high school students, binge drinking was positively
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related to higher number of hours of part time work. In a study of health behaviours amongst
women, those who were smokers, dieting, leading a sedentary lifestyle, and those with higher
levels of interpersonal stress were more likely to binge drink (Bradstock et. al., 1988). Tyssen,
Vaglum, Aasland, Gronvold, and Ekberg (1998) showed that the use of alcohol to cope with
tension was associated with binge drinking. Amongst Australian adolescents, Andrew and
Cronin (1997) found that binge drinking was related to sensation seeking. Park, Ashton,
Causey, and Moon (1998) showed that proscriptiveness of religious affiliation regarding
alcohol use was not related to binge drinking, while other studies have indicated that binge
drinking is negatively related to strength of religious affiliation (e.g., Weschler, Dowdall,
Davenport, & Castillo, 1995). Greater numbers of college students, both male and female
who are involved in athletics, appear to binge drink compared to students not involved with
athletics (Weschler, Davenport, Dowdall, Grossman, & Zanakos, 1997).
In general, males tend to binge drink more frequently than females (Weschler, Dowdall,
Davenport, & Castillo, 1995), and differences between males and females in reasons for
initiation of binge drinking have been investigated to some extent. Liu and Kaplan (1996)
demonstrated that females initiated binge drinking when they felt angry or worthless and
when they wanted to get away from their troubles. Males on the other hand were more likely
to initiate binge drinking to gain peer approval or show that they were not afraid.
In summary, Baron et al. (1998) identified several risk factors for binge drinking, which
have emerged out of the literature. Of the six factors that they identified, two are
unchangeable (being a White male 17–23 years of age and having a family history of drug
abuse or depression) and one is personality related (having an impulsive personality) and thus
very difficult to change. Two others focus on psychiatric disorders (having depression or
anxiety) and on showing early signs of antisocial behaviour—often considered generic risk
factors for various problems in addition to being difficult to treat. Finally, the last risk factor
mentioned was a motivational one, that is, drinking to get drunk. All in all, this list does not
sound promising in terms of prevention or intervention at anything but a general level and
does not provide specific guidelines for action.
5. Treatment and prevention of binge drinking
Various strategies have been used to decrease binge drinking—such as teaching refusal
skills, clarifying values, rewriting drinking policies at university or college, changing social
norms, increasing knowledge, and using peer education and scare tactics—but these have had
very little success in preventing or decreasing binge drinking (Haines & Spear 1996).
Similarly, alcohol education courses have not been effective interventions for reducing
alcohol consumption (Crundall, 1995). Public Service Announcements (PSAs) aimed at
decreasing drinking—and binge drinking in particular—are generally created for an undifferentiated audience, a problem exacerbated by the fact that adolescent and young adult
audiences are hardest to reach (Treise, Wolburg, & Otnes, 1999). It has been shown,
however, that rates of binge drinking are sensitive to changes in the price of alcohol, where
increases in alcohol price tend to result in lower levels of binge drinking (Abel, 1998). In
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addition, perceived certainty of legal consequences is significantly related to lower drinking
and driving rates amongst binge drinking twelfth graders (Grosvenor, Toomey, & Wagenaar,
1999). Teaching of refusal skills has sometimes been successful in increasing ability to refuse
alcohol, although in many cases, knowledge of refusal skills has increased while there was no
effect on behaviour (Herrmann & McWhirter, 1997). However, Murgraff, White, and Phillips
(1996) found that prior planning, in this case planning how to refuse a drink, increased the
likelihood of execution amongst young adult binge drinkers during a 2-week period.
It is important to note that while a number of strategies have been employed in attempting
to decrease the levels of alcohol consumption amongst young people, the majority of these
have not been particularly successful. One of the main reasons for this lack of efficaciousness
is the fact that the strategies used have been generally focused and based on correlational
studies, which provide little information as to the factors to target. It is thus crucial, in light of
the serious consequences associated with binge drinking, to provide a theoretical account of
binge drinking and to use the variables from this model to inform prevention and intervention
strategies.
6. Theoretical approaches to binge drinking
What characterises most of the research and intervention efforts into binge drinking
specifically, but also alcohol use in general, is the lack of a coherent theoretical approach. Not
only has little research been conducted into binge drinking, but most research has not
attempted to characterise binge drinkers in terms of anything other than demographic or
lifestyle variables. The general approach has been to identify binge drinkers from their
consumption patterns and compare them to others who do not show a bingeing pattern in
terms of an array of variables and factors. This approach results in circular definitions of
consumption and the various associated variables. Goldman (1989) noted that alcohol use is
governed by a long list of antecedent factors; however, no specific process is elucidated when
the relationship between various background variables and alcohol consumption is simply
noted. In addition, knowledge of these variables contributes little to treatment and prevention,
as many of the variables such as gender, age, and various personality factors are impossible or
extremely difficult to change. In this respect, it is important to go beyond simple descriptive
accounts of binge drinkers and formulate a coherent theory in order to improve understanding
of the aetiology of binge drinking and guide treatment and prevention efforts. This section
outlines some of the more theoretical approaches to binge drinking; however, it must be
pointed out that a number of these are individual studies and some have included sociodemographic features in addition to taking a more theoretical approach.
A social bond model has been used to examine binge drinking (Durkin, Wolfe, & Clark,
1999). The social bond refers to the connection between the individual and society and posits
that deviance, in this case binge drinking, occurs when the social bond is weak or lacking.
There are four components of the social bond: attachment, involvement, commitment, and
belief. The authors found that the model explained 22% of the variance in binge drinking.
Significant predictors of binge drinking were respect for authority, acceptance of conven-
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tional beliefs, GPA, and parental attachment, all of which were negatively related to binge
drinking. Although the model explained a considerable amount of variance in binge drinking,
it tends to describe what does not characterise binge drinkers rather than what does.
Norman, Bennett, and Lewis (1998) examined binge drinking from the perspective of the
Theory of Planned Behaviour. The Theory of Planned Behaviour outlines three major
influences on behaviour: the evaluation of the behaviour (attitude), perception of social
pressure to engage in the behaviour (subjective norm), and perception of control over
performing the behaviour (perceived behavioural control). The results indicated that frequent
binge drinkers were more likely to have a positive attitude to binge drinking, perceive social
pressure to binge drink, believe that binge drinking leads to various positive consequences, and
to see many facilitators of binge drinking. At the same time, they were less likely to believe
that binge drinking leads to negative consequences and that they had control over their
drinking. In a multivariate analysis, however, Norman et al. found that there were only two
significant predictors of binge drinking, behavioural control, and positive control beliefs; that
is, frequent binge drinkers were less likely to believe that they had control over their drinking
and were more likely to see many facilitators of binge drinking. Essentially, the study
suggested that perceived control over drinking behaviour was the most important factor in
determining whether someone will binge drink. This variable is important as it links to the
model described here, particularly in terms of drinking refusal self-efficacy (DRSE), the
perceived ability to refuse a drink (Young, Oei, & Crook, 1991; Oei, Hasking, & Young 2003).
One strand of research has focused on the social context of drinking—a construct that
involves patterns of personal motivation to drink within specific social settings (Ichiyama &
Kruse, 1998). Thus, the social context of alcohol consumption involves both social and
motivational aspects of drinking (Beck, Summons, & Thombs, 1991). Beck and Treiman
(1996) found that social facilitation, stress control, and school defiance were social contexts
that discriminated high-risk drinkers from low-risk drinkers. Social facilitation and perceived
social norms regarding close friends’ drinking were associated with binge drinking in
particular. Frequent binge drinkers (more than once in past 2 weeks) had a stronger tendency
to drink to cope with negative emotions, drink in motor vehicles, drink for purposes of
seeking sex, and to facilitate social interactions compared to occasional binge drinkers and
nonbinge drinkers (Ichiyama & Kruse, 1998). Binge drinkers also tended to be less
conscientious and have a greater tendency towards thrill seeking. Clapp, Shillington, and
Segars (2000) found that drinking with friends and events where food was available were
factors protective against binge drinking, while drinking events where illicit drugs were
available had a higher risk for binge drinking. Similarly, studies have shown differences in
binge drinking between different colleges and those living in fraternities or sororities
compared to those who do not. For example, Dowdall et al. (1998) found that women’s
colleges tended to have lower rates of binge drinking and associated consequences compared
to co-educational colleges. While this approach is useful in providing evidence as to the
specific contexts and situations in which adolescents and young adults binge drink, it
nevertheless may be difficult to implement as an intervention strategy, as it may be
challenging to attempt to change these contexts. What is required, is a specific focus on
the motivations and cognitions in these specific contexts and a way to address these.
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Schulenberg, Wadsworth, O’Malley, Bachman, and Johnston (1996) examined trends in
binge drinking over the course of several years in adolescents during the transition to young
adulthood. There was little difference between male and female adolescent characteristics that
made one vulnerable to binge drinking during the transition. They found that risk factors for
senior year binge drinking were being male, White, having a lower GPA, personality factors
of anti-sociality or alienation and lower conventionality, drinking motivations of drinking to
get drunk and to cope, as well as expected future use and social context (drinking greater
quantity when with friends). Protective factors against continued high binge drinking were
being female, higher self-efficacy and work role readiness, lower identity focus, less drinking
to get drunk, and greater loneliness. Gender, self-efficacy (lower personal control), and
drinking to get drunk predicted future binge drinking regardless of the level of drinking
exhibited in senior high school. While this study incorporated a number of sociodemographic
factors, it did attempt to look for additional factors such as motivations for use and social
contexts for use and demonstrating that these additional factors were also important in
predicting trends in binge drinking.
7. A cognitive model of binge drinking
One way of spanning the gap between drinking-related variables and alcohol consumption
is Alcohol Expectancy Theory (Oei & Baldwin, 1994). Alcohol Expectancy Theory stems
from Social Learning Theory (SLT), which assumes that cognitive activities such as
anticipation, expectancy, memory about history of alcohol use, and modelling play a primary
role in determining behaviour (Abrams & Niaura, 1987). Youthful drinking behaviours and
expectancies are formed mainly through social influences of culture, family, and peers, while
predisposing individual difference factors may interact with the influence of socialising
agents.
The concept of alcohol expectancies (AEs) stems from research indicating that the effects
of alcohol are not simply a factor of alcohol’s physiological effects but rather a function of the
beliefs one holds regarding these effects. For example, individuals who believe they have
consumed alcohol behave in accordance with their expectations of alcohol effects, even when
they actually receive a placebo (e.g., Marlatt & Rohensow, 1980). AEs are beliefs about the
effects of alcohol on various aspects of behaviour and cognition in the form of an if–then
relationship (Goldman, Brown, Christiansen, & Smith, 1991). Although most AE research
has not focused on the issue of binge drinking specifically, it can provide a useful theoretical
framework for examining what characterises a binge drinker in terms of cognitive motivations
for drinking. AEs can also be potentially modified, unlike many of the factors examined by
previous studies on binge drinking.
Bandura (1977, 1986) differentiated between two types of expectancies: efficacy expectancy and outcome expectancy. Efficacy expectancy is generally defined as the judgment
about one’s ability to perform a particular activity, but in the context of alcohol use, it is one’s
perceived ability to refuse/resist alcohol in specific situations, while outcome expectancy is
the belief about the consequences of carrying out that activity. Although the outcome
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expectancy and efficacy expectancy distinction was proposed by Bandura more than 2
decades ago, most AE research has focused solely on outcome expectancies. Only recently
has the concept of DRSE been introduced to drinking research (Oei & Baldwin, 1994), and
findings have indicated that it might prove to be a more important predictor of alcohol
consumption than AEs (Oei, Fergusson, & Lee, 1998). In fact, it has been suggested that ‘‘the
decision to drink or exercise restraint (self-control) is ultimately determined by self-efficacy
and outcome expectancies formulated around a current situational context’’ (Abrams &
Niaura, 1987, p. 152). Although recent research has supported the importance of these
constructs in determining alcohol consumption, most studies have considered them in
isolation (Evans & Dunn, 1995) and no research has looked specifically at AE and DRSE
determinants of binge drinking. In addition, the specificity of both AE and DRSE to alcohol
use has only recently been demonstrated (Oei & Burrow, 2000).
8. Alcohol expectancies
Research indicates that AEs emerge before an individual has had any experience with
alcohol, and AEs approximating those of adults have been shown in very young children as
well as adolescents. Miller, Smith, and Goldman (1990) found that even young children hold
diffuse and global AEs and that these tend to crystallise with age. Expectancies originate as a
result of parental modelling (Brown, Creamer, & Stetson, 1987), mass media, and peer group
influences (Christiansen, Smith, Roehling, & Goldman, 1989). The effect of expectancies on
drinking behaviour is based on information about alcohol and its effects acquired in
childhood and adolescence and stored in long-term memory in the form of a semantic
network (Darkes & Goldman, 1993). AEs are hypothesised to be the cognitive channels
through which sources of social influence, such as family, peers, and modelling of alcohol use
have their effect (Christiansen, Goldman, & Inn, 1982).
Once these expectancies have become established, they guide behaviour when exposed to
alcohol such that an individual may produce the expected effects when alcohol is consumed.
Thus, it is the individual’s beliefs about the power of alcohol to change behaviour rather than
actual physiological actions of alcohol that determine the behavioural effects of alcohol
(Leigh, 1989), resulting in a self-fulfilling prophecy. Automatic processing of behavioural
consequences of alcohol use, in part, governs the choice to use alcohol and the behaviours
that follow, but these are predetermined by expectancies. Therefore, when alcohol is
consumed, expectancies are confirmed. Both environmental contingencies and actual
physiological effects of drinking reinforce early expectations about alcohol effects, while
the maintenance of alcohol consumption depends on these expectancies being confirmed or
contradicted (Oei et al., 1998). This suggests that in those at high risk for alcohol problems
due to background/biological factors, expectancies can become unusually strengthened
(Goldman, 1989).
The individual’s initiation of a drinking episode is driven in part by the expectancies of
the desirable effects that alcohol will have, such as increased sociability or tension
reduction. Expectancies influence perception, such that drinking situations are perceived
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selectively in order to confirm the expectations; for example, an individual may look at the
people having fun at a party rather than at the person who is ill as a consequence of alcohol
consumption. In this situation, individuals are not sensitive to disconfirming stimuli; hence,
partly through a self-fulfilling prophecy, positive expectancies are confirmed providing
further incentive to drink.
AEs have been shown to be better predictors of various drinking patterns than demographic and background variables (Brown, 1985; Christiansen & Goldman, 1983). In terms of
social context variables, Martin and Hoffman (1993) showed that although peer influence and
living environment both added significantly to the prediction of college student drinking (5%
and 8% of the variance, respectively), AEs (global positive, social and physical pleasure, and
social assertion) played a much larger role (36% of the variance). Cumulative research
indicates that for adults, AEs account for 10–19% of variance in concurrent alcohol use and
up to 35% of the variance in drinking longitudinally. For adolescents, AEs account for up to
45% of the variance in concurrent drinking and up to 25% in drinking longitudinally (Leigh,
1989). In addition, the causal effects of AEs have been shown by studies that have
demonstrated short-term changes in drinking behaviour after expectancy challenge (Darkes
& Goldman, 1993; Massey & Goldman, 1988). Furthermore, Kraus, Smith, and Ratner
(1990; cited in Darkes & Goldman, 1993) showed that development of AEs in children was
slowed with the use of films to undermine expectancies.
In general, expectancies are better predictors of alcohol consumption for adolescents than
for adults. This perhaps reflects the symbolic power of expectancies to sway behaviour
towards drinking amongst young people, while those experienced with alcohol may drink
more from habit (Leigh, 1989). In addition, expectancies are more closely related to drinking
amongst older than younger adolescents (Aas, Klepp, Laberg, & Aaro, 1995). Christiansen,
Goldman, and Brown (1985) found that as adolescents get older, they are more likely to
believe that alcohol improves social behaviour, increases arousal, and reduces tension while
expectancies for global change and enhanced sexuality level off, and expectancies of
improved cognitive-physical functioning decrease. Different AEs can predict different
patterns of drinking. For example, adolescents who expect alcohol to enhance social
behaviour show a pattern of social drinking, while those who expect alcohol to improve
their cognitive and motor performance are more likely to develop problem drinking patterns
(Christiansen & Goldman, 1983). Similarly, expectations of enhanced social and physical
pleasures were associated with frequent social drinking, while the expectancy that alcohol
would reduce tension was associated with problem drinking (Brown, 1985).
AEs of social pleasure amongst adolescents predicted transition from nonproblem to
problem drinking over a year and differentiated best amongst serious problem drinkers,
problem drinkers, and nonproblem drinkers, while other AEs discriminated the nonproblem
group from either both problem groups or from the serious problem group (Christiansen et al.,
1989). Several studies have focused on differences in AEs between various subtypes of
drinkers. For example, different AEs have been shown for males and females (Brown,
Goldman, Inn, & Anderson, 1980; Gustafson, 1993; McMahon, Jones, & O’Donnell, 1994;
Leigh, 1987). In general, females endorse more global positive AEs, while males focus on
sexual enhancement and arousal. Both genders, however, appear to strongly endorse the
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social expectancies. Similarly, AEs have distinguished between lone and group problem
drinkers (Jones & McMahon, 1992) and between restrained and unrestrained drinkers
(Bensley, 1991).
Although AEs appear to distinguish between various groups and subtypes of drinkers,
binge drinking per se has not been examined in the AE literature as measures of quantity and
frequency are often combined, making it impossible to differentiate the frequent light social
drinker and the binge drinker. The model of binge drinking proposed here is thus based on
previous findings, which have demonstrated that AEs can discriminate between different
groups of drinkers, and more successfully than a number of other variables. In light of the
population which is the focus of attention in the binge drinking literature, that of adolescents
and young adults it is particularly important that AEs tend to be most predictive of alcohol
consumption patterns for this age group. The reasons for this have been outlined above, as
well as in Oei and Baldwin (1994). Essentially, adolescents and young adults have overall had
relatively little experience with alcohol, and many of their drinking decisions are based on
their expectations and beliefs about alcohol and their perceptions of how other individuals use
and react to alcohol.
There is little doubt that AEs play an important role at many stages of alcohol use;
however, the relationship between various drinking patterns and populations is still not fully
explicated. In terms of binge drinking, AE research has rarely attempted to determine
expectancies typical of this type of drinker. Research has shown that AEs can distinguish
between different types of drinkers and between males and females; however, these findings
have not been entirely consistent. It is likely that, except in the early stages of alcohol use,
decision making about drinking is automatic (Goldman et al., 1991). Oei and Baldwin (1994)
proposed a two-process model of drinking behaviour, which also assumes that during
initiation of drinking, decisions about drinking may be more under an individual’s cognitive
control, while later on, automatic, classically conditioned responses may become dominant.
In automatic processing, expectancies that are more retrievable are those with significance for
reinforcement and hence those that more readily influence behaviour. The two-process model
examines DRSE in addition to AEs to more clearly delineate the AE profiles of different
drinkers.
9. Drinking refusal self-efficacy
Quantity and frequency of drinking are two important factors in determining drinking
patterns, and it has been suggested that ‘‘dosage is an aspect of consumption which is
largely under an individual’s control, whereas the frequency of drinking occasions may be
greatly influenced by social factors’’ (Vogel-Sprott, 1974, p. 1391). Frequently, AE research
has not differentiated between quantity and frequency, and it is the specific combination of
low frequency and high quantity that defines binge drinking. Thus, in accordance with
Bandura’s (1977) distinction between outcome and efficacy expectancies, the role of AEs
may be modified by DRSE, which is one’s belief about one’s ability to resist/refuse alcohol
in particular situations. Bandura argues that these concepts are related; however, he
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171
concludes ‘‘It is because expectancy outcomes are highly dependent on self-efficacy
judgments that expected outcomes may not add much on their own to the prediction of
behaviour’’ (p. 392–393).
Although there is a significant amount of research on both AEs and DRSE, the relative
contributions of each to drinking behaviour remain unclear (Lee, Oei, & Greeley, 1999). Most
research has focused on AEs rather than DRSE, and very few have looked at both processes
at the same time despite Bandura’s (1977) distinction between the two constructs. DRSE can
be defined as the perceived ability to refuse alcohol in specific situations rather than whether
or not one drinks (Lee & Oei, 1993). DRSE has been shown to play a role in the amount of
alcohol consumed (Baldwin, Oei, & Young, 1993), in relapse (Heather, Rollnick, & Winton,
1983), and posttreatment recovery in problem drinkers (Burling, Reilly, Moltzen, & Ziff,
1989; Oei & Jackson, 1982).
Cooney, Gillespie, Baker, and Kaplan (1987) demonstrated that alcohol-dependent subjects showed an increase in positive AEs and a decrease in DRSE while holding and smelling
an alcoholic beverage. Oei and Jackson (1982) used cognitive restructuring and social skills
training in the treatment of alcoholics and showed a strong relationship between social skill
improvement (e.g., resisting alcohol) and decreased alcohol consumption. Similarly, selfefficacy changed systematically across treatment and profoundly affected treatment outcome,
with abstainers having higher self-efficacy than relapsers at follow-up (Burling et al., 1989).
In line with suggestions of the importance of both AEs and DRSE, Skutle (1999) found that
alcohol-abusing subjects who had experienced greater psychological benefit from drinking
had lower DRSE than those who reported less psychological benefit. Furthermore, high-risk
drinkers had lower DRSE and higher AEs and particularly higher expectations of loss of
control when drinking (Lee, Oei, & Greeley, 1999). In addition, low DRSE was related to
higher consumption levels in nontreatment populations (Hays & Ellickson, 1990).
Solomon and Annis (1990) found that outcome expectancy was not associated with level
of consumption on any of the drinking measures, while self-efficacy (to change) was
associated with level of consumption on drinking occasions at follow-up but failed to predict
occurrence of abstinence or frequency of drinking occasions. Evans and Dunn (1995) showed
that lower self-efficacy judgments and positive AEs were significantly associated with
increased alcohol consumption and greater occurrence of alcohol-related problem behaviours
in a student population.
In one of the first studies to examine both AEs and DRSE, Aas et al. (1995) found that
DRSE was a weaker but significant predictor of drinking. Adolescents with previous drinking
experience reported more positive AEs and lower DRSE than those without experience with
alcohol. The researchers suggested that adolescent drinking is both a result of and an
important precursor for development of positive AEs, lower DRSE, and stronger intentions to
drink. Similarly, low DRSE in social and opportunistic situations for young drinkers has been
found to predict consumption (Young et al., 1991).
Several studies have provided indirect evidence for the importance of DRSE, although
they did not identify this as a specific construct. Norman et al. (1998) found that frequent
binge drinkers perceived that they had less control over their drinking and in addition saw
many facilitators to binge drinking. Schulenberg, Wadsworth, et al. (1996) demonstrated that
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self-efficacy predicted future binge drinking, regardless of current level of drinking. In terms
of intervention, planning how to refuse a drink reduced the level of binge drinking amongst
young adults over a period of 2 weeks (Murgraff et al., 1996). Research on the social contexts
of binge drinking suggests that different contexts can lead to differing patterns of consumption, certain contexts can trigger expectancies (Goldman, 1989), and different levels of
DRSE may be associated with different contexts.
It has been suggested that AEs are better predictors of quantity of alcohol consumed than of
frequency of drinking occasions (Mooney, Fromme, Kivlahan, & Marlatt, 1987). Hasking and
Oei (2002) and Lee and Oei (1993) found differential effects of AEs and DRSE on frequency
and quantity of consumption. Low DRSE was related to higher frequency of consumption; that
is, when given the opportunity to drink, those with lower DRSE consumed alcohol more
frequently. Lower DRSE was also associated with greater maximum consumption. AEs, on the
other hand, were related to frequency but not quantity; those who expected greater negative
affective states when drinking (affective AE) drank usual and maximum amounts less often,
and those with higher expectations of poor control over drinking (dependence AE) drank their
usual and maximum amounts more often. In summary, AEs determine how often one drinks,
while DRSE determines both the frequency of consumption and the level of consumption.
Similarly, Oei et al. (1998) demonstrated that light, moderate, and problem drinkers could be
discriminated using both AEs and DRSE.
10. Cognitive model of binge drinking
Recent evidence indicates that the combination of AEs and DRSE may be most useful for
describing alcohol consumption patterns in a theoretical manner. Oei and Baldwin (1994)
examined the relationship between AE and DRSE in terms of a two-process theory of
initiation and maintenance of alcohol use. According to the model, expectancies develop
through operant learning, modelling processes, and classically conditioned responses. The
first phase—acquisition—is dominated by controlled processing, while in the second phase—
maintenance—nonconscious conditioned processes automatically elicit a drinking response.
Thus, the drinking practices of nonproblem drinkers are best explained by the acquisition
phase, and those of problem drinkers are best explained by the maintenance phase. The theory
suggests that AEs are important in weighing up the decision of whether or not to drink, and
DRSE intervenes prior to the behavioural response, and hence both are important in
determining drinking behaviour. Oei and Burrow (2000) suggested that both DRSE and
AEs are important predictors of alcohol consumption, but AEs contribute to prediction only
in an indirect manner through its relationship with DRSE.
According to the model, AEs and DRSE together should be better predictors of drinking
styles and should better discriminate between drinker types than each considered individually.
The relationship amongst AEs, DRSE, and different patterns of alcohol consumption
predicted by the model is shown in Fig. 1. It is important to note that while the current
discussion is focused specifically on binge drinking, the model is actually applicable to all
patterns of drinking. As the model can be broadly applied to alcohol consumption patterns, it
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173
Fig. 1. The cognitive model of binge drinking.
is crucial to differentiate binge drinkers from other types of drinkers, and thus the AE profiles
of other drinking styles will be described briefly. Binge drinkers are characterised by + DRSE
and
AEs. That is, a binge drinker can refuse drinks easily ( + DRSE) but has low AE
( AE). Consequently, as a result of their beliefs about the effects of alcohol, once they find
themselves in a situation where alcohol is present, they are unable to stop drinking. In
contrast, according to the model, social and nondrinkers are characterised by + DRSE
combined with + AEs. Social drinkers tend to consume only small quantities in situations
where alcohol is present, as they have low expectations about the effects of alcohol and are
able to resist it.
In terms of alcoholics, the model suggests that they have AE and DRSE. However,
problems drinkers, those who regularly consume greater quantities of alcohol but who do not
meet criteria for alcoholism, would have + AEs as these have not yet become automatic and
conditioned, as is the case for problem drinkers, and
DRSE, effectively resulting in
frequent high level drinking (see Fig. 1).
The model thus predicts that social and binge drinkers can be discriminated on the basis of
their AEs, while binge drinkers and alcoholics can be discriminated on the basis of DRSE.
However, rather than thinking of these constructs in an all or none manner, it is more useful
to consider the drinker types on a continuum, ranging from high to low on both DRSE and
AEs. According to such a formulation, problem drinkers would tend to have lower DRSE,
although not as low as alcoholics, while social drinkers would have higher (+) DRSE,
although again perhaps not as high as nondrinkers. Binge drinkers, on the other hand, would
be characterised by moderate DRSE—not as high as social drinkers but not as low as
alcoholics. Similarly, with AEs, alcoholics would tend to hold the highest expectancies,
social drinkers the lowest, and binge drinkers should lie at the midpoint between these two
extremes.
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AEs and DRSE together are proposed to be more effective at discriminating between
patterns of drinking for young drinkers than either considered in isolation. Viewed as a
continuum, AEs and DRSE are predicted to discriminate binge drinkers from other types of
drinkers, particularly social drinkers. This distinction is perhaps the most important for the
student population, as most university students would fall into one of these two categories.
Previous research has shown that there are very few students who do not drink (e.g., Leigh,
1987), and a pattern of heavy problem drinking is in general incompatible with the
requirements of university; hence, a simple selection process would eliminate such
individuals from this population. However, a small proportion of heavy drinkers do remain
at university, and hence it would be useful to discriminate these from other types of
drinkers as well.
According to the proposed model, different styles of drinking are determined by different
motivational and cognitive influences, and the authors have recently tested the predictive
ability of the cognitive model for binge drinkers (Morawska & Oei, 2003). While previous
research has supported the importance of both these constructs in determining alcohol
consumption, most studies have considered them in isolation (Evans & Dunn, 1995). The
study conducted by the authors demonstrated that in accordance with the cognitive model,
both AEs and DRSE are necessary to discriminate amongst binge, social, and heavy drinkers
amongst university students. In contrast, only AEs discriminated between binge and social
drinkers. The model was also supported by the ability to predict those who would binge drink
over a period of 4 weeks solely on the basis of AEs.
The AE profile of binge drinkers, combining high AEs and moderate DRSE, will be useful
because it can provide a testable model and a description of the motivations for excessive
alcohol consumption. As such, it can provide information for both prevention and treatment,
as both expectancies and self-efficacy can potentially be modified, unlike many of the
variables previously examined in the literature. In terms of prevention, the AE/DRSE model
can enable more specific and effective programs targeted at specific populations of drinkers.
Rather than creating preventive alcohol campaigns aimed at young adults in general,
knowledge of the motivations of teenage and young adult drinkers can provide a more
focused target audience and more specific messages. Similarly, knowledge of the cognitive
variables involved in young adults’ drinking patterns can inform treatment in order to make it
more specific and effective.
11. Concluding comments
While the ramifications of binge drinking are clear, effective ways to prevent or intervene
in problematic binge drinking have not yet been demonstrated. In particular, government
messages aimed at decreasing binge drinking are generally created for an undifferentiated
audience, a problem exacerbated by the fact that adolescent and young adult audiences are
hardest to reach (Treise et al., 1999). In addition, there has been criticism of messages about
alcohol disseminated by governments and health organisations as too simplistic and overly
broad (Wood, 1996). In terms of binge drinking, one reason for this may be the lack of
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evidence supporting specific factors, which can be targeted by such campaigns. Previous
research has largely focused on demographic or personality factors that are extremely
difficult, if not impossible to change. For example, knowing that binge drinkers tend to be
younger and male is not very helpful for designing interventions targeting these individuals.
In light of the deficiencies in knowledge regarding factors to target, the present review has
aimed to provide a framework in which to address the problem of binge drinking—by
focusing on the expectancies and self-efficacy cognitions held by youth, which should be
modifiable factors in drinking, public messages about alcohol can be targeted more
specifically. In addition, the modifiable nature of these variables can serve as a starting point
for an informed and theoretical approach to treatment and secondary intervention.
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