Social norms information for alcohol misuse in university and college students

David R Foxcroft; Maria Teresa Moreira; Nerissa ML Almeida Santimano; Lesley A Smith

doi:10.1002/14651858.CD006748.pub4

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Figure 1

Study flow diagram.

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Figure 2

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Figure 3

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Figure 4

Funnel plot of comparison: 1 Social norms (SN) vs control, outcome: 1.2 Alcohol‐related problems: 4+ months.

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Figure 5

Funnel plot of comparison: 1 Social norms (SN) vs control, outcome: 1.4 Binge drinking: 4+ months.

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Figure 6

Funnel plot of comparison: 1 Social norms (SN) vs control, outcome: 1.6 Quantity of drinking: 4+ months.

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Figure 7

Funnel plot of comparison: 1 Social norms (SN) vs control, outcome: 1.8 Frequency: 4+ months.

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Analysis 1.1

Comparison 1 Social norms (SN) vs control, Outcome 1 Alcohol‐related problems: up to 3 months.

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Analysis 1.2

Comparison 1 Social norms (SN) vs control, Outcome 2 Alcohol‐related problems: 4+ months.

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Analysis 1.3

Comparison 1 Social norms (SN) vs control, Outcome 3 Binge drinking: up to 3 months.

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Analysis 1.4

Comparison 1 Social norms (SN) vs control, Outcome 4 Binge drinking: 4+ months.

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Analysis 1.5

Comparison 1 Social norms (SN) vs control, Outcome 5 Quantity of drinking: up to 3 months.

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Analysis 1.6

Comparison 1 Social norms (SN) vs control, Outcome 6 Quantity of drinking: 4+ months.

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Analysis 1.7

Comparison 1 Social norms (SN) vs control, Outcome 7 Frequency: up to 3 months.

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Analysis 1.8

Comparison 1 Social norms (SN) vs control, Outcome 8 Frequency: 4+ months.

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Analysis 1.9

Comparison 1 Social norms (SN) vs control, Outcome 9 Peak BAC: up to 3 months.

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Analysis 1.10

Comparison 1 Social norms (SN) vs control, Outcome 10 Peak BAC: 4+ months.

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Analysis 1.11

Comparison 1 Social norms (SN) vs control, Outcome 11 Typical BAC: up to 3 months.

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Analysis 1.12

Comparison 1 Social norms (SN) vs control, Outcome 12 Typical BAC: 4+ months.

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Analysis 1.13

Comparison 1 Social norms (SN) vs control, Outcome 13 Drinking norms: up to 3 months.

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Analysis 1.14

Comparison 1 Social norms (SN) vs control, Outcome 14 Drinking norms: 4+ months.

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Social norms information compared with controls for prevention of alcohol misuse
Patient or population: university or college students Settings: college or university settings Intervention: social norms information (personalised feedback or information campaigns); by delivery mode if subgroup differences were noted between different delivery modes (mailed normative feedback; web/computer feedback; individual face‐to‐face feedback; group face‐to‐face feedback) Comparison: no intervention (assessment only or alcohol information or alternative (non‐normative) intervention) Follow‐up: 4+ months Measurement: self‐reported alcohol consumption (questionnaire scale)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Assumed risk	Corresponding risk	Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
Alcohol‐related problems: 4+ months—web/computer normative feedback	Mean alcohol problems scale score was 8.91 in the control group, with a standard deviation of 9.17 (the 69‐point RAPI scale was used by Martens 2013)	The SMD from the meta‐analysis (‐0.04) will result in a decrease of 0.37 in the alcohol problems scale score (95% CI 0.18 to 1.00), from an average of 8.91 to 8.54, based on Martens 2013	(SMD ‐0.04, 95% CI ‐0.11 to 0.02)	11,767 (15)	⊕⊕⊝⊝ Low	Limitations in design and implementation, especially blinding and in some studies high risk of attrition bias (loss to follow‐up). Borderline substantial heterogeneity (I² = 51%)
Alcohol‐related problems: 4+ months—individual face‐to‐face normative feedback	Mean alcohol problems scale score was 8.91 in the control group, with a standard deviation of 9.17 (the 69‐point RAPI scale was used by Martens 2013)	The SMD from the meta‐analysis (‐0.15) will result in a decrease of 1.28 in the alcohol problems scale score (95% CI 0.37 to 2.20), from an average of 8.91 to 7.63, based on Martens 2013	(SMD ‐0.14, 95% CI ‐0.24 to ‐0.04)	2327 (11)	⊕⊕⊕⊝ Moderate	Limitations in design and implementation, especially blinding and in some studies high risk of attrition bias (loss to follow‐up)
Binge drinking: 4+ months (all delivery modes)	43.9% of control group participants were binge drinkers, defined as those who drink above recommended limits for acute risk (> 40 g/> 60 g ethanol on 1 occasion in the preceding 4 weeks for women and men, respectively) in a study by Kypri 2014	The SMD from the meta‐analysis (‐0.06) will result in 2.7% fewer binge drinkers (95% CI 0.9% to 4.8%), from 43.9% to 41.2%, based on Kypri 2014	(SMD ‐0.06, 95% CI ‐0.11 to ‐0.02)	11,292 (16)	⊕⊕⊕⊝ Moderate	Limitations in design and implementation, especially blinding and in some studies high risk of attrition bias (loss to follow‐up)
Quantity of drinking: 4+ months (all delivery modes)	Mean number of drinks per week was 13.74 in the control group, with a standard deviation of 10.77, from the DDQ measure in Martens 2013	The SMD from the meta‐analysis (‐0.08) will result in a decrease of 0.9 drinks consumed each week (95% CI 0.4 to 1.3), from an average of 13.7 drinks per week to 12.8 drinks per week, based on Martens 2013	(SMD ‐0.08, 95% CI ‐0.12 to ‐0.04)	21,169 (32)	⊕⊕⊕⊝ Moderate	Limitations in design and implementation, especially blinding and in some studies high risk of attrition bias (loss to follow‐up)
Frequency: 4+ months—web/computer normative feedback	Mean number of drinking days per week was 2.74 in the control group, with a standard deviation of 1.54, from the DDQ measure in Martens 2013	The SMD from the meta‐analysis (‐0.11) will result in a decrease of 0.17 drinking days per week (95% CI 0.06 to 0.26), from an average of 2.74 drinking days per week to 2.57 drinking days per week, based on Martens 2013	(SMD ‐0.11, 95% CI ‐0.17 to ‐0.04)	9929 (10)	⊕⊕⊕⊝ Moderate	Limitations in design and implementation, especially blinding and in some studies high risk of attrition bias (loss to follow‐up)
Frequency: 4+ months—individual face‐to‐face normative feedback	Mean number of drinking days per week was 2.74 in the control group, with a standard deviation of 1.54, from the DDQ measure in Martens 2013	The SMD from the meta‐analysis (‐0.21) will result in a decrease of 0.32 drinking days per week (95% CI 0.15 to 0.48), from an average of 2.74 drinking days per week to 2.42 drinking days per week, based on Martens 2013	(SMD ‐0.21, 95% CI ‐0.31 to ‐0.10)	1464 (8)	⊕⊕⊕⊝ Moderate	Limitations in design and implementation, especially blinding and in some studies high risk of attrition bias (loss to follow‐up)
Frequency: 4+ months—group face‐to‐face normative feedback	Mean number of drinking days per week was 2.74 in the control group, with a standard deviation of 1.54, from the DDQ measure in Martens 2013	The SMD from the meta‐analysis (‐0.26) will result in a decrease of 0.40 drinking days per week (95% CI 0.03 to 0.83), from an average of 2.74 drinking days per week to 2.34 drinking days per week, based on Martens 2013	(SMD ‐0.26, 95% CI ‐0.54 to 0.02)	449 (5)	⊕⊕⊝⊝ Low	Limitations in design and implementation, especially blinding and in some studies high risk of attrition bias (loss to follow‐up). Substantial heterogeneity (I² = 55%)
Peak BAC: 4+ months (all delivery modes)	Mean peak BAC was 0.144% in the control group, with a standard deviation of 0.111, from Martens 2013	The SMD from the meta‐analysis (‐0.08) will result in a decrease of 0.009 for peak BAC (95% CI 0.000 to 0.019), from an average of 0.144% to 0.135%, based on Martens 2013	(SMD ‐0.08, 95% CI ‐0.17 to 0.00)	7198 (11)	⊕⊕⊝⊝ Low	Limitations in design and implementation, especially blinding and in some studies high risk of attrition bias (loss to follow‐up). Borderline substantial heterogeneity (I² = 50%)
Typical BAC: 4+ months—individual face‐to‐face normative feedback	Mean typical BAC was 0.08% in the control group, with a standard deviation of 0.048, from Schaus 2009	The SMD from the meta‐analysis (‐0.08) will result in a decrease of 0.004 for typical BAC (95% CI ‐0.005 to 0.013), from an average of 0.080% to 0.076%, based on Schaus 2009	(SMD ‐0.08, 95% CI ‐0.26 to 0.10)	490 (4)	⊕⊕⊕⊝ Moderate	Limitations in design and implementation, especially blinding and in some studies high risk of attrition bias (loss to follow‐up)
The basis for the assumed risk* is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). BAC: Blood alcohol concentration; CI: Confidence interval; SMD: Standardised mean difference; DDQ: daily drinking questionnaire; RAPI: Rutgers Alcohol Problem Index (frequency of occurrence of 23 problems from "None" (scored 0) to "More than 5 times" (scored 3) to give a range of scores from 0 to 69).
GRADE Working Group grades of evidence. High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
In the columns illustrating comparative risks: for outcomes where the pooled analysis point estimate and confidence interval showed some effect, we have used results (mean scores and standard deviations) from Martens 2013 to illustrate the effect sizes in terms of the measures used in that study. We chose Martens 2013 because the outcome measures they use are well‐known, generally well regarded, and are typical of the measures used in this field of research: they used the Daily Drinking Questionnaire (DDQ) and the Rutgers Alcohol Problem Index (RAPI).

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Comparison 1. Social norms (SN) vs control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Alcohol‐related problems: up to 3 months Show forest plot	37		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Mailed feedback	6	1045	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.02, 0.22]
1.2 Web feedback	21	10166	Std. Mean Difference (IV, Random, 95% CI)	‐0.15 [‐0.26, ‐0.05]
1.3 Individual face‐to‐face	8	1205	Std. Mean Difference (IV, Random, 95% CI)	‐0.14 [‐0.27, ‐0.00]
1.4 Group face‐to‐face	4	382	Std. Mean Difference (IV, Random, 95% CI)	‐0.16 [‐0.42, 0.10]
2 Alcohol‐related problems: 4+ months Show forest plot	30		Std. Mean Difference (Random, 95% CI)	Subtotals only

2.1 Mailed feedback	1	64	Std. Mean Difference (Random, 95% CI)	‐0.34 [‐0.83, 0.15]
2.2 Web feedback	15	11767	Std. Mean Difference (Random, 95% CI)	‐0.04 [‐0.11, 0.02]
2.3 Individual face‐to‐face	11	2327	Std. Mean Difference (Random, 95% CI)	‐0.14 [‐0.24, ‐0.04]
2.4 Group face‐to‐face	1	126	Std. Mean Difference (Random, 95% CI)	‐0.62 [‐0.97, ‐0.26]
2.5 Marketing campaign	2	4943	Std. Mean Difference (Random, 95% CI)	‐0.03 [‐0.17, 0.10]
3 Binge drinking: up to 3 months Show forest plot	26	10667	Std. Mean Difference (Random, 95% CI)	‐0.17 [‐0.24, ‐0.09]

3.1 Mailed feedback	2	615	Std. Mean Difference (Random, 95% CI)	‐0.07 [‐0.51, 0.36]
3.2 Web feedback	14	8744	Std. Mean Difference (Random, 95% CI)	‐0.15 [‐0.24, ‐0.06]
3.3 Individual face‐to‐face	6	932	Std. Mean Difference (Random, 95% CI)	‐0.21 [‐0.35, ‐0.07]
3.4 Group face‐to‐face	5	376	Std. Mean Difference (Random, 95% CI)	‐0.28 [‐0.48, ‐0.07]
4 Binge drinking: 4+ months Show forest plot	16	11292	Std. Mean Difference (Random, 95% CI)	‐0.06 [‐0.11, ‐0.02]

4.1 Mailed feedback	1	65	Std. Mean Difference (Random, 95% CI)	‐0.17 [‐0.66, 0.32]
4.2 Web feedback	10	10719	Std. Mean Difference (Random, 95% CI)	‐0.07 [‐0.12, ‐0.02]
4.3 Individual face‐to‐face	5	508	Std. Mean Difference (Random, 95% CI)	0.01 [‐0.17, 0.18]
5 Quantity of drinking: up to 3 months Show forest plot	45	14184	Std. Mean Difference (IV, Random, 95% CI)	‐0.14 [‐0.19, ‐0.09]

5.1 Mailed feedback	5	1020	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.21, 0.13]
5.2 Web feedback	28	10889	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.18, ‐0.07]
5.3 Individual face‐to‐face	8	1309	Std. Mean Difference (IV, Random, 95% CI)	‐0.24 [‐0.38, ‐0.11]
5.4 Group face‐to‐face	5	411	Std. Mean Difference (IV, Random, 95% CI)	‐0.30 [‐0.49, ‐0.10]
5.5 Marketing campaign	1	555	Std. Mean Difference (IV, Random, 95% CI)	‐0.05 [‐0.22, 0.11]
6 Quantity of drinking: 4+ months Show forest plot	32	21169	Std. Mean Difference (Random, 95% CI)	‐0.08 [‐0.12, ‐0.04]

6.1 Mailed feedback	2	533	Std. Mean Difference (Random, 95% CI)	‐0.13 [‐0.32, 0.06]
6.2 Web feedback	18	13319	Std. Mean Difference (Random, 95% CI)	‐0.07 [‐0.12, ‐0.02]
6.3 Individual face‐to‐face	12	2374	Std. Mean Difference (Random, 95% CI)	‐0.15 [‐0.23, ‐0.08]
6.4 Marketing campaign	2	4943	Std. Mean Difference (Random, 95% CI)	‐0.02 [‐0.13, 0.09]
7 Frequency: up to 3 months Show forest plot	19		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

7.1 Mailed feedback	1	521	Std. Mean Difference (IV, Random, 95% CI)	0.12 [‐0.05, 0.29]
7.2 Web feedback	12	6385	Std. Mean Difference (IV, Random, 95% CI)	‐0.17 [‐0.25, ‐0.09]
7.3 Individual face‐to‐face	4	515	Std. Mean Difference (IV, Random, 95% CI)	‐0.45 [‐0.63, ‐0.28]
7.4 Group face‐to‐face	3	264	Std. Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.27, 0.21]
8 Frequency: 4+ months Show forest plot	25		Std. Mean Difference (Random, 95% CI)	Subtotals only

8.1 Web feedback	10	9929	Std. Mean Difference (Random, 95% CI)	‐0.11 [‐0.17, ‐0.04]
8.2 Individual face‐to‐face	8	1464	Std. Mean Difference (Random, 95% CI)	‐0.21 [‐0.31, ‐0.10]
8.3 Group face‐to‐face	5	449	Std. Mean Difference (Random, 95% CI)	‐0.26 [‐0.54, 0.02]
8.4 Marketing campaign	2	4943	Std. Mean Difference (Random, 95% CI)	‐0.01 [‐0.09, 0.06]
9 Peak BAC: up to 3 months Show forest plot	11	1902	Std. Mean Difference (IV, Random, 95% CI)	‐0.22 [‐0.33, ‐0.11]

9.1 Mailed feedback	1	94	Std. Mean Difference (IV, Random, 95% CI)	‐0.20 [‐0.60, 0.21]
9.2 Web feedback	4	477	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.35, 0.09]
9.3 Individual face‐to‐face	7	1331	Std. Mean Difference (IV, Random, 95% CI)	‐0.26 [‐0.39, ‐0.13]
10 Peak BAC: 4+ months Show forest plot	11	7198	Std. Mean Difference (IV, Random, 95% CI)	‐0.08 [‐0.17, 0.00]

10.1 Mailed feedback	1	468	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.33, 0.08]
10.2 Web feedback	3	355	Std. Mean Difference (IV, Random, 95% CI)	‐0.08 [‐0.29, 0.13]
10.3 Individual face‐to‐face	7	1432	Std. Mean Difference (IV, Random, 95% CI)	‐0.16 [‐0.26, ‐0.05]
10.4 Marketing campaign	2	4943	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.18, 0.21]
11 Typical BAC: up to 3 months Show forest plot	8	1336	Std. Mean Difference (IV, Random, 95% CI)	‐0.17 [‐0.31, ‐0.03]

11.1 Mailed feedback	3	253	Std. Mean Difference (IV, Random, 95% CI)	‐0.10 [‐0.35, 0.15]
11.2 Web feedback	1	282	Std. Mean Difference (IV, Random, 95% CI)	‐0.25 [‐0.48, ‐0.01]
11.3 Individual face‐to‐face	4	801	Std. Mean Difference (IV, Random, 95% CI)	‐0.14 [‐0.40, 0.12]
12 Typical BAC: 4+ months Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

12.1 Individual face‐to‐face	4	490	Std. Mean Difference (IV, Random, 95% CI)	‐0.08 [‐0.26, 0.10]
13 Drinking norms: up to 3 months Show forest plot	14		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

13.1 Mailed feedback	2	698	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.56, 0.14]
13.2 Web feedback	8	1196	Std. Mean Difference (IV, Random, 95% CI)	‐0.51 [‐0.71, ‐0.31]
13.3 Group face‐to‐face	3	297	Std. Mean Difference (IV, Random, 95% CI)	‐0.44 [‐0.84, ‐0.04]
13.4 Individual face‐to‐face	1	244	Std. Mean Difference (IV, Random, 95% CI)	‐1.40 [‐1.68, ‐1.12]
14 Drinking norms: 4+ months Show forest plot	9		Std. Mean Difference (Random, 95% CI)	Subtotals only

14.1 Web feedback	6	2227	Std. Mean Difference (Random, 95% CI)	‐0.34 [‐0.57, ‐0.11]
14.2 Individual face‐to‐face	1	240	Std. Mean Difference (Random, 95% CI)	‐1.19 [‐1.47, ‐0.92]
14.3 Marketing campaign	2	4943	Std. Mean Difference (Random, 95% CI)	‐0.06 [‐0.23, 0.11]

Comparison 1. Social norms (SN) vs control

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