University Students' Attitudes Regarding Harm Reduction

UNIVERSITY STUDENTS' ATTITUDES REGARDING HARM REDUCTION FOR
RECREATIONAL SUBSTANCE USERS
Erica A. Hoffmann
A Thesis
Submitted to the Graduate College of Bowling Green

State University in partial fulfillment of
the requirements for the degree of
MASTER OF ARTS
May 2009
Committee:
Harold Rosenberg, Advisor
William O'Brien
Steve Jex

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ABSTRACT
Harold Rosenberg, Ph.D., Advisor
Harm reduction is both a treatment philosophy and set of interventions designed to
reduce negative consequences of substance use for people who are unwilling or unable to stop
use. Harm reduction is most often targeted for injection drug users as they are at high risk for
negative outcomes such as HIV, liver disease and overdose. Despite the success of some harm
reduction interventions (e.g. needle exchange programs) in reducing overdose deaths and the
number of HIV transmissions, such interventions are often controversial and not well accepted in
the United States by treatment professionals. Young adults in college may also benefit from
harm reduction’s practical and useful interventions as substance use and related negative
consequences are common in this population. However, no one has assessed the acceptability of
harm reduction for college students who are recreational substance users. The current study
recruited 104 students from a public Midwestern university to assess their acceptance of and
their perceived advantages/disadvantages of six harm reduction and two abstinence-focused
interventions designed for recreational substance users. Results indicate that university students
rated most interventions (reducing drugs and alcohol, stopping drugs and alcohol, treatment
instead of prosecution, providing condoms, harm reduction broadly) as at least somewhat
acceptable; only pill testing was rated as less than acceptable. In addition, interventions that
require community resources were rated as less acceptable than encouraging the user to reduce or
stop use. I also evaluated the association of acceptability ratings with participants’ levels of
sensation seeking, health locus of control, and personal substance use. Intervention acceptance
was not correlated with participants’ levels of sensation seeking. However, participants’ health
locus of control was correlated with pill testing, reducing alcohol, providing condoms and
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treatment instead of prosecution. Acceptance did not vary as a function of respondents’ drug use
history. In response to open-ended questions, the most frequently identified advantages of
interventions were reducing substance use and related problems, improving physical health and
well-being, and increasing awareness. Ineffectiveness, encouraging substance use, and
increasing resistance were the most frequently identified disadvantages of interventions.

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ACKNOWLEDGMENTS
I would like to thank my advisor, Dr. Harold Rosenberg, for his encouragement and
dedication to my professional development; I value his knowledge and guidance tremendously. I
also appreciate the useful feedback and supportive environment provided by my committee
members, Dr. William O’Brien and Dr. Steve Jex. I owe many thanks to my coders, Liz Kryzsak
and Amanda Gumble, for their effort and persistence on a difficult task. Thank you to my peer
mentors, Erin Bonar and Michelle Pavlick, as well as the rest of my research group for their
feedback and assistance at various stages of my project.
Thank you to my friends, near and far, and my mom, dad, brother, and family. I value
each of these individuals in indescribable ways.

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TABLE OF CONTENTS
Page
INTRODUCTION…..……….................................................................................................... 1
METHOD…..………................................................................................................................. 16
Participants…................................................................................................................. 16
Measures…..………...................................................................................................... 17
Initial Thoughts, Advantages/Disadvantages, and Acceptability
Rating Task (ITADART)............................................................................. 18
Content Analysis of ITADART Qualitative Data........................... 19
Brief Sensation Seeking Scale (BSSS) ………................................................ 21
Multidimensional Health Locus of Control (MHLC)....................................... 22
Marlowe-Crowne Social Desirability Scale (M-C 2)....................................... 23
Background Information................................................................................... 23
Procedure……............................................................................................................... 23
Summary of Hypotheses................................................................................................ 23
RESULTS…………………....................................................................................................... 25
Acceptance of Harm Reduction and Abstinence-oriented Interventions...................... 25
Acceptance of Subsets of Interventions......................................................................... 26
Personality Characteristics and Intervention Acceptance............................................. 27
Drug Use History............................................................................................... 27
Sensation Seeking.............................................................................................. 27
Health Locus of Control.................................................................................... 27
Social Desirability............................................................................................. 28
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Qualitative Data Themes and Frequencies.................................................................... 28
Advantages of Interventions.............................................................................. 28
Disadvantages of Interventions......................................................................... 30
DISCUSSION…….................................................................................................................... 32
REFERENCE…........................................................................................................................ 38
APPENDIX A. ITADART........................................................................................................ 43
APPENDIX B. BSSS ............................................................................................................... 49
APPENDIX C. MHLC.............................................................................................................. 50
APPENDIX D. M-C 2............................................................................................................... 52
APPENDIX E. BACKGROUND INFORMATION................................................................ 53
APPENDIX F. INTRODUCTION PROTOCOL..................................................................... 56
APPENDIX G. EXAMPLE OF PARTICIPANTS’ RESPONSES FOR
INTERVENTION ADVANTAGE CATEGORIES.................................... 57
APPENDIX H. EXAMPLE OF PARTICIPANTS’ RESPONSES FOR
INTERVENTION DISADVANTAGE CATEGORIES……........................ 59

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LIST OF TABLES
Table Page
1 Participant Demographics.............................................................................................. 60
2 Participants’ Alcohol Use History................................................................................. 62
3 Participants’ Drug Use History...................................................................................... 64
4 Intercorrelations of Acceptability Ratings of Each Intervention.................................. 66
5 Advantages of Interventions: Number of Participant Responses per Category.......... 67
6 Disadvantages of Interventions: Number of Participant Responses per Category...... 69
7 Mean Acceptability of Each Intervention across Full Sample
And by Lifetime Drug Use............................................................................................ 71

Harm Reduction for Recreational Users 1
INTRODUCTION
Substance abuse and dependence are debilitating and costly disorders that contribute to
numerous health problems, financial strains, and social burdens at individual and systemic levels in
the United States and many other countries. A 2004 report from the National Survey on Drug Use
and Health estimated that approximately 12% of people aged 18-25, and about 4% of those aged
26 and older, had abused or were dependent on alcohol and/or illicit drugs in the United States
within the past year (SAMHSA, 2005). The Office of National Drug Control Policy (2004)
reported that the total economic cost of alcohol abuse was $185 billion in 2002. Drug abuse cost
society $15.8 billion for health care and $128.6 billion for productivity losses in 2002, which was
an average annual increase of 5.9% since 1992. Substance abuse treatment accounts for a
meaningful part of these societal health care costs.
Most treatment agencies in the United States consider abstinence the only acceptable
outcome, whether they provide detoxification or other inpatient services, outpatient counseling, or
Alcoholics Anonymous. Most abstinence-focused programs teach skills that align with the
ultimate goal of preventing relapse and maintaining “recovery.” Furthermore, abstinence is not
just the goal for substance abusers in our society, but also for the general population as
demonstrated by policies and laws that encourage “drug free” schools and work places.
Previous research has found that 60 to 70% of alcohol, heroin, or nicotine users
“slip” (indulge in isolated or short-term episodes of substance use and then continue abstinence)
and/or fully relapse (return to their regular problem-causing pattern of substance use) within six
months of completing treatment (Hunt, Barnett, & Branch, 1971). The Drug Abuse Treatment
Outcome Studies evaluated a nationwide US sample of substance users following treatment in
different settings, including long-term residential (LTR), outpatient drug-free (ODF), short-term
inpatient (STI), and outpatient methadone treatment (OMT) (Hubbard, Craddock, Flynn,
Anderson, & Etheridge, 1997). A one-year post-treatment follow up indicated that an average of
50% of cocaine, marijuana, and alcohol users had not remained abstinent. These findings were
consistent across LTR, ODF, and STI settings. The exception was in OMT, which showed a
decline in weekly use of heroin from 89% before treatment to 27% post-treatment.
Another phenomenon that illustrates the tenuousness of abstinence is that some clients
continue to use substances even while attending abstinence-focused treatment, and many of them
do not complete treatment. In their article evaluating clients’ reasons for discontinuing substance
abuse treatment, Ball, Carroll, Canning-Ball, and Rounsaville (2006) reviewed previous research
on both the prevalence of and client characteristics associated with early attrition. As Ball et al.
noted, 50% of participants drop out within one month of starting treatment in drug-free outpatient
and residential settings.
One explanation for high relapse rates, continued substance use while in treatment, and
high drop-out rates is that clients are ambivalent about quitting and their drug use goal may not
align with the goals of abstinence-based programs (Prochaska, DiClemente, & Norcross, 1992).
Prochaska et al. proposed that modification of addictive behaviors involves progression through
five stages of change (precontemplation, contemplation, preparation, action, and maintenance) that
are based on the user’s intention, motivation, and behavior. This model contends that some people
will never recognize a substance abuse problem or be motivated to change, and that those who are
motivated to change may experience frequent waxing and waning in their levels of determination
and commitment.
Recognizing that continuous abstinence is an infrequent outcome for many users, due to the
limited effectiveness of current treatments and the fluctuating motivation of users, a small subset
of clinicians and public health advocates have adopted a harm reduction approach. A recent
definition identifies harm reduction as minimizing negative consequences (e.g. disease, overdose)
of ongoing drug use through immediate and achievable interventions to preserve users’ health,
accepting that drugs are a part of society and reducing harm is an integral part of a public health
framework (Ritter & Cameron, 2006). For clients who may not be able, ready, or willing to
abstain from substances, harm reduction interventions are designed to reduce morbidity and
mortality in those who continue to take drugs (MacCoun, 1998).
Many harm reduction interventions have been developed for injection drug users (IDU),
most of whom abuse heroin, cocaine, or amphetamines. One purpose of these harm reduction
interventions is to reduce the spread of blood-borne diseases such as hepatitis and human
immunodeficiency virus (HIV) because sharing needles is a leading pathway of contagion
(Strathdee & Vlahov, 2001). Examples of interventions for injection drug users include needle
exchange programs (NEPs) and safer injection facilities that provide users with clean injection
equipment and a sheltered environment in which to inject. Other interventions educate and
encourage IDUs to rotate injection sites on the body, clean re-used needles and syringes with
bleach, and smoke and snort their drugs rather than inject. Even though IDUs are a small
proportion of all drug users, they experience many potentially fatal health problems.
Another set of harm reduction interventions are designed for the larger population of
recreational drug users who do not inject their drugs. Interventions related to these recreational
drugs include drinking water when using ecstasy to prevent dehydration and drug potency testing
for pills, such as ecstasy/MDMA, amphetamines, and prescription drugs, to evaluate their
ingredients. Other interventions relevant to recreational users involve changing current laws.
These include de-criminalizing marijuana and substituting treatment for jail time when caught
possessing marijuana, prescription drugs used recreationally, and alcohol (if under 21). Some of
these interventions are arguably more controversial than interventions for injection drug users, and
most are not yet commonly available.
Another subset of harm reduction interventions appear to be more common and accepted in
society compared to the previously listed harm reduction interventions. These interventions
include having a designated driver among a group of drinkers, encouraging moderate rather than
binge drinking, and drinking with responsible friends rather than alone or with strangers. The
acceptance of these approaches is probably a result, in part, of the widespread societal acceptance
of alcohol (versus illicit drugs).
Despite the potential benefits of harm reduction, many treatment providers, law makers,
and members of the lay public are resistant to harm reduction and find such approaches
unacceptable. Some opponents believe that harm reduction promotes or reinforces substance use
by people who are using, abusing, or dependent (MacCoun, 1998). Another argument is that harm
reduction undermines or is contradictory to conventional treatment because it does not insist on
abstinence as the only healthy outcome of treatment. For example, Rosenberg and Phillips (2003)
found that 47% of surveyed American treatment agencies rated harm reduction education as
unavailable in their agency because it would be “sending the wrong message.” Additionally, large
percentages of respondents reported that needle exchange (47%) and harm reduction education
(67%) were “not consistent with agency philosophy.”
Risk compensation is yet another concern of those who do not agree with harm reduction.
In this context, risk compensation refers to the idea that, as harm reduction interventions increase
the safety of drug use or specific routes of administration, more people will be encouraged to use
drugs and to inject them. However, research does not support the notion of risk compensation with
at least two forms of harm reduction. In 1992, the Australian Capital Territory decriminalized
cannabis; following this, rates of cannabis use did not increase in a sample of Australian National
University College students from 1992 to 1994 (McGeorge & Aitken, 1997). Additionally, a large
review study on effectiveness of harm reduction interventions found that needle exchange
programs did not increase injection drug use nor did they lower the perceived risks of injecting
(Ritter & Cameron, 2006).
Some of the resistance to harm reduction is based on the misconception that harm reduction
is incompatible with abstinence. However, harm reduction is more accurately viewed on a
continuum, ranging from continued excessive use with fewer harmful consequences at one pole, to
abstinence as the ideal outcome at the other pole (Marlatt, 1996). In this context, harm reduction
interventions are “step-down” approaches that encourage users to “take it one step at a time” to
reduce harmful consequences of their behavior (Marlatt, 1996), perhaps ultimately by quitting drug
use completely. Many proponents of harm reduction argue that abstinence is the ultimate form of
harm reduction.
For users who are unwilling or unable to achieve abstinence as their goal, outcome studies
show that harm reduction interventions are effective in promoting health of users. In a literature
review on efficacy of harm reduction, Ritter and Cameron (2006) found that needle exchange
programs reduced infectious disease rates and were cost effective. The same review found that
outreach efforts with illicit drugs, such as supervised injecting facilities, have been effective in
preventing overdose. To date, the effectiveness of most harm reduction interventions with illicit
drugs have yet to be researched. Harm reduction interventions with alcohol are also not well
documented, but there is some support that interventions such as random breath testing and post –
driving under the influence education programs reduce road accidents (Ritter & Cameron, 2006).
The apparent effectiveness of some harm reduction interventions appears to be impacting
world wide availability of certain approaches, such as needle exchange programs (NEPs), though
not to the degree that would be the most beneficial in reducing harm. Strathdee and Vlahov (2001)
conducted a literature review on the efficacy of NEPs. As of 2000, there were 46 regions,
countries, and territories that had at least one NEP. In 29 cities with established NEPs, HIV
prevalence decreased on average by 5.8% per year, and it increased on average by 5.9% per year in
51 cities without NEPs. Yet, such programs exist in fewer than half of the countries reporting HIV
infection among IDUs (Strathdee & Vlahov, 2001).
The promise and apparent effectiveness of harm reduction seems to have influenced the
acceptability and availability of harm reduction interventions in countries such as the United
Kingdom, Australia, Netherlands, and Canada, but to a lesser degree in the United States. For
example, Rosenberg and Melville (2005) looked at the acceptability of controlled drinking and
drug use in 436 British treatment services using a self-report questionnaire. Their findings
indicated that large majorities of treatment providers in the United Kingdom were somewhat or
completely accepting of controlled drinking and controlled drug use for those abusing such
substances, but less accepting of moderation goals for drinkers and drug users described as
dependent.
Canada is another country whose treatment services have more tolerant views toward harm
reduction. For example, Ogborne and Birchmore-Timney (1998) conducted a mail survey of
addiction treatment services in Ontario, Canada and found that 82-95% of respondents supported
NEPs and 51-98% were in favor of short-term non-abstinence goals for clients with alcohol or
drug problems, depending on the type of agency at which they worked. In another study,
Macdonald and Erickson (1999) used a self-report questionnaire to study judges in Canada and
found that those who were more knowledgeable about drug effects were significantly more likely
to favor harm reduction approaches. This study also found that younger judges were significantly
more likely to favor harm reduction approaches. Thus, harm reduction interventions may become
more prevalent in sentencing as older judges retire and if younger judges’ beliefs remain stable.
Studies in the United States have shown mixed results when evaluating acceptance of harm
reduction in treatment agencies, depending upon specific interventions and client characteristics.
Rosenberg and Phillips (2003) surveyed 222 treatment providers and found that certain harm
reduction interventions (NEPs, education regarding safer drug ingestion practices, cue exposure
therapy) were rated as somewhat or completely acceptable by 50% of respondents. Non-
abstinence as an intermediate outcome goal was rated as somewhat to completely acceptable for
substance abusers by 49% of respondents, but only 26% rated non-abstinence as acceptable if it
were a drug user’s final outcome goal. Wryobeck and Rosenberg (2005) examined the association
of client characteristics with psychologists’ ratings of acceptability of harm reduction
interventions. They found that acceptance of needle exchange was positively correlated with HIV
status and number of previous treatment attempts, though some treatment professionals rated this
intervention as acceptable regardless of client characteristics.
Treatment providers’ acceptability of harm reduction is important because they are in the
best position to educate users and help facilitate interventions. Without the support of treatment
providers, it will be difficult to increase the availability of harm reduction interventions in the US.
Research suggests that exposure to education may help increase acceptability of harm reduction as
a concept and set of interventions. For example, Goddard (2003) conducted a 2-hour educational
presentation on harm reduction for 137 treatment professionals in Midwestern US. Using a self-
report questionnaire that participants completed before and after the presentation, she found that
attitudes towards and acceptability of harm reduction were more favorable following this
presentation, even among professionals with conventional orientations such as AA/12-Step. Thus,
it may be plausible that education and “spreading the word” about harm reduction is one way to
change pre-conceived notions and fallacies about this approach to preserving the health of drug
takers.
In general, research on acceptance of harm reduction has focused on professional
stakeholders, that is, agency administrators and treatment providers. Only a small number of
studies have evaluated the attitudes of active drug users, clients in treatment, or the lay public.
One such study was conducted by Branigan and Wellings (1999), who assessed the acceptability of
harm reduction messages to young people in London dance clubs and the general public riding on
the London Underground. They found that the target group (club goers) accepted the publicity
campaign and the non-targeted group (general public) did not show the anticipated negative
reaction, as there was only one letter of disapproval. In another study, Akram and Galt (1999)
studied 125 users of MDMA/ecstasy using self-report questionnaires, and found that harm
reduction interventions specific to stimulants were being implemented in the dance club
environment. “Chill out” rooms and drinking water were found to be the most common harm
reduction interventions and were used by 80% of respondents.
Another population whose attitudes regarding harm reduction have been studied
infrequently is drug users who are currently in treatment. One recently published study of this type
was conducted by Phillips, Rosenberg, and Sanikop (2007), who interviewed 40 American and 48
British substance users who were in treatment to assess their attitudes regarding drug replacement
therapies, health promotion interventions (e.g. NEPs and harm reduction education), non-abstinent
goals, and drop-in centers. Results indicated that over 80% of respondents were accepting of short
term methadone use and 66% of respondents were accepting of health promotion interventions.
However, only small proportions (15%) of the American sample reported non-abstinent goals or
safer injection facilities acceptable. Thus, it appears that clients’ attitudes regarding harm
reduction vary by type of intervention and geographic region.
Some forms of harm reduction are at least somewhat acceptable to both treatment
professionals and to those who abuse or are dependent on drugs. However, there is little research
evaluating the acceptability of harm reduction with functional or recreational users who could
benefit from such interventions. In one such group of functional users - young adults in college -
drug and alcohol use are common. According to the 2004 report from the National Survey on
Drug Use and Health, 86.2% of people aged 18 to 25 reported a lifetime prevalence of alcohol use
(SAMHSA, 2005). Furthermore, 41.2% reported binge drinking and 15.1% reported heavy
alcohol use within the past month. A longitudinal study conducted by the Harvard School of
Public Health (Mohler-Kuo, Lee, & Wechsler, 2003) that sampled students from 119 colleges and
universities found a significant increase in students’ past year use of marijuana (from 23% to 30%
between 1993 to 2001). During the same time periods, the use of cocaine, barbiturates,
tranquilizers, and opiates also increased (ranging from .05-3% in 1993 to 1-7% in 2001.) Ecstasy
use increased from 3% in 1997 to 7% in 2001.
Substance use and abuse can have problematic outcomes for young adults. A study
conducted by Kriegler, Baldwin, and Scott (1994) showed that drug and alcohol use negatively
impacted college students in health professions (e.g. medicine, nursing, pharmacy, dentistry, allied
health). Of 981 students, 76% had accepted a ride with a driver under the influence, 20.3% had
experienced blackouts, 19% had missed class/work due to a hangover, and 13% reported having
gone to class/work under the influence. Furthermore, 2-5% of this sample received lower
grades/evaluations, encountered legal problems, took drugs from their employer/training site,
interacted with patients while under the influence, had marital/relationship problems or
encountered financial problems. Siebert, Wilke, Delva, Smith, and Howell (2003) also found
significant correlations between drinking and harmful consequences in a study of 1,110 college
students. Within the one year reporting period, 45% of respondents did something they would
later regret, 38% forgot where they were or what they did, 25% physically injured themselves,
23% had unprotected sex, and, within the most recent 30 days, 17% had driven after consuming at
least five drinks.
In an attempt to prevent unhealthy outcomes in this sub-group, alcohol-focused harm
reduction programs have been implemented with college student populations in the United States.
For example, the Alcohol-related Harm Prevention program (a two-session skill-building
workshop centered on harm reduction interventions in social settings) was well received by 94% of
participants and showed significant effects on outcomes hypothesized to mediate long-term health-
relevant outcomes (Graham, Tatterson, Roberts, & Johnson, 2004). Fromme and Orrick (2004)
developed and evaluated the Lifestyle Management Class (LMC), which was a 4-hour brief
intervention based on a holistic approach to college students’ drinking, that encompassed the
concepts of harm reduction. LMC participants showed significant decreases in heavy drinking,
driving after drinking, and a trend toward decreases in negative consequences of intoxication.
Despite the success of such programs to address drinking by college students, harm reduction
interventions are available in only a small number of universities. Additionally, such programs
have been limited to alcohol, probably because the idea of harm reduction with illegal drugs is still
controversial.
Students, parents, and policy makers in college communities have vested interests in
prevention and treatment of alcohol and drug problems. Yet, an abstinence-only approach is less
applicable for college students given peer influence, youth culture, easy access to various
substances, and rarity of addiction. Substance use in this context is prevalent and will not be
eliminated, so it may be useful to use harm reduction approaches with college substance users.
Given the controversy regarding harm reduction for IDUs, and novelty of harm reduction for
college students, a valuable first step in the process of developing harm reduction for college
students would be to understand their attitudes towards and acceptance of harm reduction.
Therefore, my thesis was designed to assess university students’ views of the concept of
harm reduction, five specific harm reduction interventions, and two traditional, abstinence-focused
interventions. I focused on five harm reduction interventions most pertinent to recreational
substance users, such as college students, who maintain functional social, work, and family life,
yet may experience periodic repercussions of substance use. These interventions include reducing
problematic drinking, reducing problematic drug use, encouraging condom use during sexual
activity after using substances, providing testing of drugs for content and strength (i.e., pill
testing), and substituting treatment instead of prosecution the first time one is caught possessing
drugs. Some of these interventions require community and institutional support, while others can
be used by the individual regardless of such support. I also included two common outcome goals
for clients in treatment that may be less relevant for a college age population, encouraging stopping
alcohol and stopping drug use.
Previous studies of acceptability and attitudes toward harm reduction have largely used
simple rating scales as a dependent measure (Branigan & Wellings, 1999; Goddard, 2003;
Macdonald & Erickson, 1999; Rosenberg & Phillips, 2003). This method is suitable if one’s goals
are to recruit large, geographically dispersed samples and to facilitate data collection and analysis;
however, only a limited amount of information is obtained from close-ended questionnaires and
the questions may be susceptible to desirability bias. In my study, to address these potential
problems, I used two open-ended questions in addition to having participants rate acceptability
using standard likert-type response choices.
One of the open-ended measures I used was a question designed to assess participants’ first
thoughts regarding different harm reduction and abstinence-focused interventions. A similar
method has been used with adolescents to assess attitudes towards alcohol and illicit drugs
(Benthin, Slovic, Moran, Severson, & Gerrard, 1995; Leeming, Hanley, & Lyttle, 2002). In this
procedure, participants were asked to report their immediate associations to each of several target
behaviors. The presumption of this procedure was that participants’ unguarded reactions would be
elicited by asking participants to verbalize their initial thoughts regarding the presented stimuli.
Thus, attitudes would be expressed that would not otherwise be assessed using questionnaires that
ask participants simply to rate their acceptance of various activities or interventions.
To my knowledge, there is only one study that has assessed the perceived advantages and
disadvantages of harm reduction articulated by drug clients (Phillips et al., 2007). Therefore, the
other open-ended measure I included asked participants to list two advantages and two
disadvantages of each harm reduction intervention. The advantage of this open-ended question
was to allow the opportunity for participants to provide a more concrete but still open-ended view
of each harm reduction intervention. Despite the virtues of using open-ended questions to assess
participants’ views of harm reduction, I recognized that both of my open-ended measures may
yield some responses that are superficial, vague, incomprehensible, and difficult to code and
analyze.
Another measurement concern I had related to the potential for biased responding due to
the controversial nature of harm reduction. I thought that participants may respond in a socially
desirable manner as opposed to relaying first impressions and genuine reactions. To account for
this potential bias, I used a social desirability scale as part of my methodology to assess the degree
to which my participants tended to present themselves in a socially desirable manner.
Because of a lack of previous research into acceptance of and attitudes towards harm
reduction by college students, my hypotheses were based on current attitudes towards drug and
alcohol use in American society. Specifically, I hypothesized that students would find alcohol
interventions more acceptable than drug interventions, simply because alcohol is legal and drugs
are not. Furthermore, I predicted that quitting substance use would be more acceptable than
reducing alcohol and drug use because abstinence approaches dominate society and are ingrained
in many young adults since childhood (Caulkins & Reuter, 1997). Similarly, I expected that all of
the harm reduction interventions would be less acceptable than our culture’s standard outcome goal
(i.e., stopping use). I also hypothesized that college students would be less accepting of more
controversial and expensive harm reduction interventions (pill testing, providing condoms, and
treatment in lieu of prosecution) than of moderating or reducing use, due to predominately
conservative societal and religious upbringings in the Midwest United States, as well as college
students’ lack of personal finances and strong fiscal responsibility.
Along with societal values, personal characteristics such as health-related attitudes and
personality traits may influence participants’ attitudes toward and acceptability of harm reduction.
One personality trait that may be related to acceptability of harm reduction is sensation seeking.
This construct has been defined by Zuckerman (1979, 1994) as the need for novel and complex
sensations, varied experiences, and the willingness to take risks for the sake of such experiences.
According to Zuckerman (1979), sensation seeking is a motive that can be satisfied by a variety of
activities, such as illegal and/or risky behaviors, including illicit drug use. Research supports the
positive association between sensation seeking and both licit and illicit drug use in young adults,
using longitudinal or cross-lagged panel designs (Crawford, Pentz, Chou, Li, & Dwyer, 2003;
Horvath, Milich, Lynam, Leukefeld, & Clayton, 2004; Newcomb & McGee, 1991; Sher,
Bartholow, & Wood, 2000; Wood, Cochran, Pfefferbaum, & Arneklev, 1995). In fact, sensation
seeking may be the most potent predictor of substance use according to a metanalysis conducted by
Derzon (2001). Therefore, one prediction could be a positive relationship between sensation
seeking tendencies and acceptability of harm reduction. Furthermore, many harm reduction
interventions are controversial or illegal which may be a draw to sensation seekers. However,
another prediction could be a negative association because high sensation seekers may worry less
about their level of safety or of reducing their harm. Because of the lack of previous research and
potential outcomes in either direction, these analyses were exploratory.
Another characteristic that may impact individuals’ opinions of harm reduction is their
health locus of control. This refers to the beliefs that people have about their perceived control in
relation to their health along three different dimensions: internal control, health as a matter of
chance, and health under the control of powerful others (Wallston, Wallston, & DeVellis, 1978).
Individuals who have high internal control beliefs think their health is within their control and
typically engage in healthy behavior; those with high chance beliefs view their health as
independent of their behavior and are more likely to engage in health damaging behaviors; and
individuals with high beliefs in powerful others are more likely to give doctors or medical
authorities control, and their individual health behaviors are difficult to predict (Bennett, Norman,
Murphy, Moore, & Tudor-Smith, 1998). Despite the predicted relationships among internal
control, chance beliefs, and health behaviors, Bennet et al. (1998) found an inconsistent
relationship between drinking and all three specific control dimensions. These mixed results are
not uncommon, as Cox and Luhrs (1978) found positive associations between drinking and scores
on the powerful others and health as chance dimensions, but Calnan (1989) reported negative
correlations among these variables. Previous research has not confirmed the strength and direction
of the association between substance use and health locus of control. Therefore, I explored the
relationship between health locus of control and acceptability of harm reduction without a formal
hypothesis.
In addition to sensation seeking and health locus of control, another personal characteristic
that might influence acceptance of harm reduction is one’s own drug use history. Drug users are
familiar with the effects of use and may even have experienced negative outcomes themselves or
witnessed friends who have. Because of this personal experience, drug users may see the benefits
in and be more accepting of interventions that reduce drug-related harm. Individuals who have
never used drugs may be less accepting of harm reduction interventions as they are unfamiliar with
or do not see the need for such interventions.

METHOD
Participants
I recruited 104 college students attending a large, public Midwestern university. All
participants were enrolled in undergraduate psychology courses, signed up through experimetrix,
and received extra credit in their class as compensation. Table 1 describes participants’
demographic characteristics. Participants included 73 females and 31 males; the vast majority self-
identified as Caucasian (85%). These gender and ethnic ratios are consistent with those of the
university where participants were recruited. Consistent with a mean age of 19 (range = 18 to 24
years), 72% were either 1st or 2nd year university students. Over half (54%) reported a grade point
average above 3.0 and roughly 46% held at least a part-time job. Participants’ college majors were
varied; the most populous being Health and Human Services (35%), Arts and Sciences (30%), and
Education (17%).
Table 2 displays information regarding participants’ reported alcohol use history. Only six
participants had never consumed alcohol, and almost three-fourths reported drinking more than 20
times in their life. The mean age of first use was 15. Furthermore, 89% of respondents reported
that half or more of their friends drink. Of the 98 people who had drunk alcohol, 22 participants
drank less than one day per week, 36 drank one to two days per week, 28 drank two days per week,
and 12 drank three or more days per week. Participants said they drank on average four beers, <1
glass of wine, and 3 drinks or shots with hard liquor on a typical drinking day, though answers
ranged from 0 to 16 beers, 0 to 9 glasses of wine, and 0 to 30 hard liquor drinks/shots. Over two-
thirds (70%) of the respondents felt that there drinking was “completely” under their control, and
22% said it was “mostly” under their control. Moreover, 66% said it would be “very easy” to
abstain from drinking for a month, while 18% responded “mostly easy” and 9% responded “mostly
difficult.”
Table 3 displays information regarding participants’ drug use history. Over half of
participants reported having taken drugs (52%); their mean age of first use was 16. Of the 54 who
had ever used drugs, 53 had used marijuana at some point in their life. Marijuana had been used
less than five times by 20 respondents, five to 50 times by 14 respondents, and more than 50 times
by 19 respondents. Other illegal drug use was not as prevalent: 13 had used hallucinogens, 11 had
used MDMA/Ecstasy, 9 had used cocaine, and 3 had used some type of amphetamine; these
specific drugs had been used on average five times by participants. However, 20 people had used
prescription drugs for non-medical purposes, and 10 of these individuals had used more than one
type of prescription drug. On average, prescription drugs used for non-medical purposes had been
used by participants 10 times. In response to an open ended question asking what prescription
drugs they had used recreationally, participants reported using opioids (i.e.,
“Vicodin”/“hydrocodone,” “codeine,” “oxycodone,” “Percocet”/”Perks,” “Darvocet”),
psychostimulants (i.e., “Adderall”), benzodiazepines (i.e., “Xanax”), and muscle relaxants (i.e.,
“Flexeril”). Three respondents also said they had used over-the-counter cough suppressants
recreationally (i.e., “coricidin”, “DXM,” “cough syrup”), which may contain the psychoactive drug
dextromethorphan. The large majority of those 54 participants who had used drugs reported that
the use of their favorite drug was “completely” under their control (80%) and 18% reported use
was “mostly” under their control. Furthermore, 87% said it would be “very easy” to abstain from
their drug of choice for a month. The majority of all 104 respondents (67%) said that fewer than
half (but more than zero) of their friends use drugs.
Measures
Initial Thoughts, Advantages/Disadvantages, and Acceptability Rating Task (ITADART)
I devised the Initial Thoughts, Advantages/Disadvantages, and Acceptability Rating Task
(ITADART) to assess participants’ attitudes regarding harm reduction (see Appendix A). This
measure was pilot tested with 10 graduate and 10 undergraduate students to evaluate the clarity and
wording of stimuli, assess how long it took to complete the measure, and evaluate if participants
understood the instructions. The ITADART asked participants to write down their first two to
three thoughts pertaining to each of seven different specific interventions. The five harm reduction
interventions included providing testing of recreational drugs for content and strength, encouraging
moderate drug use, encouraging moderate alcohol use, referring a user caught for drug possession
to substance abuse treatment rather than enforcing standard punishment, and providing condoms to
sexually active substance users. The two abstinence-oriented interventions were encouraging
people to stop using alcohol and encouraging people to stop using drugs. Participants were then
asked to write down two advantages and two disadvantages of each of these seven stimuli. Next,
participants were asked to rate the acceptability of each of these seven interventions on a five-point
scale ranging from “Completely Unacceptable” to “Completely Acceptable.” There were four
different versions of the ITADART that presented the seven specific interventions in different
random orders. Lastly, participants were asked to perform the above three tasks (initial thoughts,
advantages/disadvantages, acceptability rating) in response to a broad definition of harm reduction.
This definition was based on Ritter and Cameron (2006), but I modified their description of harm
reduction to improve clarity for a lay audience.
Intercorrelations among the six harm reduction and two abstinence-focused interventions of
the ITADART revealed low correlations among the interventions (see Table 4). Pearson
correlations were significant for only six pairings; specifically, reducing drugs was associated with
drug testing [r(104) = .242, p = .013], stopping drugs was associated with reducing drugs [r(104) =
-.305, p = .002], reducing alcohol was associated with reducing drugs [r(104) = .641, p < .001],
stopping alcohol was associated with stopping drugs [r(104) = .731, p < .001], stopping alcohol
was associated with reducing alcohol [r(104) = -.248, p = .011], and lastly, harm reduction broadly
defined was associated with reducing alcohol [r(104) = .224, p = .022]. Internal consistency
reliability of the eight interventions was poor (α = .40), suggesting that the eight acceptance ratings
should not be averaged into a single scale score.
Content Analyses of ITADART Qualitative Data
Initially, an independent reader and I examined the qualitative data collected from the
participants’ first thoughts and advantages/disadvantages of the interventions. We decided that
participants’ first thoughts would be difficult to categorize reliably or meaningfully based on the
wide range of responses that were often vague or ambiguous in meaning (e.g. “pharmacy,”
“helpful”). However, our examination of the reported advantages and disadvantages of each
intervention indicated that the responses could be coded into meaningful categories. In
consultation with my advisor, I formed categories for each intervention separately; many of these
categories applied to more than one intervention.
Table 5, Column 1 displays the specific categories of advantages for each intervention. As
examination of Table 5 indicates, there were seven to 12 categories depending on the specific
intervention. These categories include improving physical health, improving well-being not
otherwise specified, reducing problems not otherwise specified, reducing/stopping use of substance
not otherwise specified, tracking use, improving education, weaning off use, encouraging change,
appealing intervention option, improving relationships, improving financial situation, reducing the
number of people in jail, increasing awareness, reducing emotional problems, increasing personal
responsibility, increasing knowledge of drug content, reducing relapse, reducing pregnancies,
reducing sexually transmitted diseases, improving safer sex not otherwise specified, miscellaneous
response, and no advantage noted.
Table 6, Column 1 displays the specific categories of disadvantages for each intervention.
As examination of Table 6 indicates, there were six to 11 categories depending on the specific
intervention. These categories include encouraging substance use, ineffectiveness of intervention,
increasing urge to use, increasing withdrawal effects, increasing resistance, increasing emotional
problems, increasing relationship problems, encouraging drug compensation, continuing use of
substances, misusing service, high resource costs, receiving too light a punishment, concerns with
legality, encouraging sex, decreasing personal responsibility, concerns about consensual sex,
miscellaneous response, and no disadvantage noted.
Two first-year clinical psychology graduate students were employed to analyze and code
data into the above categories. For initial training, coders reviewed the category system and
independently analyzed data from five pilot subjects. These results were discussed to assess
agreement between coders and myself, as well as to modify coding categories to enhance clarity
and reliability of the categories. Final training consisted of coders independently analyzing data
from four more pilot subjects and discussing results. The coders and I discussed coding category
disagreements until agreement was attained.
Each coder then independently analyzed data from 62 subjects; 42 of these 62 were unique
to each coder. Responses from the remaining 20 subjects were coded by both raters to provide
data to calculate the coders’ inter-rater reliability. Across all responses, inter-rater reliability
(number of coder agreements divided by total number of responses coded) was fairly high at .75.
However, I noted that a large proportion of the discrepancies in coding were between the
“miscellaneous” category and a specific advantage or disadvantage category. Therefore, I also
calculated inter-rater reliability by excluding all responses coded as “miscellaneous,” adding the
total number of coder agreements, and dividing agreements by the total number of responses minus
“miscellaneous” codes. This measure of inter-rater reliability was higher at .81. For the 20 inter-
rater reliability subjects, I made the final decision regarding how to categorize data when my
coders’ disagreed.
Brief Sensation Seeking Scale (BSSS)
The Brief Sensation Seeking Scale (BSSS) is an eight-item self-report measure which was
used to assess participants’ levels of sensation seeking (Hoyle, Stephenson, Palmgreen, Lorch, &
Donohew, 2002, see Appendix B). The eight items that comprise the BSSS were adapted from the
40-item Sensation Seeking Scale- Form V (SSS-V), which is the most commonly used measure of
sensation seeking (Zuckerman, Eysenck, & Eysenck, 1978). The BSSS incorporates two items
from each of the SSS-V’s four subscales: Thrill and Adventure Seeking (TAS), Experience
Seeking (ES), Disinhibition (DIS), and Boredom Susceptibility (BS). Participants were asked to
rate their level of agreement with each item as indicated by a five-point scale labeled “Strongly
Disagree” to “Strongly Agree.” In a study by Hoyle et al. (2002) of 1,302 middle and high school
students, internal consistency of the eight items was 0.76. A study completed with 6,281
adolescents found that the BSSS was significantly correlated with the use of alcohol, marijuana,
and hallucinogens (Hoyle, Stephenson, Palmgreen, Lorch, & Donohew, 2002).
In my sample, internal consistency was attained initially for each of the four BSSS
subscales. Cronbach alpha for the Experience Seeking subscale was .60, Boredom Susceptibility
subscale was .41, Thrill and Adventure Seeking subscale was .59, and Disinhibition subscale was .
72. These alpha scores ranged from low to moderate, whereas an internal consistency score across
all eight BSSS items was higher at .76. I also evaluated the degree to which the four BSSS
subscales were independent measures. Subscales on the Brief Sensation Seeking Scale were
significantly correlated with each other; Pearson correlations ranged between [r(104) = .31, p < .
01] and [r(104) = .46, p < .01]. This suggested that subscales did not measure sufficiently
independent elements of the construct of sensation seeking.
Multidimensional Health Locus of Control (MHLC)
The Multidimensional Health Locus of Control (Form A) (MHLC) is an 18-item self-report
measure used to determine whether or not participants believe their health is determined by their
behavior (Wallston, Wallston, & DeVellis, 1978, see Appendix C). The MHLC contains three
sub-scales, with six items per sub-scale, of health locus of control beliefs: internality, powerful
others externality, and chance externality. Participants responded to items using a six-point likert
scale ranging from “Strongly Disagree” to “Strongly Agree.” As mentioned in Wallston’s (2005)
review of the MHLC’s validity, reliability scores of the MHLC typically fall within the moderate
range (Cronbach alphas range from .60-.75 and test-retest reliability coefficients range from .60
to .70). Furthermore, there is evidence that MHLC subscales have construct validity (Wallston,
2005).
I evaluated internal consistency reliability in my sample on each of the three MHLC
subscales. The cronbach alpha score for the internality sub-scale was .77, chance externality
subscale was .56, and powerful others’ subscale was .67. I also assessed the degree to which the
MHLC subscales were independent in my sample. Consistent with Wallston et al. (1978), MHLC
sub-scales were not significantly correlated with each other: Chance with Internal [r(99) = -.09, p
= .363], Chance with Powerful Others [r(101) = .12, p = .223], and Internal with Powerful Others
[r(98) = .04, p = .736]. Therefore, I used three subscale scores instead of a total score in further
analyses.
Marlowe-Crowne Social Desirability Scale (M-C 2)
The Marlowe-Crowne 2(10) Social Desirability Scale (M-C 2) was used to assess the
degree to which participants present themselves in a socially desirable manner (Strahan & Gerbasi,
1972, see Appendix D). The M-C 2 consists of 10 true/false items and is a brief version of the
original Marlowe-Crowne Social Desirability Scale. The 40-item version of the M-C was highly
correlated with the M-C 2; coefficients ranged from the .80’s to .90’s (Reynolds, 1982). Reynolds
(1982) found internal consistency reliability of the M-C 2 to be .66. Despite relatively low
reliability, the M-C 2 has been recommended in situations where interview time is limited, and this
scale is more practical to administer for larger sample sizes (Strahan & Gerbasi, 1972). Internal
consistency reliability of the M-C 2 in my sample was .52.
Background Information
Participants completed demographic questions (e.g. age, gender, ethnicity) as well as
questions pertaining to their personal substance use (see Appendix E).
Procedure
In groups of four to six, participants met with the experimenter in a room in the Psychology
Building. They received an informed consent letter explaining the purposes of the study and that
their participation was voluntary. The experimenter then read a standardized instruction protocol
aloud to the participants (see Appendix F). Participants were then asked to complete a packet
containing the measures in the following order: ITADART, BSSS, MHLC, M-C 2, and
background information.
Summary of Hypotheses
1) I hypothesized that the six harm reduction interventions would be less acceptable than the
two abstinence-focused interventions.
2) I hypothesized that encouraging users to stop their alcohol and drug use would be more
acceptable than encouraging users to reduce their alcohol and drug use.
3) I hypothesized that encouraging people to reduce or to stop their alcohol use would be
more acceptable than encouraging people to reduce or to stop their drug use.
4) I hypothesized that pill testing, providing condoms, and treatment in lieu of prosecution
would be less acceptable than both reducing alcohol and drug use and stopping alcohol and
drug use.
5) I hypothesized that individuals who reported a history of drug use would rate the six harm
reduction interventions as more acceptable than individuals who reported no drug use
history.
6) I explored whether there would be a relationship between acceptability of the six harm
reduction interventions and sensation seeking scores.
7) I explored whether there would be a relationship between acceptability of the six harm
reduction interventions and each of the MHLC’s three subscales.

RESULTS
Acceptance of Harm Reduction and Abstinence-oriented Interventions
To test whether acceptance varied as a function of the specific intervention being rated, I
conducted a repeated measures ANOVA. Participants’ acceptability ratings varied significantly
by intervention (F(7, 97) = 17.95, p < .001). Therefore, I ran 27 paired t-tests to determine which
specific interventions were rated as more acceptable when compared to each other intervention.
To reduce Type I error, I used the Bonferroni correction which resulted in an alpha of .002. The
acceptability of pill testing (M =2.57, SD = 1.3) was significantly lower than the acceptability of
all other interventions: providing condoms for users [M = 3.78, SD = 1.2, t(103) = 7.786, p < .
001], stopping alcohol [M=3.74, SD = 1.3, t(103) = 6.482, p < .001], reducing alcohol [M = 4.02,
SD = 1.0, t(103) = 9.746, p < .001], stopping drugs [M = 3.79, SD = 1.3, t(103) = 6.625, p < .001],
reducing drugs [M = 3.53, SD = 1.3, t(103) = 6.222, p < .001], treatment instead of prosecution [M
= 4.00, SD = 1.1, t(103) = 8.999, p < .001], and broad definition of harm reduction [M = 4.09, SD
= 1.1, t(103) = 10.108, p < .001]. Acceptability of the broad definition of harm reduction (M =
4.09, SD = 1.1) was also significantly higher than reducing drug use [M = 3.53, SD = 1.3, t(103) =
3.809, p < .001]. Reducing drugs (M = 3.53, SD = 1.3) was also significantly less acceptable than
reducing alcohol use [M = 4.02, SD = 1.0, t(103) = 5.076, p < .001].
As examination of Table 7 reveals, mean acceptability scores of the interventions ranged
from 2.57 to 4.09 on the ITADART’s one to five-point acceptability rating scale. Participants
rated three interventions to be somewhat acceptable; these interventions included the broad
definition of harm reduction (M = 4.09), reducing alcohol (M = 4.02), and treatment instead of
prosecution (M = 4.00). Three other interventions were rated as somewhat acceptable, though to a
lesser degree; these included stopping drugs (M = 3.79), providing condoms (M = 3.78), and
stopping alcohol (M = 3.74). Reducing drugs was rated between somewhat acceptable and neither
acceptable nor unacceptable (M = 3.53). Pill testing was rated the lowest of all interventions and
fell between somewhat unacceptable and neither acceptable nor unacceptable (M = 2.57).
Acceptance of Subsets of Interventions
Next, I wanted to test my hypotheses that acceptability would vary by subsets of
interventions. For this, I calculated mean scores across pre-specified subsets of interventions of
interest and performed paired t-tests. Because I conducted four significance tests I used a
Bonferroni correction (α = .013). Firstly, I assessed whether a mean of the six harm reduction
interventions combined was less acceptable than the two abstinence-oriented interventions
combined. Contrary to my hypothesis, harm reduction interventions (M = 3.66, SD = 0.6) were
not significantly less acceptable [t(103) = -.742, p = .460] than abstinence-oriented interventions
(M = 3.76, SD = 1.2). I then assessed whether the mean of the two interventions that encouraged
stopping substance use combined was more acceptable than the mean of the two interventions
encouraging reduction of substance use combined. Abstinence-oriented interventions involving
stopping alcohol and drug use (M = 3.76, SD = 1.2) were also not significantly more acceptable
[t(103) = -.056, p = .955] than interventions pertaining to reducing use (M = 3.77, SD = 1.0).
Next, I assessed whether the mean of the two interventions encouraging stopping or reducing
alcohol use combined was more acceptable than the mean of the two interventions encouraging
stopping or reducing drug use combined. In support of my hypothesis, interventions that involved
reducing or stopping alcohol (M = 3.88, SD = 0.7) were significantly more acceptable [t(103) =
4.15, p < .001] than interventions pertaining to reducing or stopping drugs (M = 3.66, SD = 0.8).
Lastly, I assessed whether the mean of the three community-supported interventions combined was
less acceptable than the mean of the four individually implemented interventions combined.
Providing condoms, pill testing, and treatment instead of prosecution (M = 3.45, SD = 0.8) were
significantly less acceptable [t(103) = -3.439, p = .001] than reducing and stopping alcohol and
drug use (M = 3.77, SD = 0.67).
Personality Characteristics and Intervention Acceptance
Drug Use History: To test my hypothesis that acceptability of each intervention would
vary by participants’ drug use history, I conducted eight independent sample t-tests. I used a
Bonferroni correction to reduce Type I error (α = .006). There were no significant differences for
intervention by participants’ drug use history. Only acceptability of providing condoms for
substance users would have been significant using the traditional criterion for significance (t(101)
= 2.333, p = .022), with drug-experienced participants being more accepting of providing condoms
to users (M = 4.06, SD = 0.9) than those who had never used drugs (M = 3.53, SD = 1.3). See
Table 7 for mean acceptability scores of interventions by drug use history.
Sensation Seeking: I explored whether a relationship existed between acceptability of the
six harm reduction interventions and sensation seeking scores. Participants’ mean total Brief
Sensation Seeking Scale score was 3.25 (SD = 0.67) suggesting that participants scored in the mid-
range on their overall level of sensation seeking. The total BSSS score was not significantly
correlated with any intervention; however, acceptability of pill testing and the Disinhibition sub-
scale were correlated [r(104) = .25, p = .010].
Health Locus of Control: I explored whether there would be a relationship between
acceptability of the six harm reduction interventions and each of the MHLC’s three subscales.
Participants’ scored relatively high on the Multidimensional Health Locus of Control’s Internal
sub-scale (M = 27.17, SD = 4.51), and mid-range on the Chance Externality (M =17.33, SD =
4.23) and the Powerful Others (M = 18.1, SD = 4.7) sub-scales. These scores suggest that
respondents tend to believe that they have control over the fate of their health, as opposed to it
being controlled by others or chance. Pearson correlations showed that Chance Externality sub-
scale scores had a significant positive correlation with acceptability ratings of pill testing [r(103)
= .25, p = .010], reducing alcohol [r(103) = .24, p = .013], and providing condoms to users [r(103)
= .22, p = .029]. Additionally, Internal sub-scale scores had a significant negative correlation with
acceptability ratings of treatment instead of prosecution [r(100) = -.27, p = .007].
Social Desirability: Participants’ mean score on the Marlowe-Crowne Social Desirability
Scale was 5.20 (SD = 1.9) indicating that participants tended not to respond in an extreme socially
desirable or undesirable manner. Social desirability scores were significantly, though weakly,
correlated with ratings of the acceptability of reducing drugs [r(103) = .194, p = .049], but were
not correlated with any of the other interventions.
Qualitative Data Themes and Frequencies
Advantages of Interventions: Participants generated between 141 and 164 specific
advantages for each of the eight interventions. Table 5 displays the frequency of different types of
advantages for each intervention. I will highlight the most frequently mentioned advantages
below, which excludes categories in which fewer than 10% of total responses were coded.
Examples of advantages per each coding category are found in Appendix G.
Firstly, I will review advantages of harm reduction interventions that require community
support. Participants most frequently stated that advantages of pill testing included knowing
contents of the drug (n=42), increasing education about the drug (n = 32), improving users’
physical health (n = 24), and reducing problems for the user (n = 15). Different advantages were
more prominent for participants when asked about treatment instead of prosecution; this
intervention was viewed as likely to encourage positive change (n = 73) and reduce or stop
substance use (n = 26). Participants’ responses differed most from other interventions when asked
about providing condoms. Advantages of this intervention included reducing pregnancies (n = 56),
reducing sexually transmitted diseases (n = 49), and promoting safer sex for users generally (n =
36).
The next interventions I will summarize are harm reduction interventions that can be used
on an individual basis. Participants stated that advantages of reducing alcohol were that it was a
more appealing option than other treatments (n = 40), users could wean off their use (n = 20),
problems could be reduced (n = 18), users could stop or reduce use (n = 16), and potentially
improve users’ physical health (n = 14) and well-being (n =14). Participants noted similar
advantages for reducing drugs, including this intervention being a more appealing option than
other treatments (n = 39), users could wean off their use (n = 35), users could stop or reduce use (n
= 16), and improve their physical health (n = 15).
I next reviewed advantages for the broad definition of harm reduction. Participants’
responses to this intervention varied considerably, with the largest number of advantages being
placed in the miscellaneous category (n = 38), followed by improving users’ physical health (n =
31), improving users’ well-being (n = 23), and reducing problems generally (n = 14).
Lastly, I will summarize advantages of the abstinence-oriented interventions. When asked
about advantages of stopping alcohol use, participants’ most frequent responses involved stopping
use generally (n = 27), reducing problems for users (n = 25), miscellaneous responses (n = 23),
improving users’ well-being (n = 22), and improving users’ physical health (n = 16). Similar
categories were obtained for participants’ advantages of stopping drug use, including stopping use
generally (n = 37), miscellaneous responses (n = 24), improving users’ well-being (n = 23),
improving physical health of the user (n = 15), and reducing problems for the user (n =15).
Disadvantages of Interventions: Participants generated between 125 and 145 specific
disadvantages for each of the eight interventions. Table 6 displays the frequency of disadvantage
categories for each intervention. I will highlight the most frequently stated disadvantages below,
which excludes categories in which fewer than 10% of total responses were coded. Examples of
disadvantages per each coding category are found in Appendix H.
Firstly, I will summarize participants’ reported disadvantages of harm reduction
interventions that require community support. Primary disadvantages of pill testing included
encouraging substance use (n = 54), using the service in a way that was not intended (n = 51),
miscellaneous (n = 16), and concerns about this intervention being illegal (n = 14). When asked
about treatment instead of prosecution, the majority of participants’ disadvantages fell into two
main categories, concern about the effectiveness of this intervention (n = 59) and treatment being
too light a punishment (n = 55). The last community-supported intervention in which
disadvantages were asked about was providing condoms for substance users; frequently mentioned
types of disadvantage categories included encouraging sex (n = 49), not using the service (or
condom) appropriately (n = 33), and miscellaneous (n = 21).
The next interventions I will review are harm reduction interventions that can be used on
an individual basis. Participants reported that the primary disadvantages of reducing alcohol were
the ineffectiveness of this intervention (n = 60), the idea that people may continue to use alcohol (n
= 22), and miscellaneous (n = 13). Reported disadvantages of reducing drugs included questioning
the effectiveness of this intervention (n = 54) and the notion that people would still be using the
drug (n = 45).
I next summarized the disadvantages associated with the broad definition of harm
reduction. The most frequently reported disadvantages include ineffectiveness (n = 39), increasing
user resistance (n = 23), the notion that people were still using substances (n = 19), and
encouraging substance use (n = 18).
Lastly, I will review participants’ reported disadvantages of traditional, abstinence-focused
interventions. Participants reported that the main disadvantages of stopping alcohol included
ineffectiveness (n = 71), likelihood of withdrawal (n = 19), and increasing user resistance (n = 14).
As they did with cessation of drinking, participants saw the most frequent disadvantages of
stopping drugs as ineffectiveness (n = 69), likelihood of withdrawal (n = 23), and increasing user
resistance (n = 18).
DISCUSSION
The current study assessed college students’ acceptance of and attitudes toward harm
reduction interventions that may be used with recreational alcohol and drug users. I recruited 104
college students to write their initial thoughts, to list several advantages/disadvantages, and to rate
the acceptability of five harm reduction interventions, two traditional (abstinence-focused)
interventions, and a broad definition of harm reduction. I also evaluated the association of
acceptability ratings with participants’ levels of sensation seeking, health locus of control, and
personal history of substance use.
Results indicated that participants were, on average, at least somewhat accepting of both
harm reduction and abstinence-focused interventions. The exception was pill testing, which
participants rated as less than acceptable. Participants were equally accepting of both harm
reduction and abstinence-oriented interventions, and of stopping or reducing drug or alcohol use.
However, interventions that targeted reduction or cessation of alcohol were viewed more favorably
than interventions to reduce use of or abstain from drugs. Also, community-supported
interventions (i.e., pill testing, providing condoms, and treatment instead of prosecution) were less
acceptable than interventions pertaining to reducing or stopping alcohol or drug use. Acceptability
of interventions did not vary between participants who had ever used drugs compared to those who
have always abstained, except that participants who had used drugs were more accepting of
providing condoms to users. Acceptability of the eight interventions was not related to
participants’ overall level of sensation seeking. However, chance health locus of control was
positively correlated with acceptance of pill testing, reducing alcohol, and providing condoms, and
internal health locus of control was negatively correlated with acceptance of treatment instead of
prosecution.
I found several common themes when assessing participants’ listed advantages of each
intervention. For example, problem reduction was recognized as an advantage of every
intervention. Additionally, people noted that improving physical health, increasing awareness, and
improving users’ well-being were advantages of the majority of interventions listed. A large
proportion of participants identified reducing drugs or alcohol as more appealing interventions than
stopping drugs or alcohol, and smaller proportions reported that stopping drugs or alcohol were
more appealing than reducing these substances. Moving in the direction of stopping use or
“weaning off” was the most frequently reported advantage of reducing alcohol and drug use.
Respondents listed fewer disadvantages than advantages for each intervention and we
developed fewer categories to summarize these responses. Despite their overall acceptance and the
many noted advantages of interventions, participants reported ineffectiveness as a disadvantage
common to most interventions. Additionally, people mentioned increased resistance to change, or
pressure from others to change, as disadvantages of both reducing and stopping alcohol and drug
consumption. Despite identifying alcohol and drug reduction as more appealing than stopping use,
participants also noted that problems may still arise from moderating use as opposed to abstaining
from use. However, participants indicated that withdrawal was a disadvantage of stopping alcohol
or drug use, but not of reducing use. Pill testing evoked disadvantages that were the most distinct
categorically and among the highest in frequency of all interventions; specifically, many people
thought that pill testing would encourage drug use and that the service would not be used properly.
Comparing my results with other surveys suggests that university students view harm
reduction interventions as more acceptable than do American treatment providers. Except for pill
testing (whose acceptance has never been assessed by previous research), the remaining five harm
reduction interventions and two abstinence-focused interventions were rated as equally acceptable.
Previous US research found that while the majority of treatment professionals polled were
accepting of health promotion interventions and education, and almost half were accepting of
moderation as intermediate goals, far fewer were accepting of non-abstinence goals or moderation
as outcome goals in the US (Rosenberg & Phillips, 2003).
The differences between my findings and those of previous research in the United States
may be attributed to the interventions I chose, which were targeted for recreational substance users.
In addition, previous US research has assessed the acceptability of interventions such as NEPs and
safer ingestion practices for heroin and other commonly injected drugs, which are not well
accepted in our society. It is possible that acceptability of interventions may vary depending on the
type of drug and ingestion method.
One group of drugs, including heroin, are primarily injected intravenously and cause
increased fear of negative outcomes. Another group of drugs includes ecstasy and other “party
drugs” which have notable risks, yet safer means of ingestion. Attitudes toward “party drugs” may
be exemplified by pill testing (which is a harm reduction intervention for ecstasy) receiving a
rating of moderately unacceptable in my study. Marijuana falls into the mildest drug group
because it has fewer negative consequences than alcohol and is commonly used recreationally in
our society.
Another factor that may have accounted for greater acceptability of harm reduction
interventions in my study was that I studied attitudes of college students. College students may
have a differing idea of substance use than users in treatment or treatment providers because the
majority of college students are recreational or binge users of alcohol and, to a lesser degree, drugs.
Even though half of my sample had tried marijuana, few were heavy users and even fewer had
used other illicit drugs. Recreational drug and alcohol users may have experienced negative
outcomes from their own or friends’ use, but these problems were not severe enough to warrant
quitting. Thus, they may see the benefits of harm reduction interventions that are applicable to
them. Drug takers in treatment and treatment providers may be less accepting of harm reduction
because they follow an abstinence-focused model and may have experienced significant problems
from use or worked with those who have.
American college students appear to be as accepting of harm reduction as the general
population in the UK, Canada, and Australia. Harm reduction appears to be acceptable in the UK
and Canada regardless of whether one is a treatment provider, substance user in treatment, club
goer, or jurist (Rosenbeg & Melville, 2005; Macdonald & Erickson, 1999; Akram & Galt, 1999;
Branigan & Wells, 1999; Phillips, Rosenberg, & Sanikop, 2007). One explanation for lower
acceptance of harm reduction in the United States is that generally our society is more socially
conservative and religious compared to many other western countries which tend to be liberal in
practice and policy. However, the next generation of Americans may be more open to the harm
reduction philosophy given my findings regarding attitudes of college students. Another
explanation for acceptance in my study is that students may find value in harm reduction for
recreational users and/or college students, whereas both treatment professionals and lay public may
view harm reduction for abusers or dependent users unfavorably.
My study expanded upon previous acceptability research in many ways and was the first, to
my knowledge, to assess college students and harm reduction interventions aimed for recreational
users. Furthermore, my methodology expanded upon previous research in that I used multiple
methods to assess attitudes (open-ended questions in conjunction with a rating scale), whereas
previous research used rating scales solely. The strength of my methodology was that participants
had a chance to respond to open-ended questions asking about advantages and disadvantages, as
well as initial thoughts, of each intervention. This allowed for recognition of and insight into
disadvantages and advantages of interventions beyond the simple rating task which showed overall
acceptance of interventions. Another strength of my study was the recruitment of a sample from a
large public university, which is likely to include participants representing a range of intelligence
levels and socioeconomic statuses.
However, there were also aspects of my sample that could limit external validity of my
results. One limitation was that the attitudes of students at a Midwestern college may not represent
harm reduction acceptability in other areas of the United States. More socially liberal parts of
United States, such as the Coasts and cities, may have more exposure to substance-related
problems and thus be more accepting of harm reduction interventions. Socially conservative parts,
including the South and rural areas, may be less accepting of the same interventions. Another
potential limitation was that my sample comprised predominately Caucasian female first year
college students; therefore, opinions of men, older students, and other ethnic and racial
backgrounds may not have been sufficiently represented.
Another potential limitation concerns the phrasing of items on the questionnaire.
Specifically, the ITADART was designed for this study and, despite being pilot tested, it may not
have captured participants’ views on acceptability in the most effective way due to potentially
ambiguous language and wording. One concern was that the construct of acceptability was not
operationally defined. Therefore, the meaning of acceptability may have been dependent on
whether the participant felt the intervention was morally right or wrong, whether they would
personally use it, whether they would spend money on it, or other subjective definitions. Another
concern is that students’ responses may have reflected their opinions of the verbs in my questions,
such as “encouraging,” rather than acceptability of the target interventions. Future researchers
could hold focus groups with students and/or recruit harm reduction acceptability researchers to
provide feedback on and improvements regarding wording and question clarity. Lastly, even
though my coders had high inter-rater reliability, qualitative methodology involves experimenter
and coder subjectivity that may have biased the creation of my coding categories and the frequency
of responses per category.
Future harm reduction research could assess acceptability of interventions for different
classes of drugs and target populations, as well as the implementation of harm reduction within
these settings. It may be useful to assess acceptability based on a broader variety of drugs, as
students may be less accepting of interventions pertaining to “harder” drugs, such as heroin, but
more accepting of interventions pertaining to more commonly used drugs such as alcohol,
marijuana, and ecstasy. For example, students may be less accepting of needle exchange
programs, but more accepting of serving as or designating a sober driver. It may also prove
beneficial to sample other target populations that are of greater risk of experimenting or developing
problems with substances, such as pre-college adolescents, young adults involved in the greek
system, athletic department, who have a history of trauma, or come from high-risk families.
I believe that my study represents college students’ views on harm reduction for
recreational users. My findings suggest acceptability of five harm reduction interventions for and
by younger generations of users. In a study published in 2003, Rosenberg and Phillips found that
harm reduction was perceived as “sending the wrong message” according to treatment providers.
However, if my study is a precursor of acceptability of harm reduction with younger generations of
stakeholders, and if their attitudes persist, it is possible that negative views towards harm reduction
interventions may change.

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APPENDIX A
ITADART
For the following questions, a “recreational drug” is defined as an illegal drug or a prescription drug that a
person uses for non-medical reasons. Please respond so that your writing is clear and readable.
Part One:
For each of the following questions, write down the first two or three thoughts that come into your
head when you think about each activity. It does not matter if your thoughts are good or bad, I
only want to know what your first thoughts are.
1) Write down your first two or three thoughts about…… providing a place where recreational
drug users can bring drugs to have them tested so they will know the contents and strength
of the drug before they take it.
Thought 1:____________________________________________________
Thought 2:____________________________________________________
Thought 3:____________________________________________________
2) Write down your first two or three thoughts about….. sending recreational drug users to
substance abuse treatment instead of legal prosecution/punishment the first time they are
caught possessing drugs.
Thought 1:____________________________________________________
Thought 2:____________________________________________________
Thought 3:____________________________________________________
3) Write down your first two or three thoughts about….. encouraging recreational DRUG users
who are experiencing problems from their DRUG use to REDUCE or cut back their use
(RATHER THAN STOPPING completely).
Thought 1:____________________________________________________
Thought 2:____________________________________________________
Thought 3:____________________________________________________
4) Write down your first two or three thoughts about….. encouraging recreational DRUG users
who are experiencing problems from their DRUG use to STOP their use and NEVER USE
the drug again.
Thought 1:____________________________________________________
Thought 2:____________________________________________________
Thought 3:____________________________________________________
5) Write down your first two or three thoughts about..... encouraging recreational DRINKERS
who are experiencing problems from their ALCOHOL use to REDUCE or cut back their
drinking (RATHER THAN STOPPING completely).
Thought 1:____________________________________________________
Thought 2:____________________________________________________
Thought 3:____________________________________________________
6) Write down your first two or three thoughts about….. encouraging recreational DRINKERS
who are experiencing problems from their ALCOHOL use to STOP their drinking and
NEVER DRINK again.
Thought 1:____________________________________________________
Thought 2:____________________________________________________
Thought 3:____________________________________________________
7) Write down your first two or three thoughts about….. providing recreational drinkers and
drug users with condoms in case they are sexually active after using alcohol or drugs.
Thought 1:____________________________________________________
Thought 2:____________________________________________________
Thought 3:____________________________________________________
Part Two:
NEXT, for each of the same activities, write down two advantages and two disadvantages of each
option.
1) Write down two advantages and two disadvantages of...... providing a place where
recreational drug users can bring drugs to have them tested so they will know the contents
and strength of the drug before they take it.
Advantage 1:______________________________________________________
Advantage 2:______________________________________________________
Disadvantage 1:____________________________________________________
Disadvantage 2:____________________________________________________
2) Write down two advantages and two disadvantages of….. sending recreational drug users to
substance abuse treatment instead of legal prosecution/punishment the first time they are
caught possessing drugs.
Advantage 1:______________________________________________________
Advantage 2:______________________________________________________
Disadvantage 1:____________________________________________________
Disadvantage 2:____________________________________________________
3) Write down two advantages and two disadvantages of…... encouraging recreational DRUG
users who are experiencing problems from their DRUG use to REDUCE or cut back their
use (RATHER THAN STOPPING completely).
Advantage 1:______________________________________________________
Advantage 2:______________________________________________________
Disadvantage 1:____________________________________________________
Disadvantage 2:____________________________________________________
4) Write down two advantages and two disadvantages of….. encouraging recreational DRUG
users who are experiencing problems from their DRUG use to STOP their use and NEVER
USE the drug again.
Advantage 1:______________________________________________________
Advantage 2:______________________________________________________
Disadvantage 1:____________________________________________________
Disadvantage 2:____________________________________________________
5) Write down two advantages and two disadvantages of…. encouraging recreational
DRINKERS who are experiencing problems from their ALCOHOL use to REDUCE or cut
back their drinking (RATHER THAN STOPPING completely).
Advantage 1:______________________________________________________
Advantage 2:______________________________________________________
Disadvantage 1:____________________________________________________
Disadvantage 2:____________________________________________________
6) Write down two advantages and two disadvantages of….. encouraging recreational
DRINKERS who are experiencing problems from their ALCOHOL use to STOP their
drinking and NEVER DRINK again.
Advantage 1:______________________________________________________
Advantage 2:______________________________________________________
Disadvantage 1:____________________________________________________
Disadvantage 2:____________________________________________________
7) Write down two advantages and two disadvantages of….. providing recreational drinkers and
drug users with condoms in case they are sexually active after using alcohol or drugs.
Advantage 1:______________________________________________________
Advantage 2:______________________________________________________
Disadvantage 1:____________________________________________________
Disadvantage 2:____________________________________________________
Part Three:
Please circle your acceptability rating of each activity on the scale from “Completely
Unacceptable” to “Completely Acceptable”.
1) Rate the acceptability of….. providing a place where recreational drug users can bring
drugs to have them tested so they will know the contents and strength of the drug before they
take it.
Completely Somewhat Neither Acceptable Somewhat Completely

Unacceptable Unacceptable or Unacceptable Acceptable Acceptable
2) Rate the acceptability of….. sending recreational drug users to substance abuse treatment
instead of legal prosecution/punishment the first time they are caught possessing drugs.

3) Rate the acceptability of.…. encouraging recreational DRUG users who are experiencing
problems from their DRUG use to REDUCE or cut back their use (RATHER THAN
STOPPING completely).

4) Rate the acceptability of….. encouraging recreational DRUG users who are experiencing
problems from their DRUG use to STOP their use and NEVER USE the drug again.

5) Rate the acceptability of.…. encouraging recreational DRINKERS who are experiencing
problems from their ALCOHOL use to REDUCE or cut back their drinking (RATHER
THAN STOPPING completely).

6) Rate the acceptability of….. encouraging recreational DRINKERS who are experiencing
problems from their ALCOHOL use to STOP their drinking and NEVER DRINK again.

7) Rate the acceptability of….. providing recreational drinkers and drug users with condoms
in case they are sexually active after using alcohol or drugs.

Part Four:
1) Write down your first two or three thoughts about….. helping people reduce the harmful
consequences (e.g. disease, overdose, illness, legal problems) of their ongoing drug use in
order to protect their health and well-being if they are unable or unwilling to stop using
drugs.
Thought 1:____________________________________________________
Thought 2:____________________________________________________
Thought 3:____________________________________________________
2) Write down two advantages and two disadvantages of ….. helping people reduce the harmful
consequences (e.g. disease, overdose, illness, legal problems) of their ongoing drug use in
order to protect their health and well-being if they are unable or unwilling to stop using
drugs.
Advantage 1:______________________________________________________
Advantage 2:______________________________________________________
Disadvantage 1:____________________________________________________
Disadvantage 2:____________________________________________________
3) Rate the acceptability of ….. helping people reduce the harmful consequences (e.g. disease,
overdose, illness, legal problems) of their ongoing drug use in order to protect their health
and well-being if they are unable or unwilling to stop using drugs.

APPENDIX B
BSSS
Please circle the response from “Strongly Disagree” to “Strongly Agree” that best corresponds
with your personal view about each statement.
1. I would like to explore strange places.

Strongly Disagree Neither Disagree Agree Strongly
Disagree nor Agree Agree
2. I would like to take off on a trip with no pre-planned routes or timetables.

3. I get restless when I spend too much time at home.

4. I prefer friends who are excitingly unpredictable.

5. I like to do frightening things.

6. I would like to try bungee jumping.

7. I like wild parties.

8. I would love to have new and exciting experiences, even if they are illegal.
APPENDIX C
MHLC
Form A
Instructions: Each item below is a belief statement about your medical condition with which you
may agree or disagree. Beside each statement is a scale which ranges from strongly disagree (1) to
strongly agree (6). For each item we would like you to circle the number that represents the extent
to which you agree or disagree with that statement. The more you agree with a statement, the
higher will be the number you circle. The more you disagree with a statement, the lower will be the
number you circle. Please make sure that you answer EVERY ITEM and that you circle ONLY
ONE number per item. This is a measure of your personal beliefs; obviously, there are no right or
wrong answers.
1=STRONGLY DISAGREE (SD)
2=MODERATELY DISAGREE (MD)
3=SLIGHTLY DISAGREE (D)
4=SLIGHTLY AGREE (A)
5=MODERATELY AGREE (MA)
6=STRONGLY AGREE (SA)
SD MD D A MA SA
If I get sick, it is my own behavior which determines how soon I get
1 1 2 3 4 5 6
well again.
2 No matter what I do, if I am going to get sick, I will get sick. 1 2 3 4 5 6
Having regular contact with my physician is the best way for me to
3 1 2 3 4 5 6
avoid illness.
4 Most things that affect my health happen to me by accident. 1 2 3 4 5 6
Whenever I don't feel well, I should consult a medically trained
5 1 2 3 4 5 6
professional.
6 I am in control of my health. 1 2 3 4 5 6
7 My family has a lot to do with my becoming sick or staying healthy. 1 2 3 4 5 6
8 When I get sick, I am to blame. 1 2 3 4 5 6
Luck plays a big part in determining how soon I will recover from an
9 1 2 3 4 5 6
illness.
10 Health professionals control my health. 1 2 3 4 5 6
11 My good health is largely a matter of good fortune. 1 2 3 4 5 6
12 The main thing which affects my health is what I myself do. 1 2 3 4 5 6
13 If I take care of myself, I can avoid illness. 1 2 3 4 5 6
14 Whenever I recover from an illness, it's usually because other people 1 2 3 4 5 6
(for example, doctors, nurses, family, and friends) have been taking
good care of me.

15 No matter what I do, I 'm likely to get sick. 1 2 3 4 5 6
16 If it's meant to be, I will stay healthy. 1 2 3 4 5 6
17 If I take the right actions, I can stay healthy. 1 2 3 4 5 6
18 Regarding my health, I can only do what my doctor tells me to do. 1 2 3 4 5 6
APPENDIX D
M-C 2
Listed below are a number of statements concerning personal attitudes and traits. Read each item
and decide whether the statement is true (T) or false (F) as it pertains to you personally.
True False
1. I never hesitate to go out of my way to help someone in trouble. T F
2. I have never intensely disliked anyone. T F
3. There have been times when I was quite jealous of the good fortune of others. T F
4. I would never think of letting someone else be punished for my wrong doings. T F
5. I sometimes feel resentful when I don’t get my way. T F
6. There have been times when I felt like rebelling against people in authority T F
even though I knew they were right.
7. I am always courteous, even to people who are disagreeable. T F
8. When I don’t know something I don’t at all mind admitting it. T F
9. I can remember “playing sick” to get out of something. T F
10. I am sometimes irritated by people who ask favors of me. T F

APPENDIX E
BACKGROUND INFORMATION
1. Please indicate your age in years: _______
2. Please indicate your ethnicity: (check)

___White/European American ___Asian-American/Pacific Islander
___Black/African American ___Native American Indian/First Nation
___Latino(a)/Hispanic-American ___Other (please specify):______________
3. Please indicate your sex: (check) ___male ___female
4. Please indicate your year in college: (check)
___first year ___second year ___third year ___fourth year ___fifth yr or higher
5. Are you a: ___ Full-time student ___ Part-time student
6. Please indicate your current overall GPA: (check)

___ below 2.0 ___2.0 – 3.0 ___ above 3.0
7. Are you employed (besides being a student)? (check)

___no ___yes, I have a part-time job ___yes, I have a full-time job
8. In what college are you going to major? (check one)

___Education ___Business ___Arts and Sciences
___Technology ___Health and Human Services ___Musical Arts
___Undecided
9. Please indicate where live: ___I live on campus ___I live off campus
Please answer the following questions about ALCOHOL:
1. What percent of your friends drink alcohol?

___None ___Less than half ___More than half, but not all ___Almost all or all
2. Circle the answer below that indicates how many times you have drunk alcohol in your life:
Never / Less than 5 times / 5-10 times / 11-20 times / 21-50 times/ more than 50 times
3. How old were you when you had your first drink of alcohol? _______
4. On about how many days do you drink alcohol in a typical week? _______
5. How many beers do you drink on a typical day when you are drinking? ________
6. How many glasses of wine do you drink on a typical day when you are drinking? _________
7. How many drinks/shots with hard liquor do you drink on a typical day when you are
drinking? ________
8. When you drink alcohol, who are you usually with?
___ alone ___ with friends ___ with family ___ Others: ___________________
9. Circle the answer below that best describes the degree to which your use of alcohol is under
your control:
Completely Somewhat Somewhat Completely

under my control under my control out of my control out of my control
10. Circle how easy or difficult it would be for you to go without drinking alcohol for the next
month?
Very easy Somewhat easy Somewhat difficult Very difficult
11. How many times in the past 2 weeks have you consumed 5 or more drinks in a row (if you are
a man) or 4 or more drinks in a row (if you are a woman): ____________
Please answer the following questions about DRUGS (ILLEGAL DRUGS or PRESCRIPTION
DRUGS USED FOR NON-MEDICAL REASONS):
1. What percent of your friends use drugs?

___None ___Less than half ___More than half, but not all ___Almost all or all
2. Have you ever tried drugs? ___________ **If you answered “no” please end here**
3. How old were you the first time you tried any drug? ___________
4. Circle the answer below that indicates how many times you have used MARIJUANA in your
life:
Never / Less than 5 times / 5-10 times / 11-20 times / 21-50 times/ more than 50 times
5. How many times do you use marijuana in a typical month? _______
6. Please put a check mark next to the drugs you have EVER used and write in the number of
times you have used the drug (if applicable):
____MDMA/ECSTASY a) How many times have you ever used MDMA/ecstasy?_______

____HALLUCINOGENS b) How many times have you ever used hallucinogens?_______
____COCAINE c) How many times have you ever used cocaine?_______
____METH/ d) How many times have you ever used amphetamines?_______
other AMPHETAMINES
____HEROIN e) How many times have you ever used heroin?_______
____PRESCRIPTION DRUGS (USED FOR NON-MEDICAL REASONS)
Name of drug:_____________________ f) How many times used?_______

Name of drug:_____________________ g) How many times used?_______
____OTHER DRUG Name of drug:_______________ h) How many times used?_______
7. When you use your favorite drug, what drug is this: _____________________ and who are you
usually with?
___ alone ___ with friends ___ with family ___ Others: ___________________
8. Circle the answer below that best describes the degree to which use of your favorite drug is
under your control:
Completely Somewhat Somewhat Completely

under my control under my control out of my control out of my control
9. Circle how easy or difficult it would be for you to go without using your favorite drug for the
next month?
Very easy Somewhat easy Somewhat difficult Very difficult

APPENDIX F
INTRODUCTION PROTOCOL
Are there any questions about the consent?
There are just a few other things before we begin:
♦ Please turn your cell phone off
♦ The questionnaire is 5 pages, front and back
♦ Please use pen, write neatly and complete the questions in order; I have pens if you do not
♦ You will be asked about different substance use interventions, some related to alcohol,
others to drugs, please read each question carefully as there are few differences between
some interventions
♦ I am interested your opinions and any thoughts you have; your responses are valuable to
me
♦ Please raise your hand and ask questions at any time if you need clarification
♦ When finished, please turn your clipboard over and wait quietly or read a magazine until
everyone is finished
♦ When everyone is done, I will debrief, ask you a few informal questions, and make sure
everything is set for compensation
♦ Are there any questions before we begin?

APPENDIX G
EXAMPLES OF PARTICIPANTS’ RESPONSES FOR INTERVENTION ADVANTAGE

CATEGORIES
Categories Examples of Advantages

Reduce Problems “would reduce their problems”
NOS “prevent accidents”
Reduce/Stop Use “they would be sober if they stopped”
NOS “they would start taking less of the substance”
Improve Physical “can save lives”
Health “less harsh detox”
Increase “be more aware and know what they did wrong to not do it again”
Awareness “the user can feel like they have self control over drug”
Improve Well- “healthier lifestyle”
being NOS “may help them in the long run”
More Appealing “people who try this have a better chance of rehabilitation”
Option “this is realistic”
Increase Education “user will know which drugs are safe and which aren’t”
“increase their knowledge”
Improve “possibly help keep families together”
Relationships “build back up relationships with family and friends if broken”
Reduce Relapse “lowers the rate of relapse alcoholics”
“a number of people will never turn back”
Weaning off use “reducing helps wean the person off their habit”
“reducing can help ease into quitting”
Improve Emotions “may be in a better mood”
“maybe it would give them hope”
Improve Finances “save money”
“will save money for more essential items”
Fewer People in “won't use up room in prisons which are over crowded”
Jail “release pressure of prison resources”
Reduce pregnancy “prevent pregnancy”
“cut back on pregnancy”
Reduce STDs “there may be less STDs transmitted”
“reduce spread of STI's”
Know Drug “they know what they're putting into their bodies”
Content “they will know if it is strong enough to kill them”
Safer Sex NOS “could help them be safe sexually”
“encourages safe sex”
Encourage Change “gives them a second chance”
“helps them get the help they need”
Improve Tracking “good way to count/estimate number of drugs users”
“government could keep better track of drug use”
Increase “teaches some responsibility”
Responsibility “makes them look a little more responsible”
Miscellaneous “help alcoholics attend AA meetings”

“substitute with healthy hobby”
None “none, because I believe it won't work”
“none”
APPENDIX H
EXAMPLES OF PARTICIPANTS RESPONSES FOR INTERVENTION DISADVANTAGE

CATEGORIES
Categories Examples of Disadvantages

Ineffective “too extreme for everyday drug users”
Intervention “they are just minimizing the problem not solving it”
Encourages Use “it's like you're saying "it's ok if it's a weak drug"”
“encourages experimenting w/ drugs”
Increased “they just won't listen”
Resistance “users may not want to quit it”
Emotional “they may become depressed”
Problems “will cause more anger problems”
High Resource “making these places will cost money”
Costs “very costly I would imagine”
Urges Increase “making them stop would probably make them want it more”
“causes a more intense need for it after quitting”
Drug “may go down other routes (drugs)”
Compensation “this could lead to other addiction in place of drinking”
Still Using the “still consuming some alcohol may not help reduce their addiction”
Substance “it is still harmful for them to continue using the drug”
Less Individual “shows drug/alcohol user no responsibility of their own actions”
Responsibility “encourages people to not take responsibility for themselves”
Relationship “this rapid change will cause loss in friendship and social networking”
Problems “may still be affecting family/friends/job in negative way”
Negative Use of “they could sell the drugs knowing how strong they are”
Service “if their drunk or high, will they even be able to use it?”
Withdrawal Effects “bad withdrawls”
“the withdrawal may be to much”
Light Punishment “too lenient? Giving them a chance to do bad again”
“not harsh enough punishment”
Encourages Sex “promotes sex in a way”
“may give people the idea that it's okay to get messed up and sleep with
anyone”
Legality Issues “it's illegal”
“they may get in trouble by the law”
Sexual Consent “does not address consent of sexual activity”
Issues “may help, if addict is sexual predator, in raping”
Miscellaneous “may effect user more”
“they shouldn't have a place to take drugs to”
None “cutting down the abuse, its as great as stopping it completely”
“I don't see a disadvantage”
Table 1
Participant Demographics
Characteristics Mean (SD) or N (%)
N = 104
Age 19.36 (1.4)
*Ethnicity
White/European American 88 (85.4%)

Black/African American 10 (9.7%)
Latino(a)/Hispanic 2 (1.9%)
Other 3 (2.9%)
Gender
Female 73 (70.2%)
Male 31 (29.8%)
Year in College
First Year 47 (45.2%)

Second Year 28 (26.9%)
Third Year 12 (11.5%)
Fourth Year 9 (8.7%)
Fifth Year or Higher 8 (7.7%)
*Grade Point Average
Above 3.0 56 (54.4%)

2.0 – 3.0 44 (42.7%)
Below 2.0 3 (2.9%)
*College Major
Health and Human Services 36 (35.0%)

Arts and Sciences 31 (30.1%)
Education 17 (16.5%)
Business 9 (8.7%)
Technology 2 (1.9%)
Undecided 8 (7.8%)
*College Status
Full-Time Student 101 (98.1%)

Part-Time Student 2 (1.9%)
**Housing
Live On Campus 69 (68.3%)

Live Off Campus 32 (31.7%)
Employment
No Job 56 (53.8%)
Part-Time Job 42 (40.4%)
Full-Time Job 6 (5.8%)
*n = 103
**n = 101
Table 2
Participants’ Alcohol Use History

Characteristics Mean (SD) or Frequency (%)
n = 98
Age of first drink 15.48 (2.6)
Number of days drink in typical week 1.40 (1.0)
Typical day when drinking: Number of beers 4.12 (3.4)
Typical day when drinking: Number of drinks/shots with hard 3.05 (3.7)
liquor
Typical day when drinking: Number of glasses of wine 0.67 (1.3)
*Number of times have drunk in life
Never 6 (5.8%)
Less than 5 8 (7.7%)
5 – 10 8 (7.7%)
11 – 20 10 (9.6%)
21 – 50 33 (31.7%)
More than 50 39 (37.5%)
Number of days drink alcohol per week
None 17 (17.3%)
0–1 5 (5.1%)
1 29 (29.6)
1–2 7 (7.1%)
2 28 (28.6)
3 7 (7.1%)
3–4 3 (3.1%)
4 2 (2%)
Ability to control use
Completely under my control 73 (74.5%)

Somewhat under my control 23 (23.5%)
Somewhat out of my control 1 (1.0%)
Completely out of my control 1 (1.0%)
**Ease with which could abstain for a month
Very easy 69 (71.1%)

Mostly easy 19 (19.6%)
Mostly difficult 9 (9.3%)
93 (94.9%)
Drink with friends
Drink with family 26 (26.5%)
Drink by themselves 4 (4.1%)
Drink with others 4 (4.1%)
*Number of friends who drink
One to less than half 11 (10.6 %)

More than half, but not all 44 (42.3 %)
All or almost all 49 (47.1 %)
*n = 104
**n = 97
Table 3
Participants’ Drug Use History

Characteristics Mean (SD) or Frequency (%)
Ever tried drugs (n = 103)
Yes 54 (52.4%)
No 49 (47.6%)
Age of first drug use (n = 54) 16.31 (2.0)
Lifetime use of marijuana (n = 103)
Never 50 (48.5%)
Less than 5 20 (19.4%)
5 – 10 6 (5.8%)
11 – 20 3 (2.9%)
21 – 50 5 (4.9%)
More than 50 19 (18.4%)
Lifetime use of MDMA/Ecstasy (n = 102)
Never 91 (89.3%)
1–5 8 (7.8%)
6 – 10 3 (2.9%)
Lifetime use of hallucinogens (n = 102)
Never 89 (87.3%)
1–5 9 (8.8%)
6 – 10 4 (3.9%)
Lifetime use of meth/amphetamine (n = 103)
Never 100 (97.1%)

1–5 1 (1.0%)
6 – 10 2 (1.9%)
Lifetime use of cocaine (n = 101)
Never 92 (91.0%)
1–5 5 (5.0%)
6 – 10 2 (2.0%)
11 or more 2 (2.0%)
Lifetime use of 1 prescription drug used recreationally (n = 101)
Never 81 (80.2%)
1–5 10 (9.9%)
6 – 10 6 (5.9%)
11 or more 4 (4.0%)
Lifetime use of 2+ prescription drugs used recreationally (n = 101)
Never 91 (90.1%)
1–5 7 (6.9%)
6 – 10 2 (2.0%)
11 or more 1 (1.0%)
Lifetime use of over-the-counter meds used recreationally (n = 103)
Never 100 (97.1%)

1–5 2 (1.9%)
6 – 10 1 (1.0%)
Ability to control drug use (n = 50)
Completely under my control 40 (80.0%)

Somewhat under my control 9 (18.0%)
Somewhat out of my control 1 (2.0%)
Ease with which could abstain from drugs for a month (n = 53)
Very easy 46 (86.8%)

Mostly easy 3 (5.7%)
Mostly difficult 4 (7.5%)
Number of friends who use drugs (n = 103)
None 18 (17.5%)
One to less than half 69 (67.0%)
More than half, but not all 15 (14.6%)
All or almost all 1 (1.0%)
Table 4
Intercorrelations of Acceptability Ratings of Each Intervention (N = 104)
Acceptability Pill Treatment Reducing Stopping Reducing Stopping Providing Harm

of: Testing Instead of Drugs Drugs Alcohol Alcohol Condoms Reduction
Prosecution Definition
Pill Testing -- -- -- -- -- -- -- --
Treatment
Instead of .082 -- -- -- -- -- -- --
Prosecution
Reducing
Drugs .242* .098 -- -- -- -- -- --
Stopping
Drugs -.043 -.013 -.305** -- -- -- -- --
Reducing
Alcohol .116 .073 .641** -.150 -- -- -- --
Stopping
Alcohol -.065 -.021 -.177 .731** -.248* -- -- --
Providing
Condoms .173 .060 -.142 .146 .038 .094 -- --
Harm
Reduction .139 .164 .166 .122 .224* .056 .056 --
Definition
* p < .05
** p < .01
Table 5
Advantages of Interventions: Number of Participant Responses per Category
Categories Pill Treatment Providing Reducing Stopping Reducing Stopping Harm

Testing Instead of Condoms Alcohol Alcohol Drugs Drugs Reduction
Reduce 15 5 8 18 25 8 15 14
Problems
NOS
Reduce/Stop 13 26 -- 16 27 16 37 8
Use NOS
Improve 24 -- -- 14 16 15 15 31
Physical
Health
Increase -- 9 -- 11 10 6 8 9
Awareness
Improve Well- -- -- -- 14 22 9 23 23
being NOS
More -- -- -- 40 8 39 13 --
Appealing
Option
Increase 32 12 -- -- -- -- 2 6
Education
Improve -- -- -- 2 6 -- 2 5
Relationships
Reduce -- -- -- 2 1 1 1 --
Relapse
Weaning -- -- -- 20 -- 35 -- 5
Off Use
Improve -- 2 -- 1 1 -- -- --
Emotions
Improve -- -- -- 2 -- 2 2 --
Finances
Fewer People -- 13 -- -- 3 -- -- --
in Jail
Reduce -- -- 56 -- -- -- -- --
Pregnancy
Reduce STDs -- -- 49 -- -- -- -- --
Know Drug 42 -- -- -- -- -- -- --
Content
Safer Sex -- -- 36 -- -- -- -- --
NOS
Encourage -- 73 -- -- -- -- -- 11
Change
Improve 9 -- -- -- -- -- -- --
Tracking
Increase -- -- 4 -- -- -- -- --
Responsibility
Miscellaneous 10 13 10 8 23 5 24 38
None -- -- 1 -- 1 5 -- --
Table 6
Disadvantages of Interventions: Number of Participant Responses per Category
Categories Pill Treatment Providing Reducing Stopping Reducing Stopping Harm

Testing Instead of Condoms Alcohol Alcohol Drugs Drugs Reduction
Ineffective -- 59 -- 60 71 54 69 39
Intervention
Encourages Use 54 7 -- 5 -- 8 -- 18
Increased -- -- -- 10 14 10 18 23
Resistance
Emotional -- -- -- 6 12 1 12 2
Problems
High Resource 9 6 5 -- -- -- -- 11
Costs
Urges Increase -- -- -- 4 5 6 8 --
Drug -- -- -- 1 3 2 1 --
Compensation
Still Using the -- -- -- 22 -- 45 -- 19

Substance
Less Individual -- -- 12 1 -- -- -- 4
Responsibility
Relationship -- -- -- 2 3 2 -- --
Problems
Negative Use of 51 -- 33 -- -- -- -- --
Service
Withdrawal -- -- -- -- 19 23 --
Effects
Light -- 55 -- -- -- -- -- --
Punishment
Encourages Sex -- -- 49 -- -- -- -- --
Legality Issues 14 -- -- -- -- -- -- --
Sexual Consent -- -- 6 -- -- -- -- --
Issues
Miscellaneous 16 11 21 13 10 9 8 12
None 1 2 6 1 3 1 1 6
Table 7
Mean Acceptability of Each Intervention across Full Sample and by Lifetime Drug Use
Full Sample Positive Drug Negative Drug

(N = 104) History History
(n = 54) (n = 49)
List of Interventions M (SD) M (SD) M (SD)
Acceptability of Pill Testing 2.57 (1.3) 2.52 (1.3) 2.65 (1.3)
Acceptability of Treatment Instead of 4.00 (1.1) 4.13 (1.1) 3.84 (1.1)

Prosecution
Acceptability of Reducing Drugs 3.53 (1.3) 3.61 (1.3) 3.43 (1.3)
Acceptability of Stopping Drugs 3.79 (1.3) 3.67 (1.4) 3.96 (1.2)
Acceptability of Reducing Alcohol 4.02 (1.0) 4.04 (1.0) 4.00 (1.0)
Acceptability of Stopping Alcohol 3.74 (1.2) 3.67 (1.3) 3.88 (1.2)
Acceptability of Providing Condoms to 3.78 (1.2) 4.06 (0.9) 3.53 (1.3)

Users
Acceptability of Broad Definition of 4.09 (1.0) 4.06 (1.1) 4.12 (1.0)

Harm Reduction
Note. No pairwise comparisons were significant for acceptance of interventions by drug history
using Bonferroni correction; alpha is .006

University Students&#39; Attitudes Regarding Harm Reduction

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UNIVERSITY STUDENTS' ATTITUDES REGARDING HARM REDUCTION FOR

RECREATIONAL SUBSTANCE USERS

Submitted to the Graduate College of Bowling Green

Harold Rosenberg, Advisor

Harold Rosenberg, Ph.D., Advisor

Harm reduction is both a treatment philosophy and set of interventions designed to

their perceived advantages/disadvantages of six harm reduction and two abstinence-focused

instead of prosecution, providing condoms, harm reduction broadly) as at least somewhat

history. In response to open-ended questions, the most frequently identified advantages of

well-being, and increasing awareness. Ineffectiveness, encouraging substance use, and

increasing resistance were the most frequently identified disadvantages of interventions.

dedication to my professional development; I value his knowledge and guidance tremendously. I

feedback and assistance at various stages of my project.

each of these individuals in indescribable ways.

Initial Thoughts, Advantages/Disadvantages, and Acceptability

Rating Task (ITADART)............................................................................. 18

Content Analysis of ITADART Qualitative Data........................... 19

Brief Sensation Seeking Scale (BSSS) ………................................................ 21

Multidimensional Health Locus of Control (MHLC)....................................... 22

Marlowe-Crowne Social Desirability Scale (M-C 2)....................................... 23

Acceptance of Harm Reduction and Abstinence-oriented Interventions...................... 25

Acceptance of Subsets of Interventions......................................................................... 26

Personality Characteristics and Intervention Acceptance............................................. 27

Drug Use History............................................................................................... 27

Health Locus of Control.................................................................................... 27

Qualitative Data Themes and Frequencies.................................................................... 28

APPENDIX B. BSSS ............................................................................................................... 49

APPENDIX D. M-C 2............................................................................................................... 52

APPENDIX E. BACKGROUND INFORMATION................................................................ 53

APPENDIX F. INTRODUCTION PROTOCOL..................................................................... 56

APPENDIX G. EXAMPLE OF PARTICIPANTS’ RESPONSES FOR

INTERVENTION ADVANTAGE CATEGORIES.................................... 57

APPENDIX H. EXAMPLE OF PARTICIPANTS’ RESPONSES FOR

INTERVENTION DISADVANTAGE CATEGORIES……........................ 59

2 Participants’ Alcohol Use History................................................................................. 62

3 Participants’ Drug Use History...................................................................................... 64

4 Intercorrelations of Acceptability Ratings of Each Intervention.................................. 66

5 Advantages of Interventions: Number of Participant Responses per Category.......... 67

6 Disadvantages of Interventions: Number of Participant Responses per Category...... 69

7 Mean Acceptability of Each Intervention across Full Sample

And by Lifetime Drug Use............................................................................................ 71

meaningful part of these societal health care costs.

Outcome Studies evaluated a nationwide US sample of substance users following treatment in

and residential settings.

mortality in those who continue to take drugs (MacCoun, 1998).

immunodeficiency virus (HIV) because sharing needles is a leading pathway of contagion

most are not yet commonly available.

of alcohol (versus illicit drugs).

reduction undermines or is contradictory to conventional treatment because it does not insist on

(67%) were “not consistent with agency philosophy.”

(Ritter & Cameron, 2006).

is incompatible with abstinence. However, harm reduction is more accurately viewed on a

The apparent effectiveness of some harm reduction interventions appears to be impacting

infection among IDUs (Strathdee & Vlahov, 2001).

therapy) were rated as somewhat or completely acceptable by 50% of respondents. Non-

of client characteristics with psychologists’ ratings of acceptability of harm reduction

intervention as acceptable regardless of client characteristics.

In general, research on acceptance of harm reduction has focused on professional

reduction interventions and were used by 80% of respondents.

reduction vary by type of intervention and geographic region.

use increased from 3% in 1997 to 7% in 2001.

least five drinks.

In an attempt to prevent unhealthy outcomes in this sub-group, alcohol-focused harm

University Students' Attitudes Regarding Harm Reduction

University Students' Attitudes Regarding Harm Reduction