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A Study on Injunctive Norms, Social-Drinking Refusal Self-Efficacy Skills, Social Anxiety and Alcohol Intentions

Ilse S. Fleuren University of Amsterdam

Author Note

Master Thesis by Ilse S. Fleuren, Graduate School of Communication, Master’s programme Communication Science, University of Amsterdam. Tutored by: Saar Mollen, contact:

S.Mollen@uva.nl. Date of completion: 24/06/2017. Word count: 8033.

Correspondence concerning this thesis should be addressed to Ilse Fleuren, contact: Ilse.Fleuren@student.uva.nl

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Table of Contents

Acknowledgement ... 3

Abstract ... 4

Introduction ... 4

Theoretical Framework ... 6

Social Anxiety and Alcohol ... 6

Drinking Norms ... 8

Drinking Refusal Self-Efficacy ... 10

Method ... 13 Design ... 13 Participants ... 13 Procedure ... 15 Measurements ... 16 Results ... 17 Randomization check ... 17 Manipulation checks ... 17

Intention to drink alcohol ... 18

Behavioral willingness to drink alcohol ... 20

Discussion ... 23

Limitation and recommendations ... 25

Conclusion ... 26

Reference list... 26

Appendix A Pre-test results ... 34

Appendix B Social Anxiety Interaction Scale (SIAS) ... 35

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Acknowledgement

The past three months of thesis writing have been unexpectedly pleasant. For this, I want to thank Saar Mollen, for her enthusiastic, punctual and gentle guidance. Her positivity was

motivating and foremost inspiring. Also, I want to thank Alex Fleuren, who has devoted plenty of his time to second read. Furthermore, I want to thank Jessica Dumay and Thomas

Kriense for their warm support throughout the process. Lastly, special thanks to Rafne ten Oever, who helped me through all the minor (and major) challenges (and crises) while writing

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Abstract

This research applies a 2x2x2 between-subjects factorial design to test whether social

drinking refusal self-efficacy (social-DRSE) mitigates the influence of injunctive social norms on intention and behavioral willingness to use alcohol for college students with elevated versus non-elevated levels of social anxiety. Participants’ (N = 203) social anxiety was measured and they were assigned to the elevated or average level of social anxiety condition. Thereafter they were exposed to a norm condition and a social-DRSE condition. Injunctive norms were manipulated in a short article by providing either a positive, approving attitude of students’ excessive alcohol consumption, or by providing a negative, disapproving attitude of students’ excessive alcohol consumption. Social-DRSE was manipulated by requiring

participants to resist alcohol through application of effective- and less effective

recommendations, for their future personal drinking circumstances. Results showed that the social-DRSE manipulation was presumably not effective and therefore results regarding social-DRSE were inconclusive. However, results also showed that a positive injunctive norm lead to increased intention, but not behavioral willingness, of alcohol use for students with elevated vs. non-elevated levels of social anxiety. A negative injunctive norm lead to a decreased intention, but not behavioral willingness, of alcohol use for students with elevated vs. non-elevated levels of social anxiety. This research confirmed previous research

concerning the strong effect of injunctive norms on students with elevated levels of social anxiety.

Introduction

Heavy drinking behaviour amongst undergraduate college students remains an

important public health problem. In the USA, an estimated 40% of college students engage in heavy drinking or binge drinking and 18% of this group would classify as having alcohol use disorder (Linden, Lau-Baracoa, & Braitman, 2012). In the Netherlands, students are at high risk as well for alcohol disorders and heavy alcohol use as well (GGZ, 2015). In comparison with other European countries, Dutch students tend to drink more frequently, consume more alcohol per drinking occasion and have a somewhat higher prevalence of heavy drinking (Kraag, Dupont, & Kok, 2017). Also, Dutch students drink more than non-studying people of the same age (Trimbos Institute, 2016).

Many problems of alcohol use amongst college students have been identified, like poor class attendance, injuries and trouble with authority (LaBrie, Hummer, & Neighbors,

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2008). Other types of problems of alcohol misuse, amongst college students, include regretted sexual situations and intoxicated driving (Gilles, 2006). Alcohol misuse is also related to developing cognitive defections (White & Hingson, 2013). Students encounter plenty of novel social situations where high alcohol use is standardized, which increase the risk for brain damage (Zeigler et al., 2005).

Students with elevated social anxiety are at risk for alcohol misuse. Social anxiety refers to social- or performance situations in which a person fears scrutiny by others

(American Psychiatric Association, 2013). Clinically diagnosed social anxiety disorder (SAD) serves as a risk factor for the onset of alcohol dependence (Buckner et al., 2008). Students with elevated levels of social anxiety do not drink more frequently, but drink more to manage their anxiety in social situations. Therefore they experience consequences like physical dependence more often (Black et al., 2012). Students with elevated levels of social anxiety also experience slightly more alcohol-related problems from their drinking behaviour, e.g. avoiding responsibilities due to alcohol misuse (Schry & White, 2013). Tran, Anthenelli, Smith, Corcoran and Rofey (2004) found that socially anxious individuals comprise a significant subset of college hazardous drinkers. Students are at risk in general because symptoms of anxiety are wide-spread among the student population (Pini et al., 2014). Social norms are influential in predicting alcohol use for students with elevated levels of social anxiety, because the alignment of behaviour with the social norm is a means to avoid scrutiny and gain acceptance of peers (Neighbors et al., 2007).Students with elevated levels of social anxiety are e.g. more susceptible to binge drinking when they perceive their peers to approve of this. Yet they engage less in binge drinking and experience less negative alcohol-related consequences (like blackouts), when they do not perceive drinking approval of peers (Linden et al., 2012).

According to Jang, Rimal and Cho (2013), having more self-efficacy appears to mitigate the harmful effects of social norms on drinking intentions and behaviour. This is called drinking refusal self-efficacy, and refers to the amount of resistance individuals think they can offer, when peers offer them alcohol. Students with higher levels of social anxiety report lower alcohol refusal self-efficacy in social drinking situations than students with lower social anxiety (Tran et al., 2004). Therefore, stimulation of the drinking refusal self-efficacy (DRSE) may be particularly effective to alter their alcohol related behaviour.

Current research related to DRSE skills in relation to drinking norms is, however, inconclusive and unclear. The effectiveness of DRSE in alcohol interventions is often unclear

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because multiple factors are stimulated: e.g. norm perceptions, general social skills, harm reduction and drinking refusal self-efficacy (Midford, 2010). Moreover, DRSE is

conceptualized to measure general refusal skills, underexposing the potency of refusal skills in social situations (Cuijpers, 2002). DRSE is presumably influential in predicting alcohol behaviour in social situations, because it is triggered by the drinking context (Ralston and Palfai, 2010). Furthermore, DRSE related research is mostly correlational and based on self-report (i.e., Jang et al., 2013; Gilles, Turk & Fresco, 2006). Therefore, the causal relationship is only assumed and not proven empirically.

Hence, the goals of this research are to investigate whether a stronger DRSE can mitigate the harmful effects of social norms on drinking intentions and willingness to drink, and whether this may be an effective strategy to reduce problematic drinking for students with elevated social anxiety. This research contributes to the existing literature by (i) disentangling DRSE conceptually to apply to social situations (ii) testing a way to stimulate social-DRSE and (iii) applying an experimental design that clarifies the causal relationship between DRSE, social norms and social anxiety.

The following research question will guide this research:

Can the influence of social norms, on the intention and willingness to drink alcohol of students with elevated versus average levels of social anxiety, be mitigated with the use of social-DRSE?

Theoretical Framework Social Anxiety and Alcohol

Social anxiety refers to excessive social stress and fear of negative judgement from peers (Terlecki & Buckner, 2014). Social anxiety induces irrational amounts of fear in social situations, which leads to social avoidance and impeded social functioning in general (Linden et al., 2012). If these symptoms limit individual functioning in social and working

environments considerably, this is called social anxiety disorder, or SAD (Terlecki et al., 2012; Schneier, 2001). In the current research, ‘anxious students’ refer to students with elevated levels of social anxiety which are not clinically diagnosed but assessed by the SIAS (Brown, 1997; Mattick & Clarke, 1998), unless indicated otherwise.

Past research has shown comorbidity between anxiety and alcohol use amongst college students (Schry & White, 2013). Anxious students are especially susceptible to drinking excessively in social situations and experiencing alcohol-related problems, like

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learning problems (Jaworowski et al., 2014). Alcohol use therefore imposes particularly negative risks for these students.

Anxious students drink normal amounts in most drinking situations, but in socially challenging situations they drink nearly twice as much (Terlecki, Ecker & Bucker, 2014). Also, students who received the diagnosis ‘alcohol disorder’ had a significantly greater chance of having social anxiety disorder, 39% opposed to 21% of those who did not have an alcohol disorder (Kushner and Sher, 1993). Moreover, the percentage of individuals suffering from alcohol dependence problems was 24%, amongst students identified with high social anxiety. Finally, students with social anxiety disorder were found to be two to three times more likely to develop an alcohol use disorder (Morris, Stewart & Ham, 2005). These

findings illustrate the extent to which anxious students are at risk for problematic alcohol use. Three theoretical models offer insight into the relationship of anxiety and alcohol use for students. Two of these, attribute the attractiveness of alcohol for students with social anxiety to its stress and tension reducing effects. First the Stress Dampening Model (SDM) suggests alcohol consumption is a coping mechanism, which is used to alleviate daily

stressful events (Backer-Fulghum, 2012; Patock-Peckham, King, Roufa & Hagen, 2012). An exemplary experiment of Balodis, Wynne-Edwards & Olmstead (2011) examined

participants’ self-reported and biological stress responses to a stressful or relaxing task. Participants were either intoxicated with alcohol, drank a placebo, or were not given alcohol at all. The intoxicated and placebo group experienced less subjective and physiological

responses to the stress condition, as compared to the control group. Therefore, alcohol and the expectation of alcohol ‘dampen’ mental and physical stress reactions.

Second, the Tension Reduction Model (TRT) states alcohol reduces tension through suppression and depression of the central nervous system. Drinking is therefore reinforced by the tension reduction effect it provides (Young, Oei & Knight, 1990). This effect is illustrated by a study in which anxious participants and non-anxious participants were asked to give a speech, while given either alcohol, a placebo or orange juice. Socially anxious participants reported more anxiety during the speech, than control participants. Also alcohol reduced self-reported anxiety only for participants who were socially anxious (Stevens, Cooper, Bantin, Hermann & Gerlach, 2017).

When individuals get too dependent on the tension reduction properties to deal with social anxiety symptoms, they may come to believe they need alcohol to cope with negative affective states related to social anxiety (Buckner et al., 2008). This forms the core of the

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Stress-Negative Affect model (SNA), which posits that substance use is an attempt for anxious individuals to alleviate negative affect resulting from stressful experience (Hussong, 1993). The SNA is supported by neuroscientific evidence that found deviant activity in brain regions related to emotional regulation, when participants with a social anxiety disorder experienced negative emotions in response to social threats (Goldin, Manber, Hakimi, Canli & Gross, 2009).

According to aforementioned models, using alcohol is a way for anxious individuals to reduce stress and tension resulting from social events. This way of using alcohol stimulates alcohol use in dealing with negative affect and increases risk of dependence.

Drinking Norms

An important moderator in the relationship of alcohol and anxiety are social drinking norms. Social drinking norms are one of the strongest predictors of alcohol use among college students in general, but in particular for anxious students (Rinker & Neighbors, 2013). Perceived social drinking norms refer to the beliefs that a student has about peers’ drinking behaviour, which are divided in descriptive and injunctive norms. Perceived

descriptive norms, relate to how much a student thinks most peers are drinking, or perceived use. Descriptive norms are thought to guide behaviour because they provide implied social proof: ‘if most others are doing it, then it must be the right thing to do’. They thus, provide information about the right way to act in ambiguous situations (Cialdini & Trost, 1998). Therefore, descriptive norms can be a valid point of reference for decision making in specific social situations.

Injunctive norms regarding alcohol use relate to the’ perceived approval or disapproval of drinking behaviour of most peers. A positive injunctive norm refers to approval, while a negative injunctive norm refers to disapproval. Injunctive norms guide behavior because of the human desire to be connected to others. We conform to injunctive norms to obtain social approval and to build meaningful relationships with others (Cialdini, Reno & Kallgren, 1990). Unlike descriptive norms, injunctive norms remain valid across contexts (Mollen, Rimal, Ruiter, Jang & Kok, 2013).

For students with high levels of anxiety in comparison with low levels of anxiety, positive perceived approval leads to more alcohol use, while high (vs. low) perceived use leads to less alcohol use for these students (Buckner, Ecker & Proctor, 2011). Injunctive, as compared to descriptive, norms are more influential in predicting alcohol misuse for anxious

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students, because behaving in accordance with these norms obtains social approval and avoids social scrutiny (Zehe et al., 2013; Buckner et al., 2011). Therefore, injunctive norms are the focus of this research.

Injunctive norms are strongly and positively correlated with high personal alcohol use for students (Cox & Bates, 2011; Gannon-Loew, Eickhoff, & Moreno, 2016; Lee, Geisner, Markman, Neighbors & Larimer, 2007; Talbott, Wilinkinson, Usdan & Moore, 2014). Previous research also found injunctive norms to be associated: past year use, past month frequency, past month quantity, amount of drinks per occasion and negative consequences of use, as alcohol use outcomes (Pedersen et al., 2017). Moreover, students tend to overestimate the alcohol approval of their friends, thereby increasing the alcohol misuse (DeMartini, Carey, Lao & Luciano, 2011). These findings suggest injunctive norms have a considerable influence on alcohol use for students.

However, evidence suggests injunctive norms are especially influential in predicting alcohol behaviour of students with elevated levels of social anxiety. First, students high and low in social anxiety reported the same injunctive norm perceptions, which was more prevailing for students high in social anxiety as compared to low (Neighbors et al., 2007). Second, for anxious students, injunctive norms have a stronger effect than drinking for conformity reasons, while for those lower in social anxiety this effect is vice versa (Linden, Lau-Barraco & Braitman, 2012). This means that for anxious students, norms supersede motivation to fit in. To illustrate: When an anxious student is among a small group of peers who approve of drinking but the general norm on campus is drinking disapprovement, the alcohol use of this student is more influenced by the general injunctive norm than the specific group norm. This supports the idea that injunctive norms are especially influential in directing the alcohol use of anxious students.

It is unclear whether the described effects are influential only to students with clinical levels of social anxiety (SAD), or also for elevated levels of social anxiety. Some research finds that injunctive norms only serve as a risk factor for problem drinking when social

anxiety has reached severe clinical levels, while these are not found for high subclinical levels of social anxiety (Ham, 2003). Yet, other studies do find that subclinical levels of social anxiety are affected by injunctive norms (Linden et al., 2002; Buckner et al., 2007). According to a meta-analysis inconsistent findings of norms on social anxiety are found because different measurement scales used with more and less conservative ways of estimating social anxiety (Schry & White, 2013).

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Furthermore, there has been some debate about the reference group for which injunctive norms are effective. Some research suggests the impact of injunctive norms is relative, because especially proximal reference groups (friends, parents) are positively associated with drinking behaviour, while distal reference groups (typical students) are not (Neigbors et al., 2008; Lewis & Neighbors, 2006). Meisel, Colder and Read (2016), however, indicated that injunctive norms from both proximal and distal reference groups consistently predicted alcohol behaviour in their research. Other research found even the use of a distal reference group leads to a change in the normative norm perception, as long as there is an emphasis on the credibility of the source of the norm feedback, i.e. providing information from a high-quality paper (Hummer & Davison, 2016). Therefore, this research assumes that a fictive norm originating from a credible source can alter injunctive norm perceptions among college students.

Lastly, no gender differences in the relationship between anxiety, perceived norms and alcohol use for college students were found (Neighbors et al., 2007). However, research on early adolescents (aged 11 to 13 years) found that only anxious girls were at risk for alcohol use when the perceived peer approval was high, while they were protected from use when the perceived peer approval was low (Zehe et al., 2013). These gender differences have, to the best of the researcher’s knowledge, not been found for college students and therefore expectations do not differ on basis of gender.

The following hypothesis guides the presented information:

H1: Students intend and are willing to drink more alcohol when injunctive norms are positive regarding alcohol consumption compared to when injunctive norms are negative regarding alcohol consumption. This effect is more pronounced for anxious students than for students with normal levels of social anxiety.

Drinking Refusal Self-Efficacy

A possible solution for the risk of injunctive norms to anxious students, would be to alter injunctive norms in alcohol interventions targeted at college students. Some alcohol interventions have found to be successful in diminishing alcohol misuse by college students by altering injunctive norms perceptions for college students (Barnett et al., 1996; Voogt, et al., 2013; Labrie, Hummer, Huchting & Neighbors, 2009). However, another intervention program found that altering perceived norms is an effective strategy to reduce heavy drinking

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among students with normal anxiety levels, but not for anxious students (Terlecki, Buckner, Larimer and Copelands, 2012). Two reasons for this are discussed.

First, injunctive norms are found to be related to abstinence of alcohol via disapproval and lack of interest (Rinker & Neighbors, 2013). Prior literature clearly stated that anxious students are more personally invested in using alcohol than students with average levels of social anxiety. This is because they use alcohol to deal with their social anxiety symptoms, and therefore it is not likely that less interest in alcohol can be induced for these students by injunctive norms interventions.

Second, programs that were found to be especially successful in altering injunctive norms were delivered through interactive methods like facilitated discussions, small group activities and role-playing scenarios (Botvin & Griffin, 2009). However, in a meta-analysis of alcohol and anxiety, studies that did not require in-person participation resulted in a

significant mean effect on frequency and quantity of alcohol use, while in-person studies did not have a significant mean effect (Schry and White, 2013). This means anxious students are inclined to avoid social interaction with the researcher and other participants in a research setting or intervention. This proves that interventions aimed solely at altering injunctive norms are less effective in reaching anxious students.

In addition to the focus on injunctive norms, self-efficacy is another potentially important factor that may affect drinking behaviour among anxious students. Self-efficacy concerning social pressure is called social-drinking refusal self-efficacy. Social-DRSE refers to the ability of individuals to refuse alcohol in social (pressure) situations and to limit drinking to more responsible amounts. Social-DRSE is negatively correlated with both frequency and amount of alcohol consumption (Young, Hasking & Oei, 2007). More social-DRSE therefore results in more ability of students to resist alcohol.

Social-DRSE has been found to be influential in predicting alcohol outcomes for anxious students. For example, students with high (vs. low) social anxiety and low social-DRSE (vs. high social social-DRSE) experienced most alcohol related problems when participating in drinking games (Kenney, Napper and Labrie, 2014). This suggests that higher social-DRSE mitigates the risks of alcohol use for anxious students.

It is possible to stimulate social-DRSE by inducing in vivo mastery experience:

participants are asked to imagine themselves conducting certain behaviour in future (Bandura, 1998). A web-based alcohol intervention developed by Voogt, Kuntsche, Kleinjan, Engels and Kuntsche (2014) implemented this method and successfully stimulated social-DRSE. This

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effect was measured directly after the experiment and sustained until a follow-up six months later. According to Voogt et al. (2004), the increased social-DRSE is likely to be responsible for the sustained preventive effects of the intervention on weekly alcohol consumption and frequency of binge drinking. This research proves that students’ ability to resist alcohol, can be stimulated in a short experiment and that this effect is sustainable.

Anxious students report a stronger belief of social facilitation of alcohol and lower social-DRSE, in situations where others are drinking, as compared to students with low levels of social anxiety (Burke & Stephens, 1999; Tran et al., 2004). Consequently, those anxious students report more alcohol consumption (Gilles et al., 2006). This strong belief of social facilitation refers to the belief that alcohol helps in dealing with social anxiety symptoms and to avoid peer disapproval.

However, by stimulating and increasing social-DRSE, the confidence of anxious students to refuse drinks can be increased and this may lead them to feel less need to conform to peer’s approving injunctive norms. Cho (2006) examined social-DRSE and social norms on readiness/willingness to intend to change alcohol behaviour among heavy drinking college students. This study found that normative beliefs associated positively- and self-efficacy associated negatively, with being unready to change alcohol behaviour. This means that the more positive injunctive norms were, the more heavy drinking students were

unready/unwilling to change their behaviour. Also, it means that higher self-efficacy

participants made participants more ready to change their alcohol consumption. This research suggests that stimulating self-efficacy concerning social pressure can be instrumental to altering normative influences on heavy drinking.

The interaction effect Cho (2006) presumes to exist for social-DRSE and injunctive norms on intention and willingness to use alcohol, was found for descriptive norms. Namely, an interaction effect was found between strong social-DRSE (vs. weak social-DRSE) and less influence of peer’s use of alcohol (descriptive norm) on drinking intentions and behavior (Jang, Rimal and Cho, 2013). This suggests DRSE mitigates the influence of descriptive norms on alcohol use for students in general. However, the question is whether this effect is also found for injunctive norms and students with elevated levels of social anxiety.

The current study empirically tests the assumption of Cho (2006), indicating a possible interaction effect between social-DRSE and injunctive norms in determining intention and willingness to change alcohol behaviour. In doing so, this research focusses on experimental analysis of the relationship between injunctive norms, social-DRSE and social anxiety.

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Causality of the expected effects is assured because social anxiety is assessed prior to the manipulation and then both injunctive norms and social-DRSE are manipulated.

Furthermore, this research tests whether this interaction effect is found specifically for anxious students, because students with elevated levels of social anxiety are especially

susceptible to the influence of injunctive norms (Buckner et al., 2011). The hypothesis that guides this experiment is:

H2: Anxious students vs. students with normal anxiety intend and are willing to drink more alcohol when injunctive norms are positive but not when injunctive drinking norms are negative. This effect is less pronounced when social-DRSE is stimulated strongly instead of weakly.

Method

Design

A 2 (injunctive norms: positive vs. negative) by 2 (DRSE: strong vs. weak social-DRSE condition) by 2 (elevated vs. normal social anxiety) between-subjects factorial design experiment was conducted to (see table 1). Participants were randomly assigned to a

normative condition and a social-DRSE condition, while participants were afterwards assigned to an anxious/normal level of social anxiety condition on basis of their anxiety scores, making the design a 2x2x2.

Table 1: Manipulation design

Participants

Participants were Dutch students in the age range of 18 to 25 years old. This range was chosen because students younger than 18 are not allowed to drink alcohol and because most students over 25 are nearly finished with their studies and therefore presumable less involved with the typically student-life-like high alcohol consumption. Only students from higher

Injunctive norms Social-DRSE Positive Negative

Weak Weak, Positive

(2) Weak, Negative (4) Strong Strong, Postive (1) Strong, Negative (3)

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educational levels were included, because for students from higher educational levels

(HBO/WO) heavier drinking patterns were reported than for post-secondary colleges (MBO) or adolescents that do not study (Trimbos Institute, 2015). Furthermore, only students that drink alcohol at least once a month were included. Students were recruited via Facebook, e-mail and personally at the building of the communication science department of the

University of Amsterdam.

In total, three hundred and twenty-five students completed the experiment. Only completely filled out questionnaires that met the criteria for age range, education level, alcohol minimum and norm message processing were used. A group of N = 203 participants remained, with 64% females. Most of them were undergraduates or master’s students (N=157). Fourteen participants read the article in less than 13.7 seconds. Whenever students read 500 or more words per minute, this results in a low- to extremely low understanding of a text (Carver, 1985), therefore these participants were excluded. There were no participants excluded for other reasons.

Materials

Injunctive norms. Injunctive norms were manipulated with a short fictional article of 114 words in both conditions. The article was adopted from a norm manipulation used by Prince and Carey (2010) and further adjusted to fit the current research. Participants were confronted with either a positive (approving) or a negative (disapproving) drinking norm. The source of the article was supposedly ‘De Studentenkrant’. This source was considered

trustworthy source because their objective is solely to inform about students matters on a national level (De Studentenkrant, 2016). The article began with a claim that Dutch students have approved/disapproved of excessive drinking in the past. It continued by stating that recent research from the University of Amsterdam replicated these results and found that the majority of students approved/disapproved of excessive drinking. It concluded with recent research that suggested that Dutch students approved/disapproved of excessive drinking. Social-DRSE. Social-DRSE was manipulated through strong recommendations versus weak effective recommendations to maximize the difference in ability to resist alcohol

between conditions. The manipulation was based on the WDYD web-intervention by Voogt et al. (2013), which stimulated social-DRSE by requiring participants to choose between social drinking situations and read recommendations specified to each chosen drinking situation. A pre-test was done to examine during which drinking situations of the WDYD,

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students found it most difficult to refuse drinks and how helpful they rated the accompanying recommendations per drinking situation. Participants chose 3 drinking situations out of 7 drinking situations and rated the accompanying recommendations on perceived effectiveness to help resist alcohol, on a scale from 1 (totally unhelpful) to 5 (very helpful). The sample consisted of acquainted students (N = 32) aged 18-25 attending higher education (HBO/WO). The 3 most popular drinking situations; being at a festival (chosen 17/32 times), drinking with friends (chosen 17/32 times) and going ‘out’, to a party, nightclub or concert (chosen 29/32 times), were used in the final research.

For all three drinking situations, a pairwise T-test was performed on the most- and least effective recommendation per drinking situation. For an overview of the

recommendations and corresponding scores, see appendix A. For being at a festival, the difference between both recommendations, -2.12, BCa 95% CI [1.21, 3.03], was significant t (16) = 4.95, p < 0.000. Then, for drinking with friends, the difference between both

recommendations, 0.824, BCa 95% CI [0.05, 1.60], was significant t (16) = 2.25, p = 0.039. Lastly, for going out (party/nightclub/concert), the difference between both recommendations, 1.21, BCa 95% CI [0.63, 1.80], was significant t (27) = 4.29, p = 0.000.

Procedure

The research was an online experiment that took about 20 minutes to complete. Participants were told a cover story: regarding introversion/extraversion personality traits and alcohol use. After ethically approving of participating in the study, social anxiety was assessed. The measurement of social anxiety was introduced as an introversion/extraversion test (see appendix B). Then, participants were asked about their age, education level and alcohol consumption. If participants met the research criteria, they were assigned to one of four manipulation conditions. After that, participants were instructed to carefully read the

positive/negative norm article. To ensure careful processing of the norm information, timers were set. To further ensure careful processing, a few questions after reading the text were implemented: 1: How much of this information is new to you? 2: Would you share this

information with friends? Then, the social-DRSE manipulation followed for all three drinking situations. Participants in the weak social-DRSE condition were presented with the least effective recommendation/most effective recommendation per drinking situation and asked to write how they would apply the recommendation specifically. Then the dependent variables were measured. First intention to drink alcohol was assessed for future expected drinking.

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Then, behavioral willingness was assessed for the three drinking situations separately. Next, the norm manipulation was checked by asking participants if they thought Dutch students would approve of excessive alcohol use, on a scale of 1-10. Then, the social-DRSE condition checked how sure participants were they could resist alcohol in all three drinking situations together, on a scale of 1 (Sure I cannot resist alcohol) to 5 (Sure I can resist alcohol). Following this, participants were asked to state what they thought the research was about. Lastly, participants were debriefed. The true intent of the research was explained, and the fictional character of the norm manipulation was disclosed.

Measurements

Scales constructed for analysis with a Cronbach’s α of >.060 were considered adequate for research purposes (Allen & Bennett, 2010)

Social anxiety. Social anxiety is measured using the Social Interaction Anxiety Scale, a scale which showed to possess high levels of internal consistency and test-retest reliability (Mattick & Clarke, 1998). The SIAS assesses fears in general social interaction and

corresponds to the DSM-III-R descriptions of social anxiety (Heimberg, Mueller, Holt, Hope & Liebowitz, 1993). On a scale from 0 (not at all) to 4 (extremely), participants rated how nervous, tense or worried they feel in presented social situations. Examples of questions are: ‘’I find it difficult to disagree with another’s point of view’’ and ‘’I am tense mixing in a group’’ (see appendix B).

With a possible range of 0-80, a total score of 34 or higher indicates elevated social anxiety (Brown, 1997). For all participants, positively framed questions (5, 9, 11) were reversed and scores were added up on all 20 questions. This lead 186 participants to achieve a score of less than 34 and be assigned to the average social anxiety condition, and 17

participants to achieve a score of 34 or more and to be assigned to the anxious condition (=>34). Cronbach’s α for the 20-items was .80 (M = 20.31, SD = 8.60).

Intention to drink alcohol. The intention scale of Stok, de Ridder, de Vet and de Wit (2012) is adjusted for this research: ‘’eat sufficient fruit in the coming period of time’’ was changed to ‘’drink less alcohol in the coming period of time’’. Drinking intentions were measured with four items answered on a 5-point scale (1 = completely disagree, 5 =

completely agree): ‘I want to/intend to/expect to/shall drink less alcohol in the coming period. Cronbach’s α for the 4-items was .94 (M = 2.76, SD = 1.20).

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willingness. Participants were first asked to imagine being at a festival, then with friends and then going out (to a party, festival or nightclub) and answer three questions for each of these situations. For each of these situations, participants rated how willing they are to a) accept the drink, b) say no and refuse c) leave the situation, on a scale from 1 (not at all willing to) to 7 (very much willing to). For each drinking situation separately, scores per question were added up. The scores on the first question were reversed. Cronbach’s α for the 3-items of festival was .64 (M = 11.94, SD = 3.84). Cronbach’s α for the 3-items of festival was .94 (M = 2.76, SD = 1.20). For the 3-items of drinking with friends, Cronbach’s α was .60 (M = 12.02, SD = 14.52). For the 3-items of going out (party/festival/nightclub), Cronbach’s α was .69 (M = 12.13, SD = 4.16). Then, a total mean score of behavioral willingness was made, representing all three drinking situations. The Cronbach’s α was 0.90 (M = 4.01, SD = 1.20).

Results

Randomization check

In this research the variables Age, Level of Education, Gender and Social anxiety score were checked to ensure random distribution across all manipulation conditions. A One-way

ANOVA was performed for Condition (1, 2, 3 and 4) on Age and Level of Education. Lastly, Gender and Elevated level of social anxiety were analyzed with a Chi-Square test because these are factors with two categorical variables of a single population. For all four variables, there were no violations of random distribution found across the conditions. Thus, no covariates were included in the main analysis.

Table 2: Randomization check of variables over manipulation conditions (N = 203) Variables

Age Level of

education

Gender Elevated SIAS level Manipulation condition (1, 2, 3,4) F (3, 199) = .57, p = .635 F (3, 199) = 1.10, p = .352 χ2 (3) = 5.56, p = .135 χ2 (3) = 0.92, p = 0.820 Manipulation checks

Norm perceptions. To investigate whether the injunctive normative message successfully influenced the perception of injunctive norms, a One-Way ANOVA was performed on the injunctive norm perception question with norm condition as factor.

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Bootstrapping is used because Levene’s test was significant (F = 18.78, p < .001) and

therefore homogeneity of variances in the population cannot be assumed. Students who were exposed to the negative, disapproving norm condition indicated excessive drinking as less approved by Dutch students than participants who were exposed to the positive, approving condition. This difference, 1.69, BCa 95% CI [6.40, 6.95], was significant, F (1, 202) = 53,605, p < .000.

DRSE. Then, to investigate whether the social-DRSE manipulation effectively influenced ability to resist alcohol in social situations (social- DRSE), a One-way ANOVA was performed on the question assessing ability to resist alcohol. The ANOVA provided non-significant results F (1, 201) = 0.18, p = .674. This means that participants in the strong DRSE condition did not have a significantly higher score on ability to resist alcohol than participants in the weak DRSE condition, and therefore the DRSE manipulation was presumable not effective in changing participants’ perceived ability to resist alcohol.

Intention to drink alcohol

Hypothesis 1. A factorial between-groups analysis of variance (ANOVA) was

conducted to compare the effect of injunctive norms, social-DRSE and anxiety on intention to drink alcohol in future.

As expected, anxious participants exposed to an injunctive norm message that communicated disapproval regarding excessive drinking showed higher intentions to reduce drinking in the upcoming period, compared to those exposed to an injunctive norm message that communicated approval regarding excessive drinking. A weak interaction effect was found between norm condition and social anxiety on intention to drink alcohol, F (1, 195) = 4.43, p = 0.037, partial η2 = 0.022. This was not the case for participants in with normal levels of anxiety, as there was no main effect of injunctive norm message on intention to drink alcohol, F (1, 195) = 1.02, p = 0.315, partial η2 = 0.01.

Pairwise comparisons reveal a significant difference between anxious participants exposed to a disapproving injunctive norm message and anxious participants exposed to an approving injunctive norm message (see table 3). This difference was not found for

participants with normal anxiety levels in both norm conditions. This means the effect of the norm condition on intention to drink alcohol is particularly strong for anxious students, and not so much for students with normal levels of social anxiety. Therefore, H1 is confirmed for intention to drink alcohol in future. Frankly there was no main effect of anxiety on intention

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to drink alcohol, F (1, 195) = 0.40, p = 0.528, partial η2 < 0.01. Anxiety did not influence the intention to drink alcohol in future.

Hypothesis 2. For the second hypothesis, the expectation was that anxious participants versus participants with normal levels of anxiety would intend to drink more alcohol when their injunctive norms are positive instead of when they are negative, and that this effect is less pronounced when social-DRSE is stimulated strongly instead of weakly.

There was however no interaction between social-DRSE, injunctive norms and anxiety on intention to drink alcohol, F (1, 195) = 1.70, p = 0.193, partial η2 = 0.01. Social-DRSE therefore did not seem to be mitigating the effect of injunctive norms on anxious participants on behavioral willingness items to drink alcohol. This was also not the case for participants with normal levels of anxiety, as there was no interaction between injunctive norms and DRSE condition on intention to drink alcohol F (1, 195) = 0.12, p = 0.735, partial η2 = 0.01. Therefore, H2 is rejected.

Furthermore, social-DRSE did not interact with anxiety to reduce intention to drink alcohol, F (1, 195) = 1.69, p = 0.195, partial η2 = 0.01. Social-DRSE did not reduce the intention to drink alcohol in future for anxious participants. However, this was also not the case for students with normal levels of anxiety, as there was no main effect of social-DRSE on intention to drink alcohol in future for students with normal levels of anxiety, F (1,195) = 1.97, p = 0.162, partial η2 = 0.01.

Table 3: Means (SD’s) for all conditions (Injunctive norms, social-DRSE, Anxiety) on intention to

drink alcohol Intention Norm DRSE Non-Anxious M (SD) Anxious M (SD) Anxiety total M (SD) Norm Strong Strong 2.42 (1.34) 2.88 (1.65) 2.46 (1.36) Weak 2.75 (1.18) 3.20 (1.15) 2.80 (1.18) Total 2.58 (1.27) 3.06 (1.31) 2.62 (1.28) Norm Weak Strong 3.06 (1.23) 1.42 (0.72) 2.96 (1.17) Weak 2.79 (1.06) 2.75 (1.32) 2.79 (1.07) Total 2.92 (1.10) 2.25 (1.27) 2.87 (1.12) Norm total Strong 2.75 (1.28) 2.25 (1.46) 2.72 (1.28) Weak 2.77 (1.11) 2.98 (1.19) 2.79 (1.12)

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Behavioral willingness to drink alcohol

A MANOVA was conducted to test the effect of the independent variables injunctive norms, social-DRSE and anxiety on the dependent variables behavioral willingness to drink alcohol on a festival, with friends, and while going out (party/festival/concert) and on the total mean score of these three items, called behavioral willingness overall.

The Shapiro-Wilk test of univariate normality for the dependent variable behavioral willingness on a festival was significant, W (186) = 0.98, p = 0.016. It was also significant for behavioral willingness with friends, W (186) = 0.98, p = 0.008. Lastly, it was significant for behavioral willingness while going out, W (186) = 0.98, p = 0.020. A boxplot of the normality distribution indicated only a small deviation. Moreover, the MANOVA can perform analysis with this deviation, if the group sizes exceed 30 (Allen & Bennett, 2010). Then, correlations between the dependent variables were not too high, which indicates that multicollinearity was not of concern. This means the independent variables in the analysis were not too closely related to provide erroneous results.

The result of the MANOVA was that all multivariate effects were insignificant, see description below. Furthermore, all the corresponding univariate effects for the main effects and interaction effects were non-significant for all behavioral willingness items.

Hypothesis 1. Unexpectedly, anxious participants exposed to an injunctive norm message that communicated disapproval regarding excessive drinking did not show more behavioural

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willingness to reduce drinking in future, compared to those exposed to an injunctive norm message that communicated approval regarding excessive drinking. There was no multivariate interaction effect of anxiety and injunctive norm message on behavioural willingness items, F (3,193) = 0.17, p = 0.919, partial η2 < 0.01. For participants with normal levels of anxiety, injunctive norm messages did also not alter their behavioural willingness to drink alcohol, F (3, 193) = 0.14, p = 0.940, partial η2 < 0.01. Furthermore, social anxiety did not have a main effect on behavioral willingness items, F (3, 193) = 0.65, p = 0.585, partial η2 = 0.01.

Hypothesis 2. For the second hypothesis, the expectation was that anxious participants versus participants with normal levels of anxiety would be willing to drink more alcohol when their injunctive norms are positive instead of when they are negative, and that this effect is less pronounced when social-DRSE is stimulated strongly instead of weakly.

There was however no multivariate interaction effect between social-DRSE, injunctive norms and anxiety on willingness to drink alcohol items, F (3, 193) = 0.55, p = 0.651, partial η2

= 0.01. Social-DRSE therefore did not seem to be mitigating the effect of injunctive norms for anxious participants on behavioral willingness items to drink alcohol. This was also not the case for participants with normal levels of social anxiety, as norm message and DRSE stimulation did not have a significant combined effect on willingness to drink alcohol, F (3, 193) = 0.15, p = 0.928, η2 =.00. Therefore, H2 is rejected.

Furthermore, social-DRSE did not interact with social anxiety on behavioral

willingness to drink alcohol items, F (3,193) = 2.34, p = 0.075, partial η2 = 0.04. This suggests social-DRSE did not reduce the behavioral willingness to drink alcohol for anxious

participants. However, this was also not the case for students with normal levels of social anxiety, as there was no main effect of social-DRSE on behavioral willingness to drink alcohol for students with average levels of social anxiety, F (3, 193) = 1,76, p = 0.157, partial η2

= 0.03.

Table 4: Means (SD’s) for all conditions (Injunctive norms, social-DRSE, Anxiety) on Behavioral Willingness to

drink alcohol DRSE Non-Anxious M (SD) Anxious M (SD) Anxiety total M (SD)

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Behavioural willingness Festival

Norm Positive Strong 3.96 (1.31) 3.33 (1.09) 3.91 (1.29)

Weak 4.13 (1.33) 4.27 (1.32) 4.14 (1.31) Total 4.04 (1.31) 3.85 (1.25) 4.02 (1.30) Negative Strong 3.92 (1.23) 3.56 (1.07) 3.90 (1.22) Weak 3.92 (1.23) 4.53 (2.09) 3.98 (1.32) Total 3.92 (1.23) 4.17 (1.75) 3.94 (1.26) Total Strong 3.94 (1.26) 3.43 (0.99) 3.91 (1.25) Weak 4.01 (1.72) 4.40 (1.65) 4.05 (1.31) Total 3.98 (1.26) 4.00 (1.47) 3.98 (1.28) Behavioural willingness Friends

Norm Positive Strong 3.88 (1.27) 3.42 (1.34) 3.84 (1.27)

Weak 4.21 (1.36) 4.47 (1.35) 3.84 (1.27) Total 4.04 (1.32) 4.00 (1.37) 4.04 (1.32) Negative Strong 3.82 (1.28) 4.00 (0.33) 3.83 (1.25) Weak 4.09 (1.16) 4.60 (1.75) 4.13 (1.21) Total 3.95 (1.22) 4.38 (1.37) 3.98 (1.23) Total Strong 3.85 (1.27) 3.67 (1.02) 3.84 (1.25) Weak 4.14 (1.25) 4.53 (1.48) 4.18 (1.27) Total 3.99 (1.27) 4.18 (1.34) 4.01 (1.27) Behavioural willingness Going Out

Norm Positive Strong 3.92 (1.42) 3.83 (1.67) 3.91 (1.42)

Weak 4.19 (1.44) 4.33 (1.51) 4.20 (1.43) Total 4.05 (1.43) 4.11 (1.50) 4.05 (1.43) Negative Strong 3.79 (1.28) 4.67 (0.88) 3.84 (1.27) Weak 4.21 (1.36) 4.33 (2.07) 4.22 (1.42) Total 4.00 (1.33) 4.46 (1.64) 4.04 (1.35) Total Strong 3.85 (1.34) 4.19 (1.36) 3.88 (1.34) Weak 4.20 (1.39) 4.33 (1.71) 4.21 (1.42) DRSE Non-Anxious M (SD) Anxious M (SD) Anxiety total M (SD)

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Discussion

In this research, anxious students more strongly intended, but were not willing to, reduce their drinking behavior in future than students with normal levels of social anxiety. This confirms earlier research which considers the impact of injunctive norms on alcohol behaviour to be especially influential for anxious students (Buckner et al., 2011; Zehe et al., 2011; Neighbors et al., 2007; Linden, Lau-Barraco & Braitman, 2012).

The results also find proof that a distal reference norm group, namely a typical Dutch student, can be used to alter injunctive norm perceptions. This result contradicts earlier findings that only proximal groups like friends or family are influential for alteration of injunctive norm perceptions (Neigbors et al., 2008; Lewis & Neigbors, 2006). The

communicated injunctive norm however fictively originated from a credible source. Thus this confirms that distal reference groups are influential in changing injunctive norm perceptions as long as they originate from a credible source (Hummer & Davison, 2006).

Furthermore, research of Ham (2003) suggested that anxiety only serves as a risk factor for problem drinking when social anxiety has reached severe clinical levels, while high

Total 4.02 (1.37) 4.27 (1.53) 4.04 (1.93) Behavioural

willingness Total

Norm Positive Strong 3.92 (1.23) 3.53 (1.17) 3.89 (1.22)

Weak 4.18 (1.30) 1.36 (1.29) 4.20 (1.28) Total 4.04 (1.26) 3.99 (1.24) 4.04 (1.25) Negative Strong 3.84 (1.11) 4.07 (0.23) 3.86 (1.08) Weak 4.07 (1.16) 4.49 (1.91) 4.11 (1.22) Total 3.96 (1.14) 4.33 (1.45) 3.99 (1.16) Total Strong 3.98 (1.16) 3.76 (0.89) 3.87 (1.14) Weak 4.12 (1.22) 4.42 (1.54) 4.15 (1.25) Total 3.40 (1.19) 4.15 (1.32) 4.01 (1.20)

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subclinical levels of anxiety can protect students from excessive drinking because of concerns of negative evaluation by peers. This research does not support this finding and indicates that also for students with subclinical levels of social anxiety (SIAS score 34-43, see method section) injunctive norms are influential in determining intention to use alcohol.

Then, injunctive norms were only effective for anxious students on intention to drink alcohol, and not on behavioral willingness to drink alcohol. According to Gibbons (1998), behavioral willingness is characterized by denying the relation between the risk behavior and personal consequences, because the point of reference is a proposed situation. Those who are intending to engage in risky behavior acknowledge their personal risk more, and those who are willing to behave in a certain way are more likely to deny the relation between the risk behavior and personal consequences. This is attributable to how both concepts are measured. For intention scales the individual is the point of reference (I intend to, I shall, etc.), while for behavioral willingness the proposed situation is the point of reference. It is plausible that the norm perception was unsuccessful in altering willingness to drink alcohol, because students disregard their personal agency to avoid the risk. They behave in this manner, because the proposed situation makes them unaware of their responsibility to avoid this risk. This could account for the lack of effects found for behavioral willingness relative to intention to drink alcohol.

Then, the second hypothesis was rejected because (anxious) students were not less influenced by the positive or negative norm perception in their intention and willingness to drink alcohol when their social-DRSE was stimulated strongly instead of weakly. The non-significant results of the social-DRSE manipulation check indicate the social-DRSE

manipulation was unsuccessful and that this was the reason why there was no effect of social-DRSE, injunctive norms and anxiety on intention and behavioral willingness to drink alcohol. The current research disconfirms the expectation of correlational research of Kenny et al. (2014) that social-DRSE is influential in predicting alcohol outcomes for anxious students. Also, earlier correlational research was disconfirmed in their expectation of a combined effect of social-DRSE, injunctive norms and social anxiety on intention and willingness to drink alcohol (Burke & Stephens, 1999; Tran et al., 2004). The validity of this result is, however, questionable because the social-DRSE manipulation was presumable unsuccessful. Reasons for this are discussed.

Firstly, the difference between the social-DRSE strong and weak conditions was not large enough. Even though the recommendations did significantly differ in their perceived

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effectiveness, their effectiveness was tested on a relatively small sample of students. This makes it unclear whether these differences are substantial. Second, the recommendations of the ‘What do you drink’ intervention resulted from conversations with experts. Their

effectiveness has not been empirically tested, before they were implemented in the ‘What do you drink’ intervention. Also, the successful results of the strengthening effect of social-DRSE found in that intervention (Voogt et al., 2014), resulted from the entire intervention. This included also the correcting of descriptive norm perceptions and providing participants with personal feedback regarding their alcohol behavior. This is a more rigorous manipulation of social-DRSE, than the personal application of given recommendations required for the social-DRSE manipulation in the current research. The current method was quite simple and thus participants overestimated and misunderstood the task at hand. This could have created resistance, which could account for the lack of effectiveness of social-DRSE.

Limitation and recommendations

An important general limitation of the research was that the main analysis comprised a small sample (17 out of 203 individuals). Thus, only 8 people were compared, for the effect for anxiety and injunctive norms. Future research should investigate social-DRSE in a bigger sample of anxious students. If the overall student sample increases and social anxiety is measured with the same cut-off point, like in the research of Buckner et al. (2011), this will result in a bigger sample of students with elevated social anxiety. Also, a more pure effect can be established if future research would manipulate anxiety, or include more extensive scales of measuring social anxiety. The SIAS is after all, a narrow indication of social anxiety.

Lastly, a limitation of this research is that the dependent variables measure intention and willingness, instead of actual alcohol behavior. To obtain conclusive results, future research should gather follow-up results and investigate whether the social-DRSE has an actual influence on drinking behaviour.

Future research should find novel and effective ways to manipulate social-DRSE. To successfully manipulate social-DRSE, it might be important to create a more extensive task, like in the ‘What do you drink’ intervention. However, the task should not be too extensive, because resistance might result from a task too complex and this might deteriorate the effects of the manipulation. This current research suggests that it is important that participants do not resist the manipulation task, because this probably leads to less influence on their

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social-DRSE. A more challenging and interactive task, like in the intervention of Voogt et al. (2013), could therefore be more effective.

Conclusion

Injunctive norms perceptions regarding approval or disapproval of heavy drinking altered the intention to drink alcohol for anxious students. However, the effect of injunctive norms on behavioral willingness items was not found. Social-DRSE did not seem to mitigate the influence of injunctive norms on intention and behavioral willingness to drink alcohol for anxious students. The absence of this effect is probably attributable to an unsuccessful

manipulation of social-DRSE. Anxious students, however, benefit from alcohol use in dealing with their social anxiety symptoms (Zehe et al., 2013, Buckner et al., 2011). It is therefore questionable whether anxious students want to improve their drinking refusal self-efficacy. Morever, Voogt et al. (2014) found that social-DRSE could be increased with a short intervention, but it is unclear whether increased social-DRSE actually lead to decreased alcohol consumption. However, influencing injunctive norm perceptions was possible for anxious students in their intention and willingness to drink alcohol, underscoring the need to change injunctive norms for this group. Therefore, more extensive research of social-DRSE and injunctive norms in a bigger sample of anxious students and measurement of actual alcohol behavior is needed.

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