CLUSTER PROFILES OF THE DRINKING MOTIVES IN A SAMPLE OF FIREFIGHTERS AND EMTS

Despite the extensive literature that exists on alcohol use, misuse, and drinking to cope, a drinking culture remains prevalent in occupations that experience high volumes of induced occupational stress and exposure to trauma. To our knowledge, patterns of alcohol use motives have never been characterized in a firefighter/emergency medical technician (FF/EMT) sample, nor have they been evaluated in the context of other relevant factors. The current study investigated the Drinking Motives Questionnairerevised (DMQ-r) within a sample of FF/EMT who reported that they currently drink alcohol (N=183). This study sought to confirm the factor structure of the DMQ-r, identify empirically derived drinking motive cluster subtypes from the DMQ-r subscales, and examine differences among the resulting clusters. Analyses confirmed the original factor structure of the DMQ-r and revealed four clusters among the DMQ-r subscales. These clusters were labeled 1) Low Motives, 2) Average/Below Average Motives, 3) High Enhancement/Social Reinforcement; Low Coping/Conformity, and 4) High Motives; Highest Coping/Conformity. Clusters differed significantly on years of service, impulsivity and sensation seeking, tension reduction, social lubrication, and alcohol use, with the differences mainly being found between the Low Motives Cluster (Cluster 1) and High Motives Clusters (Clusters 3 & 4). Lower motivation for alcohol use, as demonstrated by the Low Motive Cluster, also indicated lower levels of alcohol consumption rates, whereas our highest motivational drinking patterns, as seen in both Cluster 3 and Cluster 4, indicated a level of high-risk alcohol consumption behavior. Results of a MANOVA on psychosocial variables aided the understanding of the drinking patterns by cluster. For example, lower scores on both tension reduction and social lubrication were identified within the Low Motives cluster. Overall, this study provides an exploratory foundation for future research on these specific motive subtypes. These subtypes will enable researchers to develop tailored interventions that can help firefighters and EMTs with the underlying reasons they drink and move away from the more generalized approach to intervention assuming all firefighters and EMTs are drinking for the same reasons.


LIST OF TABLES
and CBS News ranked firefighting as the second most stressful job in the United States (Renzulli, 2019;Min, 2019). On a daily basis, the men and women of the fire service are exposed to a variety of stressors, including but not limited to, life threatening situations, structure and vehicle fires, hazardous materials incidents, large scale disasters, loss of human life, and injuries or death to children. With this exposure to continuous, and at times, significant traumatic stress, firefighters and emergency medical technicians (FFs/ EMTs) face a variety of behavioral health risks and/or conditions, including but not limited to, alcohol use and misuse. Research has shown a clear link between stress and alcohol use and misuse within a FF/EMT population (Bing-Canar et al., 2019, Smith et al., 2019, Tomaka et al., 2017, with one specific motivation for consuming alcohol is drinking to cope (Bacharach et al., 2008).
Since the 1990s, research expanded to understand an individual's motivations to consume alcohol (Cooper, 1994) with several explanations underlying an individual's motivation to consume alcohol; however, little to no known research has examined the relationship between the drinking motives within a FF/EMT population beyond drinking to cope. With such a large number of FFs/EMTs drinking alcohol in an unhealthy and often risky way, it is important to better understand the specific pattern and relationship between the motives that underlie drinking in this occupation. While some work has been done on the drinking motives themselves (Hasking et al., 2011;Hawn et al., 2018), no known work has been done to determine if this large group of drinkers in the FF/EMT occupation can be better understood by examining patterns within their motives to drink.

Alcohol Use among FFs/EMTs
Numerous studies have examined the impact of various behavioral health risks and/or conditions existing within a population of FFs/EMTs (Bacharach et al., 2008;Gallyer et al., 2018;Haddock et al., 2012;Smith et al., 2019). Furthermore, it is widely known that this high-risk population is at an increased risk for developing both physical (i.e., cancer, lung disease, heart failure) and behavioral health outcomes (i.e., depression, PTSD, Substance Abuse Disorders). One particular issue, problematic alcohol use, has been identified as a reoccurring theme within a FF/EMT population throughout the late 1990s and presently into the twenty-first century (Bacharach et al., 2008;Boxer & Wild, 1995). Next, is a brief review of past research concerning alcohol use amongst FFs/ EMTs.
In a large national study of career firefighters, Haddock et al. (2015) found that more that 85% of firefighters consume alcohol, nearly half drink to excess (i.e., three or more drinks per day on average), and approximately one-third reported periodic heavy drinking when off duty (i.e., five or more drinks on an occasion). These results are consistent with previous research suggesting that first responders represent a particularly vulnerable population with regard to alcohol misuse and alcohol use disorder (AUD; Bartlett et al., 2019;Carey et al., 2011;Haddock et al., 2012;North et al., 2002;Piazza-Gardner et al., 2014), including alcohol abuse and dependence as defined by the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (Smith et al., 2019). Lifetime AUD prevalence rates of 47% have been documented among firefighters , in comparison to 29.1% reported for the general population (Grant et al., 2015).
In 2011, Carey et al. sampled 112 firefighters to assess for sleep problems, depression, and substance use. Although their study was limited by a small sample size, they found problematic drinking behavior existed in their sample as well (i.e., 58% reported binge drinking behavior; 14% reported hazardous drinking behavior, and 80% used alcohol with an average of > 10 drinks/wk). Although high-risk health behaviors that impact psychosomatic well-being were confirmed to exist in the firefighting profession, Carey et al. (2011) admitted there was still a need to explore further the intercorrelation relationships between these behaviors.
Although there is sufficient data indicating a problem of alcohol use within the fire service, the question still remains as to why. Presently, the examination of first responder behavioral health continues to be a source of discussion within the realm of substance abuse, in particular, alcohol use disorders . AUDs stemming from frequent exposure to traumatic events continues to be examined and results replicated by researchers around the globe. When addressing exposure to traumatic events and its resulting affect, one of the most relevant topics and source of information pertaining to a firefighter population is the phenomena of occupational stress. A brief overview of occupational stress followed by its effect on a firefighters' drinking to cope is necessary to understand the connection between stress and alcohol use.

Stress and Alcohol Use
Occupational stress, or sometimes referred to as job-related stress, can be defined as a situation wherein job-related factors interact with the worker to change his or her psychological and/or physiological condition such that the person is forced to deviate from normal functioning (Singh et al., 2019). Occupational or work-related stress constitutes one of the most prevalent work-related health problems in Europe and around the world (Brookes et al., 2013). Occupational stress is known to contribute to a range of psychological, behavioral, and physical health problems ; it is perhaps not surprising then, that firefighters have been shown to be at an increased risk for substance use disorders, depression, posttraumatic stress disorder (PTSD), and occupational burnout (Beaton & Murphy, 1993;Corneil et al., 1999). It is understood that firefighters face a significant amount of occupational stress. These men and women provide many essential public services, including responding to fires, medical emergencies, traffic accidents, and natural disasters. Attributable to the unique nature of their occupation, firefighters often report elevated levels of occupational stress (Beaton & Murphy, 1993;Corneil et al., 1999;Murphy et al., 1999). For example, firefighters must cope with exposure to potentially traumatic events (e.g., recovering dead bodies, suicides, & deaths including children) on a regular basis (Beaton et al., 1996;Corneil et al., 1999;Murphy et al., 1999), and they are required to perform many physically and psychologically demanding tasks in dangerous and high-pressure situations such as suppressing fires, entering burning buildings to rescue trapped victims, and providing medical aid to seriously injured victims (Kimbrel et al., 2011). Research has offered a number of physiological explanations for the linkages between incident exposure, subsequent negative affect, and problematic drinking behaviors as an attempt to cope with stress and trauma (Bacharach et al., 2008).
The rates of alcohol use above have been linked, but not limited to, drinking to cope with the stress/distress of the occupation and it is important to note that several major theories view stress as a precipitant of Substance Use Disorders (SUDs; Lin et al., 2020). For example, the stress-coping model (Wills & Shiffman, 1985), tension-reduction model (Conger, 1956), and the self-medication model (Khantzian, 1987), all high-lighted the use of substance as a maladaptive coping strategy in response to stress (Lin et al., 2020).
Although the topic is far too extensive to elaborate on, understanding the biology of the stress response behind an individual's response to consume alcohol also should be briefly mentioned. The "fight or flight" response, first described by Walter Cannon in 1932, describes the physiological reaction in a human as a response to a perceived harmful event, attack, or threat to their survival. There is no denying that first responders face this "response" daily in their occupations. Accompanied by this exposure to uncontrollable stress is fear. Fear prompts the release of corticotropin-releasing hormone (CRH), which in turn stimulates the release of proopiomelanocortin (POMC), a large molecule that is broken up into several parts including adrenocorticotropic hormone (ACTH), which is responsible for the familiar "fight or flight" response. Furthermore, beta-endorphin, which may have the survival advantage of numbing pain in the organism, is attacked (Volpicelli et al., 1999). In order to condense and simplify, research has proposed that the link between incident exposure and drinking may be endorphin related (Volpicelli et al., 1999). Endorphins are neurochemicals which act on the opiate receptors in our brain and are responsible for reducing pain and boosting pleasure (Cafasso, 2017).
Previous findings from such studies, such as Volpicelli and colleagues (1999), suggest that individuals who experience a traumatic event often experience a biochemical response of an endorphin release, which helps to numb the physical and emotional pain of the trauma (Bacharach et al., 2008). However, in order to replace the endorphin-based numbing effect after it has subsided, some individuals may turn to alcohol to cope with the ongoing stress and trauma. Therefore, people who either experience several traumatic events (e.g., first responders) or continually re-experience the same event (e.g., individuals diagnosed with PTSD), will drink to reproduce the numbing effects experienced with increased levels of endorphins (Volpicelli et al., 1999). Epidemiological evidence suggests that the job-related stressors impacting fire service personnel creates a heavy toll on their health, particularly in terms of an elevated occupational prevalence of PTSD, and many other adverse health outcomes (Beaton et al., 1996). There continues to be widespread agreement that certain coping responses are generally adaptive or protective, while others, such as an over-reliance on alcohol, are maladaptive , especially pertaining to traumatic experiences produced from high-risk occupations.
In 1985, the National Institute for Occupational Safety and Health (NIOSH) initiated a study of occupational stress among first responders at the request of the International Association of Fire Fighters (IAFF) (Boxer & Wild, 1993). In the years to follow, Boxer and Wild would end up sampling 145 first responders from the Cincinnati Fire Department in order to enumerate potential occupational stressors, assess psychological distress and problems with alcohol use, and determine whether a relationship existed between those variables and self-reported stressors. Their work can be considered ground-breaking in the topic of alcohol use and abuse within the fire service, in particular, their attempt at linking the role of stress (i.e., psychological distress) to alcohol abuse. Their results suggested that participants frequently experienced psychological distress (>33%), struggled with depression (33% at least mild depression), and suffered from possible or probable alcohol abuse (29%).

Alcohol Use as a Coping Mechanism
Although an important revelation was brought to the surface, Boxer and Wild's (1993) message of alcohol abuse seemed to dissipate until approximately fifteen years later when evidence supporting a mediating role of psychological distress in the traumaproblem drinking relationship had been continued in part by work done by Bacharach et al. (2018). Some research within high-stress occupations continued throughout the 1990s, such as the work of Kessler et al. (1995) and Bremner et al. (1996)  Despite clear theoretical linkages between firefighting, posttraumatic stress symptoms (PTSS), alcohol misuse, and maladaptive coping strategies, there continues to be gaps within the literature. Joe Tomaka and his colleagues (2017) attempted to rectify some of these omissions in our understanding of PTSS, alcohol misuse, and coping. In the end, they expressed their concern for necessary periodic screening for PTSS and atrisk drinking among employees within these high-risk and trauma exposed professions. Houston firefighters who endorsed exposure to potentially traumatic events and lifetime alcohol use in an attempt to explain the role impulsivity may have on a first responder's PTSS severity and alcohol consumption. Bartlett et al. (2019) hypothesized that firefighters with higher levels of PTSD symptomatology, who reported heightened impulsivity, would manifest the highest levels of alcohol use severity. Their results confirmed their hypothesis and was the first study to provide a focused examination on impulsivity and its association between PTSD symptomatology and alcohol use among first responders.

Motives to Drink
As illustrated above, much research has shown the link between alcohol use, stress, and coping but it is important to understand that other drinking motives exist as well. Drinking motives have been identified as an important component in understanding why individuals choose to use alcohol (Martens, 2008). Cooper, Frone, Russell, and Mudar (1995) found that the desire to control negative affective states through drinking is a significant motive for alcohol use. This is consistent with literature demonstrating that, although there are other common drinking motives such as enhancement and social motives, drinking to cope is related to more drinking problems (Catanzaro & Laurent, 2004;Cooper et al., 1995;Grant et al., 2007;Hasking et al., 2011;McNally et al., 2003).
Extant empirical work suggests that firefighters may resort to drinking in order to cope with job-related stress (Bacharach et al., 2008) and as mentioned previously, studies conducted on firefighters have found that alcohol use was one of the most frequently reported coping strategies for managing work-related stress . A brief review of the most common assessment of motivational drinking as established by Cooper and her colleagues (1995) is discussed next.
In 1995, Cooper et al. developed a motivational model of alcohol use in which people were hypothesized to consume alcohol to regulate both positive and negative emotion. In theory, individuals drink alcohol to control or impact the quality of their emotional mental condition. Specifically, individuals may use alcohol to either reduce negative affect when they are anxious or over-aroused, or to enhance positive affect when they are fatigued, under-aroused, or desire to enhance social occasions or interpersonal cohesion (Wills & Shiffman, 1985). In addition, Read et al. (2003) expanded this model to include social factors for alcohol consumption. In their research, they found that social reinforcement motives, combined with both enhancement and coping motives, played a role in the connection between social influence factors and alcohol use.
One of the most routinely used measures to examine drinking motives is the Drinking Motives Measure (DMM: Cooper, 1994;Cooper et al., 1992). The DMM was originally developed as a three-subscale measure that assessed social, enhancement, and coping motives for alcohol use. In a follow-up study, Cooper (1994) developed items to assess a second, negatively impacting reinforcing motive, conformity, because she believed that a desire to fit in with one's peers would be a strong motivating factor to choose alcohol among adolescents. The end result was The Drinking Motives Questionnaire-revised (DMQ-r; Cooper, 1994) which took into account all four motivations for drinking.
Enhancement Motives. Enhancement motives involve the strategic use of alcohol to increase positive affective states or emotional experiences. Drinking to enhance is therefore conceptualized as an appetitive process and as a behavior emitted to achieve a desired state or outcome rather than avoid or minimize an aversive one (Cooper et al., 1995). In previous literature, salient predictors of enhancement motives were social lubrication outcome expectancies and impulsivity-sensation seeking measures. As performed in prior research, these constructs were also utilized in our study as variables to enhance our understanding of drinking motives. Impulsivity, which is defined as a general tendency to act without planning ahead and to seek out immediate gratification, has been thought to be related to all types of drinking motivations (Mackinnon et al., 2014), whereas sensation seeking represents the need for intense, novel, and exciting experiences (Zuckerman, 1994).
Coping Motives. Coping motives for alcohol consumption, or more commonly referred to as drinking to cope motivation, are presumed to operate on the principal of negative reinforcement and involve drinking to make one's negative feelings more tolerable (Cooper et al., 1992;Read et al., 2003). Notable predictors of drinking to cope motivation are negative affect and tension-reduction alcohol expectancies. Research has linked both negative affect (Cooper, 1994;Cooper et al., 1995, Read et al., 2003 and tension-reduction alcohol expectancies (Conger, 1956;Kushner et al., 1994) to alcohol use and misuse and can be considered important predictors of drinking to cope motivations; therefore, these variables were also utilized in this study.
Tension-reduction alcohol expectancies appeared to be more applicable to our study as opposed to negative affect. Tension-reduction theory (Conger, 1956) has been put forward as a model explaining alcohol use, which suggests that 1.) alcohol reduces tension states such as anxiety and 2.) alcohol is sought and consumed for its tension-reducing properties (Kushner et al., 1994). Furthermore, tension-reduction alcohol expectancies have been demonstrated to be associated with problem drinking and individuals who possess these expectancies will be motivated to drink at times when they experience negative mood states (Kushner et al., 1994;Read et al., 2003). Also, research conducted on specific populations, such as FFs/EMTs, has linked stress, specifically occupational stress, with drinking to cope motivations for alcohol use Murphy et al., 1999).

Social Reinforcement Motives. Social reinforcement motives involve drinking
alcohol for social purposes, such as to enhance the enjoyment of a social occasion, to facilitate social interaction, or to partake in a shared social activity (Cooper, 1994).
Although no study, to our knowledge, has examined social reinforcement motives among FFs/EMTs, these motives are believed to play a central role in alcohol consumption amongst this population. In the world of the fire service, firefighting is an occupation with characteristics such as close quarter living and/or camaraderie. For instance, firefighters spend many hours in their assigned stations and during these hours they perform activities together such as cooking for an evening meal or exercising with each other. Spending many hours together creates a social bond between many of the members. This bond is commonly known within the fire service as "brotherhood." Traditionally, brotherhood signifies what one is willing to do for their brother (i.e., FF/ EMT colleague). It is a solemn oath to face danger and fear and possibly give one's life, if necessary, for their brother. It is not a matter of receiving, but a matter of giving. It is not a matter of avoiding personal accountability, rather a matter of accepting responsibility (Crosby, 2007). Many firefighters continue this social bonding after their shift has ended; and given the fact that the concept of brotherhood is deeply rooted in the common experience of individuals within the fire service, research examining social reinforcement motives and other social influence correlates in this population constitutes an important focus. It is possible that due to this social bond, one's drinking behavior may be affected by their social or peer influences.
As used by Read et al. (2003), a notable variable linked with social reinforcement drinking motives was alcohol offers (AO). AO, as defined here, is simply a measure of direct and explicit offers to use alcohol such as being offered a drink (Read et al., 2003).
Conformity Motives. Conformity motives, which are defined as external/negative drinking motives, were originally described as drinking in response to social pressures (Cooper, 1994). Conformity motives have had inconsistent results with weak predictive power of alcohol use. However, drinking to conform is primarily responsive to external social pressures to drink (Cooper, 1994) and had appeared to be applicable to a fire service population. In our study, we attempted to design a new measure to understand conformity motives in a firefighter population by make use of the previously mentioned historical construct of "brotherhood." A silent/unexpressed goal was also to create a new and measurable variable which could be utilized for future research. Derived from the research of McMillan and Chavis (1986), we created a new measure of sense of community, which we called "sense of brotherhood." Taking into account the inconsistent results in prior literature pertaining to conformity motives, we attempted to accurately explain and enhance our perception of conformity drinking motives in a FF/EMT population with our newly constructed "brotherhood" variable. A brief description of the sense of community variable and its transition into our "brotherhood" variable is explained next.
Sense of community (SOC), often referred to as psychological sense of community, has been predominantly associated with the McMillan and Chavis (1986) model. Alternative conceptions and measures notwithstanding, the Sense of Community Index (SCI) or some adaptation of it, has been utilized by much of the empirical work used to measure SOC (Peterson et al., 2008). The SCI was intended to be an assessment of four dimensions of SOC as articulated in McMillan and Chavis' (1986) model. In

2008, Peterson et al. shortened the scale to eight items which contained a more
condensed, yet still reliable measurement of these four dimensions of one's sense of community. These dimensions include 1.) needs fulfillment (i.e., a perception that members' needs will be met by the community), 2.) group membership (i.e., a feeling of belonging or a sense of interpersonal relatedness), 3.) influence (i.e., a sense that one matters, or can make a difference, in a community and that the community matters to its members), and 4.) emotional connection (i.e., a feeling of attachment or bonding rooted in a members' shared history, place or experience; Peterson et al., 2008).
In our particular study, the wording for each item was slightly changed to address the population of interest. For example, an original item would say, "I feel connected to this neighborhood." The wording for our study said, "I feel connected to this firefighters. Brotherhood, now a measurable variable within a first responder population, could be an important future construct of usable value within the fire service.
Furthermore, it is believed, that a measurement of brotherhood could enhance the understanding of drinking within the firefighter population in our study.
The present study begins to fill this gap in the literature by utilizing a FF/EMT sample to address these three study aims: (1)

Participants
Participants were firefighters/EMTs (FF/EMTs) selected from a career fire department located in the northeastern United States. As a part of a cross-sectional study of alcohol use, 225 FFs/EMTs, were recruited in the spring of 2016. Participants with a significant amount of missing data (n =20) were removed from the sample, leaving N=205. Lastly, since the current study examined alcohol use motives, only participants who indicated any quantity of drinking consumption were retained in the sample. After removing non-drinkers (n=22) from the data, the remaining sample size was N=183.

Measures
The measures that were used in the analyses described below were employed in a three-step procedure. Below is the description of all variables collected for this study.
The full survey can be found in Appendix A.

Demographics
Age, gender, ethnicity, and length of time on the fire department (years of service) were collected via single item measures.

Relationship Status
Relationship status was measured by a single item measure which asked for participants to identify their relationship status with eight distinct options. The following items were the options available to identify with: 1.) married, 2.), widowed, 3.) divorced and now single, 4.) divorced and in a new relationship, 5.) separated, 6.) in a domestic partnership or civil union, 7.) single, but cohabiting with a significant other, and 8.) single, never married. With the intention to dichotomize relationship status into a more condensed and measurable item, the original relationship status variable was separated into categories of "single" or "in a relationship."
Impulsivity/Sensation Seeking. Impulsivity, which is defined as a general tendency to act without planning ahead and to seek out immediate gratification, has been thought to be related to all types of drinking motivations (Mackinnon et al., 2014). Impulsivitysensation seeking was measured by a 19-item personality trait measure, assessed with a true-false format by the Impulsivity/Sensation Seeking Scale (ImpSS; Zuckerman, 1994).
Items include "I usually think about what I am going to do before doing it" and "I like to have new and exciting experiences and sensations even if they are a little frightening." Sensation seeking represents the need for intense, novel, and exciting experiences (Zuckerman, 1994). Both constructs, impulsivity and sensation seeking, have often been conceptually linked and associated with increased alcohol use (cf. Mackinnon et al., 2014) and were considered relevant in a firefighter population. Coefficient alpha was 0.81 in a college sample from previous research (Read et al., 2003). In this study, however, when calculated as a complete scale for this sample, coefficient alpha was 0.667, indicating less, yet acceptable internal consistency. Furthermore, if considering both constructs, impulsivity and sensation seeking separately as subscales, internal consistency drastically declines for both impulsivity (α=0.38) and sensation seeking (α=0.522). Therefore, the full scale was utilized for this present study and items from each respective scale were summed for use in the analyses.
Social Lubrication. Social lubrication expectancies are beliefs that alcohol use will enhance social situations and make them more enjoyable (Read et al. 2003). Social lubrication is an 8-item scale devised by Sher, Walitzer, Wood, and Brent (1991). Items include "Drinking makes any celebration more enjoyable" and "Drinking makes me feel cool." Response options range from 0 (not at all) to 4 (a lot). The five items representing social lubrication were summed and the average of the items was used in the analyses.
Coefficient alpha for this variable in this sample was (α=0.881).
Tension-Reduction. As mentioned previously, tension-reduction theory (Conger, 1956) has been put forward as a model explaining alcohol use, which suggests that 1.) alcohol reduces tension states such as anxiety and 2.) alcohol is sought and consumed for its tension-reducing properties (Kushner et al., 1994). Furthermore, tension-reduction alcohol expectancies have been demonstrated to be associated with problem drinking and individuals who possess these expectancies will be motivated to drink at times when they experience negative mood states (Kushner et al., 1994;Read et al., 2003). Tensionreduction alcohol expectancies is a 9-item scale devised by Sher, Walitzer, Wood, and Brent (1991). Items include "Drinking helps me forget problems at work" and "Drinking helps me to feel better when I am down." Response options range from 0 (not at all) to 4 (a lot). The five items representing tension reduction were summed and the average of the items was used for the analyses. Coefficient alpha for this scale was (α=0.908).

Occupational Stress
The Sources of Occupational Stress-14 (SOOS-14) has been previously used within a similar population (Kimbrel et al., 2011;Stanley et al., 2018;VanderVeen et al., 2012) and was most relevant to this study. The original Sources of Occupational Stress (SOOS) scale assessed occupational stressors specific to firefighters and emergency response personnel (Beaton & Murphy, 1993). The revised SOOS-14, devised by Based upon practicality, the SOOS-14 was also utilized in this study. Coefficient alpha for this study was (α=0.866).

Alcohol Offers
As used by Read et al., 2003, a notable predictor of social reinforcement drinking motives was alcohol offers (AO). As previously mentioned, AO, as defined here, is simply a measure of direct and explicit offers to use alcohol such as being offered a drink (Read et al., 2003). Alcohol offers are assessed with 4 items that assess the frequency the participant has been given or offered a drink without requesting one or has been given unwanted refills. Items include "How many times have you been given a drink without asking for it?" and "How many times has someone filled up your drink without asking you if you wanted it filled up?" Response options range from 0 (1-2 times) to 4 (10 or more times). Alcohol offers represent a more direct form of social pressure that may uniquely motivate drinking behaviors (Wood et al., 2001). Coefficient alpha for this measure has shown to be 0.88 in a college sample (Read et al., 2003). Coefficient alpha for this measure in the current study was (α=0.873), which was virtually identical to that from Read et al., 2003.

Sense of Brotherhood
As a reminder, in our study, we attempted to design a new construct to apply to a firefighter population by making use of the previously mentioned historical construct of "brotherhood." It was an attempt to create a new and measurable variable which could be utilized for future research. So, derived from the research of McMillan and Chavis (1986), we created a new measure of sense of community (i.e., sense of brotherhood) which was used to measure a firefighter's affiliation with the brotherhood.
As mentioned previously, the wording for each item within the scale was slightly changed to address the population of interest in an attempt to measure the construct "sense of brotherhood" as opposed to the original scale's measurement of "sense of community." Response options range from 1 (Strongly disagree) to 5 (strongly agree). It is hypothesized that if the mean score is 3, then the participant would have a neutral stance of where he/she feels connected to their brotherhood. The closer the mean score is to 5, the stronger the connection to brotherhood, whereas the closer the mean score is to 1, the lesser the connection to brotherhood. Cronbach's alpha for the overall BSCS in previous research showed good internal consistency of 0.92, with alphas for the subscales as 0.86 for needs fulfillment, 0.94 for group membership, 0.77 for influence, and 0.87 for emotional connection (Peterson et al., 2008). However, the current research wanted to avoid the use of only two items per subscale and thus, for this study, the overall BSCS scale was used with Cronbach's alpha being 0.924. This was almost identical to the overall internal consistency found in prior research.

Alcohol Use
The Daily Drinking Questionnaire-revised (DDQ-r) consists of a shortened version of the DDQ designed to measure volume, quantity and frequency of alcohol consumption (Collins et al., 1985). The DDQ-r asks participants to estimate average alcohol consumption for each day of the week during the previous 30 days (Kivlahan et al., 1990

Psychosocial variables in previous research
Overall, the means in this sample for all variables appear to be higher than what has been reported in other studies that have used these measures (Read et al., 2003;Sher et al., 1991;Stanley et al., 2018). These studies have been conducted with college students and the mean total scores on these psychosocial variables were as follow: impulsivity week.

Analyses
Aim 1. Confirm the factor structure of the DMQ-r.

Analysis.
A Principal Components Analysis (PCA) was conducted to establish the factor structure of the 20-item motive scale. While it was expected that the original four subscales (social, enhancement, coping, and conformity) would emerge, this step was the first thorough examination of the drinking motives measure within a population of firefighters and EMTs.
Analysis. Cluster analysis was used to uncover subgroups (profiles) among the individuals in relation to their drinking motives.
Aim 3. Examine demographic and psychosocial differences across the resulting cluster subtypes.
Analysis. Inferential statistics were used to compare the formed clusters to other psychosocial variables that were not included in the clustering process (i.e., alcohol expectancies, sense of brotherhood, sources of occupational stress, alcohol consumption, etc.). Cross tabulations analysis, multivariate analysis of variance (MANOVA), and analysis of variance (ANOVA), were conducted with the clusters depending on the variable types.
CHAPTER 4 FINDINGS Aim 1. Confirm the factor structure of the DMQ-r.
Due to a limitation in the size of the sample, the sequential approach to measurement developed was not utilized, however, a thorough examination of the DMQ-r and a Principal Components Analysis (PCA) were conducted to establish the factor structure of the 20-item motive scale. As previously stated, while it was expected that the original four subscales (social, enhancement, coping, and conformity) would emerge, this step was the first thorough examination of the drinking motives measure within a population of firefighters and EMTs.

Principal Component Analysis
Using the Eigenvalue cutoff rule (Kaiser rule), scree plot, parallel analysis and subjectively evaluating the variance explained, the number of components retained was four. Although a fifth eigenvalue was above the cutoff value of 1, this fifth component only explained 5.7% more of the data. Contrarily, using parallel analysis, the number of components suggested to retain was three. However, due to the explainability of a 4-component (i.e., factor) solution as opposed to a 5 or a 3-component solution, it was decided to keep consistent with theory and retain four components. The four subdomains were named to coincide with previous research as "Enhancement Motives," "Coping Motives," "Social Reinforcement Motives," and "Conformity Motives." It is important to note, that all items within the scale loaded on the intended subdomain with the exception of item #15 (Because you feel more self-confident and sure of yourself). Table 3 shows the eigenvalues and the percentage of variance explained. Figure 1 illustrates the scree plot and Table 4 shows the factor loadings of the DMQ-r after Varimax rotation. The resulting subscales were utilized in the remaining analyses. Table 3.   portray an accurate depiction of a FFs/EMTs motives to drink? It is believed that these motives, individually, failed to explain the differences amongst a firefighter's motivational alcohol use. Due to this, it was thought that some combination (profiles/ clusters) may shed some light on differences within this sample.

Cluster Analysis
As there is no definitive procedure for determining the number of clusters, several methods were used. While Ward's method of clustering has been found to be one of the better clustering methods (Norman et al., 1998), both the Algorithm for Cluster Establishment (ACE) and Ward's minimum variance clustering were used to determine and form the number of clusters. Several indices were used to determine the number of clusters: the pseudo F (Calinski & Harabasz, 1974), t, and the cubic clustering criteria.
Furthermore, a visual inspection of the dendrogram, the shape and configuration of the cluster profiles, level (the mean score of the case over all the variables) and scatter (the standard deviation of the scores) of the profiles were also employed. Upon examining all indices, the decision for the quantity of clusters was between 3 and 4 clusters. As mentioned previously, subjectivity is a component of cluster selection when conducting this type of analysis. Due to the fact that a fourth cluster appeared to add a significant and meaningful dimension to the study, it was decided to retain a four-cluster solution. The four clusters were labeled: 1) Low Motives (lowest scores on all four motives), 2) Average-Below Average Motives (consistently average or below average on all motives), 3) High Enhancement/Social Reinforcement; Low Coping/Conformity (high on enhancement and social motives but lower on coping and conformity, and 4) High Motives; Highest Coping/Conformity (high on all motives and highest cluster reporting coping and conformity). Figures 2 and 3 illustrate the three and four cluster solutions.  Aim 3. Examine demographic and psychosocial differences across the resulting cluster subtypes.
The aim of cluster analysis is often not simply to form a taxonomy, but to see if the groups identified are associated with an external variable(s) (Clatworthy et al., 2005).
To examine this, inferential statistics were utilized to compare the formed clusters (i.e., groups) on variables that were not included in the clustering process (i.e., demographics, consumption per week, alcohol expectancies, sources of occupational stress and sense of brotherhood). Chi-square tests, a multivariate analysis of variance (MANOVA), and analysis of variances (ANOVAs) were conducted with the clusters depending on the variable types.

Gender.
A chi-square test of independence showed that there was no significant association between gender and cluster, χ2 (3, N=183) = 3.428, p > .05. See Table 5.

Ethnicity.
A chi-square test of independence showed that there was no significant association between race and cluster, χ2 (18, N=183) = 7.317, p > .05. See Table 5.

Relationship status (single vs. non-single). A chi-square test of independence
showed that there was no significant association between relationship status and cluster, χ2 (3, N=183) = 2.514, p > .05. See Table 5.

Discussion
This study replicated prior research demonstrating the DMQ-r as a valid, reliable, and applicable scale to assess drinking motives and extended previous literature on drinking motives within a firefighter/EMT population by utilizing cluster analysis to devise clusters using all four drinking motives. Furthermore, demographic and psychosocial differences in these clusters were examined. The findings build on those of Cooper et al.'s (1995) and helped to delineate associations among psychosocial antecedents and drinking motives in a FF/EMT sample. The Low Motives Cluster (Cluster 1) was characterized by below average scores on all drinking motive subdomains. This pattern indicates that there is a group of firefighters/EMTs that appear to be far less motivated to drink based on the four drinking motives subscales. Most importantly, this cluster seemed to be somewhat shielded or protected from the heavier drinking habits that can be observed within the other clusters.
Cluster 1 (Low Drinking Motives) had the lowest consumption scores on all five alcohol consumption variables. This is not to say that Cluster 1 (Low Drinking Motives) doesn't consume alcohol. In fact, they drink fairly regularly with a consumption rate of approximately 8.2 drinks/week on a typical week of drinking and 11.2 drinks/week on a heavy week of consumption. However, they are drinking less than all three clusters, particularly Clusters 3 and 4. These differences in drinking bring to light the question of what might be responsible for the lower drinking rates among the Low Motives cluster.
An analysis of cluster differences on demographic and psychosocial variables that might account for differences was conducted to better understand these drinking motives clusters. The idea was to better understand if there are protective factors that exist within this group that shelter them from heavier alcohol use. Are there external factors that can be changed or adjusted to provide a much-needed intervention for this high-risk population? We do not see demographic differences on gender, relationship status, or ethnicity across the clusters but the Low Motives cluster (Cluster 1) did have significantly more years of service on the job with an average of almost twenty-one years of service compared to Cluster 2 (Average-Below Average Drinking Motives) = 17.1, Cluster 3 (High Enhancement/Social Reinforcement; Low Coping/Conformity) = 15.5, and Cluster 4 (High Motives; Highest Coping/Conformity) = 13.7. This may indicate that a level of experience as a firefighter, an understanding of the emotional distress that may accompany this profession, as well as, simply age/maturity of an individual may help protect a FF/EMT from certain poor behavioral health outcomes. Group differences pertaining to years of service could also be attributable to a cohort effect, since years of services is most likely connected to individuals being the same age, born around the same time period, and may have had similar life experiences. A cohort effect cannot be ruled out and should be investigated further in future studies.
Cluster 1 (Low Drinking Motives) had the lowest scores on both tension reduction and social lubrication alcohol outcome expectancies, suggesting that this group did not feel the need to drink to reduce negative affect. As a reminder, questions asked for the tension reduction measure are "Drinking helps me forget problems at work" and "Drinking helps me to feel better when I am down." Social lubrication alcohol expectancies, on the other hand, appear to describe an individual who drinks due to low self-esteem or low self-efficacy. Social lubrication items ask an individual certain questions pertaining to whether they drink to "feel sexy," "feel less shy," or "feel cool." According to our data, Cluster 1 (Low Drinking Motives) also appears to have strongest self-esteem/self-efficacy, if lower social lubrication scores also reflects higher self-esteem/self-efficacy.
Although the Low Drinking Motive cluster (Cluster 1) was noticeably different from the other clusters in these important ways, this was not the only noticeable difference discovered between groups. Cluster 3 (High Enhancement/Social Reinforcement; Low Coping/Conformity) and Cluster 4 (High Motives; Highest Coping/ Conformity), our two highest clusters pertaining to drinking motive scores, also showed the highest levels of alcohol consumption rates, in particular, Cluster 3 (High Enhancement/Social Reinforcement; Low Coping/Conformity). Cluster 3 (High Enhancement/Social reinforcement; Low Coping/Conformity) had the highest alcohol consumption rates and highest alcohol expectancy scores and it could be hypothesized these elevated levels of alcohol use, combined with high motivations to drink, in particular drinking to cope with stress, places Cluster 3 in a dangerous category of highrisk drinking. Are they seeking other means to cope with their stress and in order to produce the numbing effects that alcohol may bring? Are their highest levels of social lubrication and social reinforcement motives to drink indicative of an individual with low self-esteem out to "party" their sorrows away? This inquiry must not stop here. Since the early 1990s, Boxer and Wild started the investigation into first responder's alcohol use and misuse, and it is apparent that, almost thirty years later, this high-stressed population continues its fight with behavioral health outcomes such as heavy drinking.
The current data enriches our understanding of drinking to cope motivations among firefighters/EMTs and additionally reinforces the expectation that coping motives for alcohol use are prevalent in this population which is not always found in other convenience samples (e.g., Read et al., 2003). Firefighters are exposed to potentially serious stressors on a daily basis and drinking to cope motivations can be differentiated by cluster. FFs/EMTs drinking behaviors are somewhat unique in comparison to many other occupations. Accordingly, our FF/EMT data supports the inclusion of negative emotional factors and the concept of drinking to cope in this population.
Our findings, however, also point to the possibility that FF/EMT alcohol use may be more directly related to positive reinforcement/social motives than to negative reinforcement motives, a conceptualization that needs to be further researched. Higher levels of alcohol consumption were found within the clusters that had the highest motives in general, but particularly pertaining to their enhancement and social reinforcement motives.

Limitations
The present study has limitations. First, the exclusive reliance on self-report measures may have led to social desirability bias. Disclosing substance use/misuse/ consumption may be a sensitive issue for firefighters/EMTs, although this was offset somewhat by the fact that anonymity was guaranteed. The data shows that participants were willing to disclose this information, but as recruitment materials mentioned what information would be collected, some FF/EMTs may have chosen to not participate based on these sensitive topics being surveyed. Firefighters/EMTs may also desire to answer any questionnaire in a more courageous and noble fashion in order to appear as honorable or respectable and not as an individual "weak" or "unable to handle the stresses of the fire department and such a limitation is the lack of equality between males and females (e.g., 176 vs 7 in our study). Therefore, the results of any analyses conducted on gender differences are insignificant. However, it is important to note, that although gender differences cannot be accurately portrayed, some important insights were extracted from the data. Lastly, these FF/EMT data offers some insight into etiological pathways to alcohol use in professional FFs/EMTs but also indicates challenges in measurement and theory that need to be further examined.

Future Directions and Recommendations
There was an inclusion of three exogenous variables (occupational stress, sense of brotherhood, and relationship status) in the present study which had not been examined before in this context. Although these variables did not significantly differentiate between clusters, it is suggested that future research may desire to re-examine these variables in other contexts and within other FF/EMT samples. These variables (e.g., sources of occupational stress) have been utilized before in prior research and demonstrated to produce valuable information pertaining to the overall behavioral health of FFs/EMTs.
Although no significant differences were found on occupational stress, brotherhood, and alcohol offers by cluster, some trends in the data show that the Low behavioral processes that underpin a broad array of diagnostic presentations (Harvey et al., 2004) and tailor these factors in treatment (Barlow et al., 2004). With this approach in mind, some research has also suggested that interventions, such as mindfulness-based or acceptance-based approaches, can help with individuals who have strong coping motives to drink and have experienced trauma or posttraumatic stress (Vujanovic et al., 2011).
Although drinking to cope motives have been a common theme throughout the literature, our sample appears to have a stronger motivation to drink based upon their social interactions/reinforcements. It is possible that one way to lessen a firefighter's alcohol consumption is by educating and training firefighters towards healthier, lower risk drinking behavior. Social norms interventions may be one possible solution to consider.
Social norms theory describes situations in which individuals incorrectly perceive the attitudes and/or behaviors of peers and other community members (in this case "the brotherhood") to be different from their own when in fact they are not (Berkowitz, 2005).
A phenomenon, referred to as pluralistic ignorance (Miller & McFarland, 1991), explains how this misperception causes individuals to overestimate problem/risky behaviors and/ or underestimate healthy/protective ones. The objective of social norms interventions is to correct these misperceptions of all community members (in this case FFs/EMTs) whether they actually engage in the problem behavior or not. This type of intervention is not limited to current/active firefighters but can be also be utilized with new cadets preparing to join the fire service. Healthy behavior can start from the beginning as opposed to waiting until the problem exists and interventions are necessary; however, with the conclusion of this study, we are beginning to understand the different motivational drinking profiles that exist within this population.

Conclusions
Using a cluster analysis approach, this study added to the literature on drinking motives within a firefighter/EMT population. We helped identify FFs/EMTs drinking motive typologies and their associations with numerous demographic and psychosocial variables as well as alcohol consumption rates. The Low Motives cluster (Cluster 1) composed of FFs/EMTs who appear to have certain protective characteristics associated with their health behaviors. Further, the drinking motive profiles of the "High Enhancement/Social Reinforcement; Low Coping/Conformity" cluster (Cluster 3) indicated FFs/EMTs at risk for experiencing stress differently and engaging in unhealthy behaviors. The identification of these drinking motive profiles in relation to a FFs/EMTs alcohol consumption behaviors is an extremely important first step in uncovering the nature behind drinking behaviors in this population. It is also an important step in continuing research in this field and developing preventive interventions that our first responders most definitely need.
The fire service has a long history of tradition, heritage, and pride. It is also with great pride that the researcher in charge of this study can claim to have been a part of this incredible organization for almost the past twenty years beginning on March 19, 2001.
This study has opened the door for more research in this area and will hopefully help fellow members of this courageous profession whose profession is ultimately to help others. As this research shows, unfortunately these men and women often sacrifice so much more than others see, including their own health in relation to alcohol use and other unintended behavioral consequences. 30. How many times have you been offered a drink?
Never 1-2 times 3-5 times 6-9 times 10 or more times 31. How many times have you been given a drink without asking for it?
Never 1-2 times 3-5 times 6-9 times 10 or more times 32. How many times has someone filled up your drink without asking you if you wanted it filled up?
Never 1-2 times 3-5 times 6-9 times 10 or more times 33. How many times has someone bought you a drink without you asking for it? Never 1-2 times 3-5 times 6-9 times 10 or more times applied to you or false as applied to you. If a statement is true or mostly true, as applied to you, mark the true response "T". If a statement is false or not usually true, as applied to you, mark the false response "F". There are no right or wrong answers and no trick questions.
34. I tend to begin a new job without much advance planning on how I will do it. Rows-Zero drinks, 1-2 drinks, 3-4 drinks, 5-6 drinks, 7-8 drinks, 9 or more drinks Columns-Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday 93. In a typical week for the last 30 days, how many hours do you consume alcohol for each particular day of the week?