"For Prof. Goodman"

Why are prevention efforts needed? It is not a difficult question to answer. As you have read this text, you have received information on the problems caused by the abuse of AOD. So, if you take some action or actions that decrease the frequency of abuse, logically, the associated problems should also be reduced. For example, if there is a reduction in the number of people who chronically abuse alcohol, there should be a concomitant reduction in the number of people with medical problems resulting from chronic alcohol abuse. Therefore, prevention efforts designed to reduce the number of people who will end up abusing alcohol for many years are important and beneficial.

Most prevention efforts are directed toward young people. Again, this is logical because people generally make decisions about their use of tobacco, alcohol, and other drugs before they reach adulthood. As you know, it is illegal for people under 18 to use tobacco, for those under 21 to use alcohol, and for any age to use “street” drugs. Therefore, an examination of survey data on the use of tobacco, alcohol, and other drugs by young people can provide information on the need for substance abuse prevention. Although several prominent surveys are conducted annually on the use of tobacco, alcohol, and other drugs by young people, the information in Table 15.1 is from the Monitoring the Future (MTF) study (Johnston, O’Malley, Bachman, & Schulenberg, 2011). MTF is a survey conducted by the University of Michigan and is funded by the National Institute on Drug Abuse. In 2010, 46,500 8th, 10th, and 12th graders were surveyed. MTF has been conducted for the past 36 years, which makes trends easy to identify.

Although one may look at the data generated by these surveys in numerous ways, we find it helpful to compare 30-day prevalence rates, which mean that a respondent has said that the substance in question has been used in the past 30 days. The following table is a report of 30-day prevalence data on 8th, 10th, and 12th graders from 2010, as well as changes since last year and over the last 10 years.

The MTF survey generates much more data than are reported here. However, even this small amount contains interesting information on substance use by young people and has implications for the prevention field. Clearly, tobacco and alcohol use are far more frequent than illicit drug use. While that is not surprising, it certainly indicates that prevention efforts must involve the legal drugs in our society. The trend over 10 years has been large decreases in tobacco and alcohol use and smaller decreases in marijuana and other illicit drugs. Finally, young people frequently believe that “everybody” is using. However, most young people report that they do not use tobacco, alcohol, or illicit drugs.

On a surface level, it might seem that prevention scarcely needs a policy discussion. After all, most people would agree that preventing AOD misuse, especially by young people, is positive and that that’s the only policy necessary. Clearly, the issues are more complicated. For example, when federal agencies set “drug-free” goals, drug-free does not include tobacco or alcohol. The MTF survey identified that tobacco and alcohol are by far the most widely used drugs by young people. In addition, these legal substances (for adults) cause more harm to society than all illegal drugs combined. Unfortunately, the illogical dichotomy of legal/illegal drugs persists. So, while drug-free may be politically popular, this concept may divert attention and resources from efforts to prevent the use of tobacco and alcohol by young people.

An alternative conceptualization to drug-free is the harm reduction model. This model is based on the premises that drug use (including tobacco and alcohol) cannot be eliminated from our society, that the misuse or abuse of any drug can cause harm, and that strategies can be implemented to reduce the harm caused by misuse or abuse. A widely publicized example of a harm reduction strategy is needle exchange. This example reflects acknowledgment that some people are intravenous drug users who will not discontinue their use. By sharing needles with others, these hardcore drug users spread diseases such as hepatitis and HIV. The distribution of clean needles should reduce needle-sharing as a cause of infection. In fact, these programs have been successful in reducing the spread of AIDS (see literature review in Clark & Fadus, 2010). However, in spite of the evidence supporting needle exchange programs, the federal government, until recently, has fought efforts to fund these programs.

Harm reduction efforts are also directed at the legal drugs in our society. Sobriety checkpoints and designated driver publicity campaigns are intended to reduce the harm caused by alcohol-impaired drivers. Sting operations to identify and penalize retailers who sell tobacco to minors are designed to reduce the access of tobacco to young people. If a minor has trouble purchasing cigarettes, he or she will smoke less or not at all.

Some harm reduction processes involving alcohol use by minors are quite controversial. For example, some parents of teenagers may allow alcohol use at parties to discourage drinking and driving. Parents who allow this are engaging in a dangerous activity since it is a crime to contribute to the delinquency of a minor. In addition, in many cases they are enabling alcohol abuse. On prom and graduation nights, organizations such as Mothers Against Drunk Driving (MADD) may organize volunteers to drive for impaired students. This is certainly a difficult issue since no one wants a situation in which an impaired minor is involved in an accident, and responsible adults do not want minors to drink. Reconciling these issues is a dilemma for parents.

Related to these issues is the fact that federal prevention efforts have not focused on gateway drugs as much as they should. Gateway drugs are those that precede the use of other drugs and are usually considered to be alcohol, tobacco, and marijuana1 (Kandel, 1989). In fairness, more recent publications from the Center for Substance Abuse Prevention now refer to “alcohol, tobacco, and other drug problems,” and underage drinking initiatives have been developed. But, this has not always been the case. As we will discuss, the reasons for the lack of focus on tobacco and alcohol probably are related to political pressure as opposed to best practice. It makes sense to focus on gateway drugs in prevention programs because drug users rarely begin with drugs such as cocaine or heroin (New York State Division of Alcoholism and Alcohol Abuse, 1989). A young person usually begins drug use with tobacco or alcohol, since these drugs are readily available and their use is perceived as dangerous, exciting, and adultlike. Once a young person “takes the plunge” (begins use), it is much easier to go on to the next class of drugs. Furthermore, Hawkins, Catalano, and Miller (1992) have shown that the age of first use of any drug is related to later drug abuse by adolescents. Finally, alcohol and tobacco cause more health-related problems than other drugs. For example more than 500,000 deaths annually are associated with tobacco and alcohol, as opposed to 23,500 deaths annually from all of the currently illegal drugs combined (Fisher, 2006).

1Recent research (e.g., RAND Drug Policy Research Center, 2002) has raised questions about whether marijuana is a gateway to other illicit drug use.

For all these reasons, it makes sense to focus on preventing the initiation of use of gateway drugs. However, the alcohol and tobacco industries have powerful lobbies that present constant barriers to prevention efforts. To give you one simple example, the tobacco industry is allowed to market a product that has no medically useful purpose, is highly addicting, and kills 400,000 people a year. A product with these characteristics would never be allowed to be introduced today, and the failure to ban the promotion of tobacco is unconscionable. Since the tobacco master settlement agreement in 1998, cigarette advertisements in youth magazines increased by $54 million (Turner-Bowker & Hamilton, 2000). Obviously, alcohol is also marketed widely. In 2007, the alcohol industry spent over $1.6 billion on advertising, including nearly $900 million on television advertising. The beer industry alone spent over $700 million on television ads (Alcohol Policies Project, 2008). In comparison, the federal government’s National Youth Anti-Drug Media Campaign, designed to convince young people to avoid illicit drugs, was budgeted at $45 million in fiscal year 2010 (Office of National Drug Control Policy, 2011a). That is about 3% of what the alcohol industry spent to convince young people to drink. According to the Center on Alcohol Marketing and Youth (2010) at the Johns Hopkins Bloomberg School of Public Health, exposure to alcohol advertising and alcohol marketing increases the probability that young people will start drinking and that they will drink more if they are already using alcohol. Of course, the alcohol industry claims that it does not target underage drinkers. However, youth exposure to alcohol advertising on television increased 71% between 2001 and 2009 which was more than the exposure of alcohol to adults over 21. Furthermore, most of the increase was on cable shows more likely to be watched by minors (Center on Alcohol Marketing and Youth, 2010). The alcohol industry does place “responsibility” advertising on television. However, between 2001 and 2009, the alcohol industry spent 44 times more on advertising their products than on ads regarding responsible alcohol use (Center on Alcohol Marketing and Youth, 2010). Therefore, any efforts designed to prevent young people from initiating alcohol or tobacco use are directly countered by the marketing of these products. Legislators are heavily lobbied and receive campaign contributions from the alcohol and tobacco industries and have little motivation to pass laws that restrict or prohibit advertising. The attempt by the 1998 Congress to pass a comprehensive tobacco bill is an excellent example. The tobacco companies launched a successful effort to defeat this bill. So research indicates that we need prevention efforts that focus on the gateway drugs, but federal and state government officials do not want to upset the tobacco and alcohol industries. Furthermore, prevention efforts are sabotaged by the sophisticated marketing of tobacco and alcohol. Can you see how policy affects prevention?

The White House Office of National Drug Control Policy (ONDCP) is responsible for the development, management, and implementation of all federal programs involving illicit drugs. These programs are broadly classified as being “supply reduction,” including domestic law enforcement, interdiction, and international efforts, or “demand reduction,” including treatment and prevention. Our federal public policies regarding illicit drugs are demonstrated by how monetary resources are distributed between supply reduction and demand reduction. Domestic law enforcement includes agencies such as the Drug Enforcement Administration. Interdiction involves efforts by the Coast Guard and Customs and Border Protection to stop illegal drugs from entering the United States. International efforts include the initiatives in Colombia to destroy coca plants and in Afghanistan to stop the growing of poppies. Most treatment and prevention dollars are distributed to states by block grants administered by the Center for Substance Abuse Treatment and the Center for Substance Abuse Prevention, both in the Substance Abuse and Mental Health Services Administration in the U.S. Department of Health and Human Services.

In the fiscal year 2011 budget proposal, ONDCP allocated 64% of the budget to supply reduction and 36% to demand reduction (Office of National Drug Control Policy, 2011b). This proportion of allocation between supply and demand reduction has been consistent for many years.

With this large proportion of financial resources allocated to law enforcement and military initiatives, it would be expected that the supply of illicit drugs in this country would be significantly disrupted. However, that is not the case. Since 2001, the Department of Justice has issued an annual report called the “National Drug Threat Assessment” on the availability of illicit drugs in this country. According to the 2010 report, the availability of heroin, methamphetamine, and ecstasy was widespread and increasing (United States Department of Justice, 2010). Cocaine shortages have been seen since 2007 because of reduced production in Colombia, high demand outside of the United States, and increased seizures and efforts to stop smuggling in Mexico.

With all the competing interests for federal funds, reprioritizing the proportion of money allocated to supply reduction and demand reduction would certainly make sense. We now have ample evidence to conclude that the amount of money devoted to supply reduction is not justified. This money would be better spent on prevention and treatment.

Legalization is an extremely controversial policy issue and one that generates highly emotional arguments from both sides. Proponents of legalization argue that crime, violence, and diseases would be reduced. If all drugs were legal, the argument goes, the profitability of black-market distribution would be reduced and those who inject drugs could always use clean needles. The quality of currently illegal substances could be controlled to prevent contamination. The number of people incarcerated for possession or for crimes related to the need to buy drugs would be reduced. More money would be available for prevention and treatment due to reduced prison populations and the decreased need to interrupt drug supplies.

Opponents of legalization counter by saying that the use of currently illegal drugs would increase, especially among youth. More social problems would result from drug use because of the increased access. They doubt that black-market distribution would decrease because buying drugs on the street would still be easier than buying them from the government. Therefore, violence and crime would still characterize drug distribution. Both sides use the experience of history (e.g., prohibition) and policies from European countries to support their arguments.

As with many controversial issues, legalization is not as simple as either side would have you believe. First, drugs are legal. Alcohol and nicotine are drugs. Many other drugs with addictive potential are distributed with a physician’s prescription. The legalization issue usually involves marijuana, cocaine, methamphetamine, and heroin. Second, many proponents of legalization are actually supportingdecriminalization. Decriminalization involves allowing individuals to possess small amounts of currently illegal drugs for personal consumption. Distribution would remain illegal. This would prevent the arrest, prosecution, and incarceration of individuals who use drugs but do not commit other crimes. Third, the concept of legalization can have numerous operational definitions from unlimited and uncontrolled access and distribution to highly controlled access and distribution. Clearly, the consequences of legalization would be dependent on these processes. Finally, discussing the legalization of marijuana, cocaine, meth-amphetamine, and heroin together makes little sense. As we discussed in Chapter 2, the acute and chronic effects of these drugs are quite diverse, and the concept of dangerousness is vastly different.

We believe that it makes more sense to advocate for a logical and comprehensive discussion of our policies regarding alcohol, tobacco, and illicit drugs than to discuss the legalization of illegal drugs in isolation from other substances. For example, if marijuana were legal and marketed and distributed as alcohol and tobacco are, we have little doubt that use would dramatically increase. We believe that the legalization issue, although fun to discuss, is a diversion from a focus on all the drugs (legal and illegal) we abuse.

This classification system is based on the target population of prevention activities. Universal prevention strategies are directed toward the entire population of a country, state, community, school, or neighborhood. The goal is to deter the onset of substance abuse by providing all individuals in the population with the information and skills perceived as necessary to prevent substance abuse. Screening to assess the risk of substance abuse is not targeted to subsets of the population because everyone is assumed to be at risk for substance abuse and capable of benefiting from the prevention activities. For example, a national media campaign is part of the federal government’s prevention efforts. The television advertisements created as a part of this campaign are directed at all people who view them. School-based prevention programs that are implemented in the classroom are considered universal prevention.

Selective prevention strategies are targeted at subsets of a population who are considered at risk for substance abuse. For example, children of alcoholics or addicts, students who are failing academically, and abused children are considered “high risk” because research has shown that these children have a higher probability of later substance abuse than other children (Hawkins et al., 1992). The risk factors may be biological, psychological, social, or environmental, and the targeted subgroups may be determined by age, gender, family history, or place of residence (e.g., high-drug-use neighborhoods). The only criterion for inclusion is membership in the selected subgroup. Therefore, some individuals may be at low personal risk for substance abuse while others may already be involved with alcohol or other drug use or abuse. A mentoring program for children from a low-income, high-drug-use neighborhood is an example of a selective prevention strategy. Another example of a selective prevention strategy would be a support group for children of alcoholics and addicts.

Indicated prevention strategies are directed toward individuals who have demonstrated the potential for substance abuse based on their behavior. For example, a minor in possession of tobacco, alcohol, or other drugs would fit this criterion. It is important to determine if the individual is a substance abuser or substance dependent because the latter would indicate the need for treatment (see Chapter 6). Other indicated behaviors include involvement with the juvenile justice system for nonalcohol or other drug-related offenses, dropping out of school or excessive truancy, and conduct disorders. Examples of indicated prevention strategies include social skills classes for juvenile offenders, drug education for minors in possession, and family counseling.

The Center for Substance Abuse Prevention (CSAP), the federal agency that coordinates prevention efforts throughout the country, has utilized a prevention classification system based on six strategies. This system is not in conflict with the Institute of Medicine system since a strategy may be targeted to universal, selective, or indicated populations. The six strategies are as follows:

This involves communication of the nature, extent, and effect of substance use, abuse, and addiction on individuals, families, and communities. In addition, these strategies may involve information on prevention programs and services. One-way communication between a source and an audience, with limited or no contact between the two, characterizes information dissemination. Public service announcements, didactic instruction, audiovisual materials, displays of drugs, and publications are examples of information dissemination.

These activities are designed to build or change life and social skills—such as decision making, refusal skills, assertiveness, and making friends—that are usually thought to be associated with substance abuse prevention. Education is differentiated from information dissemination in that education encourages interaction between the facilitator or instructor and the participants. Education strategies also imply an expectation that participants will develop skills as a result of the education. Most school-based prevention programs are considered to be education, although they may include an information dissemination component. Programs designed to improve parenting skills are also examples of education strategies.

These strategies involve the development of activities that are incompatible with substance use. This is based on the assumption that young people may use AOD because of boredom or lack of access to other activities. Therefore, if healthy, productive, and fun activities are available, young people will participate in these activities rather than in AOD use. In addition, this participation may expose high-risk youth to positive role models and provide an expanded view of the possibilities for the future. Midnight basketball is often used as an example of an alternative strategy. Another common alternative strategy is the development of after-school programs, designed to provide a supervised, productive program for young people at a time when much of the youth crime is committed (3 to 7 p.m.).

This strategy is generally targeted to indicated populations who have been identified as using tobacco, alcohol, or other drugs or who have engaged in other inappropriate behaviors. Depending on the nature and severity of the problem, referrals may be made to educational programs, family therapy, or other forms of treatment. For young people who are caught in possession of tobacco, alcohol, or other drugs, consequences may be combined with mandatory education.

These strategies involve the mobilization of communities to more effectively provide prevention services. Interagency collaborations, coalition building, and networking are considered community-based strategies. For example, representatives from county government, social services, juvenile justice, education, the faith community, and the business community may join together to develop seamless (i.e., no barriers to access services from different agencies) services for youth.

Within this strategy are the written and unwritten standards, codes, laws, and attitudes that impact substance use and abuse in a community. The clearest examples are laws regarding tobacco and alcohol. States and counties have very different laws relating to the taxation and distribution of tobacco and alcohol.

A social service organization that relies on alcohol-related events (e.g., wine tasting) to raise funds is communicating a value that is counterproductive for prevention. An environmental strategy would be to lobby this organization to change its fund-raising activities. Another example would be efforts to prohibit university campus newspapers from accepting advertisements that promote excessive alcohol use.

David Hawkins and his colleagues at the University of Washington have done a considerable amount of work on the identification of factors that are associated with an increased probability of AOD abuse (risk factors) or with a decreased probability of AOD abuse (protective factors) (e.g., Hawkins et al., 1992). This conceptualization has become so popular that many states build their prevention systems by assessing the extent of each risk factor in their communities and then by designing prevention strategies to reduce these risk factors (Wong, Catalano, Hawkins, & Chappell, 1996).

Risk factors have been organized by community, family, school, and individual or peer categories. Community risk factors include the availability of tobacco, alcohol, and other drugs; community laws and norms favorable toward substances; community mobility (i.e., frequent movement of people in and out of the community); low neighborhood attachment and community disorganization; and extreme economic deprivation. Family risk factors include a family history of problem behaviors, family management problems, family conflict, and parental attitudes toward and involvement with substance use. In the school area, the risk factors are early and persistent antisocial behavior, academic failure beginning in elementary school, and lack of commitment to school. Finally, individual or peer risk factors include alienation and rebelliousness, association with peers who engage in problem behaviors, favorable attitudes toward problem behaviors, early initiation of problem behaviors; and constitutional factors (i.e., genetic predisposition to addiction or sensation seeking).

In spite of being exposed to multiple risk factors, some young people do not develop problems with alcohol or other drugs. Certain protective factors seem to buffer youngsters by reducing the impact of the risk factors or by changing the way in which the individual responds to the risks. These protective factors have been categorized as individual characteristics, bonding, and healthy beliefs and clear standards. The individual characteristics include gender (females are more protected than males), a resilient temperament, a positive social orientation, and intelligence. Obviously, these individual characteristics are difficult or impossible to change. Bonding involves the attachment to positive families, friends, school, and community. The beneficial aspects of bonding cannot be overemphasized. A child who develops a bond to positive role models or healthy systems can overcome the disadvantages of exposure to risk factors. To facilitate the development of bonding, children need the opportunity to bond, the skills to take advantage of the opportunity, and recognition for making efforts to bond. For those of you who wonder if you can make a difference in a young person’s life, this information on bonding should be a strong affirmation that you can have a major impact. Healthy beliefs and clear standards go hand-in-hand with bonding. The people and systems to which young people bond must communicate positive values and hold young people accountable for their behavior. Protection is enhanced when clear standards of behavior are expressed and consequences are applied for violations of these standards.

Although the risk and protective factor model is logical, a caution is necessary. Much of this research is correlational rather than causal. To illustrate, let’s look at one family risk factor: family conflict. Family conflict has been identified as a risk factor because of evidence that children from families in which excessive family conflict is present have a higher probability of developing substance abuse problems (and other problems as well) than children who come from families in which minimal family conflict is present. However, this does not mean that family conflict causes substance abuse problems or that reducing family conflict will prevent a child from developing a substance abuse problem. Perhaps the family conflict is due to the substance abuse of one or more of the caretakers in the family. As a result of some type of intervention, perhaps the family learns to resolve its problems in a more reasonable manner. However, the caretaker continues to abuse substances. In this instance, family conflict is just one symptom of dysfunction in the family system as a result of substance abuse. Therefore, treating one symptom is not likely to affect the development of substance abuse (or other problems) in the children.

It should be noted that a causal relationship between risk and protective factors and substance abuse is not proposed in the model developed by Hawkins and his colleagues. However, many intervention programs designed to reduce risk factors and increase protective factors have been based on an assumption that such a causal relationship exists. In our view, these factors interact in a complex fashion. As we will discuss in the next section, the development of prevention strategies and programs should be based on research on what works.

At A Glance

Institute of Medicine Classification System

· Universal (everyone regardless of risk factors)

· Selective (those with some risk factors)

· Indicated (those who have begun to demonstrate high-risk behaviors)

Prevention Strategies

· Information dissemination (no interaction)

· Education (information and skill building with interaction)

· Alternative activities (non-AOD activities for youth)

· Problem identification and referral (usually for indicated populations)

· Community-based processes (mobilization, interagency cooperation, coalition building)

· Environmental approaches (standards, codes, laws, regulations)

Risk and Protective Factors

· Community (availability of AOD, laws and norms, mobility, neighborhood attachment, economic deprivation)

· Family (history of problem behavior, management problems, conflict, involvement with AOD)

· School (antisocial behavior, academic failure, lack of commitment)

· Individual (alienation and rebelliousness, peers who use AOD, favorable attitudes toward AOD, early problem behaviors)

· Protective: Bonding and healthy beliefs and clear standards

Several issues need to be considered in evaluating prevention programs. Clearly, local, state, and federal government entities are interested in evaluating the success of prevention programs because of the money spent on the programs. As you might imagine, the typical method for evaluating success is the implementation of a prevention program in classrooms or schools and to later see whether the individuals who were involved in the program use AOD to a lesser extent than individuals who were not involved in the program. One problem is that the initiation of use by young people depends on a complex interaction of personal, familial, cultural, and societal variables. To expect a school-based prevention program to singularly impact a behavior influenced by so many variables is unrealistic. Second, we know that attitudes and behavior can be influenced by a consistent, long-term, and comprehensive effort. For example, when many of us were young, cars did not have seat belts. Seat belts were then made optional, but we still never used them. Today, they are standard features in all cars, and many states have legislation requiring their use. So, our children don’t even think about it. When they get in the car, they put on their seat belts. We do, too. However, this change in attitude and behavior in adults who grew up with seat-belt-free cars was accomplished through a long-term process involving public policy (legislation) and public awareness. Similarly, school- and community-based prevention programs should be viewed as a part of long-term, consistent, comprehensive prevention efforts and not as isolated “cures” for the problem of tobacco, alcohol, and other drug use by young people.

However, we believe that the effectiveness of prevention efforts would be enhanced if the contradictory messages were less pervasive. Marketing of tobacco and alcohol products, positive depictions of tobacco, alcohol, and drug use in the media, and modeling by adults and peers are powerful influences on young people. It is not currently possible, given financial and practical constraints, for the prevention community to counteract creative and funny beer commercials, cigarette smoking in youth-oriented movies, and mom and dad smoking a joint with their friends in the living room. Society’s prevention message is not consistent or comprehensive. Finally, school-based prevention programs are often viewed in a similar manner to other programs in a school. If you want to evaluate a new reading program, you compare the reading performance of children in the new program with the performance of children in another program. However, we would argue that prevention programs are different. For example, imagine that you begin a prevention program that costs $10,000 in materials and training. In the entire school, only one student who would have become dependent on tobacco, alcohol, or other drugs is impacted and avoids use. You will have more than made up for the money invested in the program by preventing the financial and societal impact on health care, work productivity, the legal system, and family members that this person would have caused. We are not arguing that prevention programs should be purchased and implemented without careful evaluation. We are arguing that prevention programs should not be blamed for failing to solve a complex and multifaceted problem.

Because of the importance of the problem and the money spent on prevention, the federal government has become very interested in determining which prevention strategies and programs are the most effective. For example, the National Institute on Drug Abuse has a publication on principles of effective prevention (National Institute on Drug Abuse, 2003). In addition, Paglia and Room (1998) presented an excellent review of the prevention literature, and Tobler (1992) and Tobler and Stratton (1997) conducted meta-analyses of school-based prevention programs. From these sources, conclusions regarding effective (and ineffective) prevention strategies can be reached. We will present these conclusions for each of the six CSAP strategies.

School-based information dissemination methods have been unsuccessful in impacting tobacco, alcohol, and other drug use. As Botvin and Botvin (1992) stated,

studies have rather consistently indicated that informational approaches do not reduce or prevent tobacco, alcohol, or drug use; they indicate quite clearly that increased knowledge has virtually no impact on substance use or on intentions to engage in tobacco, alcohol, or drug use in the near future. (p. 914, italics in original)

Similarly, Tobler (1992) found that prevention programs that only presented information did increase knowledge of participants but had no effect on attitudes and drug use. This is not surprising when you consider the analogy of the prevention of heart disease. Most Americans know that quitting smoking, regular aerobic exercise, eating fresh fruit and vegetables, and so forth will reduce the risk of heart disease. However, this information alone is usually insufficient to result in a significant behavior change for most people. Similarly, simply learning about the negative consequences of using tobacco, alcohol, and other drugs does not affect the reasons for use by most young people.

Although information dissemination alone is not sufficient, providing accurate information is an important component for school-based prevention programs. Paglia and Room (1998) recommend an emphasis on the short-term adverse effects of use, rather than on the long-term effects. The reasoning is that, from a developmental standpoint, short-term adverse effects have more impact on young people, particularly the effects that involve social attractiveness. Additionally, information on health risks and consequences of use should be based on research and should be delivered in a nonjudgmental manner (Bachman, Johnston, & O’Malley, 1991). Scare tactics and moral lecturing have not been shown to be effective and may actually have a detrimental effect if the information is in conflict with the personal experience of students.

As might be expected, information dissemination via the mass media should be aired at times when young people are likely to be listening or watching. The use of authority figures and exhortations has not been shown to be effective. As with school-based information dissemination, short-term risks involved in substance use should be emphasized (Brounstein, Zweig, & Gardner, 1998).

In contrast to previously discussed school-based prevention programs that are “information only,” Tobler (1992) has categorized some school-based programs as affective. This model is based on the assumption that young people use AOD because of low self-esteem, inadequate social skills, and ambiguous values. Through discussion and activities involving feelings, values, and self-awareness, an attempt is made to improve self-concept and social skills and to clarify the students’ values.

The results from Tobler’s (1992) meta-analysis show that prevention programs that used only affective education were ineffective in impacting knowledge, attitudes and values, self-reported drug use, or decision-making, assertive, and refusal skills. Furthermore, drug incident reports, school grades and attendance, and achievement test scores also were unaffected. Approaches that combine cognitive (information dissemination) and affective approaches did have a positive effect on knowledge of participants but a negligible effect on the other outcomes. Part of the problem with this approach to prevention may be the consistent finding that very little relationship has been established between self-esteem and drug use (Clayton, Leukefeld, Grant-Harrington, & Cattarello, 1996;Coggans & McKellar, 1994; Schroeder, Laflin, & Weis, 1993).

Another educational approach to prevention is based on the influences on young people that result in the initiation of tobacco, alcohol, and other drug use. Family use patterns (including parents and siblings), peer pressure, and media all may influence young people to use (or not to use). Social resistance skills approaches (also called social influence or refusal skills approaches) have been developed to counteract environmental influences. According to Botvin and Botvin (1992),

these interventions were designed to increase students’ awareness of the various social influences to engage in substance use. A distinctive feature of these prevention models is that they place more emphasis on teaching students specific skills for effectively resisting both peer and media pressures to smoke, drink, or use drugs. (p. 916)

According to Botvin and Botvin (1992), social resistance skills approaches generally contain the following components: recognizing situations in which a high probability exists that a young person will experience peer pressure to use, formulating strategies to avoid these high-risk situations, teaching students what to say and how to say it when confronted with peer pressure, and developing awareness of techniques used by the media to encourage use by young people. Peers are frequently used in implementing these programs, since peers, particularly older adolescents with perceived status, may be more influential than teachers or other adults. Information dissemination, with a focus on prevalence of use by young people, is used to counter the argument that “everyone is doing it.”

In evaluating social resistance skills approaches, Botvin and Botvin (1992) report that these programs have been associated with reductions in tobacco, alcohol, and marijuana use for up to three years. However, long-term follow-up studies have shown that these reductions are not maintained over time. Tobler (1992) found that programs using peers as implementors had a positive impact on knowledge, attitudes, self-reported drug use, and skills. However, no beneficial effect was noted on drug incident reports or on indirect measures of use such as school grades and attendance. The age group of the students, number of training sessions, use of booster sessions, instructional materials, and characteristics of the students may all impact evaluation of these programs, and Botvin and Botvin suggest that additional research is necessary to clarify the variables that are important for success.

Competency enhancement approaches are more comprehensive than the other approaches, and focus on the interaction between the individual and environment in the prevention of substance use by young people. Competency enhancement approaches emphasize the development and use of personal and social skills that are directly related to substance use but that are also applicable to many other adolescent problems. According to Botvin and Botvin (1992), competency enhancement approaches typically teach two or more of the following:

1. General problem-solving and decision-making skills

2. General cognitive skills for resisting interpersonal or media influences

3. Skills for increasing self-control and self-esteem

4. Adaptive coping strategies for relieving stress and anxiety through the use of cognitive coping skills or behavioral relaxation techniques

5. General social skills

6. General assertive skills

These skills are taught using a combination of instruction, demonstration, feedback, reinforcement, behavioral rehearsal (practice during class), and extended practice through behavioral homework assignments. (p. 320)

Evaluation studies of competency enhancement approaches seem generally positive. In a summary of these studies, Botvin and Botvin (1992) report reductions in initiating use of tobacco, alcohol, and marijuana. Effectiveness has been demonstrated using many types of trainers (e.g., peers, teachers, project staff) as well as with ethnically diverse groups. With booster sessions, the effects have been maintained for up to six years (Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995). However, this long-term follow-up study has been criticized for failing to report negative results and for issues regarding sample selection (Brown & Kreft, 1998; Gorman, 1998).

In reviewing the literature on school-based prevention, Paglia and Room (1998) and Brounstein et al. (1998) have presented some general guidelines in the structure, content, and delivery of prevention education. The recommendations include prevention programming throughout the grades, with the greatest emphasis on the median ages of first use (late elementary school and middle school). While long-term programs are superior to short-term programs, periodic booster sessions following the completion of programs are necessary to maintain benefits. Information presented should be factual. If the instructor does not know an answer, this should be admitted to students. Students should have the opportunity to discuss the reasons why people use AOD, alternatives to meeting these needs, and the dangers and benefits to using and not using. While both short-term and long-term effects should be presented, the short-term effects should be emphasized. Perceptions regarding “everybody does it” should be challenged with data. An interactive style of presentation is most beneficial, including cooperative learning, role-plays, and group exercises. Peer facilitators can be effective if they are trained and are perceived as credible. The instructional atmosphere should be tolerant and free from moralizing and scare tactics. Finally, as Paglia and Room (1998) state, “most importantly, anything taught in the school must be reinforced in the community by parents, media, and health policies” (p. 16, italics in original).

While many commercially prepared school-based prevention programs are available, the Drug Abuse Resistance Education (DARE) program should be specifically mentioned. The DARE program is unique among school-based prevention programs with its use of police officers as instructors. The program was developed by Daryl Gates, former Los Angeles chief of police. DARE officers are trained in child development, classroom management, teaching techniques, and communication skills prior to classroom instruction. Due to the fact that evaluation studies showed that DARE did not produce the desired outcomes (e.g., Ennett, Tobler, Ringwalt, & Flewelling, 1994), the elementary curriculum is being revised and expected to be implemented in 2011. A middle school curriculum, Keepin’ It Real, has been included in the National Registry of Evidence-Based Programs and Practices (see Chapter 8) but that curriculum is taught by teachers rather than by police officers.

A variety of education programs focused on the family have also been hypothesized to prevent substance use among youth. These programs can involve parent education, parenting skills training, parent support groups, and family therapy. It is particularly useful to combine school-based prevention programs with family-based programs. Most studies of family-based prevention have focused on “high-risk” families. An example of such a program is the Strengthening Families program (Kumpfer, Williams, & Baxley, 1997). Parent, child, and family skills training was targeted to substance abusing families with children in the 6- to 10-year range. Improvements were found in the problem behaviors of the children, in intentions to use AOD, in parenting skills, in family communication, and in family conflict.

A major research problem with high-risk family-focused programs is the recruitment and retention of families. In spite of this problem, programs “that include parenting skills and children’s skills training and structured family sessions, may be effective in reducing risk factors and strengthening protective factors which etiological models link to drug use. However, whether these types of effects actually become translated into the prevention of substance use or abuse among youth has yet to be confirmed by long-term empirical evaluations” (Paglia and Room, 1998, p. 22).

The research evidence regarding the effectiveness of alternative activities is mixed.

Botvin and Botvin (1992) indicate that entertainment, vocational, and social alternatives programs have been associated with more rather than less substance use, although academic, religious, and sports activities are associated with less use. They report that evaluations of alternatives programs have failed to demonstrate an impact on adolescent use. In contrast, Tobler’s (1992) meta-analysis of alternatives programs for high-risk youth showed positive effects on skills and behavior, including school grades, school attendance, and independent reports of observed drug use.

According to the review of literature conducted by Brounstein et al. (1998), alternatives should be part of a comprehensive prevention plan that includes other activities with proven effectiveness. However, when alternative activities are being developed, they must be attractive to the target group or participation will not occur. Therefore, young people must be involved in the planning process. Not surprisingly, the more intensive the activity (in terms of both hours required and length), the more effective it is.

Carmona and Stewart (1996) and Tobler (1986) point out that alternative activities serve a more general purpose than just providing something else to do besides using substances. For some high-risk youth, alternative activities are an opportunity for personal development and positive bonding to adults and the community. The development of these protective factors may be beneficial in a variety of ways. One type of alternative activity that is popular is mentoring. Mentoring programs provide young people, particularly high-risk youth, with structured time with positive adult role models. Mentoring programs have been associated with reductions in substance use; increases in positive attitudes toward others, the future, and school; and increased school attendance. As would be expected, the more highly involved the mentor, the greater the impact. It is particularly important to screen and train potential mentors. Clearly, mentors must be positive role models and must complete their commitment to the young people in the program. Many of the high-risk youth in these programs have been disappointed by adults in the past and should be protected from having similar experiences with mentors.

Certain factors are important to consider in the development of any problem identification and referral system. First, experimental users should be differentiated from problematic users. Although any use of tobacco, alcohol, or other drugs by a minor is a problem, experimentation is not uncommon and does not require intensive intervention. A significant consequence combined with education is usually the appropriate level of intervention for experimental use. In addition, if experimental users are placed in more intensive programs, they will be grouped with problematic users. This could have the unintended consequence of enabling further use. Because of these issues, problem identification and referral programs must have valid procedures and trained personnel to determine where the individual is on the use continuum (see Chapter 6).

Substance use among young people is often associated with other problems, including family dysfunction, school failure, sexual activity, and violence. Therefore, a problem identification and referral program must be prepared to screen for other problems in addition to substance use and must have adequate referral resources to assist the targeted individuals. This may include very concrete issues such as transportation. For example, a 15-year-old female was referred to a guidance team at her high school after she was found in possession of marijuana. She admitted to frequent, unprotected sex with a variety of partners. The young woman was receptive to a referral to the local health department for contraception and testing for sexually transmitted diseases, but she had no way to get there. Fortunately, school personnel were able to arrange public transportation.

Community-based coalitions are formed to improve the nature and delivery of services to the community (comprehensive service coordination), generate community activism to address substance-related problems (community mobilization), or to perform both functions (community linkage). Comprehensive service coordination requires the involvement of the leaders of the organizations in the coalition, whereas community mobilization is dependent on grassroots activists and community citizens. In order to elicit change at a systems or individual-behavior level, community partnerships must have a clear and shared vision of their objectives, commitments to participate from all partnership members, participation from diverse community groups, and comprehensive prevention activities directed at a large number of individuals.

Appropriate organization, leadership, and evaluation have been shown to be important components in successful community partnerships. While committees are usually necessary, those with specific purposes sustain higher levels of involvement than those with elaborate structures. A dynamic leader may be effective but this type of individual cannot normally be replaced. Therefore, opportunities for leadership roles from a variety of participants are helpful. Community coalitions are also advised to implement evidenced-based prevention strategies and to incorporate procedures for measuring the effectiveness of their strategies.

The approaches in this category generate a great deal of discussion in the prevention community and in state and federal governments. Environmental approaches have demonstrated a direct impact on the use of tobacco and alcohol and on the problems associated with the use of these substances. However, environmental strategies have not been as effective with regard to illicit drugs, as we saw in the earlier discussion in this chapter on supply reduction efforts.

Increasing the taxes on tobacco and alcohol is one type of environmental strategy. Tax increases have resulted in reductions in the use of both tobacco and alcohol as well as reductions in associated problems, such as alcohol-related traffic accidents. The tobacco legislation considered by the 1998 Congress included a significant tax increase on tobacco and was bitterly fought (and defeated) by the tobacco industry. Moreover, efforts to increase the price of illicit drugs through law enforcement efforts generally have not been successful.

Laws regarding the purchase of tobacco and alcohol by minors have also been effective. When the minimum purchase age for alcohol was raised to 21 in all states, alcohol consumption among minors decreased, as did alcohol-related problems. Sting operations, using underage individuals who attempt to purchase tobacco or alcohol, are effective in increasing retailer compliance with restricting sales to minors. In addition, “use and lose” laws that result in driver’s license suspension for minors convicted of an alcohol or drug violation have also been shown to increase compliance with minimum-purchase-age laws.

Deterrence laws and policies have also been shown to be effective in reducing alcohol-related accidents and underage drinking and driving. These include lowering the blood-alcohol level from 0.10 to 0.08 or lower, enforcement of drinking and driving laws, sobriety checkpoints, and zero tolerance for alcohol use by underage drivers. While sobriety checkpoints do not result in high levels of detection, publicizing that they will occur seems to have a deterrent effect.

Local communities can also implement proven environmental strategies by placing restrictions on the location and number of retail outlets authorized to sell tobacco and/or alcohol. Neighborhoods have been able to disrupt illicit drug sales through citizen surveillance and through pressure on landlords who own property where drug sales occur.

Training for individuals who serve alcohol (i.e., bartenders) and clerks who sell tobacco and alcohol is an effective strategy when it is combined with law enforcement efforts. Training is intended to educate servers and clerks about the laws, as well as teach them to identify intoxication and false identification and to provide skills in refusing to serve or sell.

Although environmental strategies are clearly effective in reducing the use of tobacco and alcohol, the involvement of community coalitions is usually essential to implement these strategies. Since many require action by policy makers and since many policy makers receive campaign contributions from the tobacco and alcohol industries, pressure from community groups is often necessary.

Our three cases at the beginning of the chapter illustrate the three possibilities in the Institute of Medicine classification system. Montel would be included in an indicated population. He has already begun to demonstrate the problem behavior by smoking cigarettes at a very young age. It would be important to assess how frequently Montel smokes and whether he has begun to experiment with AOD. This assessment would determine what type of intervention would be the most appropriate. In this case, Montel was not smoking regularly and had not really begun to use AOD. It was determined that he was smoking to “fit in” with a peer group in middle school. Therefore, for breaking a school rule, Montel did receive a consequence that included staying after school for an educational group on AOD (including tobacco) and cleaning up the school grounds. In addition, he was provided a peer mentor (a ninth grader) and had some visits with the school counselor.

Sarah would be part of a selective population because she has risk factors for substance abuse. Her poor academic performance and family history of alcoholism are both risk factors. Sarah was placed in a tutoring program to improve her academic skills and a support group at the school for children from substance abusing homes.

Manuel is in the universal population. No risk factors are present and he has not engaged in any high-risk behaviors. Manuel participates in an evidence-based school prevention program for his grade level.

In Chapter 8, we discussed evidence-based treatment and the National Registry of Evidence-Based Programs and Practices (NREPP). While this registry currently contains prevention, intervention, and treatment programs, it was initially started as a process to determine which prevention programs could be called “model programs” and, as of 2011, contains 77 programs in substance abuse prevention. Because so many evidence-based programs are available, states can ensure that the prevention programs they fund have evidence to support their effectiveness. In Chapter 8, we reviewed the process that NREPP follows to determine if a program should be included as evidence-based.

So you can get a sense of the variety of prevention programs on NREPP, the following are some of the programs and a brief description: (1) Across Ages, a school- and community-based substance abuse prevention program for youth ages 9 to 13. The unique feature of Across Ages is the pairing of older adult mentors (55 years and older) with young adolescents, specifically those making the transition to middle school. (2) The Border Binge-Drinking Reduction Program provides a process for changing the social and community norms associated with underage and binge drinking that has proven effective at reducing alcohol-related trauma caused by young American’s binge drinking across the U.S.–Mexican border. (3) Building Assets—Reducing Risks (BARR) is a multifaceted school-based prevention program designed to decrease the incidence of substance abuse (tobacco, alcohol, and other drugs), academic failure, truancy, and disciplinary incidents among ninth-grade youth. (4) Celebrating Families! is a parenting skills training program designed for families in which one or both parents are in early stages of recovery from substance addiction and in which a high risk for domestic violence and/or child abuse exists. (5) Familias Unidas is a family-based intervention for Hispanic families with children ages 12–17. The program is designed to prevent conduct disorders; use of illicit drugs, alcohol, and cigarettes; and risky sexual behaviors by improving family functioning. (6) LifeSkills Training (LST) is a school-based program that aims to prevent alcohol, tobacco, and marijuana use and violence by targeting the major social and psychological factors that promote the initiation of substance use and other risky behaviors. (7) Start Taking Alcohol Risks Seriously (STARS) for Families is a health promotion program that aims to prevent or reduce alcohol use among middle school youth ages 11–14. The program is founded on the Multi-Component Motivational Stages prevention model, which is based on the stages of behavioral change found within the Transtheoretical Model of Change (Substance Abuse and Mental Health Services Administration, 2011).

The federal Substance Abuse and Mental Health Services Administration (SAMHSA) includes the National Clearinghouse for Alcohol and Drug Information (NCADI). NCADI has federal prevention (and treatment) publications available, generally at no cost. The website is included in “Internet Resources.”

In addition, the federal Center for Substance Abuse Prevention (in SAMHSA) has a program called the Center for the Application of Prevention Technologies (CAPT). The purpose of the CAPT is to help states and community-based organizations apply evidence-based prevention strategies. The CAPT includes regionally-based staff members and consultants to cover different areas of the country. The website is included in Internet Resources. In addition, each state has a single state agency for treatment and prevention coordination. Some staff in this agency will be involved with prevention efforts.

Finally, for those of you who are interested in exploring the prevention field in more depth, we recommend a textbook by Hogan, Reed-Gabrielsen, Luna, and Grothaus (2003), Substance Abuse Prevention: The Intersection of Science and Practice.

Many institutions of higher education, community-based organizations, and school districts hire professional staff members to coordinate prevention programs. In many cases, the prevention specialist has responsibility for the prevention of suicide, violence, teen pregnancy, and other public health issues in addition to substance abuse. Prevention specialists are involved in developing and implementing programs, providing training and technical assistance, writing grants, evaluating programs, and preparing policies and procedures.

Because of an increase in the number of prevention specialists, many states have adopted certification standards and have recognized prevention specialists as a distinct professional group. While you must consult your particular state for requirements, many states have adopted the certification standards and examination process developed by the International Certification and Reciprocity Consortium (IC&RC). We have included the certification standards for the IC&RC prevention specialist in Internet Resources.

· Public policies regarding tobacco, alcohol, and other drugs have an impact on prevention efforts.

· Prevention activities are classified by the target audience (universal, selective, indicated) or the type of prevention strategy (information dissemination, education, alternative activities, problem identification and referral, community-based processes, environmental).

· The Risk and Protective Factor theory is widely used to identify variables associated with the increased or decreased probability of AOD abuse.

· Evidence-based prevention programs have been identified through a federal review process.

Substance Abuse. Information for School Counselors, Social Workers, Therapists, and Counselors, Fifth Edition

Chapter 15: Prevention

ISBN: 9780132613248 Authors: Gary L. Fisher, Thomas C. Harrison

Copyright © Pearson Education (2013)