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Strategies
to Prevent Substance Use
Education
and Skill Development Approaches
Educating
young people about alcohol, tobacco and other drugs and the risks associated with
their use has been a primary feature of most prevention initiatives. Prevention efforts
have also focused on helping youths develop life skills to help them avoid problems
with substance use. While prevention programs have often focused on schools, important
initiatives have also made use of mass media campaigns and community- and family-based
programs.
School
Programs
Truly
effective prevention programs in schools are difficult to implement. The most promising
of the prevention approaches to date is the social influence model. The basic premise
is that youths who use substances do so because of social pressures from peers, the
family, and the media, as well as internal pressures (e.g., the desire to be "cool"
and popular). Social influence programs provide information on health and social
consequences and attempt to motivate students to resist the pressures to use. (Ellickson,
1995).
However,
some studies have shown that it is not "peer pressure" per se that leads
to substance use. Rather, it may be "peer influence" or "peer preference."
Only rarely is there overt coercion by peers to try drugs. And most adolescents are
not socially incompetent and lacking in self-esteem. They play an active role in
decisions of first use, already having the intentions or "readiness" to
experiment, and tend to select users as peers (Banwell & Young, 1993; Coggans
& McKellar, 1994; Michell & West, 1996; Warner et al., 1997).
Research
has also identified several approaches that have not been successful. These include
approaches that simply provide information about alcohol, tobacco and other drugs
(Botvin, 1995; Tobler, 1992); those that provide only information on the health risks
and consequences of drug use (Bachman et al., 1991); and those that focus exclusively
on personal problems such as low self-esteem, inadequate social skills, and poor
values (Donaldson et al., 1995; Hawthorne et al., 1995; Tobler, 1992).
By
studying both effective and ineffective prevention programs, researchers have identified
a number of features that are associated with positive results. Based on this research,
it is possible to make the following recommendations to increase the success of school-based
programs for the general student population.
Structure
- Programs should be on-going from kindergarten to the final year of high school,
and should be especially intensive just prior to the average age of first use.
- Different approaches should be used for various subgroups (e.g., those with different
levels of drug sophistication, levels of use or demographic characteristics).
- Programs should involve students in curriculum planning and implementation.
Content
-
Programs should discuss the reasons people use drugs -- e.g., for self-discovery,
self-expression or some perceived benefit -- and present alternatives to substance
use.
-
They should present honest factual material. Where there are no answers, program
leaders should admit it. Programs should present both the dangers and the benefits
of using and not using drugs, and focus discussion on short--term effects. Students
will dismiss information that they perceive as contradictory to their personal experiences
or reflecting adult exaggeration and hysteria.
-
It is important to discuss and correct perceptions regarding occasional or social
use; life-skills development may also be beneficial (e.g., assertiveness, decision-making
and communi-cation techniques).
Delivery
-
It is important to provide a tolerant atmosphere, free of moralizing and scare
tactics; there should be an open dialogue between the program leader and students.
- Programs should emphasize active learning about drug effects rather than relying
on passive lectures and films; interactive delivery methods, such as small-group
discussions and role playing, are best.
-
Program leaders should be people the students trust, and who will present the
facts accurately and in an unbiased manner. Teachers can be effective with assistance
from peer leaders. It is important to choose peer leaders carefully; rigid social
groups already exist among students and, consequently, some students may be alienated
or plainly "turned off" by the choice of peer leader.
For
school-based programs to have the greatest impact, it is also important that anything
taught in the school be reinforced in the community by parents, the media and health
policies.
Programs
for Students at Risk
Schools
can also deliver programs targeted to young people who are "at-risk" for
problems related to their substance use. This includes youths who may become dependent
on substances and develop problems that continue into their adult years.
Opening
Doors (Addiction Research Foundation, 1995) is a program for at-risk students in
Grades 8 to 10. The program aims to prevent or reduce substance use and other problems,
such as dropping out of school and violence. In this context, "at-risk"
is defined as those likely to experience drug use, truancy, school problems or violence.
The preliminary results of an evaluation of Opening Doors were encouraging (DeWit,
Braun et al., 1997). After participating in the program, at-risk students were found
to drink alcohol less frequently, to have less favourable attitudes to alcohol, tobacco
and cannabis use, and to be less susceptible to peer pressure to misbehave or behave
violently. Opening Doors has been implemented in more than 50 communities throughout
Ontario and will be introduced elsewhere, as needed.
Mass
Media Campaigns
For
several decades mass media campaigns have been used in attempts to reduce youthful
substance use. Such campaigns have the potential to be effective communication and
education tools. Young people report obtaining most drug information from television,
followed by parents and other print media (Mirzaee et al., 1991).
However,
studies have shown that mass media campaigns have had their greatest impact on increasing
knowledge and awareness, but modest success in affecting attitudes and behaviours
(Bauman et al., 1991; Murray et al., 1994; Popham et al., 1994).
The
mass media are most likely to be effective when they are used to set the agenda for
public discussion (Pentz, 1995; Redman et al., 1990). For example, they are believed
to have been a significant factor in making drinking and driving socially unacceptable
and increasing public support for tougher laws (Casswell et al., 1989; Zunz, 1997).
Alternative Activities and Youth Groups
One
prevention strategy, popularized in the 1970s, is to provide youths with recreational
activities and projects, such as tutoring, sports, art, entertainment or business
ventures. It is believed that these programs provide participants with a sense of
responsibility, self-esteem and fulfilment and an environment that reinforces community
values.
However,
on their own, alternative activity programs have not been found to substantially
decrease rates of substance use among participants (for a review see Norman et al.,
1997). Still, this does not rule out the possibility that such programs could play
an important role in larger community interventions.
Family-Based Approaches
In
recent years there has been a growing "parentsØ movement" in the United
States. While the move-ment has also had more general policy concerns, it has focused
on the role of parents in preventing drug use and abuse. Based on research related
to the development of alcohol and drug use among young people, this movement has
promoted good parent-child communication, having parents serve as positive role models,
and strong parenting skills as strategies to prevent or reduce youthful substance
use.
The
Strengthening Families Program (Kumpfer et al., 1989, 1997) is an example of a successful
prevention program. The target group is six- to 10-year-old children of substance
abusers (a pro-gram for children aged 11ß14 has also been recently designed). Strengthening
Families includes parent training, childrenØs skills training (designed to in-crease
socially acceptable behaviour) and family skills training to improve family interaction.
The Centre for Addiction and Mental Health is adapting and pilot testing the Strengthening
Families Program in Ontario in collaboration with community partners.
An
evaluation of the original experiment showed that the combination of the three skills
training components was the most effective in reducing childrenØs problem behaviours,
as well as intentions to use alcohol and tobacco. Improvements were also found in
parenting skills, family conflict and family communication (DeMarsh & Kumpfer,
1986). Generally, these positive results have since been replicated across different
ethnic subgroups in urban and rural settings (Aktan et al., 1996; Kumpfer & Alvarado,
1995; Kumpfer et al., 1996). Results of a five-year follow-up study should be forthcoming,
which will likely speak to the issue of whether the program can be effective in preventing
substance use among adolescents in high-risk families.
Multi-Level
Community Approaches
Research
suggests that comprehensive community programs are more promising than the single
pre-ventive strategies discussed above. This type of program requires participation
from various sectors: schools, families, workplaces, churches, governments and the
mass media.
The
Midwestern Prevention Program (MPP) is an example of an ambitious five-year program
implemented in Kansas City and Indianapolis during the late 1980s (Pentz, 1986; Pentz,
et al., 1989). The MPP consisted of five components sequentially introduced into
the community: a school program (Project STAR), a parent program, mass media advertising,
community organization, and policy changes that restricted access and availability.
The aim in using different methods at various times was to make the prevention messages
novel and memorable.
The
evaluation of the program at a one-year follow-up indicates that students who participated
in Project STAR showed significantly lower rates of tobacco, alcohol and marijuana
use compared to the control group (Pentz, et al., 1989). After three years, the rates
for tobacco and marijuana use were still low, but the prevalence of alcohol use was
not significantly different from the control group once the students reached senior
high school(Johnson et al., 1990).
Policy
Approaches
Policy
approaches have been shown to be effec-tive in reducing problems related to substance
use, particularly when combined with other educational and community approaches.
School
Policy
While
schools appear to have inherited the "drug problem," the reality is that
they cannot solve it alone. Nonetheless, a uniform policy on substance use and possession
on school property is an important component of a comprehensive prevention strategy
for youth.
In
Ontario, all school boards were mandated to develop and implement drug education
programs and policies by 1991. Guidelines highlighted three major elements of a comprehensive
policy: a preventive curriculum, early intervention and disciplinary action (Addiction
Research Foundation, 1991). Gliksman and colleagues (1992) sought to assess the impact
of school policy on studentsØ levels of alcohol use and related problems. School
policies were separated into three categories, depending on how extensive the policies
were.
The
study showed that drug policies in schools can have some effect on student substance
use. Students who were in schools with comprehensive policies showed less alcohol
consumption than those with minimal or moderate policies. In addition, students in
schools with full or moderate policies showed less frequent heavy drinking.
There
has been recent public debate about a "zero tolerance" environment in schools.
This would emphasize punishment -- ranging from automatic school suspensions to raising
the legal age for various activities (e.g., drinking, obtaining a driverØs licence)
-- for students found possessing or distributing any substance, including cigarettes.
However,
punitive school policies are not effective in preventing or curbing substance use
(Pentz, et al., 1989). Furthermore, imposing sanctions for use may also further alienate
those students already at-risk (DØEmidio-Caston & Brown, 1998). The result may
be to discourage those who are experiencing or are at risk for drug-related problems
from seeking help.
Health Warning Labels
Studies
show that cigarette warning messages have had some positive effects on young people.
The national 1994 Youth Smoking Survey found the majority of 10- to 19-year-olds
have seen the warnings and find them credible and important (Paglia, de Groh, &
Pederson, 1996; Paglia, de Groh, Rehm et al., 1996).
A
warning label has been on alcohol beverage containers in the United States since
1989. The warning is lengthy, printed in small type and is hard to read. One study
evaluated it one year after implementation using a sample of adolescents (MacKinnon
et al., 1993). Results showed that only 40 per cent reported seeing the warning,
and, not surprisingly, alcohol consumption did not change among youth.
Taxes
Adolescents
are sensitive to high prices. Raising the price of alcohol and cigarettes through
tax hikes reduces consumption. Studies of Canadian and U.S. increases in cigarette
taxes have shown significant drops in smoking among youth (Depart-ment of Finance
Canada, 1993; Ferrence et al., 1991; Harris, 1987; Lewit et al., 1981; Sweanor et
al., 1993). Meanwhile, tax decreases have led to rises in smoking rates (Hamilton
et al., 1997) as well as the amount smoked (Brown et al., 1996).
Studies
of alcohol taxes have shown similar effects on rates of drinking as well as motor
vehicle deaths (Chaloupka et al., 1993; Saffer & Grossman, 1987). Simulation
studies show that heavy drinking would be reduced among youth if taxes on alcohol
were increased (for a review see Grossman et al., 1995).
Minimum
Drinking Age
During
the 1980s, the minimum drinking age was raised to 21 in the United States. Subsequent
studies have shown that this reduced alcohol-related problems among youth, such as
suicides and injuries (Jones et al., 1992; OØMalley & Wagenaar, 1991). Moreover,
young people did not turn to marijuana, as is commonly thought to occur when alcohol
becomes less available (OØMalley & Wagenaar, 1991). The rise in legal drinking
age has also been found to be a factor in reducing the drinking and driving rates
among youth (Klepp et al., 1996; Moskowitz, 1989; OØMalley & Wagenaar, 1991;
for a review see Wagenaar, 1993).
Deterring Sales to Minors
In
Ontario, the main source for cigarettes among students is the local grocery/convenience
store. Less than half of the underage youth attempting to purchase tobacco are usually
asked for identification (Hobbs et al., 1997). Research demonstrates that, at least
in the short-term, enforcing the law restricting sales to minors and/or providing
education can reduce the number of over-the-counter sales, and possibly the rate
of smoking, among young people (Altman et al., 1991; DiFranza et al., 1992; Feighery
et al., 1991; Hinds, 1992; Jason et al., 1991; Keay et al., 1993).
Restrictions for Young or New Drivers
Two
studies have found that "zero tolerance" laws regarding blood alcohol levels
(i.e., lowering limits to 0.02 per cent or lower) have been effective in significantly
reducing alcohol-related car crashes among young drivers (Blomberg, 1992 as cited
in Hingson et al., 1997; Hingson et al., 1994). Public awareness campaigns help the
lawsØ effectiveness.
Graduated
licencing is a staged approach to obtaining a full-status driverØs licence, allowing
new drivers to gain experience while minimizing the risks. Early stages do not allow
drivers to have any alcohol in their blood, restrict the number and age of the passengers
and prohibit driving at night. Studies of graduated licensing in New Zealand and
a preliminary study of the Ontario system show that it significantly reduces drinking
and driving and the number of crashes among youth (Langley et al., 1996; Mann et
al., 1997; Mayhew & Simpson, 1990; Sweedler & Stewart, 1993).
Harm-Reduction
Approaches
It
is important to recognize that education and prevention programs have had mixed success
in reducing substance use, depending on the pattern of substance use among the young
people in question. However, programs aimed at reducing both risky behaviours and
harmful consequences related to the use of drugs, particularly alcohol, have shown
some success. As a result, the harm reduction model, which starts from a recognition
that most adolescents use alcohol, has gained some acceptance in programs aimed at
preventing driving injuries.
In
a comprehensive community program aimed at reducing drinking and driving among youth
as well as adults, six communities in Massachusetts introduced a variety of initiatives.
Among them were: media campaigns, report hotlines, awareness days, peer-led high-school
education, Students Against Drunk Driving chapters, alcohol-free prom nights and
college prevention programs (Hingson et al., 1996). Results after the five years
showed fatal crashes involving 15- to 25-year-old drivers declined by 39 per cent
relative to the rest of the state. Furthermore, there was a 40 per cent relative
decline in the proportion of 16- to 19-year-olds who reported driving after drinking
during the previous month.
Implications
- The goals of any alcohol and drug prevention program for youth should be realistic.
The main goal should be preventing or reducing harms associated with alcohol and
other drug use, as opposed to preventing use completely. A positive result of an
effective drug prevention program would be to delay a young personØs first use of
a drug or to limit or shape his/her drug use in a safer way.
- Alcohol and drug education programs should be based on practical educational
principles, not ideology. They should be ongoing from kindergarten to the final year
of high school, with messages that are appropriate for different age levels. Educational
approaches should be matched to their target audiences, based on age, gender, level
of use, attitudes towards drug use, etc. They should combine accurate, factual information
and strategies for developing skills such as communication, decision-making and conflict
resolution.
- Alcohol and drug prevention programs should be comprehensive. They should include
different components that complement each other, such as media campaigns, in-school
programs, family education and policy interventions. Special pro-grams are required
to target youth who are at risk of developing problems, as well as general programs
for the broad student population.
- Young people need to be directly involved in program planning and implementation.
Programs should capitalize on the strengths of the youth themselves. Young people
are well positioned to identify the issues, and develop solutions, as well as deliver
appropriate messages to their peers.
- Policies and regulations can be successful in limiting and shaping substance
use, and reducing harm, as shown by the success of graduated driverØs licence programs.
Policy initiatives should be combined with other approaches.
- Zero tolerance and other "hard line" approaches do not work and may
in fact increase the risk of serious problems. They can end up punishing students
who are experimenting, as most adoles-cents do, and discouraging those students who
are at risk of developing problems from getting the help that they need.
- Alcohol and drug education programs should be evaluated in an ongoing effort
to determine what works and what doesnØt work.
- Adults, including parents, educators, service providers and policy-makers, need
to be informed about drug education. They need to be aware of alcohol drug use and
trends among young people, as well as the effectiveness of various prevention approaches.
June, 1999
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Alcohol and Drug Prevention Programs for Youth: What Works?
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