Introduction
National survey data show that drug use among our Nation's youth is increasing at an alarming rate. Some say that we are on the verge of a major epidemic. However, 20 years of research have now provided the tools to change the current course of events and to reverse the increases in teenage drug use that began in 1992. We know more about the causes of drug abuse than ever before, and we have learned a great deal about what works and what does not. We are beyond the point where we have to make uninformed choices about what might prevent or reduce teenage drug use.
This paper discusses the progress in school-based prevention, both in general and with respect to the work of the author and colleagues at Cornell University Medical College. A major assumption in this work and a major theme of this NIDA conference is that prevention should be based on science - not on hunches, guesses, and wishful thinking. As General Barry McCaffrey, director of the Office of National Drug Control Policy, has said, "Ideology must be replaced by science."
The Quest for Effective Approaches
More than two decades have been devoted to trying to find effective approaches to drug abuse prevention. The goal of identifying effective prevention approaches has been elusive. Although many approaches have increased knowledge about the adverse consequences of using drugs and some have increased antidrug attitudes, few programs have demonstrated an impact on drug use behavior. However, early prevention efforts were based largely on "intuition" rather than on theory or science. As the field of drug abuse prevention has matured, there has been an increasing reliance on theory derived from empirical evidence of the causes of drug abuse.
Over the past few years, prevention efforts in general and school-based research in particular have begun to bear fruit. During this time, mounting empirical evidence from a growing number of carefully designed and methodologically sophisticated research studies clearly indicates that at least some approaches to drug abuse prevention work.
The purpose of this paper is to provide a brief overview of what is currently known about the effectiveness of drug abuse prevention efforts in school settings. The primary focus is on approaches that have been subjected to careful evaluation using acceptable scientific methods and whose results have been published in peer-reviewed journals.
Why Conduct Drug Abuse Prevention in Schools?
A variety of drug abuse prevention approaches have been developed and tested with different degrees of success. Clearly, one of the most productive areas of prevention research has involved the testing of approaches designed to be implemented in school settings. The reasons for the focus on school-based drug abuse prevention are rather obvious and straightforward. Most prevention approaches are designed to target school-age populations, with the greatest emphasis on middle/junior high school-age adolescents. Schools, therefore, serve as natural sites for both implementing and testing prevention approaches that target individuals in this age group. Schools provide relatively easy access to a large number of individuals who are the logical targets of prevention efforts. Schools are also the logical site of prevention efforts because they offer a structured setting within which prevention programs can be conducted and evaluated in a methodologically rigorous way.
Although schools are generally most concerned about their traditional educational mission, most States require that students receive tobacco, alcohol, and other drug education, either alone or as part of a larger health education curriculum. Notwithstanding the fact that this may amount to little more than one semester during the entire middle/junior high school years, it frequently provides a natural programming slot through which drug abuse prevention curriculums can be scheduled. Educators also are gradually beginning to recognize that both health and drug abuse prevention are important to the achievement of traditional educational objectives. The problem of drug abuse, therefore, has come to be seen as both a health problem and a barrier to educational achievement. Thus, educators have become increasingly receptive to the idea of setting aside some part of their academic schedule for drug abuse prevention.
Building on a Solid Scientific Foundation
Over the past decade and a half, drug abuse prevention studies have proceeded through several phases, ranging from small-scale pilot studies designed to test the acceptability, feasibility, and preliminary efficacy of promising approaches, to large-scale randomized field trials designed to provide the strongest possible evidence that a particular prevention method works. The most promising approaches have three distinguishing features: They are based on an understanding of what is known about the etiology of drug abuse, are conceptualized within a theoretical framework, and have been subjected to empirical testing using appropriate research methods. Although all three are critically important, the most fundamental element of any prevention program is an approach that is based on an understanding of the etiology of drug abuse.
The knowledge base that has developed concerning the etiology of drug abuse indicates that drug abuse is not caused by a single etiologic factor. Instead, there are many different factors that appear to interact with one another to produce a complex, probabilistic risk equation. This makes prevention much more difficult, because instead of identifying a single cause and developing an intervention to target it, interventions must target multiple risk and protective factors. As Pandina (this volume) indicates, research on the etiology of drug abuse suggests that to be effective, prevention programs targeting children and adolescents must influence social factors as well as knowledge, attitudes, norms, skills, and personality. To the extent possible, consideration must also be given to the importance of biological, pharmacological, and developmental factors.
Information concerning the age of onset and developmental progression from the work of Kandel (1978, pp. 3-38) and others (Hamburg et al. 1975) indicates that the initiation of drug use tends to follow a logical and predictable sequence. Most individuals begin by experimenting with alcohol and tobacco, progressing later to the use of marijuana. All of these substances are widely used in our society, and not surprisingly, the progression of drug use conforms exactly to the prevalence of each substance in our society. Correspondingly, these substances are also widely and easily available, frequently in the home. Because of their availability, inhalants are also used early in this sequence. Some individuals progress later to the use of other illicit substances such as stimulants, depressants, narcotics, and hallucinogens. This suggests that the focus of early prevention efforts should be on those substances used at the beginning of this sequence, that is, alcohol, tobacco, and marijuana.
Conclusions drawn from epidemiology and etiology indicate that prevention interventions should target individuals by at least the beginning of the adolescent period (middle or junior high school), although how early prevention efforts should begin is as yet unclear. Another implication from the etiology literature for prevention is that prevention programs should target the gateway substances of tobacco, alcohol, and marijuana. The recent increase in inhalant use and its potential role as a form of gateway drug use suggest that it should also be the focus of prevention efforts. These and other conclusions drawn from etiology research provide useful information concerning the kind of drug abuse prevention program likely to be the most effective. Understanding the etiology of drug abuse also makes it easy to recognize why some prevention approaches have not succeeded.
Prevention Approaches for School Settings
Most of what is known about what works in preventing adolescent drug abuse comes from school-based prevention research. As indicated elsewhere (Botvin 1996; Botvin and Botvin 1992), school-based prevention efforts can be divided into four general approaches: (1) information dissemination, (2) affective education, (3) social influence, and (4) competence enhancement. This paper focuses primarily on the last two approaches, because the available evidence indicates that they are the most promising.
Information Dissemination
The main staple of conventional approaches to drug abuse prevention has been programs designed to disseminate information about drug use, pharmacological effects, and the adverse consequences of drug abuse. The underlying assumption of these approaches is that the problem of drug abuse is caused by a lack of knowledge about the dangers of using drugs. Correspondingly, it is assumed that drug abuse can be prevented by making individuals aware of the appropriate facts about drug abuse. It is hoped that adolescents, armed with these facts, will make a logical and rational decision not to smoke, drink, or use illicit drugs. Closely related to information dissemination approaches is the use of fear-arousal techniques or scare tactics to dramatize the dangers of drug abuse and increase motivation to avoid drugs.
Despite the widespread use of these approaches, studies testing the effectiveness of information dissemination or fear-arousal approaches have consistently shown that they do not work (Dorn and Thompson 1976; Goodstadt 1974; Kinder et al. 1980; Richards 1969; Schaps et al. 1981; Swisher and Hoffman 1975, pp. 49-62). These studies show that information dissemination approaches are effective in their efforts to increase knowledge and also frequently increase antidrug attitudes. However, they fall short where it counts most - having an impact on drug use behavior. This is not to say that knowledge is unimportant or irrelevant to prevention efforts. In fact, developmentally appropriate and personally relevant health information may indeed have a place in drug abuse prevention programs. Yet, it is clear that prevention approaches primarily designed to increase information are not effective.
Affective Education
Another popular approach to drug abuse prevention over the years is designed to enhance affective development. Affective education approaches were widely used during the 1960s and early 1970s. Typically, the focus of affective education approaches is on increasing self-understanding and -acceptance through activities such as values clarification and responsible decisionmaking; improving interpersonal relations by fostering effective communication, peer counseling, and assertiveness; and increasing students' abilities to fulfill their basic needs through existing social institutions (Swisher 1979). The results of evaluation studies testing affective education approaches have been as disappointing as information dissemination and fear-arousal approaches. Although affective education approaches, in some instances, have been able to demonstrate an impact on one or more of the correlates of drug use, they have not been able to affect behavior (Kearney and Hines 1980; Kim 1988).
Social Influence
Increases in our understanding of the etiology of drug abuse led to the recognition that social factors play a major role in the initiation and early stages of drug use. These social influences arise from the media, peers, and the family. The original research in this area was conducted by Evans and colleagues (Evans 1976; Evans et al. 1978) and focused on adolescent cigarette smoking. The prevention approach developed and tested by Evans was a major departure from previous approaches to tobacco, alcohol, and other drug abuse prevention. It is noteworthy not only because it was the first approach to produce an impact on behavior, but also because it contained several of the core components still used in the most successful drug abuse prevention approaches, which are briefly described below.
Psychological Inoculation
The main emphasis of the prevention approach developed by Evans was a concept borrowed from McGuire's persuasive communications theory that is referred to as "psychological inoculation" (McGuire 1964, pp. 192-227; 1968, pp. 136-314). The underlying concept is analogous to that of inoculation used in infectious disease control. To prevent individuals from developing positive attitudes about smoking, drinking, or illicit drug use ("infection") from prodrug social influences ("germs"), it is necessary to expose adolescents to a weak dose of those germs in a way that facilitates the development of "antibodies" and thereby increases resistance to any future exposure to persuasive messages in a more "virulent" form. For example, from this perspective, cigarette smoking is conceptualized as resulting from exposure to social influences (persuasive messages) to smoke from peers and the media that are either direct (offers to smoke from other adolescents or cigarette advertising) or indirect (exposure to high-status role models who smoke).
Thus, a major part of the smoking prevention approach developed by Evans was designed to make students aware of the various social pressures to smoke they would likely encounter as they progressed through junior high school so they would be psychologically prepared (inoculated) to resist these influences. Although psychological inoculation was the conceptual centerpiece of this research, it has received less emphasis in more recent variations on the social influence model. Other components of the approach developed by Evans have assumed greater importance, although in a somewhat different form. These include demonstrations of techniques for effectively resisting various pressures to smoke, periodic assessment of smoking with feedback to students to correct the misconception that smoking is a highly normative behavior, and information about the immediate physiological effects of smoking.
Drug Resistance Skills
The research conducted by Evans and colleagues at the end of the 1970s created a sense of excitement and optimism that had been lacking for many years. After a decade of disappointing and frustrating research, there was finally evidence that prevention could work. This sparked a flurry of research activity by other research groups in the United States, Canada, Europe, and Australia. At this point, more research has been conducted with variations on the social influence approach to drug abuse prevention than possibly any other contemporary approach over the past 20 years (e.g., Arkin et al. 1981; Hurd et al. 1980; McAlister et al. 1979; Luepker et al. 1983; Perry et al. 1983; Telch et al. 1982; Donaldson et al. 1994; Ellickson and Bell 1990; Snow et al. 1992; Sussman et al. 1993).
One of the distinct differences that emerged during this time was an increased emphasis on teaching what has come to be referred to as "drug resistance skills" or "drug refusal skills." Students are taught the requisite information and skills to recognize, avoid, or respond to high-risk situations - situations in which they will have a high likelihood of experiencing peer pressure to use drugs. Students are taught not only what to say in response to a peer pressure situation (the specific content of a refusal message), but also how to say it in the most effective way possible. In addition, students are taught how to respond to influences from the media to use drugs, particularly how to resist the persuasive impact of advertising by recognizing the advertising appeals contained in ads and formulating counterarguments to those appeals.
Correcting Normative Expectations
Adolescents typically overestimate the prevalence of smoking, drinking, and illicit drug use (Fishbein 1977). Therefore, the third major component of the social influence approach to drug abuse prevention involves correcting normative expectations, that is, correcting the misperception that many adults and most adolescents use drugs. This is sometimes referred to as "normative
education" (Hansen and O'Malley 1996, pp. 161-192). Several methods have been used to modify or correct normative expectations. One method involves providing students with information concerning the prevalence rates of drug use among their peers either from national or local survey data so that they can compare their own estimates of drug use with actual prevalence rates. Another method involves having students participate in the prevention program to organize and conduct classroom, schoolwide, or local community surveys of drug use.
Using Peer Leaders
A characteristic feature of many prevention approaches based on the social influence model is the use of peer leaders as program providers. Peer leaders are selected because of their role as opinion leaders. They are individuals who appear to have high credibility with the participants in the prevention program. They are also leaders in the sense that they serve, to varying degrees, as program providers. In most studies, peer leaders have been older students, for example, 10th graders might serve as peer leaders for 7th graders; however, in some cases, peer leaders have been the same age as the participants and may even have been from the same class. The ration-ale for using peer leaders is that peers often have higher credibility with adolescents than do teachers or other adults. Peer leaders serve a variety of functions, including serving as discussion leaders, role models who do not use drugs, and facilitators of skills training by demonstrating the drug refusal skills being taught in these prevention programs.
Competence Enhancement (Life Skills Training)
Another effective drug abuse prevention approach emphasizes teaching general personal and social skills, either alone (Caplan et al. 1992) or in combination with selected components of the social influence model (Botvin et al. 1980; Botvin and Eng 1980; Botvin, Baker, Renick et al. 1984; Botvin, Baker, Botvin et al. 1984; Botvin et al. 1983; Pentz 1983, pp. 195-232; Schinke and Gilchrist 1983, 1984; Gilchrist and Schinke 1983, pp. 125-130; Schinke 1984, pp. 31-63; Botvin, Baker, Filazzola, and Botvin 1990). This second approach, referred to as the "competence enhancement" approach, is much more comprehensive than the information dissemination, affective education, or social influence approaches. Moreover, unlike affective education approaches that rely on experiential classroom activities, the competence enhancement approach is based on a solid foundation of research and theory.
The most extensive research on the competence enhancement approach to drug abuse prevention is the Life Skills Training program, which has been tested by the author's research group at Cornell during the past 16 years. Prior research on the causes of drug abuse guided the development of this prevention approach, and the classroom teaching techniques it uses are based on proven cognitive/behavioral skills training methods. The theoretical foundation for the Life Skills Training approach is based on social learning theory (Bandura 1977) and problem behavior theory (Jessor and Jessor 1977). Drug abuse is conceptualized as a socially learned and functional behavior, resulting from the interaction of social influences that promote drug use and intrapersonal factors that affect susceptibility to these influences.
Evidence from one study suggests that broad-based competence enhancement approaches may not be effective unless they also contain some resistance skills training material (Caplan et al. 1992). This may be necessary because such material includes a focus on antidrug norms and helps students apply generic personal and social skills to situations related specifically to the prevention of substance abuse. Thus, the most effective prevention approaches appear to be those that combine the features of the problem-specific social influence model and the broader competence enhancement model.
The primary aim of programs designed to teach life skills and enhance general competence is to teach the kinds of skills for coping with life that will have a relatively broad application. This contrasts with the social influence approach, which is designed to teach information, norms, and refusal skills with a problem-specific focus. Competence enhancement approaches, such
as the Life Skills Training program, emphasize the application of general skills to situations directly related to drug use and abuse, such as the application of general assertive skills to situations involving peer pressure to smoke, drink, or use other drugs. These same skills can be used for dealing with the many challenges confronting adolescents in their everyday lives, including but not limited to drug use. The following is a brief description of the content areas covered by the Life Skills Training program.
Drug Resistance Information and Skills
The Life Skills Training prevention model that the author and colleagues have tested incorporates aspects of the social influence approach that are intended to deal directly with the social factors that promote drug use. It also includes general self-management skills and social competence skills. Components from the social influence model include (1) teaching an awareness of social influences to use drugs, (2) correcting the misperception that everyone is using drugs and promoting antidrug norms, (3) teaching prevention-related information about drug abuse, and (4) teaching drug refusal skills.
Self-Management Skills
The Life Skills Training approach also involves teaching students a set of important skills for increasing independence, personal control, and a sense of self-mastery. This includes teaching students (1) general problemsolving and decisionmaking skills, (2) critical thinking skills for resisting peer and media influences, (3) skills for increasing self-control and self-esteem (such as self-appraisal, goalsetting, self-monitoring, and self-reinforcement), and (4) adaptive coping strategies for relieving stress and anxiety through the use of cognitive coping skills or behavioral relaxation techniques.
General Social Skills
Drug use behavior is learned through modeling and reinforcement and is influenced by cognition, attitudes, and beliefs. To enhance social competence, students in the Life Skills Training program are taught a variety of general social skills. This includes teaching (1) skills for communicating effectively (such as how to avoid misunderstandings by being specific, paraphrasing, and asking clarifying questions), (2) skills for overcoming shyness, (3) skills for meeting new people and developing healthy friendships, (4) conversational skills, (5) complimenting skills, and (6) general assertiveness skills. These skills are taught through a combination of instruction, demonstration, feedback, reinforcement, behavioral rehearsal (practice during class), and extended practice (outside of class) through behavioral homework assignments from the interplay of social and personal factors.
Most of the prevention studies that have used this approach have focused on seventh graders. However, some studies have been conducted with 6th graders (Kreutter et al. 1991), and one was conducted with 8th, 9th, and 10th graders (Botvin et al. 1980). Program length has ranged from as few as 7 sessions to as many as 20 sessions. Some of these prevention programs were conducted at a rate of one class session per week, whereas others were conducted at a rate of two or more classes per week. Most of the studies conducted so far have used adults as the primary program providers. In some cases these adults were teachers, and in other cases they were outside health professionals such as project staff members, graduate students, or social workers. Some studies have included booster sessions as a means of preserving initial prevention effects.
Target Population of Prevention Research
Research concerning the etiology of drug abuse and adolescent development indicates that a critical time for experimentation with tobacco, alcohol, and illicit drugs occurs at the beginning of adolescence. For this reason, most of the drug abuse prevention research studies have involved middle or junior high school students. The primary year of intervention for these studies has generally been the seventh grade. However, some studies have included students as young as fourth, fifth, and sixth grades (Donaldson et al. 1994; Shope et al. 1992; Donaldson et al. 1995; Flynn et al. 1992). There is general agreement that at least some of the risk factors for drug abuse may have their roots in early childhood, arguing for beginning interventions at a younger age. However, a major concern of prevention researchers testing the efficacy of one or more intervention approaches is that base rates of drug use are typically quite low prior to adolescence.
To adequately test the impact of prevention programs on drug use, it is necessary to select an age range that not only makes sense from an intervention perspective, but also includes individuals who are old enough to begin using drugs in sufficient numbers for researchers to detect statistically significant differences between treatment and control groups. Generally speaking, the base rates of even the most prevalent forms of drug use are too low prior to seventh grade for meaningful prevention research.
Findings From Evaluation Studies
Short-Term Effects on Smoking
Evaluation studies have tested the efficacy of drug abuse prevention approaches almost exclusively in terms of their impact on tobacco, alcohol, and marijuana use, because the use of these substances has the highest prevalence rates and occurs at the beginning of the developmental progression of drug use. Although the largest number of studies have focused primarily on cigarette smoking, many studies have also tested the impact of prevention approaches on alcohol and marijuana use. Both the social influence and competence enhancement approaches have produced impressive initial reductions in drug use when compared with controls, who received either no treatment or an alternative treatment.
The effectiveness of social influence approaches has been documented in a number of studies (Arkin et al. 1981; Hurd et al. 1980; McAlister et al. 1979; Luepker et al. 1983; Perry et al. 1983; Telch et al. 1982; Donaldson et al. 1994; Ellickson and Bell 1990; Snow et al. 1992; Sussman et al. 1993). The results of these studies show a reduction in the rate of smoking by between 30 and 50 percent after the initial intervention. Several studies have demonstrated reductions in the overall prevalence of cigarette smoking among the participating students for both experimental smoking (less than one cigarette per week) and regular smoking (one or more cigarettes per week). The social influence approach has also been found to reduce smokeless tobacco use (Sussman et al. 1993).
Studies testing the efficacy of competence enhancement approaches have also found significant reductions in cigarette smoking relative to controls (Botvin et al. 1980; Botvin and Eng 1980; Botvin, Renick, Filazzola et al. 1984; Botvin, Baker, Botvin et al. 1984; Botvin et al. 1983; Pentz 1983; Schinke and Gilchrist 1983, 1984; Gilchrist and Schinke 1983, pp. 125-130; Schinke 1984, pp. 31-63; Botvin et al. 1990). These studies demonstrate that generic skills training approaches to drug abuse prevention can cut cigarette smoking from 40 to 75 percent. Data from two studies using the Life Skills Training program (Botvin and Eng 1982; Botvin et al. 1983) show that it can reduce regular smoking (one or more cigarettes a week) at the 1-year followup evaluation by 56 to 66 percent without additional booster sessions. With booster sessions, these reductions have been as high as 87 percent (Botvin et al. 1983). Moreover, initial reductions of an equal magnitude have also been reported for regular smoking (Botvin et al. 1983; Botvin and Eng 1982).
Short-Term Effects on Alcohol and Marijuana Use
Studies testing the efficacy of the social influence approach on alcohol and marijuana use have reported reductions of roughly the same magnitude as for cigarette smoking (Ellickson and Bell 1990; McAlister et al. 1980; Shope et al. 1992). Several studies also provide evidence for the efficacy of the competence enhancement approach on the use of alcohol (Botvin, Baker, Renick et al. 1984; Botvin, Baker, Botvin et al. 1984; Pentz 1983, pp. 195-232; Botvin, Baker, Dusenbury et al. 1990; Epstein, Botvin et al. 1995) and marijuana (Botvin, Baker, Botvin et al. 1984; Botvin, Baker, Dusenbury et al. 1990; Epstein, Botvin, Díaz et al. 1995). In general, prevention effects have been the strongest for cigarette smoking and marijuana use and the weakest and the most inconsistent across studies on alcohol use.
Long-Term Effects
Followup studies indicate that the prevention behavioral effects of these approaches have a reasonable degree of durability. Social influence approaches have produced reductions in smoking that last for up to 4 years (Luepker et al. 1983; Telch et al. 1982; Sussman et al. 1993; McAlister et al. 1980). One multicomponent study found prevention effects for up to 7 years (Perry and Kelder 1992). However, the results of most long-term followup studies indicate that prevention effects are typically not maintained and last only 1 or 2 years (Murray et al. 1988; Flay et al. 1989; Bell et al. 1993; Ellickson et al. 1993). This has led to concern by some that school-based prevention approaches may not be powerful enough to produce lasting prevention effects (Dryfoos 1993, pp. 131-147). On the other hand, others have argued that the prevention approaches tested in these studies may have had deficiencies that undermined their long-term effectiveness (Resnicow and Botvin 1993).
Long-term followup data (Botvin, Baker, Dusenbury et al. 1995) from one of the largest school-based substance abuse prevention studies ever conducted found reductions in smoking, alcohol, and marijuana use 6 years after the initial baseline assessment. This randomized, controlled field trial involved nearly 6,000 seventh graders from 56 public schools in New York State. After random assignment to prevention and control conditions, students in the prevention condition received the Life Skills Training program during the seventh grade (15 prevention sessions) with booster sessions in the eighth grade (10 sessions) and ninth grade (5 sessions). No intervention was provided during the 10th to 12th grades. Followup data were collected by survey in class, by mail, and/or by telephone at the end of the 12th grade and beyond for those students not available for the school survey.
The prevalence of cigarette smoking, alcohol use, and marijuana use for the students in the prevention condition was as much as 44 percent lower than for controls. Significant differences, up to 66 percent relative to controls, were also found with respect to the prevalence of polydrug use (i.e., students using all three gateway drugs) during the past week. The results of this study suggest that, to be effective, school-based interventions must be more comprehensive and have a stronger initial dosage than most studies that have used the social influence approach. Prevention programs also must include at least 2 additional years of booster intervention and be implemented in a manner that is faithful to the underlying intervention model.
Factors Affecting Long-Term Effectiveness
The failure to find long-term prevention effects may have to do with factors related to either the type of intervention tested in these studies or the way these interventions were implemented. The absence of long-term prevention effects in some studies should not be taken as an indictment of all school-based prevention programs. According to Resnicow and Botvin (1993), there are several reasons why durable prevention effects may not have been produced in many long-term followup studies: The length of the intervention may have been too short (i.e., the prevention approach was effective, but the initial prevention "dosage" was too low to produce a long-term effect); booster sessions were either inadequate or not included (i.e., the prevention approach was effective, but it eroded over time because of the absence or inadequacy of ongoing intervention); the intervention was not implemented with enough fidelity to the intervention model (i.e., the correct prevention approach was used, but it was implemented incompletely, improperly, or both); and the intervention was based on faulty assumptions, was incomplete, or was otherwise deficient (i.e., the prevention approach was ineffective).
Generalizability to Minority Youth
Most prevention research has been conducted with predominantly white, middle-class, suburban populations. Racial/ethnic minority youth have been underrepresented in prevention evaluation studies. Consequently, relatively little is known concerning the etiology of drug abuse among minority youth. However, several studies indicate that there is substantial overlap in the factors promoting and maintaining drug use among different populations (Bettes et al. 1990; Botvin, Baker, Botvin et al. 1993; Botvin, Epstein, Schinke et al. 1994; Botvin, Goldberg, Botvin et al. 1993; Epstein et al. 1994). This suggests that prevention approaches found to be effective with one population should also be effective with others. Over the past decade, this hypothesis has been investigated in a number of studies that tested the generalizability of
prevention approaches previously found to be effective with white youth.
Studies testing the efficacy of Life Skills Training have shown that it is effective in decreasing drug use, intentions to use drugs, and risk factors associated with drug use. Qualitative research with parents, teachers, and students found high acceptance and perceived utility for this prevention approach among black and Hispanic populations. Where appropriate, the language, examples, and behavior rehearsal scenarios were modified to increase cultural sensitivity and relevance to each of the target populations, but no modifications were made to the underlying prevention approach that focused on teaching generic personal and social skills, anti-drug-use norms, drug refusal skills, and prevention-related knowledge and information.
To date, most of the research with minority youth has involved cigarette smoking. These studies have consistently shown that the Life Skills Training approach can result in less cigarette smoking relative to controls for inner-city Hispanic youth (Botvin, Dusenbury, Baker et al. 1989; Botvin et al. 1992) and African-American youth (Botvin, Batson, Witts-Vitale et al. 1989; Botvin and Cardwell 1992). Followup data with Hispanic youth have demonstrated the continued presence of lower levels of cigarette smoking up to the end of the 10th grade (Botvin, Schinke, Epstein, and Díaz 1994). Several recent studies show that drug abuse prevention approaches such as Life Skills Training can also reduce alcohol and marijuana use among minority populations (Botvin, Schinke, Epstein, and Díaz 1994; Botvin, Schinke et al. 1995), and that tailoring the intervention to the culture of the target population can enhance its effectiveness (Botvin, Schinke et al. 1995).
Program Providers
Considerable variation exists among the individuals responsible for implementing school-based drug abuse prevention programs. Some programs have been implemented by college students, others by members of the research project staff, and still others have used classroom teachers to implement the prevention programs. It has generally been assumed that peer leaders play an important role in social influence approaches. Same-age or older peer leaders have been included in nearly all of the studies testing social influence approaches and in some of the studies testing the personal and social skills training approaches (competence enhancement). In general, evidence supports the use of peer leaders for this type of prevention strategy (Arkin et al. 1981; Perry et al. 1983).
Although peer leaders have been used successfully to varying degrees in these programs, they usually assist adult program providers and have specific and well-defined roles. The primary providers in most of these studies have been either members of the research project staff or teachers. There is also evidence to suggest that peer-led programs may not be uniformly effective for all students. For example, the results of one study suggest that although boys and girls may be equally affected by social influence programs conducted by teachers, girls may be more influenced by peer-led programs than are boys (Fisher et al. 1983).
Research studies with competence enhancement approaches have shown that they can be successfully implemented by project staff members, peer leaders, and classroom teachers (Botvin and Botvin 1992); however, not all adult program providers are equally effective (Botvin, Baker, Filazzola et al. 1990). Additional research is needed to identify the characteristics of the most effective providers as well as the optimal match between the characteristics of providers and prevention program participants.
Project DARE (Drug Abuse Resistance Education), which is conducted by police officers, is on the other end of the program provider spectrum from programs using peer leaders. DARE is without a doubt one of the best known applications of the social influence model. Project DARE was initially developed by the Los Angeles Police Department and based on research conducted at the University of Southern California. The fact that it has been embraced by police departments throughout the country has provided a natural dissemination system unparalleled by other prevention programs. Being a prevention program that is implemented by police officers and supported by law enforcement agencies around the country makes DARE unique and has no doubt contributed to its adoption by a large number of schools. According to news accounts, DARE is said to be used in approximately 60 percent of the elementary school classrooms in America.
Yet, despite its acknowledged success in promoting awareness of drug abuse and gaining adoption by more schools across the country than any other program, DARE has been plagued by disappointing evaluation results and a surprising amount of negative news coverage. According to a major meta-analysis of studies evaluating the DARE program, it is less effective than other social influence approaches and has produced only minimal effects on drug use behavior (Ennett et al. 1994). Because DARE has much in common with other prevention approaches based on the social influence model, its poor evaluation results are difficult to explain. In view of the fact that the main difference between similar programs showing reductions in drug use and DARE is the program provider, a logical conclusion is that the absence of strong prevention effects may be related more to the program provider than the program itself. The rationale for using peer leaders as program providers has been that peers have greater credibility regarding lifestyle issues than parents, teachers, or other adults who are viewed as authority figures. This is especially true during a developmental period when individuals, particularly those who are at greatest risk for engaging in deviant behaviors, are increasingly likely to rebel against authority figures. Because a police officer is the ultimate symbol of authority in our society, it is reasonable to expect them to have lower credibility with high-risk children and adolescents and, correspondingly, to be less effective as a drug abuse prevention program provider. Still, the effectiveness of police officers as program providers has not been directly tested, so it remains an open question in need of empirical clarification.
Summary and Conclusion
This chapter has focused on drug abuse prevention efforts in school settings. Schools are a natural and convenient site for conducting drug abuse prevention programs. Increasingly, educators are coming to recognize that promoting health and preventing drug abuse are vitally important both to the general well-being of students and to the achievement of primary educational objectives. When the standard of effectiveness is deterrence of drug use, prevention approaches that rely on providing students with information about the adverse consequences of using drugs have been consistently found to be ineffective. Similarly, efforts to promote affective development through unfocused, experiential activities have also been found ineffective.
The only prevention approaches that have been demonstrated to effectively reduce drug use behavior are those that teach junior high school students social resistance skills and antidrug norms, either alone or in combination with teaching generic personal and social skills. Both approaches emphasize skills training and deemphasize the provision of information concerning the adverse health consequences of drug use. These approaches have been shown to work with different program providers and different target populations, including racial/ethnic minority youth. Despite generally impressive initial prevention effects, it is evident that without booster sessions, these effects decay over time. Thus, to produce lasting prevention effects, it is necessary to have ongoing prevention activities throughout the early adolescent years and perhaps until the end of high school.
The field of drug abuse prevention has advanced considerably in the past decade and a half. Yet, despite the promise offered by existing school-based approaches, additional research is needed to further refine current prevention models to optimize their effectiveness and increase our understanding of how they work. However, for the first time in the history of drug abuse prevention, evidence from a number of rigorously designed evaluation studies shows that specific school-based prevention models are effective. It is now incumbent on health care professionals, educators, community leaders, and policymakers to move expeditiously toward wide dissemination and utilization of these approaches. It is equally important for private and governmental agencies to provide adequate funding for the important research necessary to further refine existing prevention models and to increase our understanding of the causes of substance abuse.
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