NIDA Research Priorities and Highlights

Role of Research

Prevention of Drug Use and Addiction

Understanding what determines vulnerability to substance use is crucial to developing effective prevention programming. However, there are no unique factors that determine which individuals will use drugs; rather, drug use develops as the result of a variety of genetic, biological, emotional, cognitive, and social risk factors that interact with features of the social context. Thus, both individual-level factors and social context-level factors make an individual more or less at risk for drug use.

Researchers have identified many risk factors associated with the development of drug problems. These factors typically have been organized into categories that represent individual risks and risks presented within the social context. For example, identified individual-level risks include shy, aggressive, and impulsive personality traits and poor academic achievement; family-level risks include poor parental monitoring and exposure to substance use by parents and siblings; school-level risk factors include a pro-drug use school norm and availability of drugs on or near the school campus; and community-level risks include lack of positive academic and recreational programming for children and adolescents during the afterschool and weekend hours and low levels of enforcement of laws pertaining to the use of licit and illicit substances by minors. This incomplete list of risk factors illustrates the breadth and complexity of the risks to which an individual may be exposed.

However, this list does not give much insight into how risk factors operate for individuals or groups because it does not consider the embeddedness of individuals in contexts that may place them at risk, the active role that individuals play in their own development through interactions and transactions within the social environment, developmental stages of individuals, and individual differences in the susceptibility to type and number of risks. Moreover, for many years the risk factor focus did not consider the influence of protective or resiliency factors-factors that protect individuals from developing problems such as substance use and that also operate at the individual and contextual levels through the family, peer group, school, community, workplace, and media, among others. Examples of protective or resiliency factors can include a stable temperament, a high degree of motivation, a strong parent-child bond, consistent parental supervision and discipline, bonding to prosocial institutions, association with peers who hold conventional attitudes, and consistent, communitywide anti-drug use messages and norms. An accumulation of protective factors may counteract the negative influences of a few risk factors. However, for most individuals, an accumulation of risk factors appears to have a more powerful effect than an accumulation of protective factors. [62]

Based on an understanding of risk and protective factors and social contexts that place individuals at more or less risk of drug use and addiction, several drug use preventive interventions have been developed. Studies funded by NIDA indicate that many of these preventive interventions demonstrate both short- and long-term positive outcomes in preventing the initiation of drug use, interrupting the progression to drug abuse, and reducing the likelihood of relapse. These prevention programs serve to reduce the health and social consequences of drug use. Although the bulk of the etiologic data that informs the development of the theories on which these programs have been built comes from the work of etiologic researchers, most prevention research also provides some information on the etiology of drug use initiation and progression. The next four sections of this chapter explore, first, some recent etiologic findings that have emerged from drug use prevention research; second, some results that have led to a better understanding of why programs are effective; third, descriptions of some prevention programs that have been shown to be effective; and fourth, some principles of prevention that have been derived through applying empirical tests to theory in the form of intervention studies.

Etiology

Individual

Many individual-level factors that may place youth at risk for or protect them from substance use initiation and abuse or addiction have been identified. However, ongoing research continues to uncover other such factors and to refine what is known about those that have been identified. Recent research indicates that personality and behavioral traits and styles that are evident in early childhood may have implications for later substance use behaviors. One such trait is aggressiveness. One study that examined children classified into reactive and proactive aggressive behavior types found that those in the reactive aggressive group had histories of physical abuse, early onset of behavior problems, adjustment problems in peer relations, and deficits in problem-solving processes around situations that provoked aggressive responses. On the other hand, those who were proactively aggressive anticipated positive outcomes from being aggressive. [63] These findings suggest differential prevention programming for these two groups of aggressive children.

Gender may also play a risk or protective role in substance abuse. In general, females are less likely to use illicit substances than males. However, some subgroups of females may be at heightened risk. For example, Latino girls are at greater risk of receiving drug offers than females from other ethnic groups. [64] In another study in which middle school and high school girls were compared on several risk behaviors, the younger girls displayed less knowledge of the adverse consequences of drug use behaviors and perceived less prevalence of these behaviors among their peers. On the other hand, they also expressed less belief in the media, which may serve as a protective factor. [65]

Early initiation of drug use has also been identified as a strong predictor of later abuse. New evidence shows a strong association between low levels of competency in multiple areas, as reported by both the child and the child's teacher, and tobacco and alcohol use among elementary school children. [66] Although initial use of alcohol may be driven more by social influences, later stages of problem drinking appear to be linked developmentally to intrapersonal deficits. Over time, high school students who were more susceptible to social influences and displayed lower levels of competency were more likely to exhibit increased drinking behavior. [67] Thus, there appears to be some stability in individual factors that relate to the initiation and progression of substance use over the course of development.

A small but significant relationship has been found between drug use and cognitive and affective self-management strategies in early adolescence. This relationship becomes stronger over time, and by late adolescence, increased drug use may contribute to impaired social, emotional, and psychological development. As a further complication, memory associations with drug cues and drug use outcomes may influence future drug use decisions. [68] One group of investigators speculates that cognitive deficits may actually precede and predispose some individuals to drug use initiation. Thus, weaknesses in cognitive skills and learning disabilities may be undetected risk factors that underlie other identified risk factors, such as low self-esteem and academic failure. [69]

Family

Parenting practices are central to children's development of risk for drug use. To enhance understanding of developmental patterns leading to adolescent drug use, researchers have focused extensively on the role of parenting in establishing, maintaining, or exacerbating risk trajectories in children and adolescents. Early onset is not random. Rather, it is often a predictable and identifiable outcome of a developmental progression that begins in early childhood and involves the interaction of characteristics of the child in the context of the family. It is not so much who the parents are but what skills they bring to the socialization of the child that is the most important factor. [70] A number of studies have shown that poor parental monitoring and parent-child conflict predict the initial level and trajectory of drug use, and these levels and trajectories were similar for alcohol, tobacco, and marijuana. [71] In fact, parental monitoring is linked both directly and indirectly to early onset drug use-directly, through the lack of actual supervision, and indirectly, through the additional time spent with peers. Children who are not well monitored tend to loiter in the community, freely selecting places to spend time where drug use and other delinquent activities might occur. [72] Thus, parenting practices can serve a protective role in the face of adverse, risky environments.

The social model of childhood development hypothesizes that strong emotional bonds to adults and to institutions associated with antisocial behavior contribute to the development of antisocial behavior in children. Consistent with this perspective, previous research has indicated that children who bond strongly to substance-using parents are at risk of developing substance use problems themselves. Recent work has now examined the interactive relationship between a parent's drug use, the process of bonding to parents, and substance use by children in a longitudinal study of families headed by substance users in methadone treatment for opiate addiction. Bonding to parents and child substance use are moderately negatively correlated in children whose parents ceased using drugs but are weakly positively correlated in children whose parents continued using drugs. These results support the social development model and suggest that family interventions for preventing substance use in children of substance users should focus on reducing parental drug use and promoting bonding to parents who are abstinent. [73]

Unlike families in the general population, positive family management practices showed little effect on reducing problem behaviors among children of methadone clients. This was especially true for older children for whom the effects of maternal attachment were relatively weak. [74] However, retrospective reports of addicts on family experiences during adolescence compared relationships with mothers and fathers. In general, mothers were viewed as more functional than fathers in the areas of involvement, responsibility, and attachment. [75]

Parental substance use has also been indicated as a risk factor for child substance use. Among children in grades three and five, early onset smoking was associated with exposure to parental smoking. Interestingly, it did not matter whether the parent had quit smoking. What did matter was the parent, smoking or not, taking a strong antismoking stance with the child. [76] Among adolescents, substance use by an important adult was a potential risk for substance use experimentation. Data indicated that the risk is least for tobacco, intermediate for alcohol, and greatest for marijuana. Adolescents who reported exposure to adult use of alcohol, tobacco, or marijuana were likely to be further advanced in the onset process than other students at each of the junior high school years, grades seven through nine. [77]

Integrating children's individual differences with parenting models enhances our understanding of childhood markers of later substance use. For example, fourth- and sixth-grade boys who were classified as either active or fearful were assessed relative to the parenting practices they experienced. Active boys who were poorly monitored and fearful boys who were exposed to harsh discipline exhibited higher levels of aggressive behavior, a precursor of later substance use. [78]

Peers

Peers play a major role in the development of deviant behaviors, including the use of drugs, and their influence increases during the adolescent years. In one study, researchers observed 13- to 14-, 15- to 16-, and 17- to 18-year-old male, close-friend pairs discussing problem solving situations. Although the close friends who came to the sessions changed over time, the topics, which typically included deviant and violent talk, remained essentially the same. These findings suggest that adolescent violence and antisocial behavior are embedded in the patterns of social interactions in friendships. [79]

Association with deviant peers has also been found to be predictive of the initial level and trajectory of drug use, and these levels and trajectories were similar for alcohol, tobacco, and marijuana. [80] Among fourth- and sixth-grade students, modeling of use by best friends and a high level of perceived prevalence of use among same-age peers were strongly related to the initiation and experimentation stages of tobacco and alcohol use. However, family and individual factors, such as offers from parents, adjustment to school, and behavioral regulation, were also associated with use. Among these younger children, the initiation and experimentation stages were not as highly differentiated as they were among adolescents. [81]

School

Recent findings showed substantial variation across 36 elementary schools in rates of lifetime alcohol use, lifetime cigarette use, and current cigarette use. However, contrary to expectations, lifetime alcohol and cigarette use rates were higher in schools located in neighborhoods having greater, rather than lesser, social advantages. [82] Additional findings indicate that schools with greater tobacco problems are more likely to adopt more restrictive policies on their own, regardless of whether an intervention is in place. Schools also appear to target youth at risk for school failure and other problem behaviors with tobacco policy sanctions. [83]

Workplace

Relatively little research has been conducted on preventive interventions for the workplace. An essential step is a clear definition of the problem through preintervention research. In an effort to get the most reliable data on drug use among an intervention sample of 928 steel mill workers, a combination of self-report, urinalysis, and hair analysis was used. Use of the biological assays resulted in a prevalence rate approximately 50 percent higher than that achieved with self-report only. [84] Additional research has found that employees are often unaware of or ambivalent toward workplace substance use policies. Five attitude categories about workplace policies emerged from a survey of municipal employees: (1) dissatisfied with efforts to control employee abuse, (2) satisfied, (3) antipolicy, (4) propolicy, and (5) uninformed. Different profiles were identified for each of the attitude groups. For example, dissatisfied employees reported low personal alcohol use, high coworker use, and low self-referral, whereas antipolicy employees reported high personal drug use, high coworker use, and low job identity. [85]

Special Populations

Preventive interventions appear to be most effective when they consider characteristics and risk and protective factors associated with the target group. Thus, efforts are being made to understand what risk and protective factors may be salient for specific racial and ethnic groups and subgroups. For example, although the level of tobacco use among Mexican-American 10th and 12th graders was the same for children in migrant and nonmigrant families, several risk and protective factors were identified. For example, risk factors for tobacco use included peer and family use of tobacco, whereas protective factors included close parental supervision and caring, good school adjustment, and strong religious identification. [86] Among middle school children, Latino males and females were more likely to experience drug offers than other students. However, there were no differences in the type or setting of drug offers. For all groups, offers were simple, rather than complex and pressure filled, and could be resisted with simple refusals. Drugs tended to be offered to all groups most frequently at home and in public settings rather than at school or at parties. [87]

In another sample of 448 Latino young adolescents, increased interaction with non-Latino peers was positively related to attitudes and perceived peer norms against substance use. Moreover, for youth with both high and low levels of acculturation, perceived normative expectations and negative attitudes toward substance use were deterrents of future use. [88]

Findings on Prevention Methodology

In addition to knowledge about the etiology of drug use, prevention research also results in a greater understanding of how to encourage program participation, why programs are more or less effective, and what insights into the processes that occur through intervention can have positive or negative effects on outcome. Research aimed at gaining higher participation rates by families in family interventions indicated that barriers to participation included intervention-related time demands, logistic requirements, negative beliefs and attitudes about interventions, and the influence of family members. [89] To gain participation, program planners and implementers must find ways to minimize these barriers, such as flexibility in intervention scheduling; minimizing of initial time commitments; contacts from parents and peers; and multiple incentives, such as free food coupons, refreshments, and child care. The reasons for program effectiveness are many and varied, and much more research needs to be conducted to fully understand these processes. However, some headway is being made in understanding what constitutes both effective prevention message presentation and prevention content. For example, in a meta-analysis of 120 school-based preventive interventions for 5th- through 12th-grade students, two major program types were identified: interactive and noninteractive. Results of the meta-analysis indicated that the interactive programs changed drug knowledge, attitudes, and behaviors, whereas the noninteractive programs changed only knowledge. [90] Similarly, the effectiveness of classroom and self-instruction versions of 16 theory-based prevention activities was tested with students in continuation high schools. The students who received the health educator-led activities in the classroom consistently reported higher levels of perceived quality than did those who completed the self-instruction activities only. [91]

Evidence about the effects of memory associations and drug use decisions suggests that prevention programming should concentrate on making program information, such as drug refusal strategies and awareness of potential negative consequences, highly accessible from memory in high-risk situations. [92] For example, in a yearlong intervention that exposed 7th- through 12th-grade students in experimental communities to local antidrug media messages, exposed students with low to moderate levels of drug use who recalled the messages showed beneficial effects on targeted variables compared with both the students who were exposed to the message but did not remember them and the students who were not exposed. The researchers suggest that the weight of antidrug media messages would be strengthened by combining them with interpersonal or school-based interventions.

Some findings that have emerged from analysis of prevention trials are helping to illuminate the interaction processes within interventions that either enhance positive effects or provoke negative outcomes. For example, analysis of videotaped interactions between 13- to 14-year-old boys and their friends identified a pattern of interaction that reinforces antisocial behavior. Specifically, a sequence of interactions that began with rule-breaking talk and followed with laughter was more evident in pairs where both boys were delinquent and had been arrested than in either mixed pairs in which one friend had been arrested but the other had not or in nondelinquent pairs. In the mixed and nondelinquent pairs, interactions centered on normative talk and laughter. Over a 2-year period, interactions between the delinquent boys were prognostic of increases in self-reported delinquent behavior. Thus, aggregating high-risk youth into homogeneous groups should be avoided in preventive interventions. [93]

Programs

Over the past 20 years, NIDA has sponsored research on numerous substance use preventive intervention programs. To demonstrate the programs' long-term effectiveness, the research must follow subjects for years after the completion of the intervention. The programs listed in this section are in various phases of followup, but all have demonstrated effectiveness in at least one population over at least 3 years. Three types of programs are included: (1) universal programs that target the general population, such as all students in a school; (2) selective programs that target at-risk groups or other subsets of the general population, such as children of drug users or poor school achievers; and (3) indicated programs that are designed for people who are already experimenting with drugs or who exhibit other risk-related behaviors.

Adolescents Training and Learning To Avoid Steroids

Adolescents Training and Learning To Avoid Steroids (ATLAS) is a multicomponent universal program for male high school athletes, designed to reduce risk factors for use of anabolic steroids and other drugs while providing healthy sports nutrition and strength-training alternatives to illicit use of athletics-enhancing substances. Coaches and peer teammates facilitate curriculum delivery with scripted manuals in small cooperative learning groups, taking advantage of an influential coaching staff and the team atmosphere where peers share common goals. [94]

The ATLAS program has been shown to be extremely effective in preventing the use of anabolic steroids in high school athletes. Compared with student athletes who were not exposed to ATLAS, participants had increased understanding of the effects of steroids, greater belief in personal vulnerability and the consequences of steroid use, improved drug-refusal skills, less belief in steroid-promoting media images, increased belief in the team as an information source, improved perception of athletic abilities and strength training self-efficacy, improved nutrition and exercise behaviors, reduced intentions to use steroids, and more certainty that their parents and coaches were intolerant of drug use. In addition, ATLAS students had a greater understanding of the effects of marijuana and alcohol than did student athletes not enrolled in the program. [95]

Project STAR

Project STAR is a universal drug abuse prevention program that reaches the entire community population with a comprehensive school program, mass media efforts, a parent program, community organization, and health policy changes. The school-based component is a social influence curriculum that is incorporated into regular classroom instruction by trained teachers over a 2-year period. [96]

Research results on this project have shown positive long-term effects: Students who began the program in junior high, and whose results were measured in their senior year of high school, showed significantly less use of marijuana (approximately 30 percent less), cigarettes (about 25 percent less), and alcohol (about 20 percent less) than children in schools that did not offer the program. The most important factor found to have affected drug use among the students was increased perceptions of their friends' intolerance of drug use.

Life Skills Training Program

The Life Skills Training universal classroom program is designed to address a wide range of risk and protective factors by teaching general personal and social skills in combination with drug resistance skills and normative education. The program consists of a 3-year prevention curriculum intended for middle school or junior high school students. It contains 15 periods during the first year, 10 booster sessions during the second, and 5 sessions during the third. Three major content areas are covered by the Life Skills Training program: (1) drug resistance skills and information, (2) self-management skills, and (3) general social skills. [97]

The Life Skills Training program has been extensively studied over the past 16 years. Results indicate that this prevention approach can produce a 59- to 75-percent lower level, relative to controls, of tobacco, alcohol, and marijuana use. Booster sessions can help maintain program effects. Long-term followup data from a randomized field trial involving nearly 6,000 students from 56 schools found significantly lower tobacco, alcohol, and marijuana use 6 years after the initial baseline assessment. The prevalence of cigarette smoking, alcohol use, and marijuana use for the students who received the Life Skills Training program was 44 percent lower than for control students, and the weekly use of multiple drugs was 66 percent lower. Early research on the Life Skills Training program was conducted with white populations; several recent studies show that it is also effective with inner-city minority youth when implemented under different scheduling formats and with different levels of project staff involvement. Finally, evaluation studies indicate that this prevention program is effective whether the program providers are adults or peer leaders.

Adolescent Alcohol Prevention Trial

The Adolescent Alcohol Prevention Trial (AAPT) is a universal classroom program designed for fifth-grade students, with booster sessions conducted in the seventh grade. It includes two primary strategies. Resistance skills training is designed to give children the social and behavioral skills they need to refuse explicit drug offers. Normative education is specifically designed to combat the influences of passive social pressures and social modeling effects, and it focuses on correcting erroneous perceptions about the prevalence and acceptability of substance use and on establishing conservative group norms. [98]

In the research design, the students received either information about the consequences of drug use only, resistance skills only, normative education only, or resistance skills training in combination with normative education. Results showed that the combination of resistance skills training and normative education prevented drug use; resistance skills training alone was not sufficient.

Seattle Social Development Project

A universal program, the Seattle project is a school-based intervention for grades one through six that seeks to reduce shared childhood risks for delinquency and drug abuse by enhancing protective factors. The multicomponent intervention trains elementary school teachers to use active classroom management, interactive teaching strategies, and cooperative learning in their classrooms. From grades one through six, parents are provided a training session called "How To Help Your Child Succeed in School," a family management skills training curriculum called "Catch 'Em Being Good," and the "Preparing for the Drug-Free Years" curriculum. The interventions are designed to enhance opportunities, skills, and rewards for children's prosocial involvement in both school and family settings, thereby increasing their bonds to school and family and their commitment to the norm of not using drugs. [99]

Long-term results indicate positive outcomes for students who participated in the program, including reductions in antisocial behavior, improved academic skills, greater commitment to school, reduced levels of alienation and better bonding to prosocial others, less misbehavior in school, and fewer incidents of drug use in school.

Project Family

Project Family is a series of interrelated investigations with the following goals: (1) evaluating universal family and youth competency-training interventions to examine the process of positive change in families, (2) testing the factors that influence parent participation in family programs, and (3) conducting statewide needs assessment surveys to determine family and community needs throughout Iowa. The preventive interventions evaluated through Project Family are Preparing for the Drug-Free Years (PDFY) and the Iowa Strengthening Families Program (ISFP), a revision of the University of Utah Strengthening Families program discussed below. The PDFY has five competency-training sessions for parents; one session includes the young adolescents. The ISFP has seven sessions, each attended jointly by youth and their parents. The Iowa State University Cooperative Extension Service has been instrumental in the implementation and evaluation of both programs. It also aided in the adaptation of project methods for Native American populations. [100]

Comparisons of both interventions with control group families show positive effects on parents' child management practices and on parent-child affective quality. In addition, a recent evaluation of ISFP youth outcomes at the 1-year followup shows improved youth resistance to peer pressure to use alcohol, reduced affiliation with antisocial peers, and reduced levels of problem behaviors. Importantly, intervention posttest outcome models demonstrate that positive parenting effects were significantly associated with reductions in children's problem behaviors. Study results are guiding efforts to evaluate whether addition of a family intervention to a school intervention is significantly better than use of a school intervention alone.

Strengthening Families Program

The Strengthening Families Program is a selective, multicomponent, family-focused prevention program that provides programming for 6- to 10-year-old children of substance users. The program, which began as an effort to help substance-using parents improve their parenting skills and reduce their children's risk for substance use, has been culturally modified and found effective (through independent evaluation) with African-American, Asian/Pacific Islander, and Hispanic families. The program contains three elements: (1) a parent training program, (2) a children's skills training program, and (3) a family skills training program. In each of 14 weekly sessions, parents and children are trained separately in the first hour. During the second hour, parents and children come together for family skills training. Afterward, the families share dinner and a film or other entertainment. [101]

Results indicate that the parent training improves parenting skills and reduces substance use by parents, children's skills training decreases children's negative behaviors and increases their socially acceptable behaviors through work with a program therapist, and family skills training improves the family environment by involving both generations in learning and practicing their new behaviors. This intervention approach has been evaluated in a variety of settings and with several racial and ethnic groups. The primary outcomes of the program include reductions in family conflict; improvement in family communication and organization; and reductions in youth conduct disorders, aggressiveness, and substance use.

Focus On Families

A selective program for parents receiving methadone treatment and for their children, Focus On Families' primary goal is the reduction of parents' use of illegal drugs by teaching them skills for relapse prevention and coping. Parents are also taught how to manage their families better. The parent training consists of a 5-hour family retreat and 32 parent training sessions of 1.5 hours each. Children attend 12 of the sessions to practice developmentally appropriate skills with their parents. Session topics include family goal-setting, relapse prevention, family communication, family management, creation of family expectations about alcohol and other drugs, teaching of various skills to children (such as problem solving and resisting drug offers), and help for children to succeed in school. Booster sessions and case-management services also are provided. [102] Early results indicate that parents' drug use is dramatically lowered and their parenting skills significantly improved over that of the control groups; the program's effects on children have not yet been assessed.

Reconnecting Youth Program

Reconnecting Youth is a school-based indicated prevention program that targets young people in grades 9 through 12 who show poor school achievement and the potential for dropping out of high school. Many also show signs of multiple problem behaviors, such as substance use, depression, and suicidal ideation. The program teaches skills to build resiliency with respect to risk factors and to moderate the early signs of substance use. The program incorporates social support and life skills training components, including a semester-long personal growth class, social and school bonding activities, and a school system crisis-response plan to address suicide prevention. [103]

Research shows that this program improves school performance; reduces drug involvement; decreases deviant peer bonding; increases self-esteem, personal control, school bonding, and social support; and decreases depression, anger and aggression, hopelessness, stress, and suicidal behaviors. Further analysis indicates that the support of the personal growth class teachers contributes to decreases in drug involvement and suicide risk behaviors.

Adolescent Transitions Program

The Adolescent Transitions Program (ATP) is a school-based program that focuses on parenting practices and integrates the universal, selective, and indicated approaches for middle school and junior high school interventions within a comprehensive framework. The universal level of the ATP is directed to the parents of all students in a school through the establishment of a Family Resource Room. The goal is to engage parents, establish norms for positive parenting practices, and disseminate information about risks for problem behavior and substance use. The selective level of intervention offers family assessment and professional support to identify those families at risk for problem behavior and substance use. The indicated level provides direct professional support to parents for making the indicated changes. Services may include behavioral family therapy, parenting groups, or case management services. [104] This program is based on a series of intervention trials, which constitute the Parent Focus curriculum and other intervention strategies, including working with high-risk teens in groups using a Teen Focus curriculum and directed strategies involving videotapes and newsletters. The findings from these studies indicate that parent interventions are needed for youth at high risk to reduce escalation of drug use, and repeated booster sessions are needed throughout the period of risk. These interventions were especially important because youth at high risk should not be placed together in groups because it can worsen problem behaviors, including those related to school and drug use.

Jump Start

Jump Start is a recently developed preventive intervention program with two components that are aimed at helping economically disadvantaged, high-sensation-seeking African-American teens avoid drug use. Over two implementations of the program, 289 adolescents were recruited. For the first implementation, participants were randomly selected from a summer youth employment program. For the second, a media campaign was used to recruit participants. Participants evaluated the program extremely positively, but more important, the early data on this selective intervention show that a significant pretest difference in alcohol and marijuana use between high and low sensation-seekers was neutralized in both years of the program. Attitudes toward drugs were also changed in a positive way during the first year of the program. These results suggest that sensation-seeking is a useful message design and audience-targeting variable for substance use prevention program design. [105]

Principles of Prevention

NIDA's comprehensive, multidisciplinary prevention research program examines multiple factors that contribute to drug abuse and how these factors interact. The Institute has also taken a strong role in synthesizing and disseminating findings. Recently, the Institute released a set of Prevention Principles that enumerate what has been learned through 20 years of research on what works in keeping children and adolescents from using illicit drugs. The principles that follow can be found in NIDA's Preventing Drug Use Among Children and Adolescents research-based guide:

• Prevention programs should be designed to enhance "protective factors" and to move toward reversing or reducing known "risk factors."
• Prevention programs should target all forms of drug use, including the use of tobacco, alcohol, marijuana, and inhalants.
• Prevention programs should include skills to resist drugs when offered, strengthen personal commitments against drug use, and increase social competency (e.g., in communications, peer relationships, self-efficacy, and assertiveness) in conjunction with reinforcement of attitudes against drug use.
• Prevention programs for adolescents should include interactive methods, such as peer discussion groups, rather than didactic teaching techniques alone.
• Prevention programs should include a parents' or caregivers' component that reinforces what the children are learning, such as facts about drugs and their harmful effects. Moreover, the intervention should promote opportunities for family discussions about use of legal and illegal substances and family policies about their use.
• Prevention programs should be long term and should continue over the school career, with repeated interventions to reinforce the original prevention goals. For example, school-based efforts directed at elementary school and middle school students should include booster sessions to help with critical transitions from middle school to high school.
• Family-focused prevention efforts have a greater impact than strategies that focus on parents only or children only.
• Community programs that include media campaigns and policy changes, such as new regulations that restrict access to alcohol, tobacco, or other drugs, are more effective when they are accompanied by school and family interventions.
• Community programs need to strengthen norms against drug use in all drug use prevention settings, including the family, school, and community.
• Schools offer opportunities to reach all populations and also serve as important settings for specific subpopulations at risk for drug use, such as children with behavior problems or learning disabilities and those who are potential dropouts.
• Prevention programming should be adapted to address the specific nature of the drug use problem in the local community.
• The higher the level of risk for the target population, the more intensive the prevention effort must be, and the earlier it must begin.
• Prevention programs should be age-specific, developmentally appropriate, and culturally sensitive.
• Effective prevention programs are cost-effective.