Kenneth W. Griffin, PhD, MPH and Gilbert J. Botvin, PhD
CHAPTER OUTLINE
■ REVALENCE RATES AND PROGRESSION OF USE
■ TIOLOGY AND IMPLICATIONS FOR PREVENTION
■ YPES OF PREVENTIVE INTERVENTIONS
■ UMMARY AND CONCLUSIONS
Substance use and abuse are important public health problems that contribute significantly to morbidity and mortality in this country and throughout the world. Over the past several decades, there have been significant advances in our understanding of the epidemiology and etiology of substance abuse and the development and testing of prevention and treatment approaches. Epidemiologic research shows that from a population perspective, the onset of substance use typically begins during the adolescent years. Many young people who use substances initiate use by experimenting with alcohol and cigarette smoking during early or mid-adolescence, and research demonstrates that this typically occurs in a social context with one’s peer group. National datasets show that the prevalence of alcohol, tobacco, and other drug use increases rapidly from early to late adolescence, peaking during the years of young adulthood. Furthermore, a large body of research has shown that early initiation of substance use is associated with higher levels of use and abuse later in life as well as negative outcomes such as violent and delinquent behavior, poor physical health, and mental health problems (1).
Given the well-established pattern of onset and developmental progression of substance use and abuse, a variety of prevention initiatives for children and adolescents have been developed. Relatively few prevention efforts have focused on adults because the majority of adults with substance abuse problems began their use during adolescence. Initiatives to prevent youth substance use include educational and skills training programs for young people in school settings, programs that teach parents ways to monitor their children and family members the skills needed to communicate effectively, and community-based programs that combine school and family components with additional educational, mass media, or public policy components (e.g., restricting access to alcohol and tobacco though enforcement of minimum purchasing age requirements). A goal of many prevention initiatives is to prevent early-stage substance use or delay the onset of use. Most aim to prevent alcohol, tobacco, and marijuana use because these are the most widely used substances in our society and therefore pose the greatest risk to the public health. Prevention programs often target middle or junior high school–age youth because it is during early adolescence that substance use experimentation usually begins to occur. The large body of research examining the efficacy and effectiveness of prevention programs for adolescent alcohol, tobacco, and other drug use demonstrates that the most effective approaches target salient risk and protective factors at the individual, family, and/or community levels and are guided by relevant psychosocial theories regarding the etiology of substance use and abuse (2,3).
PREVALENCE RATES AND PROGRESSION OF USE
National survey data demonstrate that the prevalence rates of substance use among adolescents peaked in the late 1970s and early 1980s, fell through much of the remainder of the 1980s, and began to increase again during the 1990s. In recent years, prevalence rates of use for most substances have gradually declined among adolescents, but remain problematic. The 2011 Monitoring the Future (MTF) study (4) found that among high school seniors, 40% had used one or more illicit drugs in the last year, and one in every two (50%) had done so at least once during his or her lifetime. For marijuana use among high school seniors, annual and lifetime prevalence rates were 36% and 46%, respectively; for hallucinogen use, rates were 5.8% and 8.8%, respectively; and for amphetamine use, rates were 8.2% and 12.2%, respectively. In terms of substances that are legal for adults, the annual prevalence rate for alcohol use among high school seniors was 64% and the lifetime rate was 70%, and for cigarette smoking, the 30-day rate was 19% and the lifetime rate was 40%. While the rates of use for some substances have decreased in recent years, the MTF study also revealed that nonmedical prescription drug abuse and the misuse of over-the-counter medications such as cough syrup to get high are growing problems among adolescents (4).
Some level of experimentation with substances has become commonplace among young people in contemporary American society. During early adolescence, substance use occurs almost exclusively in a social context. Experimentation often begins with substances that are readily available such as alcohol, tobacco, and inhalants. Eventually, some users of these substances may become regular users and/or progress to marijuana, hallucinogens, and other illicit drugs in a fairly predictable pattern (5). A subset eventually develops patterns of use characterized by both psychological and physiologic dependence. The likelihood of progressing to more serious levels of substance abuse and disorder is best understood in probabilistic terms. An individual’s risk of greater substance use involvement increases at each additional step in the developmental progression. Furthermore, the initial social motivations for substance use eventually yield to those driven increasingly by pharmacologic, genetic, and psychological factors (2,6). Knowledge of the typical patterns and progression of substance use has important implications for the focus and timing of preventive interventions. Prevention programs that effectively target risk factors for alcohol and tobacco use may not only prevent the use of these substances but also may reduce or eliminate the risk of using other substances further along the progression.
ETIOLOGY AND IMPLICATIONS FOR PREVENTION
The predictable epidemiologic patterns of substance use onset and progression during adolescence, combined with observations that substance use is frequently linked to important developmental goals and transitions of adolescence, support the notion that substance use and abuse are developmental phenomena. The degree of substance use involvement of any particular teenager is often a function of the negative prodrug social influences in his or her environment combined with his or her individual vulnerabilities to these influences.
Developmental Aspects
A developmental perspective on the etiology of substance use is informative in understanding how best to prevent early experimentation with alcohol, tobacco, and other drugs. Adolescence is a key period for experimentation not only with substances but with a wide range of behaviors and activities. Indeed, a great number of changes occur during the years of adolescence, and experimenting with new behavior occurs as part of a natural process of separating from parents, gaining acceptance and popularity with peers, developing a sense of autonomy and independence, establishing a personal identity and self-image, seeking fun and adventure, and/or rebelling against authority. However, many of these same developmental goals can increase an adolescent’s risk of smoking, drinking, or using drugs. Indeed, from the point of view of an adolescent, engaging in alcohol, tobacco, and other drug use may be seen as a functional way of achieving independence, maturity, or popularity.
The Importance of Social Influences
Research has shown that social influences are among the most powerful factors promoting experimentation or initiation of alcohol, tobacco, and other drug use among young people. Important types of negative social influence include the modeling of substance use behavior by important others (e.g., parents, older siblings, and especially peers) and exposure to positive attitudes and expectations regarding substance use (7). The positive portrayal of substance use and abuse by celebrities in movies, television, and music videos is also a powerful negative social influence (8). Advertisements that communicate positive messages about alcohol and tobacco use are likely to promote pro–substance use attitudes, expectancies, and perceived positive consequences of use that can translate into increases in substance use among young people (9).
Risk and Protective Factors
Risk factors that contribute to the initiation, maintenance, and escalation of alcohol, tobacco, and illicit drug use—along with protective factors that offset the effects of risk—occur at the level of the individual, family, school, and community.
Individual Level
Individual-level factors include cognitive, attitudinal, social, personality, pharmacologic, biologic, and developmental factors (10). Cognitive risk factors for substance use include lack of knowledge about the risks of use and abuse and believing that substance use is “normal” and most people engage in use. Affect regulation is another important factor in the etiology of substance use, as described in the self-medication hypothesis (11). Psychological characteristics such as poor self-esteem, low assertiveness, and poor behavioral self-control are associated with substance use. As an individual’s substance use increases in frequency and quantity, pharmacologic risk factors become increasingly important. Drugs of abuse such as cocaine, amphetamine, morphine, as well as nicotine and alcohol have different molecular mechanisms of action but affect the brain in a similar way by increasing strength at excitatory synapses on midbrain dopamine neurons (12). There are likely to be important individual differences in neurochemical reactivity to these drugs that place some individuals at a higher risk.
Family Level
In addition to the direct modeling of substance use behaviors and positive attitudes regarding use, factors within the family can contribute directly to increased substance use or indirectly by affecting established precursors of substance use such as aggressive behavior and other conduct problems. These family factors include harsh disciplinary practices, poor parental monitoring, low levels of family bonding, and high levels of family conflict. On the other hand, parenting practices characterized by firm and consistent limit setting, careful monitoring, and nurturing, open communication patterns with children are protective against substance use and other negative outcomes (13).
School and Community Level
Characteristics of schools have been found to be associated with levels of substance use among students (14). When large numbers of students feel disengaged from school— they do not like school, do not feel “part of” their schools, fail academically, feel unsafe at school, or do not have good relationships with teachers—this has been found to be associated with greater substance use prevalence. Similarly, when young people feel disengaged from their communities or feel unsafe in their neighborhoods, this is associated with greater substance use, as is with greater levels of community disorganization (15).
TYPES OF PREVENTIVE INTERVENTIONS
The terminology used to describe prevention efforts has evolved over time. Primary prevention interventions are designed to reach individuals in the general population before they have developed a specific disorder or disease. Secondary prevention involves screening and early intervention. Tertiary prevention involves preventing the progression of an established disorder to the point of disability. However, a problem with this terminology is that it is difficult to distinguish the difference between tertiary prevention and treatment because both involve care for persons with an existing disorder. More contemporary terminology for prevention was proposed by the Institute of Medicine (16) as part of a new framework for classifying interventions along a continuum of care that includes prevention, treatment, and maintenance. In this framework, prevention refers only to interventions that occur prior to the onset of a disorder. Prevention is further divided into three types: universal, selective, and indicated interventions. Universal prevention programs focus on the general population and aim to deter or delay the onset of a condition. Selective prevention programs target selected high-risk groups or subsets of the general population believed to be at high risk due to membership in a particular group (e.g., pregnant women or children of drug users). Indicated prevention programs are designed for those already engaging in the behavior or those showing early danger signs or engaging in related high-risk behaviors. Thus, where recruitment and participation in a selective intervention are based on subgroup membership, recruitment and participation in an indicated intervention are based on early warning signs demonstrated by an individual.
There have been significant advances in the effectiveness of both drug treatment and prevention programs (6). However, treatment remains expensive and labor intensive and suffers from high rates of recidivism. Prevention is therefore a key component in addressing the problem of drug abuse, especially given the increasing availability of effective programs. The first major breakthrough in prevention came at the end of the 1970s in the area of school-based smoking prevention. That work stimulated a great deal of prevention research and led to the development of several promising prevention approaches, including those designed to prevent the use of multiple substances. During the 1980s and up to the present, mounting empirical evidence from a growing number of methodologically sophisticated studies indicates that prevention can be highly effective. In the next several sections of the chapter, we describe contemporary approaches to drug abuse prevention for children and adolescents at the school, family, and community levels.
School-Based Prevention Approaches
In the scientific literature on universal prevention programs targeting children and adolescents, schools are the most common implementation site for such programs. School settings are desirable because schools provide access to large numbers of young people, and substance use is seen as inconsistent with the goals of educating our youth. Three types of contemporary approaches to school-based prevention of substance use are (a) social resistance skills training, (b) normative education, and (c) competence enhancement skills training. One or more of these approaches or components may be combined within a single preventive intervention.
Social Resistance Skills
These interventions are designed to increase the adolescent’s awareness of the various social influences to engage in substance use and teach young people specific skills for effectively resisting both peer and media pressures to smoke, drink, or use drugs (17). Resistance skills training programs teach adolescents how to recognize situations in which they are likely to experience peer pressure to smoke, drink, or use drugs along with ways to avoid or otherwise effectively deal with these high-risk situations. Participants are taught ways of handling pressure to engage in substance, including what to say (i.e., the specific content of a refusal message) and how to deliver it in the most effective way possible. Resistance skills programs also typically include content to increase students’ awareness of the techniques used by advertisers to promote the sale of tobacco products or alcoholic beverages and teach techniques for formulating counterarguments to the messages used by advertisers.
Normative Education
Because adolescents tend to overestimate the prevalence of smoking, drinking, and the use of certain drugs, normative education approaches include content and activities to correct inaccurate perceptions regarding the high prevalence of substance use (18). This can be done by providing feedback from survey data showing actual prevalence rates collected locally in the classroom, school, or community or by showing the relatively low prevalence rates in national survey data for young teens. Normative education also attempts to undermine popular but inaccurate beliefs that substance drug use is considered acceptable and not particularly dangerous. This can be done by highlighting evidence from national studies showing strong antidrug social norms and generally high-perceived risks of drug use in the population. Material on normative education is often included in social resistance programs.
Competence Enhancement
These programs recognize that social learning processes are important in the development of adolescent drug use. However, they also recognize that youth with poor personal and social skills are more susceptible to influences that promote drug use, and these youth may be more motivated to use drugs as an alternative to more adaptive coping strategies (19). Competence enhancement approaches typically teach some combination of the following life skills: general problem-solving and decision-making skills, general cognitive skills for resisting interpersonal or media influences, skills for increasing self-control and self-esteem, adaptive coping strategies for relieving stress and anxiety through the use of cognitive coping skills or behavioral relaxation techniques, general social skills, and general assertive skills. In contrast to the more focused drug resistance skills training approaches, competence enhancement programs are designed to teach the kind of generic skills that will have a relatively broad application. The most effective personal and social skills training programs emphasize the application of general skills to situations directly related to substance use and abuse and demonstrate that these same skills can be used for dealing with many of the challenges confronting adolescents in their everyday lives.
Effectiveness of School-Based Prevention
There have been a large number of published meta-analyses and systematic reviews of the prevention literature for school-based programs focused on preventing smoking, alcohol use, and illicit drug use among children and adolescents.
Programs Focused on Preventing Smoking
There have been many meta-analyses and systematic reviews of school-based smoking prevention programs, perhaps because there is a longer history of theory-based preventive interventions implemented for smoking compared to the use of other substances. A Cochrane Review included randomized controlled trials (RCTs) of school-based interventions to prevent smoking among children and adolescents (age 5 to 18) in which study participants were followed for at least 6 months (20). Included were programs or curricula that focused on information only, social resistance skills, competence enhancement skills, and those programs that included additional intervention components in the community. The main outcome variable was prevalence of nonsmoking at follow-up among those students not smoking at the baseline assessment. The analysis included 23 high-quality trials of school-based smoking prevention programs. Most of the intervention studies were social resistance programs, and the authors concluded that half of these interventions produced short-term effects on smoking behavior. Findings indicated that programs focusing primarily on providing information were ineffective. There was, however, evidence supporting the effectiveness of smoking prevention interventions that focused on developing generic social competence among youth as well as for interventions that took a multimodal approach that included a substantive community component.
An additional meta-analysis of school-based smoking prevention trials was designed specifically to examine long-term effects on smoking, defined as behavioral effects that last until the 12th grade or age 18 (21). The authors included school-based RCTs of smoking prevention with follow-up periods of at least 1 year postintervention and those that had smoking prevalence (defined as at least one cigarette in the past month) as a primary outcome. Of the eight articles included in the meta-analysis, the authors noted that there was significant variability in intervention intensity, presence of booster sessions, length of follow-up, and attrition rates. Findings indicated that few studies have evaluated the long-term impact of school-based smoking prevention, and the authors noted that only one long-term study (22) showed statistically significant decreased smoking prevalence in the intervention group compared to controls. The article concluded that there was “little to no evidence of long-term effectiveness” of school-based smoking prevention. The article generated a spirited discussion among researchers in a series of letters to the editor and drew criticism from prevention researchers who noted that the findings were inconsistent with several previous meta-analyses and syntheses of the literature (not cited by the authors) that had shown positive short- and long-term behavioral effects of school-based smoking prevention.
A third meta-analysis of school-based smoking prevention examined 65 adolescent psychosocial smoking prevention programs among students in grades 6 to 12 published between 1978 and 1997 in the United States (23). Programs were categorized into three prevention approaches (social resistance, social resistance + cognitive skills, and social resistance + cognitive + affective skills) and two delivery settings (school, school + community). Findings from the meta-analysis revealed that program effects on knowledge had the highest effect sizes in the short-term (≤1 year) but rapidly decreased over time. Importantly, behavioral effects were observed and persisted over a 3-year period, with the strongest effects on smoking observed with programs that included social resistance combined with cognitive and/ or affective skills training activities and/or programs that included both schools and community components in their implementation.
Several systematic reviews have summarized the evidence regarding school-based smoking prevention research. In one review, the evidence supported findings of decreased prevalence of smoking among students exposed to social influence smoking prevention programs compared to students in control groups, with the mean difference ranging from 5% to 60%, with duration of effects lasting from 1 to 4 years (24). The authors concluded that the most effective school-based smoking prevention programs are those with sustained application, booster sessions over several years, and reinforcement in the community including the involvement of parents and/or the mass media and those that are part of a comprehensive school health promotion program. A second review of school-based smoking prevention studies published from 1990 to 2002 noted that, with the exception of two programs, “school based curricula alone have been generally ineffective in the long term in preventing adolescents from initiating tobacco use.” However, the authors concluded that school-based programs combined with other approaches such as mass media and smoke-free policies can be effective (25).
Programs Focused on Preventing Alcohol Use
A Cochrane Review of universal school-based alcohol prevention programs identified 53 randomized trials that were designed to prevent alcohol use (26). These were prevention trials conducted with children up to age 18 that met specific minimum criteria regarding the rigor of the research design. The prevention trials included educational interventions that focused primarily on raising awareness of the potential dangers of alcohol misuse and changing normative beliefs as well as more comprehensive psychosocial prevention programs that developed psychological and social skills in young people (e.g., peer resistance, problem-solving and decision-making skills) in order to reduce alcohol misuse. Some of the studies included in the review (n = 11) focused on alcohol use as the sole outcome, and a second group of studies (n = 39) were more generic prevention approaches that targeted alcohol use, smoking, illicit drug use, and/or antisocial behavior. Of the 11 alcohol-specific preventive interventions examined, 6 produced statistically significant reductions in alcohol use relative to controls. Of the 39 generic preventive interventions examined, 15 reported significant positive effects on alcohol use. Among the studies reporting significant prevention effects, the most commonly observed beneficial effects were for heavier levels of alcohol use (e.g., drunkenness and binge drinking).
Programs Focused on Preventing Illicit Drug Use
In recent years, there have been several meta-analytic reviews of the literature that have specifically examined the effectiveness of prevention programs on the use of substances other than tobacco. A paper presented a summary of findings from a Cochrane Review on school-based programs for preventing illicit drug use (27). In this meta-analysis, 29 RCTs evaluating school-based interventions designed toprevent substance use were reviewed. The review focused on illicit drug use and did not include studies that looked at smoking or alcohol use prevention only. The authors classified the interventions as primarily skills focused, affect focused, or knowledge focused. All but one of the 29 RCTs were conducted in the United States and most interventions targeted 6th and 7th grade students. Findings from the meta-analysis indicated that, compared to usual curricula, skill-based interventions significantly reduced marijuana use and hard drug use and improved decision-making skills, self-esteem, peer pressure resistance, and drug knowledge. The main conclusion of the meta-analysis was that skill-based programs are effective in deterring drug use, while knowledge and affective programs are not effective in changing behavior, a finding consistent with previous meta-analyses of school-based prevention.
An additional meta-analysis examined the impact of school-based prevention programs on reducing cannabis use among youth from age 12 to 19 (28). Fifteen randomized prevention trials were included in the meta-analysis, and findings indicated that these programs had an overall positive effect on cannabis use compared to controls, with an average effect size of d = 0.58 (CI: 0.55, 0.62). Programs that focused on multiple hypothesized mediators (e.g., social resistance skills, perceived norms, and competence skills) were more effective than those programs that focused solely on resistance skills. The more effective programs had 15 or more classroom sessions, were interactive in nature, and were facilitated by providers other than classroom teachers.
In summary, several meta-analyses and systematic reviews have examined the effectiveness of school-based programs to prevent alcohol, tobacco, and other forms of substance use. Overall, these studies have found that school-based prevention is effective in reducing smoking and other forms of substance use. There is some debate on the long-term effectiveness of school-based prevention in general, although some programs have shown clear evidence of long-term behavioral effects. Although the methodologic rigor and theoretical bases of prevention programs included in these reviews varied considerably, findings have been useful in identifying characteristics of programs that are most effective. The most effective school-based prevention programs are interactive in nature, focus on building skills in drug resistance and general competence skills, and are implemented over multiple years. School-based programs that have a substantive community component that includes mass media or parental involvement also tend to be more effective than school-only programs. However, it is important to note that several major challenges remain in disseminating evidence-based prevention programs and in adequately preparing prevention providers. Only about 27% of all schools in the United States use one of the ten most effective prevention curricula available (29), and less than one in five providers use effective delivery of prevention program content (30).
Family-Based Prevention Approaches
Family-based prevention programs include training in parenting skills, often provided to parents without children present. The specific parenting skills that are taught vary somewhat with the age of the target child or adolescent, but may focus on ways to nurture, bond, and communicate with children, how to help children develop prosocial skills and social resistance skills, training on rule setting and techniques for monitoring activities, and ways to help children reduce aggressive or antisocial behaviors. Prevention programs focusing on family skills often include sessions with the parents and children together (with or without additional parent-only training) that aim to improve family functioning, communication, and practice in developing, discussing, and enforcing family policies on substance abuse (13).
Effectiveness of Family-Based Prevention
Parenting Programs
A recent systematic review evaluated parenting programs to prevent alcohol, tobacco, or drug abuse in children under 18 years of age (31). Twenty controlled studies were reviewed, although the rigor of the studies and nature of the interventions varied considerably. Findings indicated statistically significant reductions in alcohol use in 6 of 14 studies, reduction in drug use in 5 of 9 studies, and reduction in tobacco use in 9 out of 13 studies. However, three interventions produced increases in alcohol, tobacco, or drug use. The authors concluded that parenting programs can be effective in reducing or preventing substance use and that the most effective programs were those emphasizing both active parental involvement and skills development in the areas of parenting, social competence, and self-regulation skills. The authors point out that little is known about the change processes involved in such interventions and their long-term effectiveness.
Family Programs
In a Cochrane Review of family-based programs for preventing smoking, the authors identified RCTs designed to deter the use of tobacco among children (aged 5 to 12) or adolescents (aged 13 to 18) and other family members (32). The primary outcome was smoking onset among children measured at least 6 months from the start of the intervention. The authors identified nine studies that tested a family intervention against a control group and found that four of these nine had significant positive effects on smoking behavior, although one showed significant negative effects. Five additional RCTs were identified that tested a family intervention against a school intervention. However, none of the parent programs produced significant incremental effects compared to the school programs alone. The authors concluded that some well-executed RCTs provided evidence that family interventions can prevent adolescent smoking, but RCTs that were less well executed had mostly neutral or negative results. They also concluded that how well the program staff are trained and how well they deliver the program appear to be related to effectiveness, while the number of sessions in the program does not seem to predict effectiveness.
Systematic reviews of the literature have focused on family-based approaches to alcohol prevention, including a recent meta-analysis that identified 18 publications describing 9 independent family-based prevention trials (33). The programs identified focused on one or more of three outcomes: alcohol initiation, last month alcohol use, and/or frequency of alcohol use. The interventions included a variety of delivery and implementation methods including home-based family sessions, videotape and print materials on parenting and family rule setting regarding drinking, health educator–led sessions held outside the home for parents and children together, and nurse consultations followed by take-home lessons with parent–child activities to promote bonding, communication, and prevention skills. Findings indicated that the prevention trials focusing on alcohol initiation produced a summary OR (95% CI) of 0.71 (CI: 0.54, 0.94), with protective effects on alcohol initiation lasting from 18 to 30 months postintervention. Positive results were also found for specific studies that focused on past-month alcohol use and alcohol frequency as the primary outcomes.
In summary, a variety of parenting skills and family-based drug prevention programs have been studied. Those that focus on both parenting skills and family bonding appear to be the most effective in reducing or preventing substance use. An important limitation of family-based prevention is the difficulty in getting parents to participate; families most at risk for drug use are least likely to participate in prevention programs (34).
Community-Based Prevention Approaches
Community-based drug abuse prevention programs typically have multiple components, including some combination of school-based programs, family or parenting components, mass media campaigns, public policy components such as restricting youth access to alcohol and tobacco, and other types of community organization and activities. The multiple components of a community-based intervention may be managed by a coalition of stakeholders including parents, educators, and key leaders in the community.
Effectiveness of Community-Based Prevention
A recent Cochrane Review examined community-based programs to prevent smoking initiation in children and adolescents (35). This qualitative narrative synthesis included RCTs and studies using quasi-experimental designs including a control or comparison group in which the effectiveness of multicomponent interventions was compared to no intervention, to a school-only program, or to another single-component intervention. Seventeen studies were included in the review. Among the 13 studies that compared community interventions to no intervention controls, two programs produced lower smoking prevalence in the intervention versus control groups. One of two studies that compared a community intervention to school-only program found behavioral effects on smoking. Two studies found behavioral effects on smoking for multicomponent community interventions compared to mass media–only campaigns. The authors concluded that there is some limited support for the effectiveness of coordinated multicomponent community prevention programs in reducing smoking among young people and that programs with multiple components prevent smoking behavior more effectively than programs with a single component.
In summary, multicomponent community-based prevention programs can be effective in preventing adolescent substance use, particularly when the different components focus on a coordinated, comprehensive message. A limitation of community-based programs is the expense and high degree of coordination needed to implement and evaluate the type of comprehensive program most likely to be effective.
SUMMARY AND CONCLUSIONS
Substance use and abuse remain important public health problems. The prevalence of alcohol, tobacco, and other drug use increases rapidly from early to late adolescence, peaking during the transition to young adulthood. A variety of prevention initiatives for children and adolescents have been developed for schools, families, and communities. The most effective approaches target salient risk and protective factors and are guided by relevant psychosocial theories regarding the etiology of substance use and abuse. The degree of substance use involvement of any particular teenager is often a function of the negative prodrug social influences in his or her environment combined with his or her individual vulnerabilities to these influences.
Contemporary school-based prevention programs focus on skills building in the areas of drug resistance, life skills, and/or correcting inaccurate beliefs about the high prevalence of substance use. Reviews of the school-based prevention literature have found that overall, theory-based programs can reduce smoking and other forms of substance use. There is some debate on the long-term effectiveness of these programs in general, but a handful of programs have shown clear evidence of long-term behavioral effects. The most effective school-based prevention programs are interactive, focus on building skills in drug resistance and general competence skills, and are implemented over multiple years. School-based programs that include a substantive community component tend to be more effective than school-only programs. Family-based prevention programs include training in parenting skills and/or group interventions for the entire family that focus on improving family functioning, communication, and family policies on substance abuse. Family interventions that combine parenting skills and family bonding appear to be the most effective. Community-based drug abuse prevention programs typically include some combination of school, family, mass media, public policy, and community organization components. The most effective community programs present a coordinated, comprehensive message across multiple delivery components.
Despite the progress that has been made in the field of drug abuse prevention for children and adolescents, there are several factors that reduce the public health impact of effective school, family, and community prevention programs. Most schools still use non–evidence-based prevention programs, effective family programs often do not reach the families in greatest need, and community programs require substantial financial and human resources. In addition to refining our understanding of the risk and protective factors for substance abuse and translating this knowledge into improved interventions, future research is needed to find ways to effectively disseminate the most promising prevention programs into our schools, families, and communities.
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