Adolescent Substance Abuse Prevention Research Paper

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Substance abuse is a problem that countries throughout the world have struggled with for many decades. In the USA where substance abuse is the highest in the industrialized world, the annual prevalence of illicit drug use among adolescents peaked in 1979, declined for more than a decade, and then rose sharply throughout most of the 1990s (Johnston et al. 1995 96; see Fig. 1). Concern for substance abuse as a problem derives from the fact that it can lead to a host of adverse consequences including long-term disability and premature death. Broadly conceived, substance abuse involves the inappropriate use or misuse of one or more psychoactive substances including tobacco, alcohol, and illicit drugs such as marijuana, cocaine, and heroin.

Adolescent Substance Abuse Prevention Research Paper Figure 1

For most individuals, substance abuse has its roots in childhood and adolescence (Hartel and Glantz 1999). It begins with a brief period of ‘experimental’ use of one or more substance followed by escalation in both the frequency and amount of the substance(s) used. As use increases, so too does tolerance for the pharmacological effects of most substances, leading to further increases in the amount used per occasion and the frequency of use as well, as the eventual development of psychological and/or physical dependence. Thus, the developmental course of substance abuse progresses from onset and occasional use to frequent and/or heavy addictive use. It also typically progresses from the use of widely available legal substances (alcohol and tobacco) to the use of illicit substances.

Efforts to combat the problem of substance abuse have included actions by law enforcement agencies to interdict the flow of drugs, legislative initiatives, treatment interventions, mass media campaigns, and prevention programs. In view of the obvious difficulty of solving the problem of substance abuse through enforcement or treatment approaches, many experts have long argued that prevention offered the greatest potential. Since the early 1980s, there has been considerable progress in understanding both the causes of substance abuse and how to prevent it. This research paper summarizes what is currently known about both effective and ineffective prevention approaches.

1. Informational And Affective Approaches

Efforts to prevent substance abuse have largely emphasized the dissemination of factual information about psychoactive substances, their pharmacological effects, and the adverse consequences of use (Botvin et al. 1995b). These approaches assume that individuals begin using both licit and illicit substances after logically considering the potential risks and expected benefits. It is further assumed that individuals who elect to use drugs do so because they are unaware of the adverse consequences of using drugs. Given this, prevention approaches were initially designed to provide information about the risks associated with substance use so that people would be more likely to choose not to use drugs. Closely related to information dissemination were fear arousal approaches to prevention that attempted to deter use by dramatizing the dangers of substance abuse. Despite the intuitive appeal of these approaches, evaluation studies have consistently found that they do not decrease substance use (Schaps et al. 1981). Some studies suggest that these approaches may even increase substance use by stimulating curiosity.

Another approach to substance abuse prevention that was widely used during the 1960s and 1970s attempted to prevent substance abuse by promoting affective development. These ‘affective education’ approaches, as they were called, were designed to increase self-understanding and acceptance through activities such as values clarification and responsible decision making, improving interpersonal relations by promoting effective communication and assertiveness, and providing students with the opportunity to fulfill their basic needs through existing social institutions. Once again, evaluation studies have found little evidence to support the effectiveness of these approaches (Schaps et al. 1981).

2. Social Influence Approaches

In contrast to the cognitive and affective approaches, prevention approaches targeting the social factors that promote and sustain adolescent substance abuse have shown considerably more promise. These approaches were based on studies showing the important role that social factors play in the initiation and development of substance abuse. They are also based on social psychological theories of human behavior, particularly social learning theory, persuasive communications theory, and problem behavior theory.

2.1 Psychological Inoculation

Derived from persuasive communications theory, psychological inoculation involves first exposing adolescents to weak social influences promoting substance use, followed later by progressively stronger social influences. Through this process, it was hypothesized that the exposed adolescents would build up resistance to more powerful prodrug messages, similar to what they would be likely to encounter as they entered junior high school. Despite the prominence of psychological inoculation in the initial formulation of the social influence prevention approach, it has not been supported by the empirical evidence and consequently has received considerably less emphasis in more recent variations of the social influence model. Other components of the social influence model have assumed greater emphasis, particularly normative education and resistance skills training.

2.2 Normative Education

The prevalence of smoking, drinking, and illicit drug use is usually overestimated by adolescents (Fishbein 1977). This overestimate leads to the formation of inaccurate normative expectations—the forming of a set of normative beliefs that support substance use. In order to reduce pressure to use drugs, social influence approaches to substance abuse prevention generally include a component designed to correct the misperception that many adults and most adolescents use drugs. Two different strategies have been used to modify or correct normative expectations. The first is straightforward and simply involves providing adolescents with information from national or local survey data concerning the prevalence of substance use among adolescence and/or adults. A second method involves having adolescents conduct their own local surveys of substance use within their school or community. This information provides adolescents with a more realistic view of the prevalence of substance use and, because substance use in most communities is far lower than adolescents believe, it corrects the misperception that most people use drugs and helps establish antisubstance use norms.

2.3 Drug Resistance Skills

Drug resistance skills are the hallmark of most contemporary approaches to substance abuse prevention (Ellickson and Bell 1990). The primary focus of these prevention approaches is on teaching adolescents a set of skills or tactics for resisting influences to smoke, drink, or use illicit drugs— particularly influences coming from the media and peers. Adolescents are taught how to identify and respond to prodrug messages in advertisements, movies, rock videos, etc. They are also taught to identify the persuasive appeals used by advertisers to promote the sale of tobacco products and alcoholic beverages, to analyze advertisements and their messages, and to formulate counterarguments to common advertising appeals (Flay et al. 1989). Teaching these skills is designed to provide adolescents with the tools for actively resisting advertisements promoting cigarette smoking and alcoholic beverages, particularly given the growing recognition that advertisers have developed rather sophisticated ad campaigns explicitly designed to target the youth market.

Perhaps the best known aspect of resistance skills training involves teaching adolescents a set of skills that they can use to resist offers from their peers to smoke, drink, or use illicit drugs. Prevention programs that include resistance skills training emphasize verbal and nonverbal skills for resisting these offers. These programs teach adolescents what to say when they are offered or pressured to engage in some form of substance use as well as teaching them how to say it in the most effective way possible. Adolescents are taught to identify ‘high-risk’ situations where they are likely to experience peer pressure to use drugs, are taught to avoid those situations whenever possible, and are taught to develop ‘action plans’ so that they are prepared to handle situations involving peer pressure to use drugs.

In order to be optimally effective, resistance skills training must provide adolescents with a general repertoire of verbal and nonverbal skills that they can use when confronted by peer pressure to use drugs. Adolescents must not only develop these skills, but also the confidence that they can apply them when necessary. To accomplish this, prevention programs teach students these resistance skills and also provide opportunities to practice the use of these skills.

3. Personal And Social Skills Training

Since the early 1980s, prevention approaches have also been developed and tested that are broader in their focus than social influence approaches. These approaches are designed to teach information and skills that are specifically related to the problem of substance abuse within the context of enhancing the development of general personal competence, hence they are also referred to as ‘competence enhancement’ approaches. Although these approaches include elements of the social influence model, a distinguishing feature is an emphasis on teaching a variety of personal self-management skills and general social skills. An underlying assumption of this approach is that merely teaching drug refusal skills is not likely to be effective with adolescents who are motivated to use drugs. Put differently, teaching adolescents how to say no to drugs will not succeed among those adolescents who want to say yes. Moreover, advocates of this approach argue that prevention approaches that target a more comprehensive set of risk and protective factors are more likely to be effective than those intended to target a limited number of these factors.

Competence enhancement approaches teach generic skills such as general problem-solving and decision-making skills, cognitive skills for resisting interpersonal and media influences, skills for increasing self-control and self-esteem, skills for coping effectively with anxiety or stress, general social skills, and assertive skills. One prominent approach, called life skills training (LST), teaches several types of self-management skills such as self-appraisal, goal setting and self-directed behavior change, decision making and independent thinking, and anxiety management skills (Botvin et al. 1990). Adolescents are also taught a set of general social skills including communications skills, conversational skills, skills for asking someone out for a date, complimenting skills, and both verbal and nonverbal assertive skills. All of these skills are taught using a combination of instruction and demonstration, behavioral rehearsal (practice), feedback, social reinforcement (praise), and extended practice through behavioral homework assignments.

4. Evidence Of Effectiveness

A growing literature shows that several approaches to substance abuse prevention can substantially reduce adolescent substance use. However, it is now clear that not all prevention approaches are effective. In fact, the only prevention approaches that have consistently reduced substance use are those that teach resistance skills and normative education, either alone or in combination with components designed to enhance general personal and social competence. Studies testing these approaches provide strong evidence for the short-term effectiveness of prevention, but somewhat weaker evidence of long-term effectiveness.

4.1 Short-Term Effects

Studies testing the effectiveness of social influence approaches to cigarette smoking have generally shown that they are able to reduce the rate of smoking by 30 to 50 percent after the initial period of intervention (e.g., Luepker et al. 1983, Ellickson and Bell 1990, Sussman et al. 1993). One study has also demonstrated that the social influence approach can reduce the use of smokeless tobacco (Sussman et al. 1993). Studies testing interventions that contain social influence components in combination with personal and social skills training components show that they can cut cigarette smoking by 40 to 75 percent (Botvin et al. 1995a, Schinke 1984).

Social influences approaches have also been shown to reduce alcohol and marijuana use by roughly the same magnitude as for tobacco use (Ellickson and Bell 1990). Similarly, studies show that the personal and social skills training approaches can also reduce the use of alcoholic beverages and marijuana (Botvin et al. 1990). When comparing the relative impact of these prevention approaches on tobacco, alcohol, and marijuana use, the strongest effects are for cigarette smoking and marijuana use, while there are somewhat weaker and less consistent effects on the use of alcoholic beverages.

It is important to recognize that the social influence approaches and the competence enhancement approaches discussed here both include program components designed to increase drug resistance skills and promote antidrug norms. The results from one study (Caplan et al. 1992) suggests that generic competence enhancement approaches to substance abuse prevention may not be effective unless they also teach normative education and/or resistance skills training. Although approaches that combine the key elements of the social influences approach and the broader competence enhancement approach appear to be the most effective based on current evidence, additional research is necessary to better understand how and why effective prevention programs work.

4.2 Long-Term Effects

The results of longer-term follow-up studies present a somewhat mixed picture. Evidence from several studies indicates that current prevention approaches have a reasonable degree of durability. Studies show prevention effects lasting anywhere from one to four years (Luepker et al. 1983, Flay et al. 1989).

Several factors appear to play a role in determining how durable these prevention approaches are. These include (a) the length of the initial intervention, (b) the inclusion of ongoing (multiyear) intervention or booster sessions, (c) the quality and completeness of implementation, and/or (d) the number of risk and protective factors targeted. Prevention approaches that produced longer-lasting effects generally have a stronger initial dosage (eight class sessions or more), include booster sessions, are implemented with high fidelity, and utilize a more comprehensive prevention approach.

Results from a large-scale, randomized field trial involving nearly 6,000 seventh graders from 56 public schools in the USA found long-term reductions in smoking, alcohol, and marijuana use at the end of the twelfth grade (Botvin et al. 1995a). In this study schools were randomly assigned to prevention and control conditions. Participating students in the prevention condition received the LST program during the seventh grade (15 sessions) with booster sessions in the eighth grade (10 sessions) and ninth grade (five sessions). No intervention was provided during grades 10 through 12. According to the results, 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 reductions were also found with respect to the percentage of students who were using multiple substances one or more times per week. These results suggest that to be effective, prevention programs need to be more comprehensive and have a stronger initial dosage than most studies using the social influence approach. Another implication is that prevention programs also need to include at least two additional years of interventions (booster sessions) and must be implemented in a manner that is consistent with the underlying prevention model.

4.3 Effectiveness With Ethnic Minority Youth

Several studies have examined the impact of prevention approaches on minority youth. Two strategies have been followed. One strategy, common to many local prevention efforts, assumes that the etiology of substance abuse is different for different populations. Thus, many prevention providers have developed interventions designed to be population-specific (e.g., projects for African-American youth with an Afrocentric cultural focus). A second strategy assumes that the etiology of substance abuse is more similar than different across populations. This approach involves the development of preventive interventions designed to be generalizable to a broad range of individuals from different populations. As information concerning the etiology of substance use among minority youth has accumulated, it has become clear that there is substantial overlap in the factors promoting and maintaining substance use among different populations. The results of these studies suggest that prevention approaches may have application to a broad range of individuals from different populations. Indeed, studies show that both the social influence approach and the combined social influence competence enhancement approach are effective with minority youth (Botvin et al. 1995b). Research also shows, however, that in environments with homogeneous populations, prevention effects can be further enhanced by tailoring the intervention to the target populations.

5. Concluding Comments

Substantial progress has been made since the early 1980s in the area of substance abuse prevention. Much has been learned concerning the etiology of substance abuse and how to prevent it. Despite the advances in prevention, additional research is needed to determine the long-term effectiveness of current approaches; further refine existing approaches, and identify new ones that may be more powerful; identify and test the mechanisms through which effective programs work; develop and test more comprehensive prevention strategies that combine the best features of existing prevention modalities; and extend the findings from substance abuse prevention to other related health and social problems such as HIV AIDS, teen pregnancy, violence, and delinquency. Finally, it is vitally important that a concerted effort be made to translate research into practice in order to capitalize on the progress that has been made in prevention research.

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