JOURNAL OF ADOLESCENT HEALTH 1992;13:355-363
CONFERENCE PROCEEDINGS
CHERYL
L. PERRY,
Ph.
., AND STEVEN H. #ELDER,
M.P.H.
The problems associated with adolescent alcohol and drug use are global problems, particularly as our countries and economies become more interdependent, as substances become more readily available worldwide, and as the functions served by use of alcohol and drugs hold particular appeal to young people. In the United States, by the time students graduate from high school at about age 18 years, over 90% have tried alcohol, 33% report being recent heavy drinkers, 29% are regular smokers, and 44% have tried marijuana (1). Although these rates have been declining somewhat since 1975 (with the exception of alcohol use), they are still unacceptably high and are associated with significant healthrelated problems. These problems relate to four major domains of adolescent health-physical, psychologic, social, and spiritual (2). In the area of physical health, suicides, homicides, and unintentional injuries account for approximately 80% of adolescent deaths. Several studies reveal considerable involvement of alcohol and drugs in these deaths (3,4). Moreover, motor vehicle accidents kill more teenagers than any other cause of death, and the majority of these accidents involves alcohol. As for smoking, 85% of teenagers who completely smoke two cigarettes will become regular smokers, with increased risk for the major chronic diseases that have been shown to be related to smoking (5). In the domain of psychologic or mental health, drug use has generated psychologic dependency,
mood changes, impaired judgment, memory loss, and prolonged aimlessness (6,7). Newcomb and Bentler (8) summarized the findings of their longitudinal work as follows: “High levels of teenage drug use reflected a tendency toward precocious development, characterized by early involvement in marriage, family and the work force, and forsaking of education pursuits. Polydrug use as a teenager interfered with the developmental tasks of adolescence, which led to poor or unsuccessful role acquisition as young adults (e.g., failed marriages and job instability).” Finally, drug use influences personal or spiritual health by prematurely limiting the adolescent’s range of interests: he/she has less time or motivation to pursue growth-enhancing experiences or needed introspection. It is consistent with this notion of health that adolescents with a stronger religious affiliation might be less likely to use drugs (9). Primary prevention of drug use clearly appears to be warranted by the multitude and magnitude of health consquences already evident among adolescents. From a behavioral epidemiologic perspective, the primary focus of efforts at prevention ought to be placed on the three most widely used and misused drugs-tobacco, alcohol, and marijuana. These substances are experimented with first, are most frequently used, are associated with the greatest morbidity and mortality, and have been reported to be strong (“gateway”) predictors of subsequent use of harder drugs (10,ll). The major question, of course is “How?‘
From the Division of Epidemiology, University of Minnesota, Minneapolis, Minnesota. Address reprint requests to: Cheryl Perry, Ph.D. University ojMinnesota, Division of Epidemiology, School of Public Health, 1300 S. Second St., Suite 300, Minneapolis, MN 5.5455. This paper was presented at the 5th Congress of the International Association for Adolescent Heallh, Iuly 3-6, 1991, Montreux, Switzerland. Manuscript accepted jarmary 10, 1992.
The Social lnfruences Model of ha.mtion Early attempts at prevention assumed that adolescents simply lacked.information about the negative effects of drug use, and that if students were sufficiently aware of the negative consequences they would make a rational decision not to drink or
8 Society for Adolescent Medicine, 1992 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York,NY 10010
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smoke. The information model attempted to increase awareness of the adverse health, legal, and social consequences of substance use, and typically made use of fear arousal and messages with a clear moral message. Eater, programs focused on personality deficits, such as unclarified V:alues or a lack of self-esteem. Research from over a dozen years evaluating these approaches has concluded they have had little effect on substance use behaviors and may have even encouraged experimentation (12-14). Still, changing knowledge concerning the cozisequences of drug use continues to be the predominant form of drug education in schools (15). Current models of adolescent drug use prevention are driven by social psychology (16) and findings on the antecedents of drug use (17). These models identify three levels of risk factors that are critical to the development of effective prevention programs: environmental, personality, and behavioral risk factors. For example, the adolescent’s social environment provides the necessary conditions for drug use: observation of the behavior of influential role models; social support systems that encourage use; and access to alcohol, drugs, or nondrug alternatives. Prevention efforts, then, specifically address these factors by providing new role models or reducing access to these substances. Experimentation with substances generally occurs within the context of a social situation, yet not all teens in highrisk environments choose to experiment or to use tobacco, alcohol, or drugs regularly. It may be that personality and behavioral factors are critical in determining the adolescent’s response to the environment. The relative value placed on more conventional goals (versus drug-taking), and the adolescent’s ability to manage drug use situations or to participate in nondrug alternatives, may be the pivotal determinants of substance use initiation. These personality and behavioral risk factors suggest that prevention strategies should include the acquisition of specific social skills. The findings from longitudinal research increasingly support using a broad-based three-factor prevention approach rather than concentrating on a single factor or subset of risk factors (18-20). These research findings also suggest that drug use by adolescents serves specific functions for them. Specifically, the use of tobacco, alcohol, and marijuana offers an opportunity to challenge parental and societal authorities, demonstrate autonomy and independence, signal entry into a p=r group, or simply relieve the stresses of growing up- Accordingly, prevention efforts should attend to the functions served by drugs, as well as to the
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more proximal social-environmental, personality, and behavior risk factors. Most of the school-based strategies for tobacco, alcohol, and marijuana prevention that have been derived from this model have seven major components, with the programs generally involving 6-12 45-minute classroom sessions. Together, these strategies have been labeled the social influences model for primary prevention. First, the students begin by identifying the short-term social consequences of use, such as smeiiing badly, having an accident, or acting out-of-control. This generally is done through small group discussions so that the “consequences” are relevant to the age group. Second, the reasons why adolescents use substances are explored. The reasons or functions include a desire to have fun, a way of making friends, a signal of maturity, or a method of coping with personal problems (21). Third, the students discover that substance use is not a normative behavior for young adolescents. This is accomplished by comparing their expectations of how many of their peers are substance users with actual data and by discussing their overestimates of prevalence. Fourth, the students learn how these meanings are established in our culture through advertising, and through peer and adult role models. The methods used by advertisers to convince adolescents of tobacco or alcohol’s functional values are presented through discussions of selected advertisements. Mock social situations are analyzed to identify the type of influences that exist. Fifth, the students learn and practice skills to resist these influences and to become competent in a variety of social situations. They create anti-tobacco or anti-alcohol advertisements and perform skits (roleplaying) around possible social encounters. Sixth, students learn that the problems associated with drug use affect their community and their friends, and brainstorm ways that they can become more socially responsible in this environment. Seventh, near the end of most programs, students make a public commitment (or set a goal) to abstain. This commitment acts as a psychologic anchor and explicitly creates in the students’ mind their intention not to experiment with substances. Finally, all these activities are experiential-designed to require active participation-and are often led by trained same-age peer leaders. The systematic use of peer leaders in smoking and drug abuse prevention programs is a notable component. Several researchers have found peer-led programs to be significantly more successful in reducing onset and use rates than the same programs
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taught by the classroom teacher or other adults (2224). Generally, in each of the intervention classrooms, several students are elected as students who are “liked and respected.” Peer leaders chosen by classmates are familiar, positive role models who provide key social information and no,t merely facts. These students are trained to conduct more than one-half of the activities in the prevention program, particularly activities that involve sharing of social information. They lead small group discussions and brainstorming sessions, read and give directions for activities, report students’ views to the class, and organize roleplays and skits. Young adolescents can easily be trained to perform these functions and the inclusion of peer leaders appears to be particularly efficacious.
Research on the SociaZInfluences Model Most of the research that has evaluated applications of the social influences model has focused on cigarette smoking and alcohol and marijuana use in young adolescents. These substances are first used at this time and appear to have particular appeal during the transition to adolescence (25).
Smoking Prevention Several recent comprehensive reviews of the smoking prevention literature, including two metaanalyses, report positive findings in the proportion of students who begin to smoke when compared with an equivalent or randomly assigned control group (14,18,26-28). In these studies, the impact on regular (i.e., weekly) smoking ranged from reductions of 43-60%, with maintenance of these effects generally l-2 years after the intervention. For example, Murray et al. (24) tested the Minnesota Smoking Prevention Program (MSPP) and found that after 4 years, a peer-led social influences PFOgram reduced daily and weekly smoking incidence by 35-50% when compared with adult-led, health consequences, OF existing curriculum comparison groups. The effects of MSPP and other social influences programs appear to diminish over time, suggesting that additional booster education programs and community involvement might be needed during middle adolescence (29,30). Yet, even without booster sessions, the repeated success of these programs in at least delaying onset of tobacco smoking, across over 20 research studies, is encouraging. (Further discussion of the MSPP is provided below.)
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The reported impact of the social influences model on adolescent alcohol and drug use has been more limited (14,26,31). Nevertheless, Project SMART, a peer-led social influence prevention program, was effective in delaying the onset of tobacco, alcohol, and marijuana use (32). Pentz (33) reported her social skills intervention program also had a positive effect on alcohol use and academic performance. In a larger study, Bllickson and Bell (34) tested thdr social influences curriculum (called Project Alert) across widely diverse socioeconomic and demographic school environments in California and Oregon. Results of this program indicated that tobacco and marijuana use could effectively be delayed but that delaying the onset of alcohol use was more challenging. Life Skills Training In light of the limited findings using the social influences model for alcohol use prevention, Botvin (35) suggested an expansion of the model to include other life skills that might be necessary to delay onset. Whereas most social influences interventions focus on specific skills for resisting the social and environmental pressures to initiate substance use, Botvin’s Life Skills Training (LST) program also includes a general set of skilis for promoting individual social competence. To function in today’s society, adolescents are expected to have acquired a certain set of social skills. Interpersonal skills are necessary for the development of healthy social relationships, and failure to develop these skills may adversely affect an individual’s performance in personal, work, or school situations. The ability to make logical decisions without being overly influenced by others and to cope with anxiety and stress become more important as adolescents grow and increase their autonomy. As Botvin and Dusenbury (27) note, “Susceptibility to negative environmental influences [to use substances] might also be reduced by increasing self-esteem, a sense of personal control, self-confidence, self-satisfaction, and assertiveness. It would also be important to teach adolescents specific skills (e.g., interpersonal skills, goal-setting, self-directed behavior change techniques) designed to increase the likelihood of achieving desired goals as well as an array of general coping skills (e.g., anxiety reduction techniques, self-reinforcement techniques, positive thinking).” The LST program consists of 15-20 sessions fOF 7th grade students, with additional booster sessions
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Table 1. Summary of the Life Skills Training Program Description Number of sessions
Description
Topic
4
Substance Use: Myths and Realities
Common attitudes and beliefs about tobacco, alcohol, and marijuana use; current prevalence rates of adults and teenagers; the social acceptability of using these substances; the process of becoming a regular (habitual) user, and the difficulty of breaking these habits; the immediate physiological effects of smoking.
2
Decision Making and Independent Thinking
Discussion of routine decision making; description of a general decision-making strategy; social influences affecting decisions; recognizing persuasive tactics; and the importance of independent thinking.
2
Media Influence and Advertising Techniques
Discussion of media influences on behavior; advertising techniques and the manipulation of consumer behavior; formulating counterarguments and other cognitive strategies for resisting advertising pressure; cigarette and alcohol advertising as case studies in the use of these techniques.
2
Self-Image and Improvement
Discussion of self-image and how it is formed; the relationship between self-image and behavior; the importance of a positive self-image; alternative methods of improving one’s self and self-image; beginning a self-improvement project.
2
Coping with Anxiety
Discussion of common anxiety-inducing situations; demonstration and practice of cognitive-behavioral techniques for coping with anxiety; instruction on the application of these techniques to everyday situations as active coping strategies.
2
Communication Skills
Discussion of the communication process; distinguishing between verbal and nonverbal communication; techniques for avoiding misunderstandings.
1
Social Skills (A)
Discussion on overcoming shyness; initiating social contacts, giving and receiving compliments; basic conversational skills; initiating, sustaining, and ending conversations.
1
Social Skills (B)
Discussion of boy-girl relationships and the nature of attraction; conversing with the opposite sex; social activities and asking someone out for a date.
2
Assertiveness
Situations calling for assertiveness, reasons for not being assertive, verbal and nonverbal assertive skills; resisting peer pressures to smoke, drink, or use marijuana.
Note. From Substance abuse prevention and the promotion of competence (p. 143) by G.J. Botvin and L. Dusenbury, 1989. In G.W. Albee & J.M. Joffee (Eds.), Pritnnry prevention ~fp~ychpafhoh~ (Vol XII, pp. 146-178). Newhprry Park, CA: Sage. Copyright 1989 by Sage. Reprinted by permission.
in the 8th and 9th grades. Table 1 provides a description of the 7th grade program. The 7th grade is a time when students are experimenting with new behaviors and feel increasing pressure to engage in substance use. The LST program’s specific objectives are to I) provide students with skills to resist direct pressures to smoke, drink, or use marijuana; 2) decrease susceptibility to indirect social pressures by helping students develop greater autonomy, selfesteem, self-mastery, and self-confidence; 3) enable students to cope with anxiety induced by social situations; 4) increase students’ knowledge by providing them with accurate information concerning the prevalence rates of tobacco, alcohol, and marijuana use; and 5) promote the development of attitudes and beliefs consistent with nonsubstance use (27). Because pressures to use substances continue into high school, a lo-session booster for 8th graders and
a S-session booster for 9th graders were developed. The booster curricula review and reinforce the material covered in the 7th grade program. Botvin and Dusenbury (27) reported on a series of six progressively larger and more complex quasiexperimental studies comparing adolescents utilizing the LST program (with peer leaders) with adolescents in similar reference schools. Results from these studies have provided encouraging evidence for the LST program’s efficacy in preventing smoking onset @O-80% fewer smokers at post-test), alcohol use (54% fewer drinkers in the past month, 73% fewer heavy drinkers, and 79% fewer getting drunk more than one time a month), and marijuana use (71% fewer users). A current study is evaluating the program’s effectiveness in 56 New York State public schools, and another project is examining its suitability for urban minority populations.
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Summary The past decade of research on prevention of schoolbased smoking, alcohol and drug use provides an encouraging picture. When they regard substance use behaviors as social and functional and are given opportunities to learn and practice social skills, young adolescents appear to be less likely to smoke tobacco. An extension of these approaches also appears promising for delaying and minimizing alcohol and drug use. Although the preliminary evidence suggests some optimism for social influences and life skills models of prevention, the effects appear to decay over time. This suggests the need for more intensive and repeated interventions, adequate booster sessions, and greater involvement of the surrounding community.
The Class of 2989 Smoking Prevention Study The Minnesota Heart Health Program (MHHP) provided an opportunity to implement and evaluate a smoking prevention program within multiple years of school health education and community-wide change. The program was funded by the National Heart, Lung, and Blood Institute in 1980. The goal of the MHHP is to reduce morbidity and mortality from cardiovascular diseases in three north central U.S. communities when compared with three matched reference communities in the same region over the decade 1980-1990 (36). In one pair of communities, the Class of 1989 Study was undertaken. This study compared a cohort of young adolescents in two communities, from 6th to 12th grade, 19831989. In one of the communities, the adolescents participated in behavioral health programs in schools around healthy eating habits, regular physical activity, and nonuse of tobacco and alcohol in 6th-10th grades (37). Surveys were conducted annually, in March-April 1983-1989, with students in both communities. The smoking prevention effort consisted of the Minnesota Smoking Prevention Program in the 7th grade (1983-1984), a greeting card booster in 1984, and a substance use prevention program in 9th grade (1985-86), which primarily addressed drinking and driving. The Minnesota Smoking Prevention Program is a 6-session curriculum which includes a review of the major social influences that encourage and support smoking among youth. These initiating factors include peer pressure, advertising, models of smoking parents and siblings, a false belief+hat the majority
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of students smoke tobacco, and a lack of behavioral skills with which to resist many of these influences. The program is specifically designed to 1) help the students identify why people start to smoke; 2) teach them that nonsmoking is normative; 3) provide them with skills to resist peer pressure; 4) recognize the covert messages in tobacco advertisements; and 5), most importantly, to give them practice at refusing tobacco use and choosing nonuse alternatives. Peer leaders implement a majority of the activities and have proven to be effective communicators for many of the social and psychologic messages intrinsic to the program. The results from the Class of 1989 Study suggest long-term prevention effects that complement the results of the school-alone prevention programs, At the end of the 12th grade (1989), the weekly prevalence of smoking was still 40-45s lower in the educated community, 5 years after implementation of the Minnesota Smoking Prevention Program, for both males and females. The number of cigarettes smoked per week were also significantly reduced. The results are consistent with those found in the North Karelia Project in Finland. In North Karelia, a teacher-led and peer-led smoking prevention program plus community intervention showed a significant reduction after 4 and 8 years in the proportion of adolescents smoking compared with a nonintervention r&rence group (38,39). These results lead the North Keralia researchers to also conclude that community and school programs can influence youthful nonsmokers to avoid tobacco over the long term.
The WHO Collaborative Study on Alcohol Education and Young People The relevance of models developed in the United States to other cultures and countries is an important concern in future global efforts in dissemination and prevention. To examine this question, in 1985 the Division of Mental Health of the World Health Organization (WHO), Geneva, convened a group of investigators to study the efficacy of the social influences model for alcohol education in four countries: Australia, Chile, Norway, and Swaziland (40). The countries represented four continents, four languages, two developed and two developing economies, and four alcohol-related cultures (41-44). The results of a pilot study in such diverse settings were
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seen as particularly instructive and able to enhance generahzabiity to other countries. The study design was influenced by previous research in smoking prevention and the social influ’ ences model that has been described. Consensus on the design, timeline, protocal development, and instruments was reached at the First Meeting of Investigators in November 1985 at WHO in Geneva. In part, because of the potential of expanding the choice of teaching resources available, through the use of selected adolescent leaders as teachers, the major comparison in the study was between peerled and teacher-led instruction. Previous research has also pointed to peer leadership as an important component of primary prevention programs (35). Because of the association between social behavior, such as alcohol use, and the school environment, schools within each country were randomly assigned to peer-led, teacher-led, or control conditions. In the four countries 25 school+Australia (6), Chile (3), Norway (14), and Swaziland (2)--corn-pleted the alcoho! education program. Thus, the study included a total of 10 schools in the peer-led condition, 9 schools in the teacher-led condition, and 6 control schools. All 8th grade students in Australia, Chile, and Norway, and all 9th grade students in Swaziland, from selected schools, formed the study population. Matched data were available from 92.9% of the post-test study cohort in these schools; 2,536 students. A few of these students had missing data on selected items. The program consisted of 5 SO-minute sessions: 4 of these were held at l-week intervals; the fifth was a “booster” and review session held 1 month after the fourth session. The number of sessions was determined by examining the length of other programs and by what was feasible to implement in the four countries (35). An outline of the program is given in Table 2. Minor modifications of the curriculum were made within each country. All examples that were included for peer and media influences were from the appropriate country. Scenarios that formed the background for behavioral rehearsal were also Specific to the social situations in each site. The pledge statements were slightly modified in Australia and Chile to account for the large number of already-drinkers. For the most part, tailoring for each country was essentially in language and examples. No activities were modified substantially. peer leaders directed about 70% of the session content in the peer-led program. The resultsfrom the study were very encouraging
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(40). Overall, students in the peer-led program reported significantly less use of alcohol than did students in the teacher-led program or control group, independent of whether they were drinkers or non-
drinkers at baseline. The students in the peer-led condition gained more knowledge, acquired better attitudes, and reported fewer friends drinking at post-test. Even with some variation in the extent of these outcomes by country, in no case did either the teacher-led program or the control group demonstrate more positive outcomes than the peer-led program for any of the behavioral or psychosocial measures. Thus, not only does the peer-led program appear to be generally effective in reducing adolescent alcohol use, it also did not produce detrimental effects for any scale within any of the four countries. Summary The social influence models do provide some optimism for primary prevention efforts. Prevention programs appear most effective when 1) the target behavior of the intervention has received increasing societal disapproval (such as cigarette smoking), 2) multiple years of behavioral health education are planned, and 3) community-wide involvement or mass media complement a school-based peer-led program (45,46). Short-term programs and those involving alcohol use have had less favorable outcomes. Future research in primary prevention should address concerns of high-risk groups and high-risk countries, such as lower income populations in the United States or t ountries that have large adolescent homeless populations. The utilization of adolescent leaders for program dissemination might be particularly critical in these settings. A second major and global concern should focus upon alcohol use and alcohol-related problems. In many communities adolescent alcohol use is normative and even adult supported. Thus, young people are getting quite inconsistent messages on alcohol from their schools, from TV, from peers, and from parents. This inconsistency may translate into many tragic and avoidable deaths for young people. Clearly, in the area of alcohol-related problems, community-wide involvement may be necessary. A third direction for prevention research should involve issues of norms, access, and enforcement including policy interventions, such as involve the availability of cigarette vending machines or the ease of under-age buying or levels of taxation. These methods affect adolescents more acutely since their
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Table 2. WHO Alcohol Education Program timeline Week 1, Session 1 (50-60 min)
361
Program Classroom method”
Objective
Group discussion:
What are the consequences? Written assi,pxment:
How many people our age use alcohol? Group discussion:
Identify the social, physical, legal consequences of alcohol use. Individual written estimates of alcohol use prevalence. Identify positive consequences of nonuse.
What are the positive characteristics of nonusers? Week 2, Session 2 (50-60 min)
Class competition on consequences of alcohol use.
Increases knowledge on consequences of use.
Group discussion:
Correct normative expectations for use.
Comparing group estimates from Session 1 to baseline data on alcohol use. Group discussion:
Analyze social situations that involve alcohol.
What would you do in this situation? Week 3, Session 3 (50-60 minj
Group discussion: What are the types of peer influences you might confront?
Identify
Group roleplay:
Practice refusing alcohol in social situations.
direct, indirect, and insistent peer pressure.
Can you create and enact a typical social situ&ion that invoives alcohol? Week 4, Session 4 (59-60 min)
Goup discussion:
Analyze alcohol advertisements.
What techniques do advertisers use to make alcohol use attractive to young people? Written assigment:
What are the reasons you want to remain a nonuser until you’re older? Under what circumstances? Week 8, Booster Session (50-60 min)
Group discussion:
Personal pledge to not drink until older (optional).
Identify nonalcohol places and situations.
Where and when is alcohol use not allowed in our community? Why? Growp discussion:
Have you received or noticed pressure to drink in the past month? How did you handle the situation?
Reinforcement for dealing with alcohol use in social situations.
“Group discussions were in small groups led by the peer leaders in the peer-led condition: they involved the entire class, led by the teacher in the teacher-led condition.
financialresources, for the most part, are more limited. These policy level methods also signifyto adolescents what adults consider appropriate. These efforts are consistentwith and may be necessary for effective primary prevention. Finally, it may be that issues of employment, housing, health care, and the stresses of dailyliving loom larger in some populations than do concerns with tobacco and alcohol use. Yet all of these factors-including substanceuse-form a complexweb of cause and effect; it is difficultto deal with one of these issues without considering the others. The promotionof opportunitiesfor improvementin each of these areas should be considered a salutary development, and one consistent with more global
aims of promoting overall adolescent health and substanceabuse prevention.
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26. Tobler N. Meta-analysis of 143 adolescent drug prevention programs: Quantitative outcome results of program participants compared to a control or comparison group. J Drug Issues 1988;16:537-67. 27. Botvin GJ, Dusenbury L. Substance abuse prevention and the promotion of competence. In: Albee CW, Joffe JM, eds. Primary Prevention of Psychopathology, vol XII. Newberry Park: Sage Publications, 1989. 28. Pentz MA, MacKlnnon DP, Flay BR, et al. Primary prevention of chronic diseases in adolescence: Effects of the midwestern prevention project on tobacco use. Am J Epidemiol 1989; 130~713-24. 29. Botvin GJ, Renick NL, Baker E. The effects of scheduling format and booster sessions on a broad spectrum psychosocial models to smoking prevention. J Behav Med 1983; 6359-79. 30. Flay BR, Koepke D, Thompson SJ, et al. Six year follow-up of the first Waterloo School Smoking Prevention Trial. Am J Public Health 1989;79:1371-5. 31. Moskowitz JM. The primary prevention of alcohol problems: A critical review of the research literature. J Stud Alcohol 1989;50:54-88. 32. Hansen WB, Johnson CA, Flay BR, et al. Affective and social influences approaches to the prevention of multiple substance abuse among seventh grade students: Results from project SMART. Prev Med 1988;17:135-54. 33. Pentz MA, Prevention of adolescent substance abuse through social skill development. In: Glynn TJ, Luekefeld CG, Ludford JP, eds. Preventing Adolescent Drug Use: Intervention Strategies (Research Monograph No. 47). Rockville, MD: National institute on Drug Abuse, 1983:195-232. 34. Ellickson PL, Bell RM. Prospects for preventing drug use among young adolescents. Santa Monica, CA: The Rand Corporation, 1990:25-41. 35. Botvin G. Substance abuse prevention research: Recent developments and future directions. J Sch Health 1986;56: 369-74. 36. Blackburn H, Luepker RV, Kline FG, et al. The Minnesota Heart Health Program: A research and demonstration project in cardiovascular disease prevention, In: Matarazzo JD, Weiss SM, Herd JA, et al., eds., 1984. 37. Perry CL, Klepp K, Sillers C. Community-wide strategies for cardiovascular health: The Minnesota Heart Health Program youth program. Health Educ Res 1989;4:87-101. 38. Vartlainen E, Pallonen U, McAlister A, et al. Four-year followup results of the smoking prevention program in the North Karalia Youth Project. Prev Med 1986;15:692-B. 39. Vartiainen E, Pallonen U, McAlister A, Puska P. Eight-year follow-up results of an adolescent smoking prevention program: The North Karalia Youth Project. Am J Public Health 1990;80:78-9. 40. Perry CL, Grant M, Ernberg G, et al. W.H.O. collaborative study on alcohol education and young people: Outcomes of a four-country pilot study. lnt J Addict 1989;24:1145-71. 41. Fisher J, Cross D. Alcohol consumption and young people: An Australian perspective. First meeting of inveitjgators: WHO Collaborative Studv on Alcohol Education and Young People. Geneva, Switzerkmd, November 1985. 42. Florenzano RU. Responding to alcohol problems in Chile with special focus on youth. First meeting of investigators: WHO Collaborative Study on Alcohol Education and Young People. Geneva, Switzerland, November 1985. 43. Myeni AD. Alcohol consumption and alcohol-related problems in Swaziland. First meeting of investigators: WHO Col-
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45. Flay BR. Mass media linkages with school-based programs for drug abuse prevention. J Sch Health 1986;56:402-6. 46. Pentz MA, Dwyer JH, MacKinnon DP, et al. A multicommunity trial for primary prevention of adolescent drug abuse: Effects on drug use prevalence. JAMA 1989;261:325966.
CONFERENCE PROCEEDINGS
CHERYL
L. PERRY,
Ph.
., AND STEVEN H. #ELDER,
M.P.H.
The problems associated with adolescent alcohol and drug use are global problems, particularly as our countries and economies become more interdependent, as substances become more readily available worldwide, and as the functions served by use of alcohol and drugs hold particular appeal to young people. In the United States, by the time students graduate from high school at about age 18 years, over 90% have tried alcohol, 33% report being recent heavy drinkers, 29% are regular smokers, and 44% have tried marijuana (1). Although these rates have been declining somewhat since 1975 (with the exception of alcohol use), they are still unacceptably high and are associated with significant healthrelated problems. These problems relate to four major domains of adolescent health-physical, psychologic, social, and spiritual (2). In the area of physical health, suicides, homicides, and unintentional injuries account for approximately 80% of adolescent deaths. Several studies reveal considerable involvement of alcohol and drugs in these deaths (3,4). Moreover, motor vehicle accidents kill more teenagers than any other cause of death, and the majority of these accidents involves alcohol. As for smoking, 85% of teenagers who completely smoke two cigarettes will become regular smokers, with increased risk for the major chronic diseases that have been shown to be related to smoking (5). In the domain of psychologic or mental health, drug use has generated psychologic dependency,
mood changes, impaired judgment, memory loss, and prolonged aimlessness (6,7). Newcomb and Bentler (8) summarized the findings of their longitudinal work as follows: “High levels of teenage drug use reflected a tendency toward precocious development, characterized by early involvement in marriage, family and the work force, and forsaking of education pursuits. Polydrug use as a teenager interfered with the developmental tasks of adolescence, which led to poor or unsuccessful role acquisition as young adults (e.g., failed marriages and job instability).” Finally, drug use influences personal or spiritual health by prematurely limiting the adolescent’s range of interests: he/she has less time or motivation to pursue growth-enhancing experiences or needed introspection. It is consistent with this notion of health that adolescents with a stronger religious affiliation might be less likely to use drugs (9). Primary prevention of drug use clearly appears to be warranted by the multitude and magnitude of health consquences already evident among adolescents. From a behavioral epidemiologic perspective, the primary focus of efforts at prevention ought to be placed on the three most widely used and misused drugs-tobacco, alcohol, and marijuana. These substances are experimented with first, are most frequently used, are associated with the greatest morbidity and mortality, and have been reported to be strong (“gateway”) predictors of subsequent use of harder drugs (10,ll). The major question, of course is “How?‘
From the Division of Epidemiology, University of Minnesota, Minneapolis, Minnesota. Address reprint requests to: Cheryl Perry, Ph.D. University ojMinnesota, Division of Epidemiology, School of Public Health, 1300 S. Second St., Suite 300, Minneapolis, MN 5.5455. This paper was presented at the 5th Congress of the International Association for Adolescent Heallh, Iuly 3-6, 1991, Montreux, Switzerland. Manuscript accepted jarmary 10, 1992.
The Social lnfruences Model of ha.mtion Early attempts at prevention assumed that adolescents simply lacked.information about the negative effects of drug use, and that if students were sufficiently aware of the negative consequences they would make a rational decision not to drink or
8 Society for Adolescent Medicine, 1992 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York,NY 10010
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smoke. The information model attempted to increase awareness of the adverse health, legal, and social consequences of substance use, and typically made use of fear arousal and messages with a clear moral message. Eater, programs focused on personality deficits, such as unclarified V:alues or a lack of self-esteem. Research from over a dozen years evaluating these approaches has concluded they have had little effect on substance use behaviors and may have even encouraged experimentation (12-14). Still, changing knowledge concerning the cozisequences of drug use continues to be the predominant form of drug education in schools (15). Current models of adolescent drug use prevention are driven by social psychology (16) and findings on the antecedents of drug use (17). These models identify three levels of risk factors that are critical to the development of effective prevention programs: environmental, personality, and behavioral risk factors. For example, the adolescent’s social environment provides the necessary conditions for drug use: observation of the behavior of influential role models; social support systems that encourage use; and access to alcohol, drugs, or nondrug alternatives. Prevention efforts, then, specifically address these factors by providing new role models or reducing access to these substances. Experimentation with substances generally occurs within the context of a social situation, yet not all teens in highrisk environments choose to experiment or to use tobacco, alcohol, or drugs regularly. It may be that personality and behavioral factors are critical in determining the adolescent’s response to the environment. The relative value placed on more conventional goals (versus drug-taking), and the adolescent’s ability to manage drug use situations or to participate in nondrug alternatives, may be the pivotal determinants of substance use initiation. These personality and behavioral risk factors suggest that prevention strategies should include the acquisition of specific social skills. The findings from longitudinal research increasingly support using a broad-based three-factor prevention approach rather than concentrating on a single factor or subset of risk factors (18-20). These research findings also suggest that drug use by adolescents serves specific functions for them. Specifically, the use of tobacco, alcohol, and marijuana offers an opportunity to challenge parental and societal authorities, demonstrate autonomy and independence, signal entry into a p=r group, or simply relieve the stresses of growing up- Accordingly, prevention efforts should attend to the functions served by drugs, as well as to the
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more proximal social-environmental, personality, and behavior risk factors. Most of the school-based strategies for tobacco, alcohol, and marijuana prevention that have been derived from this model have seven major components, with the programs generally involving 6-12 45-minute classroom sessions. Together, these strategies have been labeled the social influences model for primary prevention. First, the students begin by identifying the short-term social consequences of use, such as smeiiing badly, having an accident, or acting out-of-control. This generally is done through small group discussions so that the “consequences” are relevant to the age group. Second, the reasons why adolescents use substances are explored. The reasons or functions include a desire to have fun, a way of making friends, a signal of maturity, or a method of coping with personal problems (21). Third, the students discover that substance use is not a normative behavior for young adolescents. This is accomplished by comparing their expectations of how many of their peers are substance users with actual data and by discussing their overestimates of prevalence. Fourth, the students learn how these meanings are established in our culture through advertising, and through peer and adult role models. The methods used by advertisers to convince adolescents of tobacco or alcohol’s functional values are presented through discussions of selected advertisements. Mock social situations are analyzed to identify the type of influences that exist. Fifth, the students learn and practice skills to resist these influences and to become competent in a variety of social situations. They create anti-tobacco or anti-alcohol advertisements and perform skits (roleplaying) around possible social encounters. Sixth, students learn that the problems associated with drug use affect their community and their friends, and brainstorm ways that they can become more socially responsible in this environment. Seventh, near the end of most programs, students make a public commitment (or set a goal) to abstain. This commitment acts as a psychologic anchor and explicitly creates in the students’ mind their intention not to experiment with substances. Finally, all these activities are experiential-designed to require active participation-and are often led by trained same-age peer leaders. The systematic use of peer leaders in smoking and drug abuse prevention programs is a notable component. Several researchers have found peer-led programs to be significantly more successful in reducing onset and use rates than the same programs
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taught by the classroom teacher or other adults (2224). Generally, in each of the intervention classrooms, several students are elected as students who are “liked and respected.” Peer leaders chosen by classmates are familiar, positive role models who provide key social information and no,t merely facts. These students are trained to conduct more than one-half of the activities in the prevention program, particularly activities that involve sharing of social information. They lead small group discussions and brainstorming sessions, read and give directions for activities, report students’ views to the class, and organize roleplays and skits. Young adolescents can easily be trained to perform these functions and the inclusion of peer leaders appears to be particularly efficacious.
Research on the SociaZInfluences Model Most of the research that has evaluated applications of the social influences model has focused on cigarette smoking and alcohol and marijuana use in young adolescents. These substances are first used at this time and appear to have particular appeal during the transition to adolescence (25).
Smoking Prevention Several recent comprehensive reviews of the smoking prevention literature, including two metaanalyses, report positive findings in the proportion of students who begin to smoke when compared with an equivalent or randomly assigned control group (14,18,26-28). In these studies, the impact on regular (i.e., weekly) smoking ranged from reductions of 43-60%, with maintenance of these effects generally l-2 years after the intervention. For example, Murray et al. (24) tested the Minnesota Smoking Prevention Program (MSPP) and found that after 4 years, a peer-led social influences PFOgram reduced daily and weekly smoking incidence by 35-50% when compared with adult-led, health consequences, OF existing curriculum comparison groups. The effects of MSPP and other social influences programs appear to diminish over time, suggesting that additional booster education programs and community involvement might be needed during middle adolescence (29,30). Yet, even without booster sessions, the repeated success of these programs in at least delaying onset of tobacco smoking, across over 20 research studies, is encouraging. (Further discussion of the MSPP is provided below.)
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The reported impact of the social influences model on adolescent alcohol and drug use has been more limited (14,26,31). Nevertheless, Project SMART, a peer-led social influence prevention program, was effective in delaying the onset of tobacco, alcohol, and marijuana use (32). Pentz (33) reported her social skills intervention program also had a positive effect on alcohol use and academic performance. In a larger study, Bllickson and Bell (34) tested thdr social influences curriculum (called Project Alert) across widely diverse socioeconomic and demographic school environments in California and Oregon. Results of this program indicated that tobacco and marijuana use could effectively be delayed but that delaying the onset of alcohol use was more challenging. Life Skills Training In light of the limited findings using the social influences model for alcohol use prevention, Botvin (35) suggested an expansion of the model to include other life skills that might be necessary to delay onset. Whereas most social influences interventions focus on specific skills for resisting the social and environmental pressures to initiate substance use, Botvin’s Life Skills Training (LST) program also includes a general set of skilis for promoting individual social competence. To function in today’s society, adolescents are expected to have acquired a certain set of social skills. Interpersonal skills are necessary for the development of healthy social relationships, and failure to develop these skills may adversely affect an individual’s performance in personal, work, or school situations. The ability to make logical decisions without being overly influenced by others and to cope with anxiety and stress become more important as adolescents grow and increase their autonomy. As Botvin and Dusenbury (27) note, “Susceptibility to negative environmental influences [to use substances] might also be reduced by increasing self-esteem, a sense of personal control, self-confidence, self-satisfaction, and assertiveness. It would also be important to teach adolescents specific skills (e.g., interpersonal skills, goal-setting, self-directed behavior change techniques) designed to increase the likelihood of achieving desired goals as well as an array of general coping skills (e.g., anxiety reduction techniques, self-reinforcement techniques, positive thinking).” The LST program consists of 15-20 sessions fOF 7th grade students, with additional booster sessions
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Table 1. Summary of the Life Skills Training Program Description Number of sessions
Description
Topic
4
Substance Use: Myths and Realities
Common attitudes and beliefs about tobacco, alcohol, and marijuana use; current prevalence rates of adults and teenagers; the social acceptability of using these substances; the process of becoming a regular (habitual) user, and the difficulty of breaking these habits; the immediate physiological effects of smoking.
2
Decision Making and Independent Thinking
Discussion of routine decision making; description of a general decision-making strategy; social influences affecting decisions; recognizing persuasive tactics; and the importance of independent thinking.
2
Media Influence and Advertising Techniques
Discussion of media influences on behavior; advertising techniques and the manipulation of consumer behavior; formulating counterarguments and other cognitive strategies for resisting advertising pressure; cigarette and alcohol advertising as case studies in the use of these techniques.
2
Self-Image and Improvement
Discussion of self-image and how it is formed; the relationship between self-image and behavior; the importance of a positive self-image; alternative methods of improving one’s self and self-image; beginning a self-improvement project.
2
Coping with Anxiety
Discussion of common anxiety-inducing situations; demonstration and practice of cognitive-behavioral techniques for coping with anxiety; instruction on the application of these techniques to everyday situations as active coping strategies.
2
Communication Skills
Discussion of the communication process; distinguishing between verbal and nonverbal communication; techniques for avoiding misunderstandings.
1
Social Skills (A)
Discussion on overcoming shyness; initiating social contacts, giving and receiving compliments; basic conversational skills; initiating, sustaining, and ending conversations.
1
Social Skills (B)
Discussion of boy-girl relationships and the nature of attraction; conversing with the opposite sex; social activities and asking someone out for a date.
2
Assertiveness
Situations calling for assertiveness, reasons for not being assertive, verbal and nonverbal assertive skills; resisting peer pressures to smoke, drink, or use marijuana.
Note. From Substance abuse prevention and the promotion of competence (p. 143) by G.J. Botvin and L. Dusenbury, 1989. In G.W. Albee & J.M. Joffee (Eds.), Pritnnry prevention ~fp~ychpafhoh~ (Vol XII, pp. 146-178). Newhprry Park, CA: Sage. Copyright 1989 by Sage. Reprinted by permission.
in the 8th and 9th grades. Table 1 provides a description of the 7th grade program. The 7th grade is a time when students are experimenting with new behaviors and feel increasing pressure to engage in substance use. The LST program’s specific objectives are to I) provide students with skills to resist direct pressures to smoke, drink, or use marijuana; 2) decrease susceptibility to indirect social pressures by helping students develop greater autonomy, selfesteem, self-mastery, and self-confidence; 3) enable students to cope with anxiety induced by social situations; 4) increase students’ knowledge by providing them with accurate information concerning the prevalence rates of tobacco, alcohol, and marijuana use; and 5) promote the development of attitudes and beliefs consistent with nonsubstance use (27). Because pressures to use substances continue into high school, a lo-session booster for 8th graders and
a S-session booster for 9th graders were developed. The booster curricula review and reinforce the material covered in the 7th grade program. Botvin and Dusenbury (27) reported on a series of six progressively larger and more complex quasiexperimental studies comparing adolescents utilizing the LST program (with peer leaders) with adolescents in similar reference schools. Results from these studies have provided encouraging evidence for the LST program’s efficacy in preventing smoking onset @O-80% fewer smokers at post-test), alcohol use (54% fewer drinkers in the past month, 73% fewer heavy drinkers, and 79% fewer getting drunk more than one time a month), and marijuana use (71% fewer users). A current study is evaluating the program’s effectiveness in 56 New York State public schools, and another project is examining its suitability for urban minority populations.
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Summary The past decade of research on prevention of schoolbased smoking, alcohol and drug use provides an encouraging picture. When they regard substance use behaviors as social and functional and are given opportunities to learn and practice social skills, young adolescents appear to be less likely to smoke tobacco. An extension of these approaches also appears promising for delaying and minimizing alcohol and drug use. Although the preliminary evidence suggests some optimism for social influences and life skills models of prevention, the effects appear to decay over time. This suggests the need for more intensive and repeated interventions, adequate booster sessions, and greater involvement of the surrounding community.
The Class of 2989 Smoking Prevention Study The Minnesota Heart Health Program (MHHP) provided an opportunity to implement and evaluate a smoking prevention program within multiple years of school health education and community-wide change. The program was funded by the National Heart, Lung, and Blood Institute in 1980. The goal of the MHHP is to reduce morbidity and mortality from cardiovascular diseases in three north central U.S. communities when compared with three matched reference communities in the same region over the decade 1980-1990 (36). In one pair of communities, the Class of 1989 Study was undertaken. This study compared a cohort of young adolescents in two communities, from 6th to 12th grade, 19831989. In one of the communities, the adolescents participated in behavioral health programs in schools around healthy eating habits, regular physical activity, and nonuse of tobacco and alcohol in 6th-10th grades (37). Surveys were conducted annually, in March-April 1983-1989, with students in both communities. The smoking prevention effort consisted of the Minnesota Smoking Prevention Program in the 7th grade (1983-1984), a greeting card booster in 1984, and a substance use prevention program in 9th grade (1985-86), which primarily addressed drinking and driving. The Minnesota Smoking Prevention Program is a 6-session curriculum which includes a review of the major social influences that encourage and support smoking among youth. These initiating factors include peer pressure, advertising, models of smoking parents and siblings, a false belief+hat the majority
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of students smoke tobacco, and a lack of behavioral skills with which to resist many of these influences. The program is specifically designed to 1) help the students identify why people start to smoke; 2) teach them that nonsmoking is normative; 3) provide them with skills to resist peer pressure; 4) recognize the covert messages in tobacco advertisements; and 5), most importantly, to give them practice at refusing tobacco use and choosing nonuse alternatives. Peer leaders implement a majority of the activities and have proven to be effective communicators for many of the social and psychologic messages intrinsic to the program. The results from the Class of 1989 Study suggest long-term prevention effects that complement the results of the school-alone prevention programs, At the end of the 12th grade (1989), the weekly prevalence of smoking was still 40-45s lower in the educated community, 5 years after implementation of the Minnesota Smoking Prevention Program, for both males and females. The number of cigarettes smoked per week were also significantly reduced. The results are consistent with those found in the North Karelia Project in Finland. In North Karelia, a teacher-led and peer-led smoking prevention program plus community intervention showed a significant reduction after 4 and 8 years in the proportion of adolescents smoking compared with a nonintervention r&rence group (38,39). These results lead the North Keralia researchers to also conclude that community and school programs can influence youthful nonsmokers to avoid tobacco over the long term.
The WHO Collaborative Study on Alcohol Education and Young People The relevance of models developed in the United States to other cultures and countries is an important concern in future global efforts in dissemination and prevention. To examine this question, in 1985 the Division of Mental Health of the World Health Organization (WHO), Geneva, convened a group of investigators to study the efficacy of the social influences model for alcohol education in four countries: Australia, Chile, Norway, and Swaziland (40). The countries represented four continents, four languages, two developed and two developing economies, and four alcohol-related cultures (41-44). The results of a pilot study in such diverse settings were
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seen as particularly instructive and able to enhance generahzabiity to other countries. The study design was influenced by previous research in smoking prevention and the social influ’ ences model that has been described. Consensus on the design, timeline, protocal development, and instruments was reached at the First Meeting of Investigators in November 1985 at WHO in Geneva. In part, because of the potential of expanding the choice of teaching resources available, through the use of selected adolescent leaders as teachers, the major comparison in the study was between peerled and teacher-led instruction. Previous research has also pointed to peer leadership as an important component of primary prevention programs (35). Because of the association between social behavior, such as alcohol use, and the school environment, schools within each country were randomly assigned to peer-led, teacher-led, or control conditions. In the four countries 25 school+Australia (6), Chile (3), Norway (14), and Swaziland (2)--corn-pleted the alcoho! education program. Thus, the study included a total of 10 schools in the peer-led condition, 9 schools in the teacher-led condition, and 6 control schools. All 8th grade students in Australia, Chile, and Norway, and all 9th grade students in Swaziland, from selected schools, formed the study population. Matched data were available from 92.9% of the post-test study cohort in these schools; 2,536 students. A few of these students had missing data on selected items. The program consisted of 5 SO-minute sessions: 4 of these were held at l-week intervals; the fifth was a “booster” and review session held 1 month after the fourth session. The number of sessions was determined by examining the length of other programs and by what was feasible to implement in the four countries (35). An outline of the program is given in Table 2. Minor modifications of the curriculum were made within each country. All examples that were included for peer and media influences were from the appropriate country. Scenarios that formed the background for behavioral rehearsal were also Specific to the social situations in each site. The pledge statements were slightly modified in Australia and Chile to account for the large number of already-drinkers. For the most part, tailoring for each country was essentially in language and examples. No activities were modified substantially. peer leaders directed about 70% of the session content in the peer-led program. The resultsfrom the study were very encouraging
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(40). Overall, students in the peer-led program reported significantly less use of alcohol than did students in the teacher-led program or control group, independent of whether they were drinkers or non-
drinkers at baseline. The students in the peer-led condition gained more knowledge, acquired better attitudes, and reported fewer friends drinking at post-test. Even with some variation in the extent of these outcomes by country, in no case did either the teacher-led program or the control group demonstrate more positive outcomes than the peer-led program for any of the behavioral or psychosocial measures. Thus, not only does the peer-led program appear to be generally effective in reducing adolescent alcohol use, it also did not produce detrimental effects for any scale within any of the four countries. Summary The social influence models do provide some optimism for primary prevention efforts. Prevention programs appear most effective when 1) the target behavior of the intervention has received increasing societal disapproval (such as cigarette smoking), 2) multiple years of behavioral health education are planned, and 3) community-wide involvement or mass media complement a school-based peer-led program (45,46). Short-term programs and those involving alcohol use have had less favorable outcomes. Future research in primary prevention should address concerns of high-risk groups and high-risk countries, such as lower income populations in the United States or t ountries that have large adolescent homeless populations. The utilization of adolescent leaders for program dissemination might be particularly critical in these settings. A second major and global concern should focus upon alcohol use and alcohol-related problems. In many communities adolescent alcohol use is normative and even adult supported. Thus, young people are getting quite inconsistent messages on alcohol from their schools, from TV, from peers, and from parents. This inconsistency may translate into many tragic and avoidable deaths for young people. Clearly, in the area of alcohol-related problems, community-wide involvement may be necessary. A third direction for prevention research should involve issues of norms, access, and enforcement including policy interventions, such as involve the availability of cigarette vending machines or the ease of under-age buying or levels of taxation. These methods affect adolescents more acutely since their
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MODELS FOR EFFECTIVE PREVENTION
Table 2. WHO Alcohol Education Program timeline Week 1, Session 1 (50-60 min)
361
Program Classroom method”
Objective
Group discussion:
What are the consequences? Written assi,pxment:
How many people our age use alcohol? Group discussion:
Identify the social, physical, legal consequences of alcohol use. Individual written estimates of alcohol use prevalence. Identify positive consequences of nonuse.
What are the positive characteristics of nonusers? Week 2, Session 2 (50-60 min)
Class competition on consequences of alcohol use.
Increases knowledge on consequences of use.
Group discussion:
Correct normative expectations for use.
Comparing group estimates from Session 1 to baseline data on alcohol use. Group discussion:
Analyze social situations that involve alcohol.
What would you do in this situation? Week 3, Session 3 (50-60 minj
Group discussion: What are the types of peer influences you might confront?
Identify
Group roleplay:
Practice refusing alcohol in social situations.
direct, indirect, and insistent peer pressure.
Can you create and enact a typical social situ&ion that invoives alcohol? Week 4, Session 4 (59-60 min)
Goup discussion:
Analyze alcohol advertisements.
What techniques do advertisers use to make alcohol use attractive to young people? Written assigment:
What are the reasons you want to remain a nonuser until you’re older? Under what circumstances? Week 8, Booster Session (50-60 min)
Group discussion:
Personal pledge to not drink until older (optional).
Identify nonalcohol places and situations.
Where and when is alcohol use not allowed in our community? Why? Growp discussion:
Have you received or noticed pressure to drink in the past month? How did you handle the situation?
Reinforcement for dealing with alcohol use in social situations.
“Group discussions were in small groups led by the peer leaders in the peer-led condition: they involved the entire class, led by the teacher in the teacher-led condition.
financialresources, for the most part, are more limited. These policy level methods also signifyto adolescents what adults consider appropriate. These efforts are consistentwith and may be necessary for effective primary prevention. Finally, it may be that issues of employment, housing, health care, and the stresses of dailyliving loom larger in some populations than do concerns with tobacco and alcohol use. Yet all of these factors-including substanceuse-form a complexweb of cause and effect; it is difficultto deal with one of these issues without considering the others. The promotionof opportunitiesfor improvementin each of these areas should be considered a salutary development, and one consistent with more global
aims of promoting overall adolescent health and substanceabuse prevention.
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