Summative lessons learned from the first European multisite trial on school-based substance abuse prevention.
5 “Unplugged,” a European school-based program for substance use prevention among adolescents: Overview of results from the EU-Dap trial Federica D. Vigna-Taglianti, Maria Rosaria Galanti, Gregor Burkhart, Maria Paola Caria, Serena Vadrucci, Fabrizio Faggiano for the EU-Dap Study Group the eu-dap study aimed to develop and evaluate a school-based curriculum for the prevention of substance use among young The EU-Dap Study Group includes (beside the authors): Barbara Zunino, GLuca Cuomo, Silena Salmaso (Piedmont Centre for Drug Addiction Epidemiology, Turin, Italy); Karl Bohrn (Institut fur ¨ Sozial und Gesundheitspsychologie, Wien, Austria); Erwin Coppens, Yannick Weyts, Johan van de Walle (De Sleutel, Merelbeke, Belgium); Peer van der Kreeft, Johan Jongbloet (University College, Ghent, Belgium); Juan Carlos Melero, Tatiana Perez, Laura Varona, Oihana Rementeria (EDEX, Bilbao, Spain); Vicky Yotsidi, Clive Richardson (University Mental Health Research Institute, Athens, Greece); Maro Vassara, Maria Kyriakidou, Gabriela Terzopoulou (Pyxida, Thessaloniki, Greece); Sara Sanchez, Charlotte Jansson (Dept of Public Health Sciences, Karolinska Institutet, Sweden); and Leila Fabiani, Maria Scatigna (Dept of Internal Medicine and Public Health, University of L’Aquila). EU-Dap was funded by the European Commission (European Public Health program 2002 grant no. SPC 2002376 and 2003–2008 grant no. 2005312), Compagnia di San Paolo (grant nos. 2002-0703 and 2007-2434), Lega Italiana per la Lotta contro i Tumori NEW DIRECTIONS FOR YOUTH DEVELOPMENT, NO. 141, SPRING 2014 © WILEY PERIODICALS, INC. Published online in Wiley Online Library (wileyonlinelibrary.com) • DOI: 10.1002/yd.20087
67
68
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
people. The school curriculum, “Unplugged,” is based on Social Influence approach and addresses social and personal skills, knowledge, and normative beliefs. It consists of 12 one-hour interactive sessions delivered by teachers. Its effectiveness was evaluated through a randomized trial involving 7,079 pupils of seven European countries. Unplugged was effective in reducing cigarette smoking, episodes of drunkenness, and the use of cannabis at short term. This association, however, was confined to boys, with age and self-esteem as possible explanations of this difference. Beneficial effects associated with the program persisted at fifteen-month follow-up for drunkenness, alcohol-related problems, and cannabis use, and were stronger among adolescents in schools of average low socioeconomic level. These results are of scientific importance, and may inform the adoption of effective public health interventions at population level.
Background Substance use, including tobacco and alcohol use, is the most important contributor to the burden of ill-health in developed countries, accounting for 20 percent of deaths and 22 percent of potential years of life lost.1 According to recent interpretations, tobacco, alcohol, and illicit drugs share common determinants for use and dependence, natural history, pathophysiology, and neurological pathways of abuse liability.2 Since the incidence of first use increases rapidly up to the age of fifteen years, when stabilization occurs, universal prevention in the school setting is one of the most common strategies to tackle substance use in youths.3 The effectiveness of school-based prevention programs is still a matter of debate in the scientific community.4 However, several systematic reviews and overviews recently concluded that some interventions may be effective.5 (grant no. 2003 43/4), Swedish Council for Working Life and Social Research (grant no. 2002-0979), and Stockholm County Council (Public Health grant no. LS 0401-0117). new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
69
The EU-Dap study (www.eudap.net) was initiated in 2003 with funding from the EC, with the scope to develop and evaluate a European school-based curriculum for the prevention of substance use among adolescents. Until then, no collaborative large studies on structured preventive interventions were conducted in Europe. The study was carried on in seven European countries: Italy, Greece, Spain, Austria, Belgium, Germany, and Sweden. The aim of this chapter is to summarize the findings of the EUDap study as previously published in several scientific papers to which we refer for details.6
Methods Unplugged is a school-based curriculum consisting of twelve units, one-hour each, delivered by trained class teachers to adolescents 12–14 years old during the school year. It is a strongly interactive curriculum including training on creative and critical thinking, decision making, problem solving, effective communication, interpersonal relationship skills, self-awareness, empathy, coping with emotions and stress, normative beliefs, and knowledge about the harmful effects of drugs.7 Theories on which the curriculum is built are Social Learning, Problem Behavior theory, Health Belief model, theory of Reasoned Action-Attitude and Planned Behavior, and Social Norms theory.8 These theories are integrated creating a complex model, which allows the inclusion of Unplugged among Comprehensive Social Influence programs, according to the definition given by Sussman.9 According to Thomas’ classification, Unplugged is a combined social competence and social influences curriculum.10 The evaluation study The effectiveness of the program was evaluated through a cluster randomized trial where schools were randomly assigned to experimental (receiving Unplugged) or control group (receiving usual curriculum). new directions for youth development • doi: 10.1002.yd
70
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
The source population were students attending junior high school (12–14 years of age) in the geographical areas of the centers participating in the study. Out of 290 eligible schools invited to take part to the trial, 170 accepted and were centrally randomized to one of the study arms. The randomization was stratified by socioeconomic level of the school area. Sixteen percent of schools dropped out before the baseline survey. The withdrawal rate was 23.5 percent for intervention arms and 4.4 percent for the control arm. The withdrawal of intervention schools mainly occurred during or just before the training of teachers, was comparable in all centers, and similar across the three levels of social stratification. The curriculum was implemented between October 2004 and January 2005 in seventy-eight schools, whereas sixty-five schools acted as controls. Pre-test data were collected from 7,079 students in October 2004. Post-test data were collected from 6,604 students in May 2005, that is, at least three months after the completion of the program. Pre- and post-test questionnaires were matched using a selfgenerated anonymous code. Across all centers, 91.5 percent of pretest questionnaires could be linked to a post-test questionnaire, and 81.3 percent to a fifteen-month follow-up questionnaire. Therefore, 6,370 students constituted the analytical sample for posttest, and 5,541 for fifteen-month follow-up. The questionnaire was self-completed and anonymous and included thirty-seven items investigating tobacco and substance use, alcohol abuse, knowledge and opinions about substances, social and personal skills, and normative beliefs. Most items were retrieved from the Evaluation Instruments Bank of the EMCDDA. Apart from language adaptation, the questionnaire was identical in all countries. The surveys were conducted in the classroom without teachers’ participation.11
The statistical analysis Multilevel regression models were used to analyze the association between program condition and change in substance use three and new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
71
fifteen months after completion of the program. Subgroup analyses were fitted by gender, age, and SES. Eight dichotomous outcome variables were used, all of them with reference to the thirty days preceding the survey: any cigarette smoking; frequent cigarette smoking (six or more cigarettes); daily cigarette smoking (twenty or more cigarettes); any episode of drunkenness; frequent drunkenness (three or more episodes); any cannabis use; frequent cannabis use (use on three occasions or more); and any use of illicit drugs. Differences in prevalence of use between centers were adjusted for by including in the model the center-specific daily smoking prevalence at baseline. All estimates were adjusted by subjects’ baseline status of the corresponding behavior.12
Results Fifty-six percent of the enrolled classes implemented all the units in the curriculum, while 66 percent received at least ten units and 77 percent at least 50 units. Less than 5 percent of classes failed to implement any part of the curriculum. On average, each unit was taught to 78 percent of the target population. The time actually needed to complete each unit exceeded the “standard lesson time” of 50 minutes by approximately 20 percent.13 The effectiveness at three and fifteen months’ follow-up The crude prevalence of all behavioral outcomes showed a pre- to post-test increase in all conditions, in line with the usual increase in the incidence of first use during adolescence. However, three months after the end of the program, the intervention group had a lower increase in the prevalence of use of tobacco and cannabis, and of frequency of recent drunkenness episodes, compared to controls. Significant effects were detected for daily cigarette use, for any and frequent episodes of drunkenness in the past thirty days, while a marginal statistical effect was detected for cannabis use (Table 5.1). new directions for youth development • doi: 10.1002.yd
∗p
< 0.05.
Any cigarette smoking Frequent cigarette smoking Daily cigarette smoking Any episode of drunkenness Frequent drunkenness Any cannabis use Frequent cannabis use
Last 30 days’ use
20.4 13.0 9.3 11.6 3.9 7.2 4.4
Prevalence control group (percent)
16.6 10.0 6.5 8.2 2.5 4.8 2.8
Prevalence intervention groups (percent)
−12 −14 −30∗ −28∗ −31∗ −23∗ −24
Percent reduction from adjusted multilevel model
Three months after the end of the program
27.0 18.5 13.0 17.9 6.4 9.4 5.8
Prevalence control group (percent)
23.3 15.1 10.8 13.9 3.8 6.6 3.8
Prevalence intervention groups (percent)
−6 −11 −8 −20∗ −38∗ −17 −26∗
Percent reduction from adjusted multilevel model
Fifteen months after the end of the program
Table 5.1. Effect of Unplugged on behavioral outcomes at three and fifteen months after the end of the program
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
73
Fifteen months after the end of the program, the increase in the use of tobacco and cannabis and the frequency of drunkenness episodes was lower among the students exposed to the curriculum compared to the control sample. A significant intervention effect was detected for episodes of drunkenness in the past thirty days, and of frequent cannabis use (Table 5.1). However, the association with decreased prevalence of cigarette smoking observed at short term was no longer statistically significant.14
Gender differences At enrolment, boys were more likely than girls to have recently used cannabis (4.2 percent versus 2.4 percent, p < 0.001) and illicit drugs (5.6 percent versus 4.1 percent, p = 0.005), while girls had a higher prevalence of any cigarette smoking (15.9 percent versus 12.7 percent, p < 0.001). The proportion reporting recent episodes of drunkenness was slightly higher among males (6.5 percent versus 5.4 percent, p = 0.07). A lower proportion of girls scored high on a positive self-esteem score (83.2 percent versus 87.7 percent, p < 0.001). Boys endorsed more often than girls positive expectations toward alcohol (“feel relaxed”: 21.2 percent versus 18.5 percent, p = 0.008, “become more popular”: 17.3 percent versus 14.7 percent, p = 0.005) and cannabis (“feel relaxed”: 41.8 percent versus 37.5 percent, p = 0.001, “become more popular”: 21.4 percent versus 18.6 percent, p = 0.006). Three months after the completion of the program, significant effects were observed among boys both for daily smoking (32 percent reduction of frequent smokers, 51 percent of daily smokers), drunkenness episodes (36 percent reduction of any episodes), and cannabis use (38 percent reduction of any cannabis users, 40 percent of frequent users). Among girls, there was an indication of decreased risk of sporadic and frequent drunkenness, but the estimates did not attain the statistical significance, and no effect was detected on tobacco smoking and cannabis use (Figure 5.1). When the gender-specific estimates were analyzed in separate strata of the self-esteem indicator, among boys the results did not new directions for youth development • doi: 10.1002.yd
74
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
Figure 5.1. Effect of Unplugged by gender
change, but among girls the program was rather associated with a tendency toward unfavorable effect in the low self-esteem group. An indication of risk reduction was found for the indicators of smoking and drunkenness among girls exposed to the experimental curriculum in the youngest age group (11–12 years). Among boys, program effects were similar in both age groups for all outcomes, but for smoking that was more affected by the program in the oldest age group (13–18 years).15 Differences by socioeconomic level of the school At baseline, students in schools of high average socioeconomic level were more likely than students in other schools to drink at least monthly (17.2 percent versus 14.6 percent, p = 0.01) and to new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
75
have intention to drink (43.7 percent versus 39.0 percent, p < 0.01) while students in schools of low socioeconomic level were more likely to report recent episodes of drunkenness (7.0 percent versus 4.0 percent, p < 0.01), intention to get drunk (20.0 percent versus 17.6 percent, p = 0.03), and alcohol-related problem behaviors (4.2 percent versus 3.0 percent, p = 0.02). Participation in the program was associated with a significantly lower prevalence of episodes of drunkenness and of intention to get drunk, compared to usual curricula, among students attending schools in low socioeconomic context (OR = 0.60). The same students had an OR of 0.68 of reporting behavioral problems due to their drinking, but this effect was only marginally significant (p = 0.06). No significant program effects emerged for students in schools of medium or high socioeconomic level. The effect on reduction of alcohol consumption did not reach statistical significance within any subgroup, but was consistently stronger among students attending schools in disadvantaged contexts.16
Discussion Results of the EU-Dap study suggest that universal prevention programs like Unplugged can be widely implemented and effective in reducing tobacco and cannabis use, and alcohol abuse in early adolescence. The study has a large size and includes diverse sociocultural contexts. The evaluation was conducted with standardized methods, materials, and protocols. In the short term, exposure to Unplugged was associated with a significantly lower prevalence of daily use of cigarettes, episodes of drunkenness, and cannabis use in the past thirty days. The estimated effect was around 30 percent, in line with the most effective school-based programs.17 The effectiveness of the program on cigarette smoking was short-lived at odds with the effects on alcohol or cannabis. This new directions for youth development • doi: 10.1002.yd
76
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
dilution of effects was somewhat expected, in line with previous trials and systematic reviews.18 Three explanations can be offered for the fading effect of the program on smoking. Dependence in adolescence can occur following sporadic use of tobacco, but less so with alcohol and cannabis.19 Cigarette smoking may be a normative behavior to a larger extent compared to episodes of drunkenness or using illicit drugs, particularly in southern European countries, which accounted for the majority of the population enrolled in the study. Lastly, the intensity of the program may not compare with that of other successful programs.20 In particular, Unplugged did not include a systematic involvement of parents nor reinforcement sessions, which have been shown to increase program effectiveness.21 Contrary to the results on smoking, the program was associated with a prolonged decreased risk for episodes of drunkenness and for cannabis use. This result is of importance since it implies a delay of the onset of substance use. There is evidence that the earlier the onset of alcohol and drug use, the higher the probability of lifetime drug dependence and alcoholism.22 The risk of alcohol dependence decreases by 14 percent with each increasing year of age at onset of use, and that of drug dependence by 4 percent.23 Some explanations for the gender differences observed in our study were investigated. The development of general life skills and coping mechanisms may differ between genders, given an attained age, with acquisition of skills and competences still being susceptible of modifications in the course of adolescence among boys, less so among girls.24 Consistently, we found indications that the program may have been effective among very young girls (11– 12 years old), while the effectiveness among boys did not differ by the age range of the study. Previous studies support the conclusion that most programs based on skill enhancement achieve better results among girls when administered at young ages.25 Furthermore, boys and girls may differ in moderators of programs’ effects such as personality characteristics. In our study, selfesteem modified the program’s effectiveness, with girls with low self-esteem having the least benefit from the program. This is not new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
77
surprising, since there is some evidence that lack of self-esteem can be a stronger risk factor for drug use among girls than among boys.26 Moreover, girls are more influenced by family protective factors, while boys are more influenced by school or community environment, and among girls self-esteem is strongly dependent on the relationship with parents.27 Lastly, self-esteem is not a direct focus of social influence programs and is difficult to improve being strongly intrapersonal.28 It is therefore possible that the Unplugged curriculum was not able to effectively tackle self-esteem. Participation in the program had a higher impact on problematic drinking among adolescents of low socioeconomic level schools. One of the possible explanations for such an effect is that neighborhood disadvantage correlates with lack of educational resources and of social and familial support to adolescents. Therefore, the relative “preventive gain” from school prevention could be higher in these underprivileged contexts. Differential teacher’s response to training is another possible explanation. Teachers in schools from socially disadvantaged communities may have taken a greater advantage of the training, improving their capability to conduct interactive classes to a larger extent than teachers in communities of medium or high socioeconomic status.
Conclusions The results of the EU-Dap study have implications both in the scientific and in the public health domain. The evaluation provides some evidence that classroom curricula based on a Comprehensive Social Influence approach can be effectively delivered in the school setting in very different European sociocultural environments, and can contribute to a delay in the onset of substance use. These curricula may perform differently among girls and boys, possibly due to developmental and personality factors. When developing and applying new prevention programs, gender-specific components should always be considered in order to reduce new directions for youth development • doi: 10.1002.yd
78
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
disparity of effects between boys and girls, introducing gendersensitive contents and anticipating the delivery in early grades. The curriculum had higher impact on students of socially deprived contexts. Since unhealthy behaviors among lower socioeconomic groups contribute substantially to socioeconomic inequalities in health, the dissemination of the program could favor a reduction of health inequalities, one of the major priorities of public health policies in Europe.
Notes 1. Single, E., Rehm, J., Robson, L., & Van Truong, M. (2000). The relative risks and etiologic fractions of different causes of death and disease attributable to alcohol, tobacco and illicit drug use in Canada. CMAJ, 162, 1669–1675. 2. McLellan, T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical disease: Implications for treatment, insurance and outcome evaluation. JAMA, 284, 1689–1695; Di Chiara, G. (2000). Role of dopamine in the behavioural actions of nicotine related to addiction. European Journal of Pharmacology, 393, 295–314. 3. Kandel, D., & Yamaguchi, K. (1993). From beer to crack— Developmental patterns of drug involvement. American Journal of Public Health, 83, 851–855; United Nations Office for Drug Control and Crime Prevention (UNICRI). (2003). School-Based Drug Education: A guide for practitioners and the wider community. Vienna, Austria: United Nations Office for Drug Control and Crime Prevention. 4. Gorman, D. M. (2005). Does measurement dependence explain the effects of Life Skills Training Program on smoking outcomes? Preventive Medicine, 40, 479–487; Gandhi, A. G., Murphy-Graham, E., Petrosino, A., Schwartz Chrismer, S., & Weiss, C. H. (2007). The devil is in the details. Examining the evidence for “proven” school-based drug abuse prevention programs. Evaluation Review, 31(1), 43–74; Gorman, D. M. (2008). Science, pseudoscience and the need for practical knowledge. Addiction, 103(10), 1752– 1753; Holder, H. (2010). Prevention programs in the 21st century: What we do not discuss in public. Addiction, 105(4), 578–581. 5. Midford, R. (2009). Drug prevention programmes for young people: Where have we been and where should we be going? Addiction, 105, 1688– 1695; Foxcroft, D. R., & Tsertsvadze, A. (2011). Universal school-based prevention programs for alcohol misuse in young people. Retrieved from Cochrane Database System Review, Issue 5. (CD009113); Catalano, R. F., Fagan, A. A., Gavin, L. E., Greenberg, M. T., Irwin, C. E., Ross, D. A., & Shek, D. T. L. (2012). Worldwide application of prevention science in adolescent health. Lancet, 379, 1653–1664; Thomas, R. E., McLellan, J., & Perera, new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
79
R. (2013). School-based programmes for preventing smoking. Retrieved from Cochrane Database System Review, Issue 4. (CD001293) 6. Galanti, M. R., Siliquini, R., Cuomo, L., Melero, J. C., Panella, M., Faggiano, F, & the EU-Dap Study Group. (2007). Testing anonymous link procedures for follow-up of adolescents in a school-based trial: The EU-DAP pilot study. Preventive Medicine, 44(2), 174–177; Faggiano, F., Richardson, C., Bohrn, K., Galanti, M. R., & the EU-Dap Study Group. (2007). A cluster randomized controlled trial of school-based prevention of tobacco, alcohol and drug use: The EU-Dap design and study population. Preventive Medicine, 44(2), 170–173; Faggiano, F., Galanti, M. R., Bohrn, K., Burkhart, G., VignaTaglianti, F., Cuomo, L., ... the EU-Dap Study Group 1 (2008). The effectiveness of a school-based substance abuse prevention program: EU-Dap Cluster Randomised Controlled Trial. Preventive Medicine, 47, 537–543; van der Kreeft, P., Wiborg, G., Galanti, M. R., Siliquini, R., Bohrn, K., Scatigna, M., ... the EU-Dap Study Group (2009). “Unplugged”: A new European school programme against substance abuse. Drugs Education, Prevention and Policy, 16(2), 167–181; Vigna-Taglianti, F., Vadrucci, S., Faggiano, F., Burkhart, G., Siliquini, R., Galanti, M. R., & the EU-Dap Study Group. (2009). Is universal prevention against youths’ substance misuse really universal? Gender specific effects in the EU-Dap school-based prevention trial. Journal of Epidemiology and Community Health, 63(9), 722–728; Faggiano, F., Vigna-Taglianti, F., Burkhart, G., Bohrn, K., Cuomo, L., Gregori, D., ... the EU-Dap Study Group (2010). The effectiveness of a school-based substance abuse prevention program: 18-month follow-up of the EU-Dap cluster randomized controlled trial. Drug and Alcohol Dependence, 108(1–2), 56–64; Caria, M. P., Faggiano, F., Bellocco, R., & Galanti, M. R. (2011). The influence of socioeconomic environment on the effectiveness of alcohol prevention among European students: A cluster randomized controlled trial. BMC Public Health, 11, 312. Retrieved from http://www.biomedcentral.com/1471-2458/11/312 7. van der Kreeft et al. (2009). 8. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall; Jessor, R., & Jessor, S. L. (1977). Problem behavior and psychological development: A longitudinal study of youth. New York, NY: Academic Press; Rosenstock, I. M. (1966). Why people use health service. Milbank Memorial Fund Quarterly, 44, 94–127; Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley; Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting human behavior. Englewood Cliffs, NJ: Prentice-Hall; Perkins, H. W., & Berkowitz, A. D. (1986). Perceiving the community norms of alcohol use among students: Some research implications for campus alcohol education programming. International Journal of Addictions, 21, 961–976. 9. Sussman, S., Earleywine, M., Wills, T., Cody, C., Biglan, T., Dent, C. W., & Newcomb, M. D. (2004). The motivation, skills, and decision-making model of “drug abuse” prevention. Substance Use and Misuse, 39(10–12), 1971–2016. 10. Thomas et al. (2013). 11. Galanti et al. (2007); Faggiano et al. (2007, 2008, 2010). new directions for youth development • doi: 10.1002.yd
80
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
12. Faggiano et al. (2008); Vigna-Taglianti Vigna-Taglianti (2009); Faggiano et al. (2010); Caria et al. (2011). 13. van der Kreeft et al. (2009). 14. Faggiano et al. (2008, 2010). 15. Vigna-Taglianti et al. (2009). 16. Caria et al. (2011). 17. Faggiano, F., Vigna-Taglianti, F., Versino, E., Zambon, A., Borraccino, A., & Lemma, P. (2005) School-based prevention for illicit drugs’ use (Cochrane Review). Retrieved from Cochrane Database System Review, Issue 2; Griffin, K. W., Botvin, G. J., Nichols, T. R., & Doyle, M. M. (2003). Effectiveness of a universal drug abuse prevention approach for youth at high risk for substance use initiation. Preventive Medicine, 36, 1–7. 18. Thomas et al. (2013); Peterson, A. V., Kealey, K. A., Mann, S. L., Marek, P. M., & Sarason, I. G. (2000). Hutchinson Smoking Prevention Project: Long-term randomized trial in school-based tobacco use preventionresults on smoking. Journal of the National Cancer Institute, 92, 1979– 1991; Muller-Riemenschneider, F., Bockelbrink, A., Reinhold, T., Rasch, A., Greiner, W., & Willich, S. N. (2008). Long-term effectiveness of behavioural interventions to prevent smoking among children and youth. Tobacco Control, 17, 301–312. 19. O’Loughlin, J., DiFranza, J., Tyndale, R. F., Meshefedjian, G., McMillan-Davey, E., Clarke, P. B., . . . Paradis, G. (2003). Nicotinedependence symptoms are associated with smoking frequency in adolescents. American Journal of Preventive Medicine, 25, 219–225; Kandel, D., Chen, K., Warner, L. A., Kessler, R. C., & Grant, B. (1997). Prevalence and demographic correlates of symptoms of last year dependence on alcohol, nicotine, marijuana and cocaine in the U.S. population. Drug and Alcohol Dependence, 44, 11–29. 20. Thomas et al. (2013). 21. Josendal, O., Aaro, L. E., & Bergh, I. (1998). Effects of a school-based smoking prevention program among subgroups of adolescents. Health Education Research, 13, 215–224; Spoth, R. L., Redmond, C., Trudeau, L., & Shin, C. (2002). Longitudinal substance initiation outcomes for a universal preventive intervention combining family and school programs. Psychology of Addictive Behaviour, 16(2), 129–134; Spoth, R., Redmond, C., Shin, C., & Azevedo, K. (2004). Brief family intervention effects on adolescent substance initiation: School-level growth curve analyses 6 years following baseline. Journal of Consulting and Clinical Psychology, 72(3), 535–542; Botvin, G. J., Baker, E., Filazzola, A. D., & Botvin, E. M. (1990). A cognitive-behavioral approach to substance abuse prevention: One-year follow-up. Addictive Behaviour, 15, 47– 63; Botvin, G. J., Baker, E., Dusenbury, L., Botvin, E. M., & Diaz, T. (1995). Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population. JAMA, 273, 1106–1112; Botvin, G. J., Griffin, K. W., Diaz, T., Miller, N., & Ifill-Williams, M. (1999). Smoking initiation and escalation in early adolescent girls: One-year follow-up of a school-based prevention intervention for minority youth. Journal of the American Medical Women’s Association, 54, 139–143, 152; Scheier, L. M., Botvin, G. J., & Griffin, new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
81
K. W. (2001). Preventive intervention effects on developmental progression in drug use: Structural equation modeling analyses using longitudinal data. Prevention Science, 2, 91–112. 22. DeWit, D. J., Adlaf, E. M., Offord, D. R., & Ogborne, A. C. (2000). Age at first alcohol use: A risk factor for the development of alcohol disorders. American Journal of Psychiatry, 157(5), 745–750; Pitkanen, T., Lyyra, A. L., & Pulkkinen, L. (2005). Age of onset of drinking and the use of alcohol in adulthood: A follow-up study from age 8–42 for females and males. Addiction, 100, 652–661. 23. Grant, B. F., & Dawson, D. A. (1997). Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse, 9, 103–110; Grant, B. F., & Dawson, D. A. (1998). Age of onset of drug use and its association with DSMIV drug abuse and dependence: Results from the national longitudinal alcohol epidemiologic survey. Journal of Substance Abuse, 10(2), 164–173. 24. Amaro, H., Blake, S. M., Schwartz, P. M., & Flinchbaugh, L. J. (2001). Developing theory-based substance abuse prevention programs for young adolescent girls. Journal of Early Adolescence, 21(3), 256–293; Hess, R. S., & Richards, M. L. (1999). Developmental and gender influences on coping: Implications for skills training. Psychology in the Schools, 36(2), 149–157. 25. Blake, S. M., Amaro, H., Schwartz, P. M., & Flinchbaugh, L. J. (2001). A review of substance abuse prevention interventions for young adolescent girls. Journal of Early Adolescence, 21, 294–324; Kumpfer, K. L., Smith, P., & Summerhays, J. F. (2008). A wakeup call to the prevention field: Are prevention programs for substance use effective for girls? Substance Use & Misuse, 43(8), 978–1001. 26. Amaro et al. (2001). 27. Kumpfer et al. (2008); Sale, E., Sambrano, S., Springer, F. J., & Turner, C. (2003). Risk, protection, and substance use in adolescents: A multi-site model. Journal of Drug Education, 33(1), 91–105. 28. Kimber, B., & Sandell Sven, R. B. (2008). Social and emotional training in Swedish schools for the promotion of mental health: An effectiveness study of 5 years of intervention. Health Education Research, 23(6), 931–940.
federica d. vigna-taglianti is a researcher at the University of Torino. maria rosaria galanti is a full professor at the Department of Public Health Sciences, Karolinska Institute, and Center for Epidemiology and Community Medicine, Stockholm Health Care District, Stockholm, Sweden. gregor burkhart is affiliated with EMCDDA, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal. new directions for youth development • doi: 10.1002.yd
82
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
maria paola caria is affiliated with the Department of Translational Medicine, Avogadro University, Novara, Italy. serena vadrucci is affiliated with the Piedmont Centre for Drug Addiction Epidemiology, Torino, Italy. fabrizio faggiano is an associate professor at the Department of Translational Medicine, Avogadro University, Novara, Italy.
new directions for youth development • doi: 10.1002.yd
5 “Unplugged,” a European school-based program for substance use prevention among adolescents: Overview of results from the EU-Dap trial Federica D. Vigna-Taglianti, Maria Rosaria Galanti, Gregor Burkhart, Maria Paola Caria, Serena Vadrucci, Fabrizio Faggiano for the EU-Dap Study Group the eu-dap study aimed to develop and evaluate a school-based curriculum for the prevention of substance use among young The EU-Dap Study Group includes (beside the authors): Barbara Zunino, GLuca Cuomo, Silena Salmaso (Piedmont Centre for Drug Addiction Epidemiology, Turin, Italy); Karl Bohrn (Institut fur ¨ Sozial und Gesundheitspsychologie, Wien, Austria); Erwin Coppens, Yannick Weyts, Johan van de Walle (De Sleutel, Merelbeke, Belgium); Peer van der Kreeft, Johan Jongbloet (University College, Ghent, Belgium); Juan Carlos Melero, Tatiana Perez, Laura Varona, Oihana Rementeria (EDEX, Bilbao, Spain); Vicky Yotsidi, Clive Richardson (University Mental Health Research Institute, Athens, Greece); Maro Vassara, Maria Kyriakidou, Gabriela Terzopoulou (Pyxida, Thessaloniki, Greece); Sara Sanchez, Charlotte Jansson (Dept of Public Health Sciences, Karolinska Institutet, Sweden); and Leila Fabiani, Maria Scatigna (Dept of Internal Medicine and Public Health, University of L’Aquila). EU-Dap was funded by the European Commission (European Public Health program 2002 grant no. SPC 2002376 and 2003–2008 grant no. 2005312), Compagnia di San Paolo (grant nos. 2002-0703 and 2007-2434), Lega Italiana per la Lotta contro i Tumori NEW DIRECTIONS FOR YOUTH DEVELOPMENT, NO. 141, SPRING 2014 © WILEY PERIODICALS, INC. Published online in Wiley Online Library (wileyonlinelibrary.com) • DOI: 10.1002/yd.20087
67
68
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
people. The school curriculum, “Unplugged,” is based on Social Influence approach and addresses social and personal skills, knowledge, and normative beliefs. It consists of 12 one-hour interactive sessions delivered by teachers. Its effectiveness was evaluated through a randomized trial involving 7,079 pupils of seven European countries. Unplugged was effective in reducing cigarette smoking, episodes of drunkenness, and the use of cannabis at short term. This association, however, was confined to boys, with age and self-esteem as possible explanations of this difference. Beneficial effects associated with the program persisted at fifteen-month follow-up for drunkenness, alcohol-related problems, and cannabis use, and were stronger among adolescents in schools of average low socioeconomic level. These results are of scientific importance, and may inform the adoption of effective public health interventions at population level.
Background Substance use, including tobacco and alcohol use, is the most important contributor to the burden of ill-health in developed countries, accounting for 20 percent of deaths and 22 percent of potential years of life lost.1 According to recent interpretations, tobacco, alcohol, and illicit drugs share common determinants for use and dependence, natural history, pathophysiology, and neurological pathways of abuse liability.2 Since the incidence of first use increases rapidly up to the age of fifteen years, when stabilization occurs, universal prevention in the school setting is one of the most common strategies to tackle substance use in youths.3 The effectiveness of school-based prevention programs is still a matter of debate in the scientific community.4 However, several systematic reviews and overviews recently concluded that some interventions may be effective.5 (grant no. 2003 43/4), Swedish Council for Working Life and Social Research (grant no. 2002-0979), and Stockholm County Council (Public Health grant no. LS 0401-0117). new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
69
The EU-Dap study (www.eudap.net) was initiated in 2003 with funding from the EC, with the scope to develop and evaluate a European school-based curriculum for the prevention of substance use among adolescents. Until then, no collaborative large studies on structured preventive interventions were conducted in Europe. The study was carried on in seven European countries: Italy, Greece, Spain, Austria, Belgium, Germany, and Sweden. The aim of this chapter is to summarize the findings of the EUDap study as previously published in several scientific papers to which we refer for details.6
Methods Unplugged is a school-based curriculum consisting of twelve units, one-hour each, delivered by trained class teachers to adolescents 12–14 years old during the school year. It is a strongly interactive curriculum including training on creative and critical thinking, decision making, problem solving, effective communication, interpersonal relationship skills, self-awareness, empathy, coping with emotions and stress, normative beliefs, and knowledge about the harmful effects of drugs.7 Theories on which the curriculum is built are Social Learning, Problem Behavior theory, Health Belief model, theory of Reasoned Action-Attitude and Planned Behavior, and Social Norms theory.8 These theories are integrated creating a complex model, which allows the inclusion of Unplugged among Comprehensive Social Influence programs, according to the definition given by Sussman.9 According to Thomas’ classification, Unplugged is a combined social competence and social influences curriculum.10 The evaluation study The effectiveness of the program was evaluated through a cluster randomized trial where schools were randomly assigned to experimental (receiving Unplugged) or control group (receiving usual curriculum). new directions for youth development • doi: 10.1002.yd
70
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
The source population were students attending junior high school (12–14 years of age) in the geographical areas of the centers participating in the study. Out of 290 eligible schools invited to take part to the trial, 170 accepted and were centrally randomized to one of the study arms. The randomization was stratified by socioeconomic level of the school area. Sixteen percent of schools dropped out before the baseline survey. The withdrawal rate was 23.5 percent for intervention arms and 4.4 percent for the control arm. The withdrawal of intervention schools mainly occurred during or just before the training of teachers, was comparable in all centers, and similar across the three levels of social stratification. The curriculum was implemented between October 2004 and January 2005 in seventy-eight schools, whereas sixty-five schools acted as controls. Pre-test data were collected from 7,079 students in October 2004. Post-test data were collected from 6,604 students in May 2005, that is, at least three months after the completion of the program. Pre- and post-test questionnaires were matched using a selfgenerated anonymous code. Across all centers, 91.5 percent of pretest questionnaires could be linked to a post-test questionnaire, and 81.3 percent to a fifteen-month follow-up questionnaire. Therefore, 6,370 students constituted the analytical sample for posttest, and 5,541 for fifteen-month follow-up. The questionnaire was self-completed and anonymous and included thirty-seven items investigating tobacco and substance use, alcohol abuse, knowledge and opinions about substances, social and personal skills, and normative beliefs. Most items were retrieved from the Evaluation Instruments Bank of the EMCDDA. Apart from language adaptation, the questionnaire was identical in all countries. The surveys were conducted in the classroom without teachers’ participation.11
The statistical analysis Multilevel regression models were used to analyze the association between program condition and change in substance use three and new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
71
fifteen months after completion of the program. Subgroup analyses were fitted by gender, age, and SES. Eight dichotomous outcome variables were used, all of them with reference to the thirty days preceding the survey: any cigarette smoking; frequent cigarette smoking (six or more cigarettes); daily cigarette smoking (twenty or more cigarettes); any episode of drunkenness; frequent drunkenness (three or more episodes); any cannabis use; frequent cannabis use (use on three occasions or more); and any use of illicit drugs. Differences in prevalence of use between centers were adjusted for by including in the model the center-specific daily smoking prevalence at baseline. All estimates were adjusted by subjects’ baseline status of the corresponding behavior.12
Results Fifty-six percent of the enrolled classes implemented all the units in the curriculum, while 66 percent received at least ten units and 77 percent at least 50 units. Less than 5 percent of classes failed to implement any part of the curriculum. On average, each unit was taught to 78 percent of the target population. The time actually needed to complete each unit exceeded the “standard lesson time” of 50 minutes by approximately 20 percent.13 The effectiveness at three and fifteen months’ follow-up The crude prevalence of all behavioral outcomes showed a pre- to post-test increase in all conditions, in line with the usual increase in the incidence of first use during adolescence. However, three months after the end of the program, the intervention group had a lower increase in the prevalence of use of tobacco and cannabis, and of frequency of recent drunkenness episodes, compared to controls. Significant effects were detected for daily cigarette use, for any and frequent episodes of drunkenness in the past thirty days, while a marginal statistical effect was detected for cannabis use (Table 5.1). new directions for youth development • doi: 10.1002.yd
∗p
< 0.05.
Any cigarette smoking Frequent cigarette smoking Daily cigarette smoking Any episode of drunkenness Frequent drunkenness Any cannabis use Frequent cannabis use
Last 30 days’ use
20.4 13.0 9.3 11.6 3.9 7.2 4.4
Prevalence control group (percent)
16.6 10.0 6.5 8.2 2.5 4.8 2.8
Prevalence intervention groups (percent)
−12 −14 −30∗ −28∗ −31∗ −23∗ −24
Percent reduction from adjusted multilevel model
Three months after the end of the program
27.0 18.5 13.0 17.9 6.4 9.4 5.8
Prevalence control group (percent)
23.3 15.1 10.8 13.9 3.8 6.6 3.8
Prevalence intervention groups (percent)
−6 −11 −8 −20∗ −38∗ −17 −26∗
Percent reduction from adjusted multilevel model
Fifteen months after the end of the program
Table 5.1. Effect of Unplugged on behavioral outcomes at three and fifteen months after the end of the program
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
73
Fifteen months after the end of the program, the increase in the use of tobacco and cannabis and the frequency of drunkenness episodes was lower among the students exposed to the curriculum compared to the control sample. A significant intervention effect was detected for episodes of drunkenness in the past thirty days, and of frequent cannabis use (Table 5.1). However, the association with decreased prevalence of cigarette smoking observed at short term was no longer statistically significant.14
Gender differences At enrolment, boys were more likely than girls to have recently used cannabis (4.2 percent versus 2.4 percent, p < 0.001) and illicit drugs (5.6 percent versus 4.1 percent, p = 0.005), while girls had a higher prevalence of any cigarette smoking (15.9 percent versus 12.7 percent, p < 0.001). The proportion reporting recent episodes of drunkenness was slightly higher among males (6.5 percent versus 5.4 percent, p = 0.07). A lower proportion of girls scored high on a positive self-esteem score (83.2 percent versus 87.7 percent, p < 0.001). Boys endorsed more often than girls positive expectations toward alcohol (“feel relaxed”: 21.2 percent versus 18.5 percent, p = 0.008, “become more popular”: 17.3 percent versus 14.7 percent, p = 0.005) and cannabis (“feel relaxed”: 41.8 percent versus 37.5 percent, p = 0.001, “become more popular”: 21.4 percent versus 18.6 percent, p = 0.006). Three months after the completion of the program, significant effects were observed among boys both for daily smoking (32 percent reduction of frequent smokers, 51 percent of daily smokers), drunkenness episodes (36 percent reduction of any episodes), and cannabis use (38 percent reduction of any cannabis users, 40 percent of frequent users). Among girls, there was an indication of decreased risk of sporadic and frequent drunkenness, but the estimates did not attain the statistical significance, and no effect was detected on tobacco smoking and cannabis use (Figure 5.1). When the gender-specific estimates were analyzed in separate strata of the self-esteem indicator, among boys the results did not new directions for youth development • doi: 10.1002.yd
74
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
Figure 5.1. Effect of Unplugged by gender
change, but among girls the program was rather associated with a tendency toward unfavorable effect in the low self-esteem group. An indication of risk reduction was found for the indicators of smoking and drunkenness among girls exposed to the experimental curriculum in the youngest age group (11–12 years). Among boys, program effects were similar in both age groups for all outcomes, but for smoking that was more affected by the program in the oldest age group (13–18 years).15 Differences by socioeconomic level of the school At baseline, students in schools of high average socioeconomic level were more likely than students in other schools to drink at least monthly (17.2 percent versus 14.6 percent, p = 0.01) and to new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
75
have intention to drink (43.7 percent versus 39.0 percent, p < 0.01) while students in schools of low socioeconomic level were more likely to report recent episodes of drunkenness (7.0 percent versus 4.0 percent, p < 0.01), intention to get drunk (20.0 percent versus 17.6 percent, p = 0.03), and alcohol-related problem behaviors (4.2 percent versus 3.0 percent, p = 0.02). Participation in the program was associated with a significantly lower prevalence of episodes of drunkenness and of intention to get drunk, compared to usual curricula, among students attending schools in low socioeconomic context (OR = 0.60). The same students had an OR of 0.68 of reporting behavioral problems due to their drinking, but this effect was only marginally significant (p = 0.06). No significant program effects emerged for students in schools of medium or high socioeconomic level. The effect on reduction of alcohol consumption did not reach statistical significance within any subgroup, but was consistently stronger among students attending schools in disadvantaged contexts.16
Discussion Results of the EU-Dap study suggest that universal prevention programs like Unplugged can be widely implemented and effective in reducing tobacco and cannabis use, and alcohol abuse in early adolescence. The study has a large size and includes diverse sociocultural contexts. The evaluation was conducted with standardized methods, materials, and protocols. In the short term, exposure to Unplugged was associated with a significantly lower prevalence of daily use of cigarettes, episodes of drunkenness, and cannabis use in the past thirty days. The estimated effect was around 30 percent, in line with the most effective school-based programs.17 The effectiveness of the program on cigarette smoking was short-lived at odds with the effects on alcohol or cannabis. This new directions for youth development • doi: 10.1002.yd
76
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
dilution of effects was somewhat expected, in line with previous trials and systematic reviews.18 Three explanations can be offered for the fading effect of the program on smoking. Dependence in adolescence can occur following sporadic use of tobacco, but less so with alcohol and cannabis.19 Cigarette smoking may be a normative behavior to a larger extent compared to episodes of drunkenness or using illicit drugs, particularly in southern European countries, which accounted for the majority of the population enrolled in the study. Lastly, the intensity of the program may not compare with that of other successful programs.20 In particular, Unplugged did not include a systematic involvement of parents nor reinforcement sessions, which have been shown to increase program effectiveness.21 Contrary to the results on smoking, the program was associated with a prolonged decreased risk for episodes of drunkenness and for cannabis use. This result is of importance since it implies a delay of the onset of substance use. There is evidence that the earlier the onset of alcohol and drug use, the higher the probability of lifetime drug dependence and alcoholism.22 The risk of alcohol dependence decreases by 14 percent with each increasing year of age at onset of use, and that of drug dependence by 4 percent.23 Some explanations for the gender differences observed in our study were investigated. The development of general life skills and coping mechanisms may differ between genders, given an attained age, with acquisition of skills and competences still being susceptible of modifications in the course of adolescence among boys, less so among girls.24 Consistently, we found indications that the program may have been effective among very young girls (11– 12 years old), while the effectiveness among boys did not differ by the age range of the study. Previous studies support the conclusion that most programs based on skill enhancement achieve better results among girls when administered at young ages.25 Furthermore, boys and girls may differ in moderators of programs’ effects such as personality characteristics. In our study, selfesteem modified the program’s effectiveness, with girls with low self-esteem having the least benefit from the program. This is not new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
77
surprising, since there is some evidence that lack of self-esteem can be a stronger risk factor for drug use among girls than among boys.26 Moreover, girls are more influenced by family protective factors, while boys are more influenced by school or community environment, and among girls self-esteem is strongly dependent on the relationship with parents.27 Lastly, self-esteem is not a direct focus of social influence programs and is difficult to improve being strongly intrapersonal.28 It is therefore possible that the Unplugged curriculum was not able to effectively tackle self-esteem. Participation in the program had a higher impact on problematic drinking among adolescents of low socioeconomic level schools. One of the possible explanations for such an effect is that neighborhood disadvantage correlates with lack of educational resources and of social and familial support to adolescents. Therefore, the relative “preventive gain” from school prevention could be higher in these underprivileged contexts. Differential teacher’s response to training is another possible explanation. Teachers in schools from socially disadvantaged communities may have taken a greater advantage of the training, improving their capability to conduct interactive classes to a larger extent than teachers in communities of medium or high socioeconomic status.
Conclusions The results of the EU-Dap study have implications both in the scientific and in the public health domain. The evaluation provides some evidence that classroom curricula based on a Comprehensive Social Influence approach can be effectively delivered in the school setting in very different European sociocultural environments, and can contribute to a delay in the onset of substance use. These curricula may perform differently among girls and boys, possibly due to developmental and personality factors. When developing and applying new prevention programs, gender-specific components should always be considered in order to reduce new directions for youth development • doi: 10.1002.yd
78
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
disparity of effects between boys and girls, introducing gendersensitive contents and anticipating the delivery in early grades. The curriculum had higher impact on students of socially deprived contexts. Since unhealthy behaviors among lower socioeconomic groups contribute substantially to socioeconomic inequalities in health, the dissemination of the program could favor a reduction of health inequalities, one of the major priorities of public health policies in Europe.
Notes 1. Single, E., Rehm, J., Robson, L., & Van Truong, M. (2000). The relative risks and etiologic fractions of different causes of death and disease attributable to alcohol, tobacco and illicit drug use in Canada. CMAJ, 162, 1669–1675. 2. McLellan, T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical disease: Implications for treatment, insurance and outcome evaluation. JAMA, 284, 1689–1695; Di Chiara, G. (2000). Role of dopamine in the behavioural actions of nicotine related to addiction. European Journal of Pharmacology, 393, 295–314. 3. Kandel, D., & Yamaguchi, K. (1993). From beer to crack— Developmental patterns of drug involvement. American Journal of Public Health, 83, 851–855; United Nations Office for Drug Control and Crime Prevention (UNICRI). (2003). School-Based Drug Education: A guide for practitioners and the wider community. Vienna, Austria: United Nations Office for Drug Control and Crime Prevention. 4. Gorman, D. M. (2005). Does measurement dependence explain the effects of Life Skills Training Program on smoking outcomes? Preventive Medicine, 40, 479–487; Gandhi, A. G., Murphy-Graham, E., Petrosino, A., Schwartz Chrismer, S., & Weiss, C. H. (2007). The devil is in the details. Examining the evidence for “proven” school-based drug abuse prevention programs. Evaluation Review, 31(1), 43–74; Gorman, D. M. (2008). Science, pseudoscience and the need for practical knowledge. Addiction, 103(10), 1752– 1753; Holder, H. (2010). Prevention programs in the 21st century: What we do not discuss in public. Addiction, 105(4), 578–581. 5. Midford, R. (2009). Drug prevention programmes for young people: Where have we been and where should we be going? Addiction, 105, 1688– 1695; Foxcroft, D. R., & Tsertsvadze, A. (2011). Universal school-based prevention programs for alcohol misuse in young people. Retrieved from Cochrane Database System Review, Issue 5. (CD009113); Catalano, R. F., Fagan, A. A., Gavin, L. E., Greenberg, M. T., Irwin, C. E., Ross, D. A., & Shek, D. T. L. (2012). Worldwide application of prevention science in adolescent health. Lancet, 379, 1653–1664; Thomas, R. E., McLellan, J., & Perera, new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
79
R. (2013). School-based programmes for preventing smoking. Retrieved from Cochrane Database System Review, Issue 4. (CD001293) 6. Galanti, M. R., Siliquini, R., Cuomo, L., Melero, J. C., Panella, M., Faggiano, F, & the EU-Dap Study Group. (2007). Testing anonymous link procedures for follow-up of adolescents in a school-based trial: The EU-DAP pilot study. Preventive Medicine, 44(2), 174–177; Faggiano, F., Richardson, C., Bohrn, K., Galanti, M. R., & the EU-Dap Study Group. (2007). A cluster randomized controlled trial of school-based prevention of tobacco, alcohol and drug use: The EU-Dap design and study population. Preventive Medicine, 44(2), 170–173; Faggiano, F., Galanti, M. R., Bohrn, K., Burkhart, G., VignaTaglianti, F., Cuomo, L., ... the EU-Dap Study Group 1 (2008). The effectiveness of a school-based substance abuse prevention program: EU-Dap Cluster Randomised Controlled Trial. Preventive Medicine, 47, 537–543; van der Kreeft, P., Wiborg, G., Galanti, M. R., Siliquini, R., Bohrn, K., Scatigna, M., ... the EU-Dap Study Group (2009). “Unplugged”: A new European school programme against substance abuse. Drugs Education, Prevention and Policy, 16(2), 167–181; Vigna-Taglianti, F., Vadrucci, S., Faggiano, F., Burkhart, G., Siliquini, R., Galanti, M. R., & the EU-Dap Study Group. (2009). Is universal prevention against youths’ substance misuse really universal? Gender specific effects in the EU-Dap school-based prevention trial. Journal of Epidemiology and Community Health, 63(9), 722–728; Faggiano, F., Vigna-Taglianti, F., Burkhart, G., Bohrn, K., Cuomo, L., Gregori, D., ... the EU-Dap Study Group (2010). The effectiveness of a school-based substance abuse prevention program: 18-month follow-up of the EU-Dap cluster randomized controlled trial. Drug and Alcohol Dependence, 108(1–2), 56–64; Caria, M. P., Faggiano, F., Bellocco, R., & Galanti, M. R. (2011). The influence of socioeconomic environment on the effectiveness of alcohol prevention among European students: A cluster randomized controlled trial. BMC Public Health, 11, 312. Retrieved from http://www.biomedcentral.com/1471-2458/11/312 7. van der Kreeft et al. (2009). 8. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall; Jessor, R., & Jessor, S. L. (1977). Problem behavior and psychological development: A longitudinal study of youth. New York, NY: Academic Press; Rosenstock, I. M. (1966). Why people use health service. Milbank Memorial Fund Quarterly, 44, 94–127; Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley; Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting human behavior. Englewood Cliffs, NJ: Prentice-Hall; Perkins, H. W., & Berkowitz, A. D. (1986). Perceiving the community norms of alcohol use among students: Some research implications for campus alcohol education programming. International Journal of Addictions, 21, 961–976. 9. Sussman, S., Earleywine, M., Wills, T., Cody, C., Biglan, T., Dent, C. W., & Newcomb, M. D. (2004). The motivation, skills, and decision-making model of “drug abuse” prevention. Substance Use and Misuse, 39(10–12), 1971–2016. 10. Thomas et al. (2013). 11. Galanti et al. (2007); Faggiano et al. (2007, 2008, 2010). new directions for youth development • doi: 10.1002.yd
80
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
12. Faggiano et al. (2008); Vigna-Taglianti Vigna-Taglianti (2009); Faggiano et al. (2010); Caria et al. (2011). 13. van der Kreeft et al. (2009). 14. Faggiano et al. (2008, 2010). 15. Vigna-Taglianti et al. (2009). 16. Caria et al. (2011). 17. Faggiano, F., Vigna-Taglianti, F., Versino, E., Zambon, A., Borraccino, A., & Lemma, P. (2005) School-based prevention for illicit drugs’ use (Cochrane Review). Retrieved from Cochrane Database System Review, Issue 2; Griffin, K. W., Botvin, G. J., Nichols, T. R., & Doyle, M. M. (2003). Effectiveness of a universal drug abuse prevention approach for youth at high risk for substance use initiation. Preventive Medicine, 36, 1–7. 18. Thomas et al. (2013); Peterson, A. V., Kealey, K. A., Mann, S. L., Marek, P. M., & Sarason, I. G. (2000). Hutchinson Smoking Prevention Project: Long-term randomized trial in school-based tobacco use preventionresults on smoking. Journal of the National Cancer Institute, 92, 1979– 1991; Muller-Riemenschneider, F., Bockelbrink, A., Reinhold, T., Rasch, A., Greiner, W., & Willich, S. N. (2008). Long-term effectiveness of behavioural interventions to prevent smoking among children and youth. Tobacco Control, 17, 301–312. 19. O’Loughlin, J., DiFranza, J., Tyndale, R. F., Meshefedjian, G., McMillan-Davey, E., Clarke, P. B., . . . Paradis, G. (2003). Nicotinedependence symptoms are associated with smoking frequency in adolescents. American Journal of Preventive Medicine, 25, 219–225; Kandel, D., Chen, K., Warner, L. A., Kessler, R. C., & Grant, B. (1997). Prevalence and demographic correlates of symptoms of last year dependence on alcohol, nicotine, marijuana and cocaine in the U.S. population. Drug and Alcohol Dependence, 44, 11–29. 20. Thomas et al. (2013). 21. Josendal, O., Aaro, L. E., & Bergh, I. (1998). Effects of a school-based smoking prevention program among subgroups of adolescents. Health Education Research, 13, 215–224; Spoth, R. L., Redmond, C., Trudeau, L., & Shin, C. (2002). Longitudinal substance initiation outcomes for a universal preventive intervention combining family and school programs. Psychology of Addictive Behaviour, 16(2), 129–134; Spoth, R., Redmond, C., Shin, C., & Azevedo, K. (2004). Brief family intervention effects on adolescent substance initiation: School-level growth curve analyses 6 years following baseline. Journal of Consulting and Clinical Psychology, 72(3), 535–542; Botvin, G. J., Baker, E., Filazzola, A. D., & Botvin, E. M. (1990). A cognitive-behavioral approach to substance abuse prevention: One-year follow-up. Addictive Behaviour, 15, 47– 63; Botvin, G. J., Baker, E., Dusenbury, L., Botvin, E. M., & Diaz, T. (1995). Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population. JAMA, 273, 1106–1112; Botvin, G. J., Griffin, K. W., Diaz, T., Miller, N., & Ifill-Williams, M. (1999). Smoking initiation and escalation in early adolescent girls: One-year follow-up of a school-based prevention intervention for minority youth. Journal of the American Medical Women’s Association, 54, 139–143, 152; Scheier, L. M., Botvin, G. J., & Griffin, new directions for youth development • doi: 10.1002.yd
OVERVIEW OF RESULTS FROM THE EU-DAP TRIAL
81
K. W. (2001). Preventive intervention effects on developmental progression in drug use: Structural equation modeling analyses using longitudinal data. Prevention Science, 2, 91–112. 22. DeWit, D. J., Adlaf, E. M., Offord, D. R., & Ogborne, A. C. (2000). Age at first alcohol use: A risk factor for the development of alcohol disorders. American Journal of Psychiatry, 157(5), 745–750; Pitkanen, T., Lyyra, A. L., & Pulkkinen, L. (2005). Age of onset of drinking and the use of alcohol in adulthood: A follow-up study from age 8–42 for females and males. Addiction, 100, 652–661. 23. Grant, B. F., & Dawson, D. A. (1997). Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse, 9, 103–110; Grant, B. F., & Dawson, D. A. (1998). Age of onset of drug use and its association with DSMIV drug abuse and dependence: Results from the national longitudinal alcohol epidemiologic survey. Journal of Substance Abuse, 10(2), 164–173. 24. Amaro, H., Blake, S. M., Schwartz, P. M., & Flinchbaugh, L. J. (2001). Developing theory-based substance abuse prevention programs for young adolescent girls. Journal of Early Adolescence, 21(3), 256–293; Hess, R. S., & Richards, M. L. (1999). Developmental and gender influences on coping: Implications for skills training. Psychology in the Schools, 36(2), 149–157. 25. Blake, S. M., Amaro, H., Schwartz, P. M., & Flinchbaugh, L. J. (2001). A review of substance abuse prevention interventions for young adolescent girls. Journal of Early Adolescence, 21, 294–324; Kumpfer, K. L., Smith, P., & Summerhays, J. F. (2008). A wakeup call to the prevention field: Are prevention programs for substance use effective for girls? Substance Use & Misuse, 43(8), 978–1001. 26. Amaro et al. (2001). 27. Kumpfer et al. (2008); Sale, E., Sambrano, S., Springer, F. J., & Turner, C. (2003). Risk, protection, and substance use in adolescents: A multi-site model. Journal of Drug Education, 33(1), 91–105. 28. Kimber, B., & Sandell Sven, R. B. (2008). Social and emotional training in Swedish schools for the promotion of mental health: An effectiveness study of 5 years of intervention. Health Education Research, 23(6), 931–940.
federica d. vigna-taglianti is a researcher at the University of Torino. maria rosaria galanti is a full professor at the Department of Public Health Sciences, Karolinska Institute, and Center for Epidemiology and Community Medicine, Stockholm Health Care District, Stockholm, Sweden. gregor burkhart is affiliated with EMCDDA, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal. new directions for youth development • doi: 10.1002.yd
82
THEORY-BASED APPROACHES TO SUBSTANCE MISUSE
maria paola caria is affiliated with the Department of Translational Medicine, Avogadro University, Novara, Italy. serena vadrucci is affiliated with the Piedmont Centre for Drug Addiction Epidemiology, Torino, Italy. fabrizio faggiano is an associate professor at the Department of Translational Medicine, Avogadro University, Novara, Italy.
new directions for youth development • doi: 10.1002.yd
