- Email: [email protected]
Achieving the Olympic ideal: Preventing doping in sport
Performance Enhancement & Health 1 (2012) 83–85
Contents lists available at SciVerse ScienceDirect
Performance Enhancement & Health journal homepage: www.elsevier.com/locate/peh
Short report
Achieving the Olympic ideal: Preventing doping in sport Susan H. Backhouse ∗ , Laurie Patterson, Jim McKenna Carnegie Research Institute, Leeds Metropolitan University, Leeds, United Kingdom
a r t i c l e
i n f o
Article history: Received 30 August 2011 Received in revised form 30 August 2011 Accepted 10 August 2012 Keywords: Primary prevention Anti-doping Intervention Drugs Sport
a b s t r a c t In the 1960s, prohibitionist ‘anti-doping’ policy was introduced to curtail the use of illicit performance enhancing substances and methods in sport. Since then, anti-doping attention and funding has been directed towards detection-based deterrence activities. However, it is now acknowledged that investment in long-term, values-based education programmes may be more appropriate. Unfortunately, research into prevention and education is in its infancy, with very little indication of best practice. Therefore, in the interim, we must draw from more developed social science research fields. The following commentary highlights the findings of a recent systematic review of factors which, to-date, have been identified as the most successful preventive approaches across four established social domains; bullying, alcohol, tobacco and social drug use. Although the systematic review highlighted no ‘magical ingredients’ for ensuring effectiveness, there were common ‘recipes for success’, including (i) targeting young participants – when attitudes and values are forming; (ii) providing interactive material that develops social skills; (iii) monitoring and delivering programmes with high degrees of fidelity; (iv) basing delivery on well-trained staff; (v) incorporating long-term ‘booster sessions’ to reinforce key messages. Now, research should contribute to an evidence-base that allows the discovery, application and evaluation of key elements of effective anti-doping education. © 2012 Elsevier Ltd. All rights reserved.
1. Introduction Illegal drug scandals in sport results not only in athletic ignominy but also they question the legitimacy of all athletic achievement. ‘Anti-doping’ refers to efforts made within sport to prevent the use of illegal performance enhancing substances and methods. However, given that few of the illegal drugs that athletes might use are confirmedly life-threatening at a population level, and the relative failure of attempts to regulate and restrict those that are (Global Commission on Drug Policy, 2011), it is clear that there are profound problems in this area. Indeed, athletes are now expressing their concerns about the practices relating to antidoping; at least one group has called for radical changes to the testing regimen they are required to support and be subject to (Palmer, Taylor, & Wingate, 2011). Notwithstanding these concerns, anti-doping research is gaining momentum. The volume of published research in the field has increased, along with the number of social science research projects funded by the World Anti-Doping Agency. Further evidence is provided by the large numbers of participants at the Humanistic
∗ Corresponding author at: Carnegie Research Institute, Leeds Metropolitan University, Headingley Campus, Leeds, LS6 3QS, United Kingdom. Tel.: +44 0 113 812 4684. E-mail address: [email protected] (S.H. Backhouse). 2211-2669/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.peh.2012.08.001
Anti-Doping Conference held in Copenhagen, November 2011. Moreover, the World Anti-Doping Agency (WADA) has identified education and social science research as strategic priorities for developing evidence-based anti-doping education (World AntiDoping Agency, 2011). Indeed, in a WADA commissioned review we highlighted the factors which have been determined, to date, as the most successful preventive approaches across four social domains; bullying, alcohol, tobacco and social drug use (Backhouse, McKenna, & Patterson, 2009). This paper provides a commentary on the review’s recommendations. 2. Why should we invest in doping prevention in sport? To ensure that anti-doping education is well planned, delivered and evaluated it is essential that we draw upon a robust evidencebase. Indeed, since 2001 the WADA has committed US $50 million to increase the volume of scientific research dedicated to developing improved detection methods. However, the BALCO scandal provides stark evidence that those who possess the knowledge to circumvent the system will do so when the rewards are high and risk is perceived to be low. We propose that this futile ‘cat and mouse’ game will prevail so long as detection is the primary focus. Instead, we suggest the need for, and value of, a renewed focus on primary prevention. This shifts attention from negative campaigns focused on doping controls, the prohibited list and sanctions toward positivity and engagement. Indeed, primary prevention
84
S.H. Backhouse et al. / Performance Enhancement & Health 1 (2012) 83–85
underpins many health-based interventions because preventing the initiation of an unhealthy/undesirable behaviour is more effective than stopping one that is already established (Backhouse et al., 2009; Woolf, 2009). Consequently, investing in evidence-based prevention is fundamental to effectively educating athletes and members of their support network so that should a choice be required, the rational decision making skills and resilience are in place to say (and to keep saying) “No, I will achieve my ambitions in a better way”.
3. Why should we look to other prevention fields to inform anti-doping programming? Importantly, and signalling the direction for subsequent research, recent communications (e.g., Fahey, 2009) from the WADA suggests a shift towards primary prevention. However, few studies have been conducted to show genuine anti-doping prevention effects and there are few templates from which to borrow. Further, even fewer programmes have monitored participants over any substantial period (nor across influential transition points) to identify rates of non-doping, episodic doping and/or sustained doping behaviours (Backhouse, McKenna, Robinson, & Atkin, 2007). In contrast, a stronger evidence base is available in the prevention of bullying and in reducing rates of using of tobacco, alcohol and social drugs. Therefore, these established research fields offer the best chance for renewing anti-doping efforts to ensure intervention effectiveness. In this understanding, we identified the evidence regarding the efficacy of prevention interventions across these four social domains (Backhouse et al., 2009). In doing so, we highlighted the most successful preventive approaches in these respective domains. Recommendation regarding a ‘recipe of success’ was then offered, with a view to further refinement and application for future anti-doping prevention programmes.
4. What are the ‘essential ingredients’ of effective prevention programmes? Although our review did not generate an exacting formula, we identified common elements of successful prevention programming. Effective prevention programmes typically pursue a multifaceted approach addressing the specific needs and circumstances of the target population. Universal, school-based interventions continue to be the most frequently studied prevention approach. This single setting seems to be favoured because it offers the most systematic way of reaching the greatest number of young people each year (Faggiano et al., 2008). Although not always articulated in this way, nor evidenced empirically, the inherent assumption is that this is also an efficient approach. More positively, when school based programmes are integrated with family and community approaches, effectiveness is enhanced (Foxcroft, Ireland, Lister-Sharp, Lowe, & Breen, 2002). However, on its own, community-based prevention appears to be ineffective in changing behaviour (Sowden & Stead, 2003). Drawing from data across the four domains we make seven recommendations that prevention programmes should be: • Targeted at a young age when attitudes and values are being formed. • Tailored to fit the target population, e.g., risk factors, developmental stage. • Delivered interactively, emphasising active participation, especially through role-plays and discussions. • Derived from social influence approaches and focused on developing core life skills (e.g., communication, decision-making,
refusal skills). Alone, knowledge dissemination is ineffective in changing behaviour. • Monitored and delivered with high degrees of fidelity, ensuring that programme implementation is as directed. • Delivered by well trained individuals who, demonstrably, deliver the programme with high fidelity. • Based on booster sessions delivered over a number of years. This reinforces and builds on intervention messages. Notably, a number of questions still remain, even in these fields with longer histories in research and evaluation. For example, intervention intensity appears to be an important determinant of intervention efficacy. However, it is unclear whether an ‘intense’ programme comprises either more sessions, or more content within fewer sessions. Similarly, while training might ensure treatment fidelity, there is no consensus regarding who fits the role of ‘best’ deliverer. 5. Are anti-doping programmes utilising these ingredients? At this point, investigation of the websites of the WADA and National Anti-Doping Organisations (NADOs) shows that antidoping education is skewed towards detection and doping control; typically, elite athletes command the limited resources available and education is geared towards the provision of information (e.g., raising awareness of the prohibited list, whereabouts reporting and testing procedures). However, organisations are increasingly taking the lead provided by the revised World Anti-Doping Agency Code (WADAC: WADA, 2009, p. 50) to meet the minimum standards of education: “Each Anti-Doping Organisation should plan, implement and monitor information and education programs. The programs should provide participants with updated and accurate information at least on the following issues: • • • •
substances and methods on the prohibited list; health consequences of doping; doping control procedures; athlete’s rights and responsibilities.”
Yet, if this provides the template for anti-doping interventions it is focused on content, whereas our review shows the need for attention on delivery processes. More specifically, to achieve the aspirations of the WADAC, we need to more obviously endorse the adoption of interactive, two-way, targeted education, which is so central to the demonstrable effectiveness of other behaviour prevention programmes (Backhouse et al., 2009). This is an essential ingredient of programme success and should displace any reliance on one-way, knowledge provision about doping in sport, which has been widely discredited in other domains (Backhouse et al., 2007; Hanson, 2009). Our review also highlighted the powerful impact of active participation of both the deliverer and the recipient, meaning that an emphasis should be placed on sharing, cooperating and contributing (McGrath, Sumnall, McVeigh, & Bellis, 2006). 6. Conclusion In sum, interactive education should feature more prominently in anti-doping efforts. However, to do so requires recognition that effective prevention education is both time- and resource-intensive. While there are no ‘magical ingredients’ that ensure effectiveness, there do seem to be some ‘recipes for success’ that should underpin any primary prevention programme (Backhouse et al., 2009). Indeed, anti-doping education is so young as a research field that there are few examples of best-practice, meaning that we are far from being able to draw on a robust evidence-base. It is also notable
S.H. Backhouse et al. / Performance Enhancement & Health 1 (2012) 83–85
that researchers in these more established fields of prevention recognise the need for, and value of, more systematic research to fully assess ideas across a variety of settings. Few domains can be as diffuse as sport, so this seems like good advice for us too. Furthermore, we must also be cautious about assuming that research findings will readily transfer across behavioural domains or achieve equivalent impacts. On balance, this commentary has reiterated some of the lessons learned from research examining the prevention of bullying, alcohol, tobacco and social drug use. The strategic goal of anti-doping education should be to develop an evidence-base that allows the ‘essential ingredients’ necessary for effective doping prevention education to be (i) discovered, (ii) applied and (iii) evaluated. In doing so, we will facilitate a long-term perspective which emphasises prevention, rather than detection, in anti-doping in sport. Anti-doping is a global issue and as such, requires ‘connected’ approaches, across countries and, most likely across related organisations (Backhouse et al., 2009). Given the lack of evidence-based practice in the anti-doping education field (Backhouse et al., 2007), the issue of implementing and disseminating effective education programmes is an urgent issue and needs to be addressed locally through to globally. References Backhouse, S. H., McKenna, J., Robinson, S., & Atkin, A. (2007). Attitudes, behaviours, knowledge and education – drugs in sport: Past, present and future. A report for the World Anti-Doping Agency, Canada. Retrieved from http://www. wada-ama.org/rtecontent/document/Backhouse et al Full Report.pdf Backhouse, S. H. McKenna, J., & Patterson, L. (2009). Prevention through education: A review of current international social science literature; a focus on the prevention
85
of bullying, tobacco, alcohol and social drug use in children, adolescents and young adults. A report for the World Anti-Doping Agency, Canada. Retrieved from http://www.wada-ama.org/Documents/Education Awareness/SocialScience Research/Funded Research Projects/2008/backhouse Prevention through Education final 2009.pdf Faggiano, F., Vigna-Taglianti, F. D., Versino, E., Zambon, A., Borraccino, A., & Lemma, P. (2008). School-based prevention for illicit drugs use: A systematic review. Preventive Medicine, 46, 385–396. Fahey, J. (2009). Are we winning the fight? Play true, 1, 1. Retrieved from http://www.wada-ama.org/Documents/Resources/Publications/PlayTrue Magazine/PlayTrue 2009 1 Engaging The Athlete EN.pdf Foxcroft, D. R., Ireland, D., Lister-Sharp, D. J., Lowe, G., & Breen, R. (2002). Primary prevention for alcohol misuse in young people. Cochrane Database of Systematic Reviews, Issue 3. Global Commission on Drug Policy. (2011). War on drugs. Retrieved from http://www.globalcommissionondrugs.org/Report Hanson, J. M. (2009). Equipping athletes to make informed decisions about performance-enhancing drug use: A constructivist perspective from educational psychology. Sport in Society, 12(3), 394–410. McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews. Evidence briefing update. NICE, London. Retrieved from http://www.nice.org.uk/niceMedia/docs/drug use prev update v9.pdf Palmer, W., Taylor, S., & Wingate, A. (2011). Adverse analyzing. A European study of anti doping organization reporting practices and the efficacy of drug testing athletes. UNI Global Union, Nyon, Switzerland. Retrieved from http://www.euathletes.org/uploads/media/Adverse Analyzing FINAL .pdf Sowden, A., & Stead, L. (2003). Community interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews, 1. Woolf, S. H. (2009). A closer look at the economic argument for disease prevention. Journal of the American Medical Association, 301(5), 536–538. World Anti-Doping Agency. (2009). World anti-doping agency code. World Anti-Doping Agency, Canada. Retrieved from http://www.wada-ama.org/ rtecontent/document/code v2009 En.pdf World Anti-Doping Agency. (2011). Strategic plan 2011–2016. World Anti-Doping Agency, Canada. Retrieved from http://www.wada-ama.org/Documents/ About WADA/Strategy/WADA Strategic Plan 2011-2016 EN.pdf
Contents lists available at SciVerse ScienceDirect
Performance Enhancement & Health journal homepage: www.elsevier.com/locate/peh
Short report
Achieving the Olympic ideal: Preventing doping in sport Susan H. Backhouse ∗ , Laurie Patterson, Jim McKenna Carnegie Research Institute, Leeds Metropolitan University, Leeds, United Kingdom
a r t i c l e
i n f o
Article history: Received 30 August 2011 Received in revised form 30 August 2011 Accepted 10 August 2012 Keywords: Primary prevention Anti-doping Intervention Drugs Sport
a b s t r a c t In the 1960s, prohibitionist ‘anti-doping’ policy was introduced to curtail the use of illicit performance enhancing substances and methods in sport. Since then, anti-doping attention and funding has been directed towards detection-based deterrence activities. However, it is now acknowledged that investment in long-term, values-based education programmes may be more appropriate. Unfortunately, research into prevention and education is in its infancy, with very little indication of best practice. Therefore, in the interim, we must draw from more developed social science research fields. The following commentary highlights the findings of a recent systematic review of factors which, to-date, have been identified as the most successful preventive approaches across four established social domains; bullying, alcohol, tobacco and social drug use. Although the systematic review highlighted no ‘magical ingredients’ for ensuring effectiveness, there were common ‘recipes for success’, including (i) targeting young participants – when attitudes and values are forming; (ii) providing interactive material that develops social skills; (iii) monitoring and delivering programmes with high degrees of fidelity; (iv) basing delivery on well-trained staff; (v) incorporating long-term ‘booster sessions’ to reinforce key messages. Now, research should contribute to an evidence-base that allows the discovery, application and evaluation of key elements of effective anti-doping education. © 2012 Elsevier Ltd. All rights reserved.
1. Introduction Illegal drug scandals in sport results not only in athletic ignominy but also they question the legitimacy of all athletic achievement. ‘Anti-doping’ refers to efforts made within sport to prevent the use of illegal performance enhancing substances and methods. However, given that few of the illegal drugs that athletes might use are confirmedly life-threatening at a population level, and the relative failure of attempts to regulate and restrict those that are (Global Commission on Drug Policy, 2011), it is clear that there are profound problems in this area. Indeed, athletes are now expressing their concerns about the practices relating to antidoping; at least one group has called for radical changes to the testing regimen they are required to support and be subject to (Palmer, Taylor, & Wingate, 2011). Notwithstanding these concerns, anti-doping research is gaining momentum. The volume of published research in the field has increased, along with the number of social science research projects funded by the World Anti-Doping Agency. Further evidence is provided by the large numbers of participants at the Humanistic
∗ Corresponding author at: Carnegie Research Institute, Leeds Metropolitan University, Headingley Campus, Leeds, LS6 3QS, United Kingdom. Tel.: +44 0 113 812 4684. E-mail address: [email protected] (S.H. Backhouse). 2211-2669/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.peh.2012.08.001
Anti-Doping Conference held in Copenhagen, November 2011. Moreover, the World Anti-Doping Agency (WADA) has identified education and social science research as strategic priorities for developing evidence-based anti-doping education (World AntiDoping Agency, 2011). Indeed, in a WADA commissioned review we highlighted the factors which have been determined, to date, as the most successful preventive approaches across four social domains; bullying, alcohol, tobacco and social drug use (Backhouse, McKenna, & Patterson, 2009). This paper provides a commentary on the review’s recommendations. 2. Why should we invest in doping prevention in sport? To ensure that anti-doping education is well planned, delivered and evaluated it is essential that we draw upon a robust evidencebase. Indeed, since 2001 the WADA has committed US $50 million to increase the volume of scientific research dedicated to developing improved detection methods. However, the BALCO scandal provides stark evidence that those who possess the knowledge to circumvent the system will do so when the rewards are high and risk is perceived to be low. We propose that this futile ‘cat and mouse’ game will prevail so long as detection is the primary focus. Instead, we suggest the need for, and value of, a renewed focus on primary prevention. This shifts attention from negative campaigns focused on doping controls, the prohibited list and sanctions toward positivity and engagement. Indeed, primary prevention
84
S.H. Backhouse et al. / Performance Enhancement & Health 1 (2012) 83–85
underpins many health-based interventions because preventing the initiation of an unhealthy/undesirable behaviour is more effective than stopping one that is already established (Backhouse et al., 2009; Woolf, 2009). Consequently, investing in evidence-based prevention is fundamental to effectively educating athletes and members of their support network so that should a choice be required, the rational decision making skills and resilience are in place to say (and to keep saying) “No, I will achieve my ambitions in a better way”.
3. Why should we look to other prevention fields to inform anti-doping programming? Importantly, and signalling the direction for subsequent research, recent communications (e.g., Fahey, 2009) from the WADA suggests a shift towards primary prevention. However, few studies have been conducted to show genuine anti-doping prevention effects and there are few templates from which to borrow. Further, even fewer programmes have monitored participants over any substantial period (nor across influential transition points) to identify rates of non-doping, episodic doping and/or sustained doping behaviours (Backhouse, McKenna, Robinson, & Atkin, 2007). In contrast, a stronger evidence base is available in the prevention of bullying and in reducing rates of using of tobacco, alcohol and social drugs. Therefore, these established research fields offer the best chance for renewing anti-doping efforts to ensure intervention effectiveness. In this understanding, we identified the evidence regarding the efficacy of prevention interventions across these four social domains (Backhouse et al., 2009). In doing so, we highlighted the most successful preventive approaches in these respective domains. Recommendation regarding a ‘recipe of success’ was then offered, with a view to further refinement and application for future anti-doping prevention programmes.
4. What are the ‘essential ingredients’ of effective prevention programmes? Although our review did not generate an exacting formula, we identified common elements of successful prevention programming. Effective prevention programmes typically pursue a multifaceted approach addressing the specific needs and circumstances of the target population. Universal, school-based interventions continue to be the most frequently studied prevention approach. This single setting seems to be favoured because it offers the most systematic way of reaching the greatest number of young people each year (Faggiano et al., 2008). Although not always articulated in this way, nor evidenced empirically, the inherent assumption is that this is also an efficient approach. More positively, when school based programmes are integrated with family and community approaches, effectiveness is enhanced (Foxcroft, Ireland, Lister-Sharp, Lowe, & Breen, 2002). However, on its own, community-based prevention appears to be ineffective in changing behaviour (Sowden & Stead, 2003). Drawing from data across the four domains we make seven recommendations that prevention programmes should be: • Targeted at a young age when attitudes and values are being formed. • Tailored to fit the target population, e.g., risk factors, developmental stage. • Delivered interactively, emphasising active participation, especially through role-plays and discussions. • Derived from social influence approaches and focused on developing core life skills (e.g., communication, decision-making,
refusal skills). Alone, knowledge dissemination is ineffective in changing behaviour. • Monitored and delivered with high degrees of fidelity, ensuring that programme implementation is as directed. • Delivered by well trained individuals who, demonstrably, deliver the programme with high fidelity. • Based on booster sessions delivered over a number of years. This reinforces and builds on intervention messages. Notably, a number of questions still remain, even in these fields with longer histories in research and evaluation. For example, intervention intensity appears to be an important determinant of intervention efficacy. However, it is unclear whether an ‘intense’ programme comprises either more sessions, or more content within fewer sessions. Similarly, while training might ensure treatment fidelity, there is no consensus regarding who fits the role of ‘best’ deliverer. 5. Are anti-doping programmes utilising these ingredients? At this point, investigation of the websites of the WADA and National Anti-Doping Organisations (NADOs) shows that antidoping education is skewed towards detection and doping control; typically, elite athletes command the limited resources available and education is geared towards the provision of information (e.g., raising awareness of the prohibited list, whereabouts reporting and testing procedures). However, organisations are increasingly taking the lead provided by the revised World Anti-Doping Agency Code (WADAC: WADA, 2009, p. 50) to meet the minimum standards of education: “Each Anti-Doping Organisation should plan, implement and monitor information and education programs. The programs should provide participants with updated and accurate information at least on the following issues: • • • •
substances and methods on the prohibited list; health consequences of doping; doping control procedures; athlete’s rights and responsibilities.”
Yet, if this provides the template for anti-doping interventions it is focused on content, whereas our review shows the need for attention on delivery processes. More specifically, to achieve the aspirations of the WADAC, we need to more obviously endorse the adoption of interactive, two-way, targeted education, which is so central to the demonstrable effectiveness of other behaviour prevention programmes (Backhouse et al., 2009). This is an essential ingredient of programme success and should displace any reliance on one-way, knowledge provision about doping in sport, which has been widely discredited in other domains (Backhouse et al., 2007; Hanson, 2009). Our review also highlighted the powerful impact of active participation of both the deliverer and the recipient, meaning that an emphasis should be placed on sharing, cooperating and contributing (McGrath, Sumnall, McVeigh, & Bellis, 2006). 6. Conclusion In sum, interactive education should feature more prominently in anti-doping efforts. However, to do so requires recognition that effective prevention education is both time- and resource-intensive. While there are no ‘magical ingredients’ that ensure effectiveness, there do seem to be some ‘recipes for success’ that should underpin any primary prevention programme (Backhouse et al., 2009). Indeed, anti-doping education is so young as a research field that there are few examples of best-practice, meaning that we are far from being able to draw on a robust evidence-base. It is also notable
S.H. Backhouse et al. / Performance Enhancement & Health 1 (2012) 83–85
that researchers in these more established fields of prevention recognise the need for, and value of, more systematic research to fully assess ideas across a variety of settings. Few domains can be as diffuse as sport, so this seems like good advice for us too. Furthermore, we must also be cautious about assuming that research findings will readily transfer across behavioural domains or achieve equivalent impacts. On balance, this commentary has reiterated some of the lessons learned from research examining the prevention of bullying, alcohol, tobacco and social drug use. The strategic goal of anti-doping education should be to develop an evidence-base that allows the ‘essential ingredients’ necessary for effective doping prevention education to be (i) discovered, (ii) applied and (iii) evaluated. In doing so, we will facilitate a long-term perspective which emphasises prevention, rather than detection, in anti-doping in sport. Anti-doping is a global issue and as such, requires ‘connected’ approaches, across countries and, most likely across related organisations (Backhouse et al., 2009). Given the lack of evidence-based practice in the anti-doping education field (Backhouse et al., 2007), the issue of implementing and disseminating effective education programmes is an urgent issue and needs to be addressed locally through to globally. References Backhouse, S. H., McKenna, J., Robinson, S., & Atkin, A. (2007). Attitudes, behaviours, knowledge and education – drugs in sport: Past, present and future. A report for the World Anti-Doping Agency, Canada. Retrieved from http://www. wada-ama.org/rtecontent/document/Backhouse et al Full Report.pdf Backhouse, S. H. McKenna, J., & Patterson, L. (2009). Prevention through education: A review of current international social science literature; a focus on the prevention
85
of bullying, tobacco, alcohol and social drug use in children, adolescents and young adults. A report for the World Anti-Doping Agency, Canada. Retrieved from http://www.wada-ama.org/Documents/Education Awareness/SocialScience Research/Funded Research Projects/2008/backhouse Prevention through Education final 2009.pdf Faggiano, F., Vigna-Taglianti, F. D., Versino, E., Zambon, A., Borraccino, A., & Lemma, P. (2008). School-based prevention for illicit drugs use: A systematic review. Preventive Medicine, 46, 385–396. Fahey, J. (2009). Are we winning the fight? Play true, 1, 1. Retrieved from http://www.wada-ama.org/Documents/Resources/Publications/PlayTrue Magazine/PlayTrue 2009 1 Engaging The Athlete EN.pdf Foxcroft, D. R., Ireland, D., Lister-Sharp, D. J., Lowe, G., & Breen, R. (2002). Primary prevention for alcohol misuse in young people. Cochrane Database of Systematic Reviews, Issue 3. Global Commission on Drug Policy. (2011). War on drugs. Retrieved from http://www.globalcommissionondrugs.org/Report Hanson, J. M. (2009). Equipping athletes to make informed decisions about performance-enhancing drug use: A constructivist perspective from educational psychology. Sport in Society, 12(3), 394–410. McGrath, Y., Sumnall, H., McVeigh, J., & Bellis, M. (2006). Drug use prevention among young people: A review of reviews. Evidence briefing update. NICE, London. Retrieved from http://www.nice.org.uk/niceMedia/docs/drug use prev update v9.pdf Palmer, W., Taylor, S., & Wingate, A. (2011). Adverse analyzing. A European study of anti doping organization reporting practices and the efficacy of drug testing athletes. UNI Global Union, Nyon, Switzerland. Retrieved from http://www.euathletes.org/uploads/media/Adverse Analyzing FINAL .pdf Sowden, A., & Stead, L. (2003). Community interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews, 1. Woolf, S. H. (2009). A closer look at the economic argument for disease prevention. Journal of the American Medical Association, 301(5), 536–538. World Anti-Doping Agency. (2009). World anti-doping agency code. World Anti-Doping Agency, Canada. Retrieved from http://www.wada-ama.org/ rtecontent/document/code v2009 En.pdf World Anti-Doping Agency. (2011). Strategic plan 2011–2016. World Anti-Doping Agency, Canada. Retrieved from http://www.wada-ama.org/Documents/ About WADA/Strategy/WADA Strategic Plan 2011-2016 EN.pdf