- Email: [email protected]
Preventing drug abuse in schools
Addictive Behaviors, Vol. 25, No. 6, pp. 887–897, 2000 Copyright © 2000 Elsevier Science Ltd. Printed in the USA. All rights reserved 0306-4603/00/$–see front matter
Pergamon
PII S0306-4603(00)00119-2
PREVENTING DRUG ABUSE IN SCHOOLS: SOCIAL AND COMPETENCE ENHANCEMENT APPROACHES TARGETING INDIVIDUAL-LEVEL ETIOLOGIC FACTORS GILBERT J. BOTVIN Weill Medical College of Cornell University
Abstract — Drug abuse continues to be an important public health problem throughout the world. Although considerable progress has been made in identifying effective prevention approaches, there is a large gap between what research has shown to be effective and the methods generally used in most schools. The most promising prevention approaches target individuals during the beginning of adolescence and teach drug resistance skills and norm setting either alone or in combination with general personal and social skills. Evaluation studies testing these approaches show that they can significantly reduce adolescent tobacco, alcohol, and marijuana use. While some studies show that these effects may decrease over time, booster interventions have been found to maintain and in some instances even enhance prevention effects. The results of one large-scale evaluation study shows that it is possible to produce reductions in drug use that last until the end of high school. Available evidence suggests that these approaches may be effective when taught by different kinds of teachers and with different populations. The current paper provides a brief review of school-based prevention approaches targeting individual-level etiologic factors, evidence supporting their effectiveness, and a discussion of potential mediating mechanisms. © 2000 Elsevier Science Ltd.
Over the past 20 years, there has been a concerted effort to develop effective drug abuse prevention approaches for implementation in schools. These approaches typically target middle or junior high school students utilizing classroom-based interventions. School settings are particularly well suited for both the implementation and testing of drug abuse prevention programs because they offer reasonably efficient access to large numbers of youth during the years that many begin to experiment with tobacco, alcohol, marijuana, and other drugs. Although the ultimate goal of these prevention approaches is to prevent drug abuse and its adverse consequences, the more immediate focus of school prevention programs is to deter early-stage drug use. Accordingly, most prevention research has tested the efficacy of school-based prevention approaches with respect to their impact on the onset and occasional use of one or more so-called “gateway” substances (i.e., tobacco, alcohol, marijuana). The success of school-based prevention approaches has been noted in past literature reviews (e.g., Botvin & Botvin, 1992; Hansen, 1992) and in meta-analytic studies (e.g., Bangert-Drowns, 1988; Tobler & Stratton, 1997). The current article provides a brief summary of school-based prevention approaches, evidence supporting their effectiveness, and a discussion of potential mediating mechanisms. E A R L Y
P R E V E N T I O N
E F F O R T S
Early efforts to prevent drug abuse were based more on intuition than theory. These prevention approaches were designed to (1) dispense factual information, (2) promote affective education, or (3) provide healthy alternatives to using drugs. ReRequests for reprints should be sent to Gilbert J. Botvin, Institute for Prevention Research, Weill Medical College of Cornell University, 345 West 70th Street, 6F, New York, NY 10023; E-mail: [email protected] 887
888
G. J. BOTVIN
search testing the efficacy of these informational approaches to prevention show they may have an impact on knowledge and anti-drug attitudes; but they have consistently failed to show any impact on use of tobacco, alcohol, or other drugs or on intentions to use drugs (e.g., Schaps, Bartolo, Moskowitz, Palley, & Churgin, 1981). Several meta-analytic studies have confirmed this overall lack of behavioral effects (Bangert-Drowns, 1988; Tobler, 1986). Some studies even suggest that providing factual information about drugs and drug use may actually increase use (Stuart, 1974; Swisher, Crawford, Goldstein, & Yura, 1971). As is the case with information dissemination approaches, affective education approaches have not had an impact on drug use, although they sometimes have an impact on one or more of the correlates of drug use (Kearney & Hines, 1980; Kim, 1988). Finally, providing adolescents with activities intended to serve as alternatives to drug use have failed to produce any impact on drug use (Schaps et al., 1981; Schaps, Moskowitz, Malvin, & Scheffer, 1986). T O W A R D
S C I E N C E - B A S E D P R E V E N T I O N A P P R O A C H E S
As knowledge concerning the etiology of drug abuse has accumulated, there has been a shift in the focus of school-based prevention approaches. Instead of focusing on knowledge about the adverse consequences of drug abuse, school-based prevention approaches have increasingly targeted the individual-level risk and protective factors that studies have found to be associated with adolescent drug use (Hawkins, Catalano, & Miller, 1992). Moreover, these preventive interventions have typically been based on key elements from social learning theory (Bandura, 1977), problem behavior theory (Jessor & Jessor, 1977), persuasive communications theory (McGuire, 1968), and peer cluster theory (Oetting & Beauvais, 1987). The hallmark of science-based prevention approaches is careful testing using rigorous research methods. The science-based prevention approaches developed and tested over the last 2 decades can be grouped into two general categories: (1) social influence approaches and (2) competence enhancement approaches. S O C I A L
I N F L U E N C E
A P P R O A C H E S
Description and methods Social influence approaches emphasize the importance of social and psychological factors in promoting the onset of drug use, and are based on an intervention model originally developed by Evans and his colleagues (Evans, 1976; Evans et al., 1978). Adolescent drug use is conceptualized as the result of social influences from peers and the media to smoke, drink alcoholic beverages, or use illicit drugs. These social influences take the form of the modeling of drug use by peers and media personalities, persuasive advertising appeals, and/or direct offers by peers to use drugs. Over the past 20 years, numerous studies have tested several variations on this model to determine its impact on adolescent tobacco, alcohol, and marijuana use. The three major components of social influence approaches are psychological inoculation, normative education, and resistance skills training. Psychological inoculation. One of the most prominent features of the social influence approach to drug abuse prevention in its original formulation by Evans (1976) was psychological inoculation. The notion of psychological inoculation derives from the primary prevention of infectious disease through inoculation and is based on McGuire’s persuasive communications theory (McGuire, 1964, 1968). Following the principle of infec-
Preventing drug abuse in schools
889
tious disease inoculation, adolescents are first exposed to weak social influences to smoke, drink alcohol, or use illicit drugs. Later, individuals are exposed to progressively stronger prodrug social influences. The underlying hypothesis is that through a gradual exposure to prodrug social influences adolescents would build up resistance to more powerful drug messages similar to what they might be expected to encounter in junior and senior high school. Despite the initial prominence of psychological inoculation, it has not been shown to be an essential ingredient in social influence prevention approaches (Evans et al., 1978). As a consequence, it has received less emphasis in more recent formulations of the social influence approach. By contrast, more emphasis has been given in recent years to other social influence components such as normative education and resistance skills training. Normative education. Adolescents generally overestimate the prevalence of smoking, drinking, and illicit drug use among other adolescents and adults (Fishbein, 1977). This leads to inaccurate normative expectations and the development of a set of norms that supports drug use behavior. Social influence approaches are designed to correct the misperception that the majority of adults and adolescents use drugs. In the original study testing the social influence approach as a smoking prevention strategy (Evans et al., 1978), the psychological inoculation component of the intervention did not produce any incremental reduction in smoking onset over that produced by the assessment/feedback procedures for modifying normative expectations. In fact, the prevention effect generally attributed to the inoculation component of the intervention was actually the result of providing students with feedback concerning the actual levels of smoking by their classmates. That is, an important component of the prevention approach developed by Evans and his colleagues was the process of correcting normative expectations that nearly everybody smoked cigarettes. Over the past 2 decades, normative education has gained considerable prominence and has been included in most variations of the social influence approach. Several methods have been used to modify or correct normative expectations. One involves providing students with information about the prevalence of drug use from national or local surveys. Another method involves having students develop and conduct their own surveys of drug use within their class, school, or community. This activity enables students to obtain a more realistic perspective on the level of drug use in a way that has high credibility. Because the actual rates of drug use in most classes, schools, and communities is far lower than adolescents believe, this activity helps correct the misperception that most people use drugs and establishes antidrug use norms. This process is referred to as normative education (Hansen & O’Malley, 1996). Recently, it has been proposed that resistance skills training may be ineffective in the absence of conservative social norms against drug use, since if the norm is to use drugs, adolescents will be less likely to resist offers of drugs (Donaldson et al., 1996). This suggests that correcting normative expectations and attempting to create or reinforce conservative beliefs about the prevalence and acceptability of drug use is of central importance to the success of resistance skills training programs. Resistance skills training. Variations on the social influence approach have been developed and tested over the past 20 years. An assumption of this approach is that adolescents begin to use drugs largely because they lack the confidence or skills to resist social influences to smoke, drink, or use illicit drugs. Therefore, an important aspect of this approach is providing students with the skills to resist prodrug social influences from peers or the media. Three common social resistance skills training methods are:
890
G. J. BOTVIN
(1) teaching students to recognize high-risk situations, (2) increasing the awareness of media influences, and (3) refusal skills training. A logical component of any social resistance skills approach to drug abuse prevention involves teaching students how to recognize high-risk situations—that is, situations where they are likely to experience peer pressure to smoke, drink, or use illicit drugs. Once these high-risk situations are recognized and identified students can be taught tactics for avoiding them. Thus, avoiding high-risk situations is the first line of resistance to prodrug peer pressure. These programs have also frequently included a component intended to make students aware of prodrug influences from the media (e.g., movies, television programs, rock videos, music, etc.). Special emphasis is often placed on teaching students to identify the techniques used by advertisers to influence consumer behavior. Students are taught to recognize advertising appeals designed to sell tobacco products or alcoholic beverages as well as how to formulate counter-arguments to those appeals. Another method commonly used in early studies testing resistance skills training included having students make a public commitment not to smoke, drink, or use drugs. However, research suggests that this component may not contribute to any observed prevention effects (Hurd et al., 1980). Finally, the centerpiece of social resistance approaches involves teaching students skills for resisting or refusing offers to use drugs. This involves teaching students both the form and substance of an effective refusal response. In other words, students are taught what to say in a peer pressure situation (i.e., the specific content or substance of a refusal message) in order to develop a repertoire of effective responses. They are also taught how to say it in the most effective way possible. With respect to the latter, appropriate emphasis is given to such things as body position and distance from the person making the drug use offer (e.g., a cigarette or alcoholic drink at a party), eye contact, tone of voice, and facial expressions. In addition to learning these refusal skills, students are often encouraged to identify “action plans” consisting of planned responses to peer pressure situations. Effectiveness Considerable research has been conducted testing social influence approaches (Arkin, Roemhild, Johnson, Luepker, & Murray, 1981; Donaldson, Graham, & Hansen, 1994; Hurd et al., 1980; Luepker, Johnson, Murray, & Pechacek, 1983; Perry, Killen, Slinkard, & McAlister, 1983; Snow, Tebes, Arthur, & Tapasak, 1992; Sussman, Dent, Stacy, & Sun, 1993; Telch, Killen, McAlister, Perry, & Maccoby, 1982). Overall, studies have shown social influence approaches to be effective. Most of these studies have focused on smoking prevention, with studies typically examining rates of smoking onset, overall smoking prevalence, or scores on an index of smoking involvement (e.g., Hurd et al., 1980; Luepker et al., 1983; Telch et al., 1982). Typically, social influence approaches produce reductions in smoking incidence and/or prevalence of between 30% and 50% after the initial intervention, based on a comparison of smoking rates for the experimental and control conditions (Arkin et al., 1981; Donaldson et al., 1994; Sussman et al., 1993). Similar reductions have been reported for studies testing the impact of social influence approaches on alcohol and marijuana use (e.g., McAlister, Perry, Killen, Slinkard, & Maccoby, 1980; Shope, Dielman, Butchart, & Campanelli, 1992). In a comprehensive review of social influence studies published from 1980 to 1990, Hansen (1992) reported that the majority of prevention studies (63%) had produced reductions in drug use behavior, while many of those not demonstrating prevention effects lacked adequate statistical power. The results of several follow-up studies of social influence approaches reported positive behavioral effects lasting for up to 3 years (Luepker et al., 1983; McAlister et al., 1980; Telch et al., 1982). However, data from
Preventing drug abuse in schools
891
several longer-term follow-up studies indicate that these effects gradually decay over time (Flay et al., 1989; Murray, Pirie, Luepker, & Pallonen, 1989), suggesting the need for ongoing intervention or booster sessions. Finally, although most studies have been conducted with White youth, there is some evidence from research that included minority youth along with White youth that this approach is also effective with minority youth (Ellickson & Bell, 1990). The most popular and visible school-based drug education program based on the social influence model is DARE (Drug Abuse Resistance Education). DARE’s core curriculum is usually taught to children in the fifth grade. It contains elements of information dissemination and affective education, as well as social influence approaches to drug abuse prevention. A distinguishing feature of DARE is that it is taught by uniformed police officers. Although popular in many communities, the results of a number of studies call into question the effectiveness of the DARE program. Some studies have reported a short-term positive impact on drug-related knowledge, attitudes, or behavior. However, most of these outcome studies have weak research designs, poor sampling and data collection procedures, inadequate measurement strategies, and inappropriate data analysis methods (Rosenbaum & Hanson, 1998). More recent studies of DARE using stronger designs (i.e., large samples, random assignment, and longitudinal follow-up) have shown that DARE has little or no impact on drug use, particularly beyond the initial posttest assessment (Clayton, Cattarello, & Johnstone, 1996; Dukes, Ullman, & Stein, 1996; Ennett, Rosenbaum, Flewelling, Bieler, Ringwalt, & Bailey, 1994; Ennett, Tobler, Ringwalt, & Flewelling, 1994; Rosenbaum et al., 1994; Rosenbaum & Hanson, 1998). As Rosenbaum and Hanson (1998) have noted, stronger research designs have been associated with weaker effects of DARE on drug use behavior. Although DARE has program elements that are similar to social influence approaches, it has been suggested that it’s effectiveness may be compromised because it targets the wrong mediating processes, uses instructional methods that are less interactive than more successful prevention programs, and/or that students “tune out” an expected message from an authority figure (Hansen & McNeal, 1997; Tobler & Stratton, 1997). C O M P E T E N C E
E N H A N C E M E N T
A P P R O A C H E S
Over 2 decades of research has been conducted on competence enhancement approaches that emphasize the teaching of generic personal and social skills either alone or in combination with elements of the social influence approach. Many generic competence enhancement approaches were designed to promote positive mental health and have not been tested with respect to their impact on tobacco, alcohol, and/or illicit drug use. For this reason, they will not be reviewed here. Excellent reviews of this literature are provided elsewhere (e.g., Weissberg & Greenberg, 1988; Zins, Elias, Greenberg, & Weissberg, 2000). However, the little evidence that does exist suggests that teaching generic personal and social skills without domain-specific material concerning drug use may be only minimally effective (e.g., Caplan et al., 1992). Thus, the focus of this section is on competence enhancement approaches that were designed to prevent drug use and frequently also include elements of the social influence model. Particular emphasis is given to a competence enhancement approach called Life Skills Training (Botvin, 1998). Description and methods The theoretical foundations for competence enhancement approaches designed to prevent drug use are Bandura’s social learning theory (Bandura, 1977) and Jessor’s
892
G. J. BOTVIN
problem behavior theory (Jessor & Jessor, 1977). According to this approach, drug use is conceptualized as a socially learned and functional behavior that is the result of an interplay between social (interpersonal) and personal (intrapersonal) factors. Drug use behavior is learned through a process of modeling, imitation, and reinforcement, and is influenced by an adolescent’s prodrug cognitions, attitudes, and beliefs. These factors, in combination with poor personal and social skills, are believed to increase an adolescent’s susceptibility to social influences in favor of drug use. A distinctive feature of competence enhancement approaches is an emphasis on the teaching of generic self-management skills and social skills. For example, the LST program teaches these skills using a combination of proven cognitive-behavioral skills training methods that include instruction and demonstration, behavioral rehearsal (inclass practice), feedback and reinforcement, and extended (out-of-class) practice through behavioral homework assignments. Examples of the kind of generic personal and social skills typically included in competence enhancement prevention approaches are decision-making and problem-solving skills, cognitive skills for resisting interpersonal and media influences, skills for increasing personal control and enhancing selfesteem (goal-setting and self-directed behavior change techniques), adaptive coping strategies for managing stress and anxiety, assertive skills, and general social skills. Most of the prevention studies using a competence enhancement approach that have been conducted thus far have focused on seventh graders. However, some studies have been conducted with sixth graders (Kreutter, Gewirtz, Davenny, & Love, 1991) and one was conducted with 8th, 9th, and 10th graders (Botvin, Eng, & Williams, 1980). Program length has ranged from as few as 7 sessions to as many as 20 sessions. Some of these prevention programs were conducted at a rate of one class session per week, while others were conducted at a rate of two or more classes per week. Most of the studies conducted so far have used adults as the primary program providers. In some cases these adults were teachers; in other cases they were outside health professionals (i.e., project staff members, graduate students, social workers). Some studies have included booster sessions as a means of preserving initial prevention effects. Effectiveness Studies testing the competency enhancement approach have consistently demonstrated prevention effects on tobacco, alcohol, and marijuana use as well as effects on hypothesized mediating variables. The magnitude of initial prevention effects has typically ranged between 40% and 80% for reductions in the rate of tobacco use (Botvin, Baker, Renick, Filazzola, & Botvin, 1984; Botvin & Eng, 1982; Botvin et al., 1980; Botvin, Renick, & Baker, 1983; Pentz, 1983; Schinke, 1984; Schinke & Gilchrist, 1983, 1984). Booster sessions have been shown to help maintain initial prevention effects and, in some instances, even enhance those effects. For example, in one study, students who received booster sessions had smoking rates that were 87% lower than for controls (Botvin et al., 1983). Results of studies utilizing competence enhancement approaches have also demonstrated an impact on other forms of drug use, including alcohol use (Botvin, Baker, Botvin, Filazzola, & Millman, 1984; Botvin, Baker, Dusenbury, Tortu, & Botvin, 1990; Botvin, Schinke, Epstein, Diaz, & Botvin, 1995; Pentz, 1983), marijuana use (Botvin, Baker, Dusenbury et al., 1990; Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995), and polydrug use (Botvin, Baker, et al., 1995; Botvin, Epstein, Baker, Diaz, & Ifill-Williams, 1997). These reductions have generally been of a magnitude equal to that found with cigarette smoking.
Preventing drug abuse in schools
893
Prevention effects also appear to be reasonably durable. Long-term follow-up data from a large-scale, randomized trial testing the LST program and involving nearly 6,000 seventh graders from 56 public schools in New York State found lower smoking, alcohol, and marijuana use among intervention students relative to controls at the end of the 12th grade (Botvin, Baker, et al., 1995). Students attending schools randomly assigned to the prevention condition received the prevention program in the seventh grade (15 sessions) with booster sessions in the eighth grade (10 sessions) and ninth grade (5 sessions). No intervention was provided during grades 10 through 12. At the follow-up conducted at the end of the 12th grade, the prevalence of cigarette smoking, alcohol use, and marijuana use for the students in the prevention condition schools was as much as 44% lower than for controls. The strongest effects were found in schools where the program was delivered with the highest integrity. Significant reductions were also found with respect to the percentage of students who were using multiple substances one or more times per week. Finally, data collected in a sample of individuals followed up during the year after high school found significantly lower levels of illicit drug use among the prevention students relative to controls with respect to the use of hallucinogens, heroin, and other narcotics (Botvin et al., in press).
Effectiveness with minority youth Although most studies have been conducted with White populations, recent research indicates that LST is also effective with inner-city minority populations. Studies show that this approach can reduce cigarette smoking among inner-city Hispanic youth (Botvin, Dusenbury, Baker, James-Ortiz, & Kerner, 1989; Botvin et al., 1992) and African American youth (Botvin, Batson, et al., 1989; Botvin & Cardwell, 1992). Long-term follow-up data also indicate that prevention effects are reasonably durable with minority youth. For example, cigarette smoking was found to be significantly lower among students receiving the preventive intervention than among controls in one study where a cohort of seventh graders were followed up to the end of 10th grade (Botvin, Griffin, Epstein, & Diaz, 1999). As with White youth, studies have shown that this prevention approach can also reduce alcohol and marijuana use in minority populations (Botvin et al., 1994; Botvin, Schinke et al., 1995; Botvin et al., 1997) and is able to produce reductions in more serious levels of drug involvement such as the use of multiple drugs (Botvin et al., 1997). Finally, despite the impact of this prevention approach on several different populations, evidence from one study suggests that even relatively modest changes that help tailor an intervention to the culture of the target population can further enhance its effectiveness (Botvin, Schinke, et al., 1995).
S O U R C E S
O F
M E D I A T I O N
The focus of most prevention research appropriately has been on the efficacy of particular prevention approaches in terms of their impact on tobacco, alcohol, and illicit drug use. However, there is an increasing recognition of the need to examine (1) the extent to which prevention programs produce an impact on hypothesized mediating variables and (2) the extent to which changes in these variables lead to changes in drug use (Botvin et al., 1992; Donaldson et al., 1994, 1996; Hansen & McNeal, 1997). This kind of research is important because it can identify the “active ingredients” in existing prevention programs, guide future refinements to existing prevention ap-
894
G. J. BOTVIN
proaches, and provide important information that may lead to the development of new prevention approaches. Examining the way in which effective prevention programs work can also lead to further refinements of the theories upon which current prevention approaches are based. Several papers have examined the impact of hypothesized mediating variables on the social influence approach (MacKinnon & Dwyer, 1993; MacKinnon et al., 1991). The results of some studies raise questions about the active ingredients and the underlying theory of these prevention approaches. For example, the MacKinnon and Dwyer study (1993) did not provide evidence of an impact on resistance skills, although the results of this study did suggest the importance of modifying normative expectations concerning cigarette smoking among adolescents. Studies have also examined the impact of LST on mediating variables (e.g., Botvin, Baker, Dusenbury, et al., 1990; Botvin et al., 1992, 1994, 1999; Botvin, Schinke, et al., 1995). These have included significant changes in knowledge and attitudes, assertiveness, refusal skills, risk-taking, locus of control, social anxiety, self-satisfaction, decision-making, and problem-solving. However, not all studies have found significant prevention effects on all of these variables. Further research is needed to understand the reason for the lack of consistency in the impact of the intervention on these variables from study to study. Other studies have examined the extent to which specific variables actually mediated the impact of the LST program on tobacco, alcohol, or marijuana use. For example, studies have identified changes resulting from the intervention on perceived norms (Botvin et al., 1992, 1999), refusal skills (Botvin, Schinke, et al., 1995; Botvin et al., 1997, 1999), and risk-taking (Botvin et al., 1997, 1999) as important mediators of the prevention program on substance use. While the research conducted thus far examining the impact of these preventive interventions on mediators as well as efforts to identify mediating mechanisms are important first steps, it is clear that additional research is needed.
S U M M A R Y
A N D
C O N C L U S I O N S
The growing prevention literature shows that some of the most widely used schoolbased prevention approaches are ineffective. Notable among these are prevention approaches that rely on providing information concerning the adverse consequences of drug abuse. Advances in prevention research over the past 2 decades demonstrate the efficacy of prevention approaches that focus on psychosocial factors associated with the onset and early stages of drug use. These approaches emphasize the teaching of information and skills designed to increase resistance to prodrug social influences and the correction of inaccurate/exaggerated normative beliefs. Evidence also exists for the efficacy of a broader prevention approach that includes elements of the social influence approach along with information and skills designed to promote increased personal and social competence. Although most of this research has been conducted with cigarette smoking, prevention effects have also been demonstrated for alcohol and marijuana use. Evidence from a few long-term follow-up studies shows that these approaches can produce meaningful reductions in drug use relative to controls that are reasonably durable. Research with these prevention approaches has been tested primarily with predominantly White, middle-class populations. Some recent studies, however, have also provided limited evidence of the utility of these approaches with inner-city minority populations. A small number of studies have also
Preventing drug abuse in schools
895
begun to elucidate the mechanism(s) through which these prevention approaches work by assessing the impact on hypothesized mediating variables. While research has demonstrated that school-based drug abuse prevention programs can work, additional research is needed to increase our understanding of the mediating mechanisms of effective prevention approaches, to better understand the conditions that may either increase or decrease the efficacy of these approaches, and to determine how to optimize the efficacy of existing prevention approaches. Finally, although this paper focused on school-based interventions targeting individual-level etiologic factors, an interesting and important area for prevention research not addressed in this paper concerns the potential impact of interventions targeting macrolevel etiologic factors through policy and other environmental approaches to the prevention of tobacco, alcohol, and illicit drug abuse.
R E F E R E N C E S Arkin, R. M., Roemhild, H. J., Johnson, C. A., Luepker, R. V., & Murray, D. M. (1981). The Minnesota smoking prevention program: A seventh grade health curriculum supplement. Journal of School Health, 51, 616–661. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall. Bangert-Drowns, R. L. (1988). The effects of school-based substance abuse education: A meta-analysis. Journal of Drug Education, 18, 243–264. Botvin, G. J. (1998). Preventing adolescent drug abuse through Life Skills Training: Theory, methods, and effectiveness. In J. Crane (Ed.), Social programs that work (pp. 225–257). New York: Russell Sage Foundation. Botvin, G. J., Baker, E., Botvin, E. M., Filazzola, A. D., & Millman, R. B. (1984). Alcohol abuse prevention through the development of personal and social competence: A pilot study. Journal of Studies on Alcohol, 45, 550–552. 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. Journal of the American Medical Association, 273, 1106–1112. Botvin, G. J., Baker, E., Dusenbury, L., Tortu, S., & Botvin, E. M. (1990). Preventing adolescent drug abuse through a multimodal cognitive-behavioral approach: Results of a three-year study. Journal of Consulting and Clinical Psychology, 58, 437–446. Botvin, G. J., Baker, E., Renick, N. L., Filazzola, A. D., & Botvin, E. M. (1984). A cognitive-behavioral approach to substance abuse prevention. Addictive Behaviors, 9, 137–147. Botvin, G. J., Batson, H., Witts-Vitale, S., Bess, V., Baker, E., & Dusenbury, L. (1989). A psychosocial approach to smoking prevention for urban black youth. Public Health Reports, 104, 573–582. Botvin, G. J., & Botvin, E. M. (1992). Adolescent tobacco, alcohol, and drug abuse: Prevention strategies, empirical findings, and assessment issues. Journal of Developmental and Behavioral Pediatrics, 13, 290–301. Botvin, G. J., & Cardwell, J. (1992). Primary prevention (smoking) of cancer in black populations. Grant contract number N01-CN-6508. Final Report to National Cancer Institute (NCI). Ithaca, NY: Cornell University Medical College. Botvin, G. J., Dusenbury, L., Baker, E., James-Ortiz, S., Botvin, E. M., & Kerner, J. (1992). Smoking prevention among urban minority youth: Assessing effects on outcome and mediating variables. Health Psychology, 11, 290–299. Botvin, G. J., Dusenbury, L., Baker, E., James-Ortiz, S., & Kerner, J. (1989). A skills training approach to smoking prevention among Hispanic youth. Journal of Behavioral Medicine, 12, 279–296. Botvin, G. J., & Eng, A. (1982). The efficacy of a multicomponent approach to the prevention of cigarette smoking. Preventive Medicine, 11, 199–211. Botvin, G. J., Eng, A., & Williams, C. L. (1980). Preventing the onset of cigarette smoking through Life Skills Training. Preventive Medicine, 9, 135–143. Botvin, G. J., Epstein, J. A., Baker, E., Diaz, T., & Ifill-Williams, M. (1997). School-based drug abuse prevention with inner-city minority youth. Journal of Child and Adolescent Substance abuse, 6, 5–20. 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. Botvin, G. J., Griffin, K. W., Diaz, T., Scheier, L. M., Williams, C., & Epstein, J. A. (in press). Preventing illicit drug use in adolescents: Long-term follow-up data from a randomized control trial of a school population. Addictive Behaviors.
896
G. J. BOTVIN
Botvin, G. J., Griffin, K. W., Epstein, J., & Diaz, T. (1999). Smoking prevention among Hispanic youth: Long-term follow-up data from a randomized control trial. Unpublished manuscript. Botvin, G. J., Renick, N., & Baker, E. (1983). The effects of scheduling format and booster sessions on a broadspectrum psychosocial approach to smoking prevention. Journal of Behavioral Medicine, 6, 359–379. Botvin, G. J., Schinke, S. P., Epstein, J. A., & Diaz, T. (1994). Effectiveness of culturally-focused and generic skills training approaches to alcohol and drug abuse prevention among minority youths. Psychology of Addictive Behaviors, 8, 116–127. Botvin, G. J., Schinke, S. P., Epstein, J. A., Diaz, T., & Botvin, E. M. (1995). Effectiveness of culturallyfocused and generic skills training approaches to alcohol and drug abuse prevention among minority adolescents: Two-Year follow-up results. Psychology of Addictive Behaviors, 9, 183–194. Caplan, M., Weissberg, R. P., Grober, J. S., Sivo, P., Grady, K., & Jacoby, C. (1992). Social competence promotion with inner-city and suburban young adolescents: Effects of social adjustment and alcohol use. Journal of Consulting and Clinical Psychology, 60, 56–63. Clayton, R. R., Cattarello, A. M., & Johnstone, B. M. (1996). The effectiveness of Drug Abuse Resistance Education (Project D.A.R.E.): Five-year follow-up results. Preventive Medicine, 25, 307–318. Donaldson, S. I., Graham, J. W., & Hansen, W. B. (1994). Testing the generalizability of intervening mechanism theories: Understanding the effects of adolescent drug use prevention interventions. Journal of Behavioral Medicine, 17, 195–216. Donaldson, S. I., Sussman, S., MacKinnon, D. P., Severson, H. H., Glynn, T., Murray, D. M., & Stone, E. J. (1996). Drug abuse prevention programming: Do we know what content works? American Behavioral Scientist, 39, 868–883. Dukes, R. L., Ullman, J. B., & Stein, J. A. (1996). Three-year follow-up of drug abuse resistance education (D.A.R.E.). Evaluation Review, 20, 49–66. Ellickson, P. L., & Bell, R. M. (1990). Drug prevention in junior high: A multi-site longitudinal test. Science, 247, 1299–1305. Ennett, S. T., Rosenbaum, D. P., Flewelling, R. L., Bieler, G. S., Ringwalt, C. L., & Bailey, S. L. (1994). Long-term evaluation of Drug Abuse Resistance Education. Addictive Behaviors, 19, 113–125. Ennett, S. T., Tobler, N. S., Ringwalt, C. L., & Flewelling, R. L. (1994). How effective is Drug Abuse Resistance Education? A meta-analysis of Project D.A.R.E. outcome evaluations. American Journal of Public Health, 84, 1394–1404. Evans, R. I. (1976). Smoking in children: Developing a social psychological strategy of deterrence. Preventive Medicine, 5, 122–127. Evans, R. I., Rozelle, R.M., Mittlemark, M. B., Hansen, W. B., Bane, A. L., & Havis, J. (1978). Deterring the onset of smoking in children: Knowledge of immediate physiological effects and coping with peer pressure, media pressure, and parent modeling. Journal of Applied Social Psychology, 8, 126–135. Fishbein, M. (1977). Consumer beliefs and behavior with respect to cigarette smoking: A critical analysis of the public literature. In Federal Trade Commission Report to Congress pursuant to the Public Health Cigarette Smoking Act of 1976. Washington, DC: U.S. Government Printing Office. Flay, B. R., Keopke, D., Thomson, S. J., Santi, S., Best, J. A., & Brown, K. S. (1989). Long-term follow-up of the first Waterloo smoking prevention trial. American Journal of Public Health, 79, 1371–1376. Hansen, W. B. (1992). School-based substance abuse prevention: A review of the state of the art in curriculum, 1980–1990. Health Education Research: Theory and Practice, 7, 403–430. Hansen, W. B., & McNeal, R. B. (1997). How D.A.R.E. works: An examination of program effects on mediating variables. Health Education and Behavior, 24, 165–176. Hansen, W. B., & O’Malley, P. M. (1996). Drug use. In R. J. DiClemente, W. B. Hansen, & L. E. Ponton (Eds.), Handbook of adolescent health risk behavior: Issues in clinical child psychology (pp. 161–192). New York: Plenum Press. Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112, 64–105. Hurd, P., Johnson, C. A., Pechacek, T., Bast, C. P., Jacobs, D., & Luepker, R. (1980). Prevention of cigarette smoking in 7th grade students. Journal of Behavioral Medicine, 3, 15–28. Jessor, R., & Jessor, S. L. (1977). Problem behavior and psychosocial development: A longitudinal study of youth. New York: Academic Press. Kearney, A. L., & Hines, M. H. (1980). Evaluation of the effectiveness of a drug prevention education program. Journal of Drug Education, 10, 127–134. Kim, S. (1988). A short- and long-term evaluation of “here’s looking at you.” II. Journal of Drug Education, 18, 235–242. Kreutter, K. J., Gewirtz, J., Davenny, J. E., & Love, C. (1991). Drug and alcohol prevention project for sixth graders: First-year findings. Adolescence, 26, 287–292. Luepker, R. V., Johnson, C. A., Murray, D. M., & Pechacek, T. F. (1983). Prevention of cigarette smoking: Three year follow-up of educational programs for youth. Journal of Behavioral Medicine, 6, 53–61. MacKinnon, D. P., & Dwyer, J. D. (1993). Estimating mediating effects in prevention studies. Evaluation Review, 1, 144–158. MacKinnon, D. P., Johnson, C. A., Pentz, M. A., Dwyer, J. H., Hansen, W. B., Flay, B. R., & Wang, E.
Preventing drug abuse in schools
897
(1991). Mediating mechanisms in a school-based drug prevention program: First year effects of the Midwestern Prevention Project. Health Psychology, 10, 164–172. McAlister, A., Perry, C. L., Killen, J., Slinkard, L. A., & Maccoby, N. (1980). Pilot study of smoking, alcohol, and drug abuse prevention. American Journal of Public Health. 70, 719–721. McGuire, W. J. (1964). Inducing resistance to persuasion: Some contemporary approaches. In L. Berkowitz (Ed.), Advances in experimental social psychology (pp. 192–227). New York: Academic Press. McGuire, W. J. (1968). The nature of attitudes and attitude change. In G. Lindzey & E. Aronson (Eds.), Handbook of social psychology (pp. 136–314). Reading, MA: Addison-Wesley. Murray, D. M., Pirie, P., Luepker, R. V., & Pallonen, U. (1989). Five and six-year follow-up results from four seventh-grade smoking prevention strategies. Journal of Behavioral Medicine, 12, 207–218. Oetting, E. R., & Beauvais, F. (1987). Peer cluster theory, socialization characteristics, and adolescent drug use: A path analysis. Journal of Consulting and Clinical Psychology, 34, 205–213. Pentz, M. A. (1983). Prevention of adolescent substance abuse through social skill development. In T. J. Glynn, C. G. Leukefeld, & J. B. Ludford (Eds.), Preventing adolescent drug abuse: Intervention strategies, 47th ed. (pp. 195–232). Washington, DC: NIDA Research Monograph. Perry, C., Killen, J. Slinkard, L. A., & McAlister, A. L. (1983). Peer teaching and smoking prevention among junior high students. Adolescence, 9, 277–281. Rosenbaum, D. P., Flewelling, R. L., Bailey, S. L., & Ringwalt, C. L. (1994). Cops in the classroom: A longitudinal evaluation of drug abuse resistance education (DARE). Journal of Research in Crime and Delinquency, 31, 3–31. Rosenbaum, D. P., & Hanson, G. S. (1998). Assessing the effects of school-based drug education: A six-year multilevel analysis of Project D.A.R.E. Journal of Research in Crime and Delinquency, 35, 381–412. Schaps, E., Bartolo, R. D., Moskowitz, J., Palley, C. S., & Churgin, S. (1981). A review of 127 drug abuse prevention program evaluations. Journal of Drug Issues, 11, 17–43. Schaps, E., Moskowitz, J. M. Malvin, J. H., & Scheffer, G. H. (1986). Evaluation of seven school-based prevention programs: A final report on the Napa Project. International Journal of the Addictions, 21, 1081– 1112. Schinke, S. P. (1984). Preventing teenage pregnancy. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification, 16th ed. (pp. 31–63). New York: Academic Press. Schinke, S. P., & Gilchrist, L. D. (1983). Primary prevention of tobacco smoking. Journal of School Health, 53, 416–419. Schinke, S. P., & Gilchrist, L. D. (1984). Preventing cigarette smoking with youth. Journal of Primary Prevention, 5, 48–56. Shope, J. T., Dielman, T. E., Butchart, A. T., & Campanelli, P. C. (1992). An elementary school-based alcohol misuse prevention program: A follow-up evaluation. Journal of Studies on Alcohol, 53, 106–121. Snow, D. L., Tebes, J. K., Arthur, M. W., & Tapasak, R. C. (1992). Two-year follow-up of a social-cognitive intervention to prevent substance use. Journal of Drug Education, 22, 101–114. Stuart, J. (1974). Teaching facts about drugs: Pushing or preventing? Journal of Educational Psychology, 66, 189–201. Sussman, S., Dent, C. W., Stacy, A. W., & Sun, P. (1993). Project Towards No Tobacco Use: 1-year behavior outcomes. American Journal of Public Health, 83, 1245–1250. Swisher, J. D., Crawford, J. L., Goldstein, R., & Yura, M. (1971). Drug education: Pushing or preventing? Peabody Journal of Education, 49, 68–75. Telch, M. J., Killen, J. D., McAlister, A. L., Perry, C. L., & Maccoby, N. (1982). Long-term follow-up of a pilot project on smoking prevention with adolescents. Journal of Behavioral Medicine, 5, 1–8. Tobler, N. S. (1986). Meta-analysis of 143 adolescent drug prevention programs: Quantitative outcome results of program participants compared to a control or comparison group. Journal of Drug Issues, 16, 537–567. Tobler, N. S. & Stratton, H. H. (1997). Effectiveness of school-based drug prevention programs: A metaanalysis of the research. Journal of Primary Prevention, 18, 71–128. Weissberg, R. P., & Greenberg, M. T. (1998). School and community competence-enhancement and prevention programs. In W. Damon (Series Ed.) & I. E. Sigel & K. A. Renninger (Vol. Eds.), Handbook of child psychology: Vol. 4. Child psychology in practice (5th ed., pp. 877–954). New York: Wiley. Zins, J. E., Elias, M. J., Greenberg, M. T., & Weissberg, R. P. (2000). Promoting social and emotional competence in children. In K. M. Minke & G. C. Bear (Eds.), Preventing school problems—Promoting school success: Strategies and programs that work (pp. 71–99). Bethesda, MD: National Association of School Psychologists.
Pergamon
PII S0306-4603(00)00119-2
PREVENTING DRUG ABUSE IN SCHOOLS: SOCIAL AND COMPETENCE ENHANCEMENT APPROACHES TARGETING INDIVIDUAL-LEVEL ETIOLOGIC FACTORS GILBERT J. BOTVIN Weill Medical College of Cornell University
Abstract — Drug abuse continues to be an important public health problem throughout the world. Although considerable progress has been made in identifying effective prevention approaches, there is a large gap between what research has shown to be effective and the methods generally used in most schools. The most promising prevention approaches target individuals during the beginning of adolescence and teach drug resistance skills and norm setting either alone or in combination with general personal and social skills. Evaluation studies testing these approaches show that they can significantly reduce adolescent tobacco, alcohol, and marijuana use. While some studies show that these effects may decrease over time, booster interventions have been found to maintain and in some instances even enhance prevention effects. The results of one large-scale evaluation study shows that it is possible to produce reductions in drug use that last until the end of high school. Available evidence suggests that these approaches may be effective when taught by different kinds of teachers and with different populations. The current paper provides a brief review of school-based prevention approaches targeting individual-level etiologic factors, evidence supporting their effectiveness, and a discussion of potential mediating mechanisms. © 2000 Elsevier Science Ltd.
Over the past 20 years, there has been a concerted effort to develop effective drug abuse prevention approaches for implementation in schools. These approaches typically target middle or junior high school students utilizing classroom-based interventions. School settings are particularly well suited for both the implementation and testing of drug abuse prevention programs because they offer reasonably efficient access to large numbers of youth during the years that many begin to experiment with tobacco, alcohol, marijuana, and other drugs. Although the ultimate goal of these prevention approaches is to prevent drug abuse and its adverse consequences, the more immediate focus of school prevention programs is to deter early-stage drug use. Accordingly, most prevention research has tested the efficacy of school-based prevention approaches with respect to their impact on the onset and occasional use of one or more so-called “gateway” substances (i.e., tobacco, alcohol, marijuana). The success of school-based prevention approaches has been noted in past literature reviews (e.g., Botvin & Botvin, 1992; Hansen, 1992) and in meta-analytic studies (e.g., Bangert-Drowns, 1988; Tobler & Stratton, 1997). The current article provides a brief summary of school-based prevention approaches, evidence supporting their effectiveness, and a discussion of potential mediating mechanisms. E A R L Y
P R E V E N T I O N
E F F O R T S
Early efforts to prevent drug abuse were based more on intuition than theory. These prevention approaches were designed to (1) dispense factual information, (2) promote affective education, or (3) provide healthy alternatives to using drugs. ReRequests for reprints should be sent to Gilbert J. Botvin, Institute for Prevention Research, Weill Medical College of Cornell University, 345 West 70th Street, 6F, New York, NY 10023; E-mail: [email protected] 887
888
G. J. BOTVIN
search testing the efficacy of these informational approaches to prevention show they may have an impact on knowledge and anti-drug attitudes; but they have consistently failed to show any impact on use of tobacco, alcohol, or other drugs or on intentions to use drugs (e.g., Schaps, Bartolo, Moskowitz, Palley, & Churgin, 1981). Several meta-analytic studies have confirmed this overall lack of behavioral effects (Bangert-Drowns, 1988; Tobler, 1986). Some studies even suggest that providing factual information about drugs and drug use may actually increase use (Stuart, 1974; Swisher, Crawford, Goldstein, & Yura, 1971). As is the case with information dissemination approaches, affective education approaches have not had an impact on drug use, although they sometimes have an impact on one or more of the correlates of drug use (Kearney & Hines, 1980; Kim, 1988). Finally, providing adolescents with activities intended to serve as alternatives to drug use have failed to produce any impact on drug use (Schaps et al., 1981; Schaps, Moskowitz, Malvin, & Scheffer, 1986). T O W A R D
S C I E N C E - B A S E D P R E V E N T I O N A P P R O A C H E S
As knowledge concerning the etiology of drug abuse has accumulated, there has been a shift in the focus of school-based prevention approaches. Instead of focusing on knowledge about the adverse consequences of drug abuse, school-based prevention approaches have increasingly targeted the individual-level risk and protective factors that studies have found to be associated with adolescent drug use (Hawkins, Catalano, & Miller, 1992). Moreover, these preventive interventions have typically been based on key elements from social learning theory (Bandura, 1977), problem behavior theory (Jessor & Jessor, 1977), persuasive communications theory (McGuire, 1968), and peer cluster theory (Oetting & Beauvais, 1987). The hallmark of science-based prevention approaches is careful testing using rigorous research methods. The science-based prevention approaches developed and tested over the last 2 decades can be grouped into two general categories: (1) social influence approaches and (2) competence enhancement approaches. S O C I A L
I N F L U E N C E
A P P R O A C H E S
Description and methods Social influence approaches emphasize the importance of social and psychological factors in promoting the onset of drug use, and are based on an intervention model originally developed by Evans and his colleagues (Evans, 1976; Evans et al., 1978). Adolescent drug use is conceptualized as the result of social influences from peers and the media to smoke, drink alcoholic beverages, or use illicit drugs. These social influences take the form of the modeling of drug use by peers and media personalities, persuasive advertising appeals, and/or direct offers by peers to use drugs. Over the past 20 years, numerous studies have tested several variations on this model to determine its impact on adolescent tobacco, alcohol, and marijuana use. The three major components of social influence approaches are psychological inoculation, normative education, and resistance skills training. Psychological inoculation. One of the most prominent features of the social influence approach to drug abuse prevention in its original formulation by Evans (1976) was psychological inoculation. The notion of psychological inoculation derives from the primary prevention of infectious disease through inoculation and is based on McGuire’s persuasive communications theory (McGuire, 1964, 1968). Following the principle of infec-
Preventing drug abuse in schools
889
tious disease inoculation, adolescents are first exposed to weak social influences to smoke, drink alcohol, or use illicit drugs. Later, individuals are exposed to progressively stronger prodrug social influences. The underlying hypothesis is that through a gradual exposure to prodrug social influences adolescents would build up resistance to more powerful drug messages similar to what they might be expected to encounter in junior and senior high school. Despite the initial prominence of psychological inoculation, it has not been shown to be an essential ingredient in social influence prevention approaches (Evans et al., 1978). As a consequence, it has received less emphasis in more recent formulations of the social influence approach. By contrast, more emphasis has been given in recent years to other social influence components such as normative education and resistance skills training. Normative education. Adolescents generally overestimate the prevalence of smoking, drinking, and illicit drug use among other adolescents and adults (Fishbein, 1977). This leads to inaccurate normative expectations and the development of a set of norms that supports drug use behavior. Social influence approaches are designed to correct the misperception that the majority of adults and adolescents use drugs. In the original study testing the social influence approach as a smoking prevention strategy (Evans et al., 1978), the psychological inoculation component of the intervention did not produce any incremental reduction in smoking onset over that produced by the assessment/feedback procedures for modifying normative expectations. In fact, the prevention effect generally attributed to the inoculation component of the intervention was actually the result of providing students with feedback concerning the actual levels of smoking by their classmates. That is, an important component of the prevention approach developed by Evans and his colleagues was the process of correcting normative expectations that nearly everybody smoked cigarettes. Over the past 2 decades, normative education has gained considerable prominence and has been included in most variations of the social influence approach. Several methods have been used to modify or correct normative expectations. One involves providing students with information about the prevalence of drug use from national or local surveys. Another method involves having students develop and conduct their own surveys of drug use within their class, school, or community. This activity enables students to obtain a more realistic perspective on the level of drug use in a way that has high credibility. Because the actual rates of drug use in most classes, schools, and communities is far lower than adolescents believe, this activity helps correct the misperception that most people use drugs and establishes antidrug use norms. This process is referred to as normative education (Hansen & O’Malley, 1996). Recently, it has been proposed that resistance skills training may be ineffective in the absence of conservative social norms against drug use, since if the norm is to use drugs, adolescents will be less likely to resist offers of drugs (Donaldson et al., 1996). This suggests that correcting normative expectations and attempting to create or reinforce conservative beliefs about the prevalence and acceptability of drug use is of central importance to the success of resistance skills training programs. Resistance skills training. Variations on the social influence approach have been developed and tested over the past 20 years. An assumption of this approach is that adolescents begin to use drugs largely because they lack the confidence or skills to resist social influences to smoke, drink, or use illicit drugs. Therefore, an important aspect of this approach is providing students with the skills to resist prodrug social influences from peers or the media. Three common social resistance skills training methods are:
890
G. J. BOTVIN
(1) teaching students to recognize high-risk situations, (2) increasing the awareness of media influences, and (3) refusal skills training. A logical component of any social resistance skills approach to drug abuse prevention involves teaching students how to recognize high-risk situations—that is, situations where they are likely to experience peer pressure to smoke, drink, or use illicit drugs. Once these high-risk situations are recognized and identified students can be taught tactics for avoiding them. Thus, avoiding high-risk situations is the first line of resistance to prodrug peer pressure. These programs have also frequently included a component intended to make students aware of prodrug influences from the media (e.g., movies, television programs, rock videos, music, etc.). Special emphasis is often placed on teaching students to identify the techniques used by advertisers to influence consumer behavior. Students are taught to recognize advertising appeals designed to sell tobacco products or alcoholic beverages as well as how to formulate counter-arguments to those appeals. Another method commonly used in early studies testing resistance skills training included having students make a public commitment not to smoke, drink, or use drugs. However, research suggests that this component may not contribute to any observed prevention effects (Hurd et al., 1980). Finally, the centerpiece of social resistance approaches involves teaching students skills for resisting or refusing offers to use drugs. This involves teaching students both the form and substance of an effective refusal response. In other words, students are taught what to say in a peer pressure situation (i.e., the specific content or substance of a refusal message) in order to develop a repertoire of effective responses. They are also taught how to say it in the most effective way possible. With respect to the latter, appropriate emphasis is given to such things as body position and distance from the person making the drug use offer (e.g., a cigarette or alcoholic drink at a party), eye contact, tone of voice, and facial expressions. In addition to learning these refusal skills, students are often encouraged to identify “action plans” consisting of planned responses to peer pressure situations. Effectiveness Considerable research has been conducted testing social influence approaches (Arkin, Roemhild, Johnson, Luepker, & Murray, 1981; Donaldson, Graham, & Hansen, 1994; Hurd et al., 1980; Luepker, Johnson, Murray, & Pechacek, 1983; Perry, Killen, Slinkard, & McAlister, 1983; Snow, Tebes, Arthur, & Tapasak, 1992; Sussman, Dent, Stacy, & Sun, 1993; Telch, Killen, McAlister, Perry, & Maccoby, 1982). Overall, studies have shown social influence approaches to be effective. Most of these studies have focused on smoking prevention, with studies typically examining rates of smoking onset, overall smoking prevalence, or scores on an index of smoking involvement (e.g., Hurd et al., 1980; Luepker et al., 1983; Telch et al., 1982). Typically, social influence approaches produce reductions in smoking incidence and/or prevalence of between 30% and 50% after the initial intervention, based on a comparison of smoking rates for the experimental and control conditions (Arkin et al., 1981; Donaldson et al., 1994; Sussman et al., 1993). Similar reductions have been reported for studies testing the impact of social influence approaches on alcohol and marijuana use (e.g., McAlister, Perry, Killen, Slinkard, & Maccoby, 1980; Shope, Dielman, Butchart, & Campanelli, 1992). In a comprehensive review of social influence studies published from 1980 to 1990, Hansen (1992) reported that the majority of prevention studies (63%) had produced reductions in drug use behavior, while many of those not demonstrating prevention effects lacked adequate statistical power. The results of several follow-up studies of social influence approaches reported positive behavioral effects lasting for up to 3 years (Luepker et al., 1983; McAlister et al., 1980; Telch et al., 1982). However, data from
Preventing drug abuse in schools
891
several longer-term follow-up studies indicate that these effects gradually decay over time (Flay et al., 1989; Murray, Pirie, Luepker, & Pallonen, 1989), suggesting the need for ongoing intervention or booster sessions. Finally, although most studies have been conducted with White youth, there is some evidence from research that included minority youth along with White youth that this approach is also effective with minority youth (Ellickson & Bell, 1990). The most popular and visible school-based drug education program based on the social influence model is DARE (Drug Abuse Resistance Education). DARE’s core curriculum is usually taught to children in the fifth grade. It contains elements of information dissemination and affective education, as well as social influence approaches to drug abuse prevention. A distinguishing feature of DARE is that it is taught by uniformed police officers. Although popular in many communities, the results of a number of studies call into question the effectiveness of the DARE program. Some studies have reported a short-term positive impact on drug-related knowledge, attitudes, or behavior. However, most of these outcome studies have weak research designs, poor sampling and data collection procedures, inadequate measurement strategies, and inappropriate data analysis methods (Rosenbaum & Hanson, 1998). More recent studies of DARE using stronger designs (i.e., large samples, random assignment, and longitudinal follow-up) have shown that DARE has little or no impact on drug use, particularly beyond the initial posttest assessment (Clayton, Cattarello, & Johnstone, 1996; Dukes, Ullman, & Stein, 1996; Ennett, Rosenbaum, Flewelling, Bieler, Ringwalt, & Bailey, 1994; Ennett, Tobler, Ringwalt, & Flewelling, 1994; Rosenbaum et al., 1994; Rosenbaum & Hanson, 1998). As Rosenbaum and Hanson (1998) have noted, stronger research designs have been associated with weaker effects of DARE on drug use behavior. Although DARE has program elements that are similar to social influence approaches, it has been suggested that it’s effectiveness may be compromised because it targets the wrong mediating processes, uses instructional methods that are less interactive than more successful prevention programs, and/or that students “tune out” an expected message from an authority figure (Hansen & McNeal, 1997; Tobler & Stratton, 1997). C O M P E T E N C E
E N H A N C E M E N T
A P P R O A C H E S
Over 2 decades of research has been conducted on competence enhancement approaches that emphasize the teaching of generic personal and social skills either alone or in combination with elements of the social influence approach. Many generic competence enhancement approaches were designed to promote positive mental health and have not been tested with respect to their impact on tobacco, alcohol, and/or illicit drug use. For this reason, they will not be reviewed here. Excellent reviews of this literature are provided elsewhere (e.g., Weissberg & Greenberg, 1988; Zins, Elias, Greenberg, & Weissberg, 2000). However, the little evidence that does exist suggests that teaching generic personal and social skills without domain-specific material concerning drug use may be only minimally effective (e.g., Caplan et al., 1992). Thus, the focus of this section is on competence enhancement approaches that were designed to prevent drug use and frequently also include elements of the social influence model. Particular emphasis is given to a competence enhancement approach called Life Skills Training (Botvin, 1998). Description and methods The theoretical foundations for competence enhancement approaches designed to prevent drug use are Bandura’s social learning theory (Bandura, 1977) and Jessor’s
892
G. J. BOTVIN
problem behavior theory (Jessor & Jessor, 1977). According to this approach, drug use is conceptualized as a socially learned and functional behavior that is the result of an interplay between social (interpersonal) and personal (intrapersonal) factors. Drug use behavior is learned through a process of modeling, imitation, and reinforcement, and is influenced by an adolescent’s prodrug cognitions, attitudes, and beliefs. These factors, in combination with poor personal and social skills, are believed to increase an adolescent’s susceptibility to social influences in favor of drug use. A distinctive feature of competence enhancement approaches is an emphasis on the teaching of generic self-management skills and social skills. For example, the LST program teaches these skills using a combination of proven cognitive-behavioral skills training methods that include instruction and demonstration, behavioral rehearsal (inclass practice), feedback and reinforcement, and extended (out-of-class) practice through behavioral homework assignments. Examples of the kind of generic personal and social skills typically included in competence enhancement prevention approaches are decision-making and problem-solving skills, cognitive skills for resisting interpersonal and media influences, skills for increasing personal control and enhancing selfesteem (goal-setting and self-directed behavior change techniques), adaptive coping strategies for managing stress and anxiety, assertive skills, and general social skills. Most of the prevention studies using a competence enhancement approach that have been conducted thus far have focused on seventh graders. However, some studies have been conducted with sixth graders (Kreutter, Gewirtz, Davenny, & Love, 1991) and one was conducted with 8th, 9th, and 10th graders (Botvin, Eng, & Williams, 1980). Program length has ranged from as few as 7 sessions to as many as 20 sessions. Some of these prevention programs were conducted at a rate of one class session per week, while others were conducted at a rate of two or more classes per week. Most of the studies conducted so far have used adults as the primary program providers. In some cases these adults were teachers; in other cases they were outside health professionals (i.e., project staff members, graduate students, social workers). Some studies have included booster sessions as a means of preserving initial prevention effects. Effectiveness Studies testing the competency enhancement approach have consistently demonstrated prevention effects on tobacco, alcohol, and marijuana use as well as effects on hypothesized mediating variables. The magnitude of initial prevention effects has typically ranged between 40% and 80% for reductions in the rate of tobacco use (Botvin, Baker, Renick, Filazzola, & Botvin, 1984; Botvin & Eng, 1982; Botvin et al., 1980; Botvin, Renick, & Baker, 1983; Pentz, 1983; Schinke, 1984; Schinke & Gilchrist, 1983, 1984). Booster sessions have been shown to help maintain initial prevention effects and, in some instances, even enhance those effects. For example, in one study, students who received booster sessions had smoking rates that were 87% lower than for controls (Botvin et al., 1983). Results of studies utilizing competence enhancement approaches have also demonstrated an impact on other forms of drug use, including alcohol use (Botvin, Baker, Botvin, Filazzola, & Millman, 1984; Botvin, Baker, Dusenbury, Tortu, & Botvin, 1990; Botvin, Schinke, Epstein, Diaz, & Botvin, 1995; Pentz, 1983), marijuana use (Botvin, Baker, Dusenbury et al., 1990; Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995), and polydrug use (Botvin, Baker, et al., 1995; Botvin, Epstein, Baker, Diaz, & Ifill-Williams, 1997). These reductions have generally been of a magnitude equal to that found with cigarette smoking.
Preventing drug abuse in schools
893
Prevention effects also appear to be reasonably durable. Long-term follow-up data from a large-scale, randomized trial testing the LST program and involving nearly 6,000 seventh graders from 56 public schools in New York State found lower smoking, alcohol, and marijuana use among intervention students relative to controls at the end of the 12th grade (Botvin, Baker, et al., 1995). Students attending schools randomly assigned to the prevention condition received the prevention program in the seventh grade (15 sessions) with booster sessions in the eighth grade (10 sessions) and ninth grade (5 sessions). No intervention was provided during grades 10 through 12. At the follow-up conducted at the end of the 12th grade, the prevalence of cigarette smoking, alcohol use, and marijuana use for the students in the prevention condition schools was as much as 44% lower than for controls. The strongest effects were found in schools where the program was delivered with the highest integrity. Significant reductions were also found with respect to the percentage of students who were using multiple substances one or more times per week. Finally, data collected in a sample of individuals followed up during the year after high school found significantly lower levels of illicit drug use among the prevention students relative to controls with respect to the use of hallucinogens, heroin, and other narcotics (Botvin et al., in press).
Effectiveness with minority youth Although most studies have been conducted with White populations, recent research indicates that LST is also effective with inner-city minority populations. Studies show that this approach can reduce cigarette smoking among inner-city Hispanic youth (Botvin, Dusenbury, Baker, James-Ortiz, & Kerner, 1989; Botvin et al., 1992) and African American youth (Botvin, Batson, et al., 1989; Botvin & Cardwell, 1992). Long-term follow-up data also indicate that prevention effects are reasonably durable with minority youth. For example, cigarette smoking was found to be significantly lower among students receiving the preventive intervention than among controls in one study where a cohort of seventh graders were followed up to the end of 10th grade (Botvin, Griffin, Epstein, & Diaz, 1999). As with White youth, studies have shown that this prevention approach can also reduce alcohol and marijuana use in minority populations (Botvin et al., 1994; Botvin, Schinke et al., 1995; Botvin et al., 1997) and is able to produce reductions in more serious levels of drug involvement such as the use of multiple drugs (Botvin et al., 1997). Finally, despite the impact of this prevention approach on several different populations, evidence from one study suggests that even relatively modest changes that help tailor an intervention to the culture of the target population can further enhance its effectiveness (Botvin, Schinke, et al., 1995).
S O U R C E S
O F
M E D I A T I O N
The focus of most prevention research appropriately has been on the efficacy of particular prevention approaches in terms of their impact on tobacco, alcohol, and illicit drug use. However, there is an increasing recognition of the need to examine (1) the extent to which prevention programs produce an impact on hypothesized mediating variables and (2) the extent to which changes in these variables lead to changes in drug use (Botvin et al., 1992; Donaldson et al., 1994, 1996; Hansen & McNeal, 1997). This kind of research is important because it can identify the “active ingredients” in existing prevention programs, guide future refinements to existing prevention ap-
894
G. J. BOTVIN
proaches, and provide important information that may lead to the development of new prevention approaches. Examining the way in which effective prevention programs work can also lead to further refinements of the theories upon which current prevention approaches are based. Several papers have examined the impact of hypothesized mediating variables on the social influence approach (MacKinnon & Dwyer, 1993; MacKinnon et al., 1991). The results of some studies raise questions about the active ingredients and the underlying theory of these prevention approaches. For example, the MacKinnon and Dwyer study (1993) did not provide evidence of an impact on resistance skills, although the results of this study did suggest the importance of modifying normative expectations concerning cigarette smoking among adolescents. Studies have also examined the impact of LST on mediating variables (e.g., Botvin, Baker, Dusenbury, et al., 1990; Botvin et al., 1992, 1994, 1999; Botvin, Schinke, et al., 1995). These have included significant changes in knowledge and attitudes, assertiveness, refusal skills, risk-taking, locus of control, social anxiety, self-satisfaction, decision-making, and problem-solving. However, not all studies have found significant prevention effects on all of these variables. Further research is needed to understand the reason for the lack of consistency in the impact of the intervention on these variables from study to study. Other studies have examined the extent to which specific variables actually mediated the impact of the LST program on tobacco, alcohol, or marijuana use. For example, studies have identified changes resulting from the intervention on perceived norms (Botvin et al., 1992, 1999), refusal skills (Botvin, Schinke, et al., 1995; Botvin et al., 1997, 1999), and risk-taking (Botvin et al., 1997, 1999) as important mediators of the prevention program on substance use. While the research conducted thus far examining the impact of these preventive interventions on mediators as well as efforts to identify mediating mechanisms are important first steps, it is clear that additional research is needed.
S U M M A R Y
A N D
C O N C L U S I O N S
The growing prevention literature shows that some of the most widely used schoolbased prevention approaches are ineffective. Notable among these are prevention approaches that rely on providing information concerning the adverse consequences of drug abuse. Advances in prevention research over the past 2 decades demonstrate the efficacy of prevention approaches that focus on psychosocial factors associated with the onset and early stages of drug use. These approaches emphasize the teaching of information and skills designed to increase resistance to prodrug social influences and the correction of inaccurate/exaggerated normative beliefs. Evidence also exists for the efficacy of a broader prevention approach that includes elements of the social influence approach along with information and skills designed to promote increased personal and social competence. Although most of this research has been conducted with cigarette smoking, prevention effects have also been demonstrated for alcohol and marijuana use. Evidence from a few long-term follow-up studies shows that these approaches can produce meaningful reductions in drug use relative to controls that are reasonably durable. Research with these prevention approaches has been tested primarily with predominantly White, middle-class populations. Some recent studies, however, have also provided limited evidence of the utility of these approaches with inner-city minority populations. A small number of studies have also
Preventing drug abuse in schools
895
begun to elucidate the mechanism(s) through which these prevention approaches work by assessing the impact on hypothesized mediating variables. While research has demonstrated that school-based drug abuse prevention programs can work, additional research is needed to increase our understanding of the mediating mechanisms of effective prevention approaches, to better understand the conditions that may either increase or decrease the efficacy of these approaches, and to determine how to optimize the efficacy of existing prevention approaches. Finally, although this paper focused on school-based interventions targeting individual-level etiologic factors, an interesting and important area for prevention research not addressed in this paper concerns the potential impact of interventions targeting macrolevel etiologic factors through policy and other environmental approaches to the prevention of tobacco, alcohol, and illicit drug abuse.
R E F E R E N C E S Arkin, R. M., Roemhild, H. J., Johnson, C. A., Luepker, R. V., & Murray, D. M. (1981). The Minnesota smoking prevention program: A seventh grade health curriculum supplement. Journal of School Health, 51, 616–661. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall. Bangert-Drowns, R. L. (1988). The effects of school-based substance abuse education: A meta-analysis. Journal of Drug Education, 18, 243–264. Botvin, G. J. (1998). Preventing adolescent drug abuse through Life Skills Training: Theory, methods, and effectiveness. In J. Crane (Ed.), Social programs that work (pp. 225–257). New York: Russell Sage Foundation. Botvin, G. J., Baker, E., Botvin, E. M., Filazzola, A. D., & Millman, R. B. (1984). Alcohol abuse prevention through the development of personal and social competence: A pilot study. Journal of Studies on Alcohol, 45, 550–552. 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. Journal of the American Medical Association, 273, 1106–1112. Botvin, G. J., Baker, E., Dusenbury, L., Tortu, S., & Botvin, E. M. (1990). Preventing adolescent drug abuse through a multimodal cognitive-behavioral approach: Results of a three-year study. Journal of Consulting and Clinical Psychology, 58, 437–446. Botvin, G. J., Baker, E., Renick, N. L., Filazzola, A. D., & Botvin, E. M. (1984). A cognitive-behavioral approach to substance abuse prevention. Addictive Behaviors, 9, 137–147. Botvin, G. J., Batson, H., Witts-Vitale, S., Bess, V., Baker, E., & Dusenbury, L. (1989). A psychosocial approach to smoking prevention for urban black youth. Public Health Reports, 104, 573–582. Botvin, G. J., & Botvin, E. M. (1992). Adolescent tobacco, alcohol, and drug abuse: Prevention strategies, empirical findings, and assessment issues. Journal of Developmental and Behavioral Pediatrics, 13, 290–301. Botvin, G. J., & Cardwell, J. (1992). Primary prevention (smoking) of cancer in black populations. Grant contract number N01-CN-6508. Final Report to National Cancer Institute (NCI). Ithaca, NY: Cornell University Medical College. Botvin, G. J., Dusenbury, L., Baker, E., James-Ortiz, S., Botvin, E. M., & Kerner, J. (1992). Smoking prevention among urban minority youth: Assessing effects on outcome and mediating variables. Health Psychology, 11, 290–299. Botvin, G. J., Dusenbury, L., Baker, E., James-Ortiz, S., & Kerner, J. (1989). A skills training approach to smoking prevention among Hispanic youth. Journal of Behavioral Medicine, 12, 279–296. Botvin, G. J., & Eng, A. (1982). The efficacy of a multicomponent approach to the prevention of cigarette smoking. Preventive Medicine, 11, 199–211. Botvin, G. J., Eng, A., & Williams, C. L. (1980). Preventing the onset of cigarette smoking through Life Skills Training. Preventive Medicine, 9, 135–143. Botvin, G. J., Epstein, J. A., Baker, E., Diaz, T., & Ifill-Williams, M. (1997). School-based drug abuse prevention with inner-city minority youth. Journal of Child and Adolescent Substance abuse, 6, 5–20. 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. Botvin, G. J., Griffin, K. W., Diaz, T., Scheier, L. M., Williams, C., & Epstein, J. A. (in press). Preventing illicit drug use in adolescents: Long-term follow-up data from a randomized control trial of a school population. Addictive Behaviors.
896
G. J. BOTVIN
Botvin, G. J., Griffin, K. W., Epstein, J., & Diaz, T. (1999). Smoking prevention among Hispanic youth: Long-term follow-up data from a randomized control trial. Unpublished manuscript. Botvin, G. J., Renick, N., & Baker, E. (1983). The effects of scheduling format and booster sessions on a broadspectrum psychosocial approach to smoking prevention. Journal of Behavioral Medicine, 6, 359–379. Botvin, G. J., Schinke, S. P., Epstein, J. A., & Diaz, T. (1994). Effectiveness of culturally-focused and generic skills training approaches to alcohol and drug abuse prevention among minority youths. Psychology of Addictive Behaviors, 8, 116–127. Botvin, G. J., Schinke, S. P., Epstein, J. A., Diaz, T., & Botvin, E. M. (1995). Effectiveness of culturallyfocused and generic skills training approaches to alcohol and drug abuse prevention among minority adolescents: Two-Year follow-up results. Psychology of Addictive Behaviors, 9, 183–194. Caplan, M., Weissberg, R. P., Grober, J. S., Sivo, P., Grady, K., & Jacoby, C. (1992). Social competence promotion with inner-city and suburban young adolescents: Effects of social adjustment and alcohol use. Journal of Consulting and Clinical Psychology, 60, 56–63. Clayton, R. R., Cattarello, A. M., & Johnstone, B. M. (1996). The effectiveness of Drug Abuse Resistance Education (Project D.A.R.E.): Five-year follow-up results. Preventive Medicine, 25, 307–318. Donaldson, S. I., Graham, J. W., & Hansen, W. B. (1994). Testing the generalizability of intervening mechanism theories: Understanding the effects of adolescent drug use prevention interventions. Journal of Behavioral Medicine, 17, 195–216. Donaldson, S. I., Sussman, S., MacKinnon, D. P., Severson, H. H., Glynn, T., Murray, D. M., & Stone, E. J. (1996). Drug abuse prevention programming: Do we know what content works? American Behavioral Scientist, 39, 868–883. Dukes, R. L., Ullman, J. B., & Stein, J. A. (1996). Three-year follow-up of drug abuse resistance education (D.A.R.E.). Evaluation Review, 20, 49–66. Ellickson, P. L., & Bell, R. M. (1990). Drug prevention in junior high: A multi-site longitudinal test. Science, 247, 1299–1305. Ennett, S. T., Rosenbaum, D. P., Flewelling, R. L., Bieler, G. S., Ringwalt, C. L., & Bailey, S. L. (1994). Long-term evaluation of Drug Abuse Resistance Education. Addictive Behaviors, 19, 113–125. Ennett, S. T., Tobler, N. S., Ringwalt, C. L., & Flewelling, R. L. (1994). How effective is Drug Abuse Resistance Education? A meta-analysis of Project D.A.R.E. outcome evaluations. American Journal of Public Health, 84, 1394–1404. Evans, R. I. (1976). Smoking in children: Developing a social psychological strategy of deterrence. Preventive Medicine, 5, 122–127. Evans, R. I., Rozelle, R.M., Mittlemark, M. B., Hansen, W. B., Bane, A. L., & Havis, J. (1978). Deterring the onset of smoking in children: Knowledge of immediate physiological effects and coping with peer pressure, media pressure, and parent modeling. Journal of Applied Social Psychology, 8, 126–135. Fishbein, M. (1977). Consumer beliefs and behavior with respect to cigarette smoking: A critical analysis of the public literature. In Federal Trade Commission Report to Congress pursuant to the Public Health Cigarette Smoking Act of 1976. Washington, DC: U.S. Government Printing Office. Flay, B. R., Keopke, D., Thomson, S. J., Santi, S., Best, J. A., & Brown, K. S. (1989). Long-term follow-up of the first Waterloo smoking prevention trial. American Journal of Public Health, 79, 1371–1376. Hansen, W. B. (1992). School-based substance abuse prevention: A review of the state of the art in curriculum, 1980–1990. Health Education Research: Theory and Practice, 7, 403–430. Hansen, W. B., & McNeal, R. B. (1997). How D.A.R.E. works: An examination of program effects on mediating variables. Health Education and Behavior, 24, 165–176. Hansen, W. B., & O’Malley, P. M. (1996). Drug use. In R. J. DiClemente, W. B. Hansen, & L. E. Ponton (Eds.), Handbook of adolescent health risk behavior: Issues in clinical child psychology (pp. 161–192). New York: Plenum Press. Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112, 64–105. Hurd, P., Johnson, C. A., Pechacek, T., Bast, C. P., Jacobs, D., & Luepker, R. (1980). Prevention of cigarette smoking in 7th grade students. Journal of Behavioral Medicine, 3, 15–28. Jessor, R., & Jessor, S. L. (1977). Problem behavior and psychosocial development: A longitudinal study of youth. New York: Academic Press. Kearney, A. L., & Hines, M. H. (1980). Evaluation of the effectiveness of a drug prevention education program. Journal of Drug Education, 10, 127–134. Kim, S. (1988). A short- and long-term evaluation of “here’s looking at you.” II. Journal of Drug Education, 18, 235–242. Kreutter, K. J., Gewirtz, J., Davenny, J. E., & Love, C. (1991). Drug and alcohol prevention project for sixth graders: First-year findings. Adolescence, 26, 287–292. Luepker, R. V., Johnson, C. A., Murray, D. M., & Pechacek, T. F. (1983). Prevention of cigarette smoking: Three year follow-up of educational programs for youth. Journal of Behavioral Medicine, 6, 53–61. MacKinnon, D. P., & Dwyer, J. D. (1993). Estimating mediating effects in prevention studies. Evaluation Review, 1, 144–158. MacKinnon, D. P., Johnson, C. A., Pentz, M. A., Dwyer, J. H., Hansen, W. B., Flay, B. R., & Wang, E.
Preventing drug abuse in schools
897
(1991). Mediating mechanisms in a school-based drug prevention program: First year effects of the Midwestern Prevention Project. Health Psychology, 10, 164–172. McAlister, A., Perry, C. L., Killen, J., Slinkard, L. A., & Maccoby, N. (1980). Pilot study of smoking, alcohol, and drug abuse prevention. American Journal of Public Health. 70, 719–721. McGuire, W. J. (1964). Inducing resistance to persuasion: Some contemporary approaches. In L. Berkowitz (Ed.), Advances in experimental social psychology (pp. 192–227). New York: Academic Press. McGuire, W. J. (1968). The nature of attitudes and attitude change. In G. Lindzey & E. Aronson (Eds.), Handbook of social psychology (pp. 136–314). Reading, MA: Addison-Wesley. Murray, D. M., Pirie, P., Luepker, R. V., & Pallonen, U. (1989). Five and six-year follow-up results from four seventh-grade smoking prevention strategies. Journal of Behavioral Medicine, 12, 207–218. Oetting, E. R., & Beauvais, F. (1987). Peer cluster theory, socialization characteristics, and adolescent drug use: A path analysis. Journal of Consulting and Clinical Psychology, 34, 205–213. Pentz, M. A. (1983). Prevention of adolescent substance abuse through social skill development. In T. J. Glynn, C. G. Leukefeld, & J. B. Ludford (Eds.), Preventing adolescent drug abuse: Intervention strategies, 47th ed. (pp. 195–232). Washington, DC: NIDA Research Monograph. Perry, C., Killen, J. Slinkard, L. A., & McAlister, A. L. (1983). Peer teaching and smoking prevention among junior high students. Adolescence, 9, 277–281. Rosenbaum, D. P., Flewelling, R. L., Bailey, S. L., & Ringwalt, C. L. (1994). Cops in the classroom: A longitudinal evaluation of drug abuse resistance education (DARE). Journal of Research in Crime and Delinquency, 31, 3–31. Rosenbaum, D. P., & Hanson, G. S. (1998). Assessing the effects of school-based drug education: A six-year multilevel analysis of Project D.A.R.E. Journal of Research in Crime and Delinquency, 35, 381–412. Schaps, E., Bartolo, R. D., Moskowitz, J., Palley, C. S., & Churgin, S. (1981). A review of 127 drug abuse prevention program evaluations. Journal of Drug Issues, 11, 17–43. Schaps, E., Moskowitz, J. M. Malvin, J. H., & Scheffer, G. H. (1986). Evaluation of seven school-based prevention programs: A final report on the Napa Project. International Journal of the Addictions, 21, 1081– 1112. Schinke, S. P. (1984). Preventing teenage pregnancy. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification, 16th ed. (pp. 31–63). New York: Academic Press. Schinke, S. P., & Gilchrist, L. D. (1983). Primary prevention of tobacco smoking. Journal of School Health, 53, 416–419. Schinke, S. P., & Gilchrist, L. D. (1984). Preventing cigarette smoking with youth. Journal of Primary Prevention, 5, 48–56. Shope, J. T., Dielman, T. E., Butchart, A. T., & Campanelli, P. C. (1992). An elementary school-based alcohol misuse prevention program: A follow-up evaluation. Journal of Studies on Alcohol, 53, 106–121. Snow, D. L., Tebes, J. K., Arthur, M. W., & Tapasak, R. C. (1992). Two-year follow-up of a social-cognitive intervention to prevent substance use. Journal of Drug Education, 22, 101–114. Stuart, J. (1974). Teaching facts about drugs: Pushing or preventing? Journal of Educational Psychology, 66, 189–201. Sussman, S., Dent, C. W., Stacy, A. W., & Sun, P. (1993). Project Towards No Tobacco Use: 1-year behavior outcomes. American Journal of Public Health, 83, 1245–1250. Swisher, J. D., Crawford, J. L., Goldstein, R., & Yura, M. (1971). Drug education: Pushing or preventing? Peabody Journal of Education, 49, 68–75. Telch, M. J., Killen, J. D., McAlister, A. L., Perry, C. L., & Maccoby, N. (1982). Long-term follow-up of a pilot project on smoking prevention with adolescents. Journal of Behavioral Medicine, 5, 1–8. Tobler, N. S. (1986). Meta-analysis of 143 adolescent drug prevention programs: Quantitative outcome results of program participants compared to a control or comparison group. Journal of Drug Issues, 16, 537–567. Tobler, N. S. & Stratton, H. H. (1997). Effectiveness of school-based drug prevention programs: A metaanalysis of the research. Journal of Primary Prevention, 18, 71–128. Weissberg, R. P., & Greenberg, M. T. (1998). School and community competence-enhancement and prevention programs. In W. Damon (Series Ed.) & I. E. Sigel & K. A. Renninger (Vol. Eds.), Handbook of child psychology: Vol. 4. Child psychology in practice (5th ed., pp. 877–954). New York: Wiley. Zins, J. E., Elias, M. J., Greenberg, M. T., & Weissberg, R. P. (2000). Promoting social and emotional competence in children. In K. M. Minke & G. C. Bear (Eds.), Preventing school problems—Promoting school success: Strategies and programs that work (pp. 71–99). Bethesda, MD: National Association of School Psychologists.