**Prevention of Substance Abuse in the Workplace:**

**Review of Research on the Delivery of Services**

Royer Cook, Ph.D.

The ISA Group

William Schlenger, Ph.D.

Research Triangle Institute

and

Duke University

ABSTRACT

> With the growing recognition that most illicit drug users and heavy
> drinkers are members of the work force, the workplace has become an
> increasingly significant, though still underutilized, vehicle for the
> delivery of substance abuse prevention services. This paper discusses
> some of the chief reasons for engaging in substance abuse prevention
> in the workplace; outlines the foundations of workplace prevention
> services; and reviews recent research on workplace substance abuse
> prevention, including the major preventive interventions aimed at the
> workplace environment and the individual worker. The paper closes with
> a discussion of future programming and research on the delivery of
> workplace prevention services.
>
> Key Words: Workplace substance abuse prevention

From the early days of industrial alcoholism programs to today's
employee assistance programs and drug testing, the workplace has played
an active role in the prevention, detection and control of alcohol and
other drugs. Although for nearly half a century the workplace has become
an increasingly active force in addressing problems of substance abuse
in the work force, the past decade has witnessed significant advances in
research on primary prevention strategies in the workplace. In this
paper, we will present some of the reasons why substance abuse
prevention activities are appropriate for the workplace, followed by a
discussion of recent research on prevention services in the workplace.

# Reasons for engaging in substance abuse prevention in the workplace

Among the reasons for engaging in substance abuse prevention in the
workplace are that: (1) most illicit drug users and heavy drinkers are
members of the work force; (2) substance abuse has a major negative
impact on worker health, safety and productivity; and (3) the workplace
is where most parents can be reached with messages about preventing
substance abuse in their children. These reasons are discussed below.

[Substance abuse prevalence in the work force.]{.underline} Most users
of illicit drugs and heavy drinkers are working adults, many of whom
were not substance abusers in adolescence. Prevalence data from the
federal National Household Survey on Drug Abuse (NHSDA) have supported
this finding for several years (SAMHSA, 1996, 1999). While it is true
that *rates* of substance abuse are higher in certain populations (such
as the unemployed and criminals), the most recent household survey found
that 70% of all current users of illicit drugs (use in the last 30 days)
aged 18-49, and 77% of all heavy drinkers (5 or more drinks on 5 or more
days in the past month) are employed full-time (SAMHSA, 1999). Although
these figures do not mean that most workers are illicit drug users or
heavy drinkers -- indeed, only 7.7% of people employed full-time are
illicit drug users and 7.6% are heavy drinkers -- they serve to
underscore the point that on most days, the large majority of substance
abusers will be found in the workplace -- not in the schools or the
streets.

The NHSDA data show that prevalence figures vary considerably by age
group, gender, education and occupation. Current illicit drug use and/or
heavy drinking is more likely to occur among young workers, males, and
workers with less education. Workers aged 18-25 have rates of current
illicit drug use (13.5%) and heavy alcohol use (11.7%) that are roughly
1.5 times higher than the national average, and workers without a high
school education have rates of current illicit drug use (11.2%) and
heavy alcohol use (14.7%) that are 1.5 to 2 times the national average.
Among the major occupational categories, workers in food preparation,
waiters, waitresses and bartenders (one occupational category) and
construction have rates of current illicit drug use (18.7% and 14.1%)
and heavy alcohol use (15% and 12.4%) that are roughly twice the
national average rates (SAMHSA, 1999).

Moreover, many illicit drug users did not begin use until after they
joined the work force. For example, according to the 1997 NHSDA, the
mean age of first use of cocaine was 20.3, a figure indicating that
although many cocaine users started in their teens, a substantial
proportion also did not begin use until their early twenties. The
figures on "age of first use" can also be misleading: Many people who
experimented with illicit drug use in their teens do not become regular
users until early adulthood, and problem drinking often does not
manifest itself until well into middle age.

The prevalence data from the NHSDA are probably the most accurate
national

data available on substance abuse in the work force, as these are the
only national data generated through rigorous (though not flawless)
methodologies. Nonetheless, it is likely that the NHSDA rates are
underestimates, as they are based solely on self-reports. Research from
Cook and his associates on methods for assessing work force drug use has
shown that when bioassay data (urinalysis and hair analysis) are
collected along with data from self-administered questionnaires, the
prevalence rates from the combined measures are typically approximately
40%-50% higher than rates produced by self-reports alone (Cook et al.,
1997; Cook et al., 1999).

Therefore, although there is little question that efforts at universal
prevention in the strictest sense -- avoiding any use of illicit drugs
or alcohol -- are most appropriately aimed at children, it also seems
clear that there is ample opportunity to prevent the regular use of
illicit drugs and problem drinking in a large segment of the population
by targeting working adults, particularly those aged 18 to 35,

[Negative effects and costs of substance abuse in the work
force.]{.underline} There are many reasons -- including important
economic concerns \-- why companies and their managed care organizations
should be engaging in substance abuse prevention for workers. There is
ample evidence that substance abuse is associated with accidents,
absenteeism, turnover and other sources of productivity losses --
although the nature of the association is not always clear. Illicit drug
use among workers has been linked to increased absenteeism and turnover
(Kandel and Yamaguchi, 1985; Lehman et al., 1995; Newcomb, 1995; Normand
et al., 1990; Rosenbaum, 1992) and job withdrawal (Lehman et al., 1992).
Illicit drug use and heavy alcohol use have been linked to an increased
risk of workplace accidents and injury (Alleyne et al., 1991; Dawson,
1994; Moody et al., 1990; Pollack et al., 1998). The cumulative costs of
these effects to industry productivity and health care have been
estimated at approximately \$100 billion annually (Drug Strategies,
1996) However, as recently pointed out by Hoffman and Larison (1999),
most of these studies have been conducted on regional or
industry-specific samples. When these investigators analyzed the NHSDA
data, they found no association between drug use and work related
accidents (although their findings on job turnover were consistent with
the results of past studies).

The results of a recent study by Mangione and his associates (1999) on
the relationship between employee drinking practices and a variety of
work performance measures provides a broad and informative analysis of
this issue. Based on survey data from 16 worksites and 6,540 workers,
this study found that self-reported work performance problems (e.g.,
missed work, done less work, done poor quality work, etc.) varied as a
function of employee drinking practices, with moderate-heavy and heavy
drinkers reporting more work performance problems than employees who
drank less. In addition to the drinking measures, both self-reported use
of marijuana and use of prescription drugs for anxiety and depression
were independently and positively associated with work performance
problems. Based on these findings, Mangione and his associates recommend
that, along with clear policy statements, organizations promote
educational interventions for alcohol and drugs similar to those
targeted to wellness topics such as exercise, nutrition etc.

There is also evidence that substance abuse is associated with more
costly use of medical benefits (Trudeau et al., in press; Winkler and
Sheridan, 1989). An analysis of medical claims data from a property
casualty insurance company conducted by Trudeau and his associates
serves to both highlight the potential effects of substance abuse on
medical costs and to place these costs in perspective. These
investigators found that behavioral healthcare claims accounted for only
2.4% of all healthcare costs, and within behavioral health claims,
substance abuse accounted for only 4.2% of costs -- a relatively small,
though not insignificant amount. However, this same study also found
that employees with behavioral health claims also had higher overall
health care costs and lower performance ratings than those without such
claims, indicating that substance abuse and other behavioral health
problems can have effects on both health care costs and performance that
go beyond the direct costs of treating a substance abuse problem
(Trudeau et al., in press).

[Reaching parents in the workplace.]{.underline} A third compelling
reason for addressing substance abuse prevention in the workplace is
that the workplace is where parents can be reached with messages about
keeping their children drug-free. After many years of focusing almost
exclusively on peer influences, the role of parents in preventing youth
substance abuse has recently started to receive the attention it
deserves, triggered in no small way by the research of Kandel (1996),
Brook (1990) and Hawkins and colleagues (1992). The literature now
reflects a general understanding that parents can have strong influences
on their children's drug use through authoritative family management
styles, positive parental modeling and less permissive attitudes toward
alcohol and other drug use. These findings have fueled the creation of
numerous parenting programs, including workplace programs such as the
Parenting Partnership, a program conducted in 24 one-hour sessions. A
quasi-experimental evaluation of this program found that in comparison
to working parents exposed to low dosages of the program, parents
exposed to high dosages exhibited numerous positive changes in ratings
of children's positive behaviors and substance abuse resistance, as well
as reduced parental depression, stress, and irritability (Felner et al.,
1994). The study also found considerable variability in employee
participation, attributable in part to the extent to which the
organization embraced and supported the program.

A recent review of parent programs for the workplace indicated that
several organizations are engaged in providing parent programs, but that
applications of such programs to the workplace are relatively rare
(SAMHSA, 1999). Moreover, although some of the programs included in the
SAMHSA review have conducted evaluations of their programs, rigorous
research on workplace applications of parent programs has been virtually
nonexistent.

The K.I.D.S. (Kids in a Drug-Free Society) program was recently
developed to provide working parents with the motivation and skills
required to communicate effectively with their children about alcohol,
tobacco and other drugs. Based on the Hawkins and Catalano model
(Hawkins et al., 1992), a central element in this national program (just
getting underway at this writing) is a workplace training program
designed to help parents strengthen family bonds, set clear expectations
for meaningful family involvement, and teach their children how to
resist peer pressure. No data are yet available on this program, but it
will bear watching over the next few years to see to what extent
workplaces and working parents participate in the program.

Despite the lack of documentation for the efficacy of workplace programs
aimed at improving parenting skills related to keeping children off
drugs, it seems likely that such programs have the potential for
reaching working parents with important substance abuse prevention
messages and materials. Unfortunately, several significant forces appear
to be keeping these programs from flourishing in the workplace. Many
employers are likely to question whether training in parenting skills is
a legitimate role for them, and those few who might be receptive to the
idea are unlikely to agree to provide the amount of employee time
required for most of these programs (e.g., the 24 hours required by the
Parenting Partnership). On the other hand, if drug prevention messages
for parents can be more efficiently integrated into employee services
and programs, perhaps more employers would embrace the interventions.
But would employees attend to the messages, and how effective would they
be? As workplaces become exposed to programs like K.I.D.S., we may begin
to learn more about the extent to which such programs are likely to be
viable interventions in the future.

[Stigma: A singular obstacle to workplace substance abuse
prevention]{.underline}

Despite all the seemingly compelling reasons for workplaces to provide
substance abuse prevention for their work forces, few companies are
actively engaged in substance abuse prevention. A variety of health
promotion and disease prevention services and facilities are prevalent
throughout American workplaces, from stress management seminars to blood
pressure screening to exercise programs. The topic of substance abuse,
however, is not afforded the same attention and support that these other
topics receive. Among the many reasons that scant attention is paid to
substance abuse prevention in the workplace is the *stigma* that remains
attached to the issue. The same worker who eagerly signs up for sessions
on weight management might not be as eager to attend a workplace seminar
on alcohol abuse prevention. The same company that embraces cholesterol
screening sessions is likely to shun programs on alcohol screening.
Substantial strides have been made toward the general acceptance of
addiction as a treatable affliction; nonetheless, workers are rarely
willing to take any action -- such as attending a seminar on "warning
signs of alcohol abuse" \-- that might, in the slightest way, indicate
that they (or someone in their family) could have a substance abuse
problem. In more than a decade of creating and delivering substance
abuse prevention activities in the workplace, from conducting seminars
to providing pamphlets and videos to workers, Cook and his associates
have found that the stigma of substance abuse is an ever-present
obstacle to effective delivery of substance abuse prevention in the
workplace (Cook et al., 1996a, Cook, 2000). Moreover, in two recent
meetings sponsored by CSAP on workplace substance abuse prevention and
managed care, the stigma surrounding substance abuse was highlighted by
several health care industry experts as a serious impediment to the
delivery of effective prevention services (CSAP Prevention Benchmarking
Meeting, 1999; CSAP Forum on Managed

Care and Researcher Collaborations, 1999). If substance abuse prevention
is to receive the attention it deserves, approaches must be adopted that
overcome stigma. One broad approach to overcoming stigma is to imbed the
topic within a more palatable, less stigmatized topic, such as health
promotion (Cook et al., 2000; Heirich et al., 1999) and employee
training (Bennett and Lehman, 1997). These are topics that employees and
employers are willing (often eager) to embrace.

## The Foundations of Workplace Substance Abuse Prevention

The current attention to substance abuse problems in the work force has
its roots in the two somewhat disparate movements that led to the
employee assistance programs and drug testing programs of today. As
indicated in the discussion below, neither of these programs has a
particularly strong prevention orientation, though each contains
preventive elements.

[Employee assistance Programs.]{.underline} The basic concept of the EAP
had its genesis in the industrial alcoholism programs of the 1940s that
were created largely through the influence of Alcoholics Anonymous
(Roman & Blum, 1999; Trice and Schonbrun, 1981). It was recognized that
through its control over one's livelihood, the workplace possessed
unique leverage to motivate individuals to change their drinking
practices. The central tenet of these early programs was that the
alcohol problem of workers would be manifested in poor performance,
serving as an indicator to supervisors. However, through the 50s and
60s, few such programs were adopted, in part because of employers'
concerns that a program might signal to customers and stockholders that
the company had an alcohol problem (an early version of the stigma
problem). And just how alcohol-based performance decrements were to be
accurately distinguished from myriad other bases for performance
decrements was never quite clear (Roman & Blum, 1999). Inroads against
these dual obstacles did not occur until the late 70s and early 80's,
when programs moved away from the focus on substance abuse and began
addressing a wide variety of behavioral-medical problems that can affect
employees' well-being and their job performance. This movement
represented "an early form of mainstreaming of substance abuse treatment
into the broader areas of health care and human resource management"
(Roman & Blum, 1999, p. 425). (As discussed below, this same
"mainstreaming" strategy was to be applied to substance abuse prevention
in the workplace, albeit in experimental fashion.) This strategy was
sufficiently successful that by 1991, it was estimated that nearly half
the nation's work force was covered by an EAP.

However, throughout this period, the primary function of EAPs continued
to be the identification and referral of individuals to treatment
services; very little attention was paid to prevention, particularly in
the universal or selective sense. Indeed, the six major functions of
EAPs as described by Roman and Blum (1999) are virtually all
treatment-oriented. This rather exclusive focus on treatment-related
functions may be entirely appropriate: When Roman and Blum conducted a
review of the impact of worksite interventions (mostly EAPs and the
like), they concluded that these types interventions were generally
efficacious in rehabilitating employees with alcohol problems (Roman &
Blum, 1996). Similarly, Sonnenstuhl (1996) has concluded that EAPs have
been "relatively successful" at helping alcoholic employees gain
sobriety, typically reporting recovery rates of 70% or better. Moreover,
it is likely that EAPs operate as a generalized diffuse force for the
prevention of substance abuse by raising awareness of the risks of
substance abuse and nudging workplace norms toward more responsible
drinking. Nonetheless, it is the rare EAP that actively pursues genuine
prevention strategies with the mainstream of workers; i.e., strategies
designed to alter drinking practices, halt experimentation with illicit
drugs or the misuse of prescription drugs, or help keep their children
from substance abuse. These universal and selective prevention targets
seem to be off the radar screen of most EAPs.

[Drug testing.]{.underline} During the 1980s, as EAPs were proliferating
by broadening their scope , another workplace intervention strategy --
drug testing -- took a very focused approach, targeting illicit drug use
in the work force. Work force drug testing began in the military in the
1970's, and by the 1980's the strategy had gained a firm foothold in the
civilian sector. In some respects, the drug testing movement came about
because of a perceived need by both industry and government to identify
workers who are users of illicit drugs, a need largely unmet by EAPs.
Workplace drug testing programs are of three types: (1) pre-employment
testing of job applicants (by far the most prevalent type); (2)
for-cause testing of employees (e.g., post-accident); and (3) random
testing of employees (Normand et al., 1994). Although concerns continue
about the accuracy of drug testing, the standard technique of screening
urine specimens with relatively inexpensive radioimmunoassays and
confirming positives with the more expensive and highly accurate gas
chromatography/mass spectrometry (GC/MS) is generally considered highly
reliable, particularly when conducted by certified laboratories in the
context of proper chain of custody procedures. During the last decade,
these types of drug testing programs have become increasingly
commonplace in both government and industry. A 1995 survey conducted by
the American Management Association revealed that nearly 80% of surveyed
firms test employees for drugs (AMA, 1995). In 1995, Walsh estimated
that approximately 30 million American workers were being tested
annually for illicit drug use. There are numerous reasons for the
explosive growth in workplace drug testing, including its presumed
impact on safety, productivity and employer costs. However, perhaps the
main impetus for the widespread adoption of drug testing was the passage
in 1988 of the federal Drug-Free Workplace Act and the subsequent
promotion by the federal government of drug testing in the workplace.

Although a variety of studies have attempted to assess the impact of
drug testing on the work force, evidence of its preventive/deterrence
effects are less definitive than generally assumed by industry and the
public. Indeed, when Normand and his associates reviewed the extant
research on the topic, they concluded that "Despite beliefs to the
contrary, the preventive effects of drug testing programs have never
been adequately demonstrated" (Normand et al., 1994). The authors admit
that there are "some suggestive data that allude to the deterrent effect
of preemployment testing," but they found no "conclusive scientific
evidence" of such effects. A close examination of these studies (e.g.,
Parish, 1989; Blank and Fenton, 1989) and those from the military (e.g.,
Bray et al., 1992) clearly support their conclusion: While the evidence
for the impact of drug testing is consistent and often seemingly
dramatic, properly controlled studies have yet to be conducted.

Trice and Steel (1995) have attributed the popularity of drug testing to
a combination of promotion by the federal government, media hype of the
"drug epidemic" (at a time when drug abuse was clearly declining), and
"corporate imitation and ritual." These authors join Normand in
concluding that the evidence supporting the deterrent effects of drug
testing is scientifically weak. As an example, they describe the U.S.
Navy experience with drug testing, often cited as a dramatic
demonstration of drug testing's deterrence effectiveness. When the drug
testing program began in the Navy in 1981, nearly half of enlisted
personnel were found positive; by 1984, the positive rate was below 5%.
The inference that the sharp decrease was caused by drug testing alone
is, however, scientifically insupportable, as the Navy program included
a wide variety of anti-drug actions in addition to drug testing.
Although lamenting the rather sweeping and uncritical acceptance of drug
testing, Trice and Steele also acknowledge that drug testing can support
the mission of EAPs by (a) sensitizing organizations to the drug abuse
issue, (b) providing objective corroboration of a supervisor's suspicion
of drug use, and (c) promote referrals to the EAP.

Yet the evidence in support of the deterrent effects of drug testing,
though not scientific, is not without its persuasive power. For example,
Walsh (1995) points out that data from the National Household Survey on
Drug Abuse show that as drug testing became prevalent in the workplace
(along with many other drug free workplace programs) between 1985 and
1990, the number of full-time workers who are current users of illegal
drugs was reduced by one-half. Walsh also cites the example of the 28%
decrease in accidents in the railroad industry from 1987, when the drug
testing requirements went into effect, to 1993. More significantly, in
1987 21% of railroad accidents involved workers who tested positive for
drug use; by 1993 that number had dropped to 5% (Walsh, 1995).
Obviously, there are myriad factors besides drug testing to which the
reductions may be attributed, from altered management policies to
secular trends in drug use; that is why there is a great need for
rigorously conducted studies. (Indeed, the central thrust of Walsh's
paper is the need for research on the issue.) But there seems little
question that the preventive power of drug testing is, at the very
least, a viable hypothesis in need of testing. Walsh and his associates
are currently conducting a research project that involves the systematic
manipulation of drug testing frequency, offering the appealing
possibility that some hard evidence of drug testing's deterrence power
will be in hand in the near future (personal communication).

# **Recent Innovations in Workplace Substance Abuse Prevention**

During the late 80s and 90s, various approaches for delivering substance
abuse prevention in the workplace were developed and tested. While
differing in many respects, these approaches shared several
characteristics, including a premise that the workplace was an
underutilized vehicle for substance abuse prevention, a belief that
prevention programs needed to be aimed at the mainstream of the work
force, and the creation of prevention strategies based on sophisticated
theoretical and conceptual frameworks. Moreover, they typically (though
not always) reflected a recognition that a workplace prevention strategy
must overcome the problem of stigma.. These recent innovations are
described below.

[Preventive Interventions Focused on the Work Environment]{.underline}

[Workplace Culture.]{.underline} The studies that have dominated the
literature for the past quarter century have focused on the role of the
work environment in preventing work-related drinking; i.e., drinking
before work or at work (Ames et al., 2000; Trice and Roman, 1972). The
perspective reflected in these studies has been shaped largely by
sociological traditions that emphasize sociocultural influences on
worker alcohol problems, viewing the work group and its norms and social
controls as central determinants of work-related drinking. Ames and her
associates recently stated that "striking differences in alcohol
consumption rates by job category indicate that the work environment may
affect drinking norms and drinking patterns," and cited nine studies
conducted across a variety of occupations and work environments that
have documented the link between work environment and drinking patterns
(Ames et al., 2000, p.203). Their latest study found significant
differences in work-related drinking practices between two work
environments with contrasting alcohol policies and the extent to which
the policies were enforced. Results of analyses supported their
conceptual model that social controls (enforced policies) influence
drinking norms which in turn influence work-related drinking.
Interestingly, there were almost no differences between worksites in
overall drinking, coming to work with a hangover, and heavy drinking.
This important research, along with related studies by this group and
other investigators (e.g., Ames & Grube, 1999; Mangione et al., 1999,
Bray et al., 1999), provides strong support for the influence of the
workplace culture on drinking practices, and contributes substantially
to our understanding of how social control variables in the workplace
affect drinking practices. However, there are limitations to the
methodologies employed by this group of investigators, as well as rather
daunting implications for workplace interventions.

The designs of these studies have been, almost without exception,
correlational, survey- research based designs. The work environment
variables are "measured" by the particular culture and set of policies
that exist in the work site or occupation being studied (sometimes also
assessed through survey self-reports), along with responses to scales in
the survey questionnaire that assess perceived drinking norms. The same
questionnaire also assesses the drinking practices of the respondent. In
these studies, there is typically no manipulation of the independent
variables, so causal relationships are not easily traced. In the recent
study by Ames et al. (2000), structural modeling procedures (EQS) were
applied to explore the relationships among the variables -- a useful,
illuminating approach, but one that does not entirely substitute for
manipulation of the independent variables. (Indeed, one of the main
methodological concerns surrounding these kinds of studies is the
limitations placed on causal inference.) The key to prevention as viewed
by Ames and her associates is the nature of the work culture and the set
of policy directives and enforcement procedures that help to shape it.
However, Ames and her associates admit that altering the work culture is
"a challenging task." One might hope that there will be field tests of
strategies designed to alter the work culture or, barring such demanding
requirements, interventions that can change the drinking practices (and
other drug use practices) -- off the job as well as on \-- of working
adults through means other than attempting an overhaul of the work
culture. Moreover, although the focus on work-related drinking is
understandable, the fact that these environment-based interventions have
little effect on overall drinking and heavy drinking suggests that they
are missing a significant part of the problem . As Cook (1996b) has
suggested elsewhere (concurring with Ames, 1993) drug use and drinking
practices by workers -- on or off the job -- that put workers at risk
for a variety of health and social problems, from family disruption to
premature death, should be more appropriately viewed as public health
problems and employer costs that deserve the attention of employers and
health scientists alike.

[Peer Assistance.]{.underline} One potential intervention strategy for
changing the workplace drinking culture is the peer assistance approach
advocated and examined by Sonnenstuhl and his colleagues (Bacharach,
Bamberger and Sonnestuhl, 1994; Sonnestuhl, 1999.) A form of EAP applied
almost exclusively in union settings, the peer assistance approach is
based on the premise that co-workers are best qualified to identify each
others' needs and to intervene appropriately. Sonnenstuhl (1996, 1999)
has documented the effectiveness of this approach in turning around a
deeply entrenched workplace drinking culture where heavy drinking was
the norm on and off the job. In their review of peer assistance
programs, Roman and Blum suggested that with the movement of American
industry away from hierachical management toward models of peer
organization, peer assistance approaches may become a more effective
method for addressing worker substance abuse. As with the standard EAP,
however, the peer assistance approach is oriented mainly toward
indicated prevention and treatment.

[Work Group Training.]{.underline} Lehman and Bennett have been
conducting a program of research on workplace substance abuse for
several years, focusing on the social-organizational factors associated
with employee substance abuse Lehman et al., 1995). Although their
research has been largely based on survey research rather than empirical
tests of specific interventions, they are currently testing the effects
of an employee training that addresses substance abuse in the context of
a wide array of organizational issues (Bennett and Lehman, 1998).
Interestingly, their approach is aimed at changing workplace drinking
norms, but the vehicle is a specially developed training program that
includes broader organizational issues of interest to supervisors.
Recent findings from a randomized experiment testing the effects of
"Team Awareness Training" found the training to increase self-reported
help-seeking behavior for substance abuse problems (Bennett and Lehman,
2000).

### Preventive Interventions Focused on the Individual Worker 

A second group of workplace researchers/program developers has been
creating and testing psycho-educational interventions based in health
behavior change theory and oriented toward changing the attitudes and
practices of individual workers. Although the role of the work
environment variables is by no means ignored, the focus is on changing
individuals' attitudes and practices. The typical intervention is a
series of group-based classes or seminars, supplemented with video
and/or print materials.

[Health Promotion-Oriented Programs.]{.underline} Over the years,
several researchers have suggested that health promotion programs could
be effective in preventing and reducing substance abuse, either
indirectly, through the adoption of more healthful practices that would
tend to supplant substance abuse, or directly, by including substance
abuse prevention components explicitly in such programs \-- or both.
Among the first researchers of record to test this approach in the
workplace were Shain and his associates (Shain et al., 1986), who found
that after workers attended a 15-hour course in stress management,
moderate drinkers showed significant decreases in alcohol consumption
(heavy drinkers maintained their consumption levels), and no such
decreases were found in the comparison group. In a related study,
Shehadeh and Shain (1990) surveyed transportation workers in Ontario and
found that 15-20% of drinking workers were: (1) concerned about their
alcohol consumption and, (2) interested in a variety of health topics
such as exercise, nutrition, stress management, and weight loss. The
"concerned heavy drinker" that emerged from this survey was a male,
blue-collar smoker who was overweight \-- precisely the person most in
need of health promotion. These data seemed to suggest that health
promotion programs may be able to address substance abuse issues in the
context of general health promotion topics.

Kishuk and her associates (1994) conducted one of the rare tests of a
workplace intervention aimed specifically at promoting "healthy alcohol
consumption." A sample of mostly male, blue-collar workers (n = 268)
were randomly assigned to the alcohol prevention sessions, nutrition
sessions or a control condition. The alcohol prevention program was
based on cognitive-behavioral approaches, adapted for "normal drinkers."
Topics included controlled consumption techniques, drink refusal skills,
and stress management. Among the eight measures of alcohol knowledge,
attitudes and consumption gathered at pretest and posttest, two measures
were significantly different between the alcohol program group and the
other two groups: The alcohol group showed more socially responsible
attitudes and lower number of drinks per week. This program is
refreshing in several respects: (1) The intervention is based on
accepted principles of behavior change, aimed directly at changing the
attitudes and drinking practices of individual workers; (2) it was a
relatively brief intervention that was implemented in a few months (not
years); and (3) it was a universal prevention intervention, targeted
toward the mainstream of workers. However, one of its chief weaknesses
was the low participation rate, with the majority of invited employees
choosing not to attend the program.

.

During the past decade, Cook and his associates have conducted a series
of studies testing approaches to substance abuse prevention in the
workplace. These approaches have been based on the health
promotion-oriented conceptual model developed by Cook and Youngblood
(1990; described above), and have typically involved multi-media
presentations (video, print, and lecture-discussion) to small groups of
workers. Specially developed videos have been central to this approach,
offering opportunities for behavioral modeling, boosting self-efficacy,
and transmitting specific skills. For example, opportunities for
behavioral modeling are provided through the use of carefully scripted,
dramatic vignettes that show people successfully addressing challenges
of reducing their alcohol consumption; viewer self-efficacy is boosted
by video segments that present individuals ("real people") describing
how they have made improvements in their lifestyle. In this approach,
casting, music, graphics, script development, etc. \-- the film and
video arts \-- are harnessed to the purpose of behavior change. In
addition to being ideally suited to the implementation of
social-cognitive learning techniques, film and video can be attractive
and engaging, helping to make health promotion and substance abuse
prevention a positive, interesting experience for the participant.

In the first field test of this model, 371 employees of a manufacturing
facility in the Northeast U.S. were randomly assigned to a health
promotion/substance abuse prevention program (HP/SAP) or to a control
condition (Cook et al., 1996a). The HP/SAP program consisted of three
one-hour sessions delivered by a trainer, using video and print
materials, interweaving health promotion concepts and strategies
(techniques and rewards of the healthy lifestyle, effective approaches
to behavior change, etc.) with techniques for examining and controlling
alcohol consumption and avoiding illicit drug use. Significant
differences were found between the HP/SAP group and the control group on
three of the four measures of health: Health and work control, measures
of internal control, and health self-efficacy. The HP/SAP group showed a
significant increase in "desire to reduce drinking" (a single item), but
there were no effects on alcohol consumption. These results indicated
that when substance abuse prevention materials are integrated with
health promotion materials, desired effects on health attitudes and
beliefs can be achieved. However, impact on substance abuse measures was
limited.

In their second field test of their workplace substance abuse prevention
approach, Cook and associates (1996b) presented an alcohol prevention
program in a health promotion framework, but in this program a greater
emphasis was placed on the hazards of alcohol abuse and strategies for
reducing alcohol use, and somewhat less emphasis placed on health
promotion strategies per se. In a quasi-experimental pretest-posttest
design, 108 employees from two sites of a medium-sized printing company
participated in an alcohol prevention program. Program effects were
demonstrated on alcohol consumption (number of drinking days in past
month and number of days having five or more drinks), motivation to
reduce consumption, and problem consequences of drinking. No effects
were found on health beliefs or self-efficacy to reduce drinking. The
findings were qualified by self-selection (only a small proportion of
eligible employees participated in the program), but nonetheless
suggested that alcohol consumption can be reduced among workers who
participate in this kind of program. As was the case with the Kishuk
(1994) program, where participation rates were low, these results
indicated that any workplace program identifiable as "alcohol
prevention" was likely to be sparsely attended.

In their most recent field test, Cook and his associates tested a "third
way" to integrate health promotion and substance abuse prevention (Cook
et al., 2000). In this approach, substance abuse prevention messages and
materials are inserted into popular health promotion offerings. Workers
at a property casualty insurance company in the Southeast U.S. were
invited to participate in one of two health promotion programs \-- a
stress management program or a nutrition/weight management program
(called "Healthy Eating"). In each program, participants (n = 416) were
randomly assigned to a health promotion-only condition or a condition in
which they received substance abuse prevention materials and messages,
along with the health promotion program. The substance abuse prevention
materials (videos and print materials called the *Connection* series)
were specially developed for relevance to the either stress management
or healthy eating. Both programs were delivered in three group sessions
of approximately 45 minutes.

Participants were assessed on a self-administered questionnaire in the
context of a private interview at three points in time (pretest, initial
posttest and 8 months later). The questionnaire administered to all
subjects contained measures of alcohol and other drug use, drinking and
drug use intentions, connections between health and substance use,
health and job control, and risks of alcohol and drug use. For
participants in the stress management program, the questionnaire also
contained five measures of stress, including stress relief strategies (a
scale that measured the extent to which the respondent used alcohol or
other drugs to gain relief from stress). For participants in the healthy
eating program, the questionnaire also included six other measures of
eating attitudes and practices.

Two major hypotheses were central to the research: (1) That participants
will display positive changes in measures of stress and healthy eating,
regardless of the presence or absence of the substance abuse prevention
component; and (2) that participants in the condition that included the
substance abuse prevention component will exhibit positive changes in
substance abuse measures, but participants in the condition without the
substance abuse prevention component will not exhibit such changes.
Results indicated that hypothesis #1 was confirmed, while hypothesis #2
was only partly confirmed.

On all five measures of stress and all five measures of healthy eating,
significant positive changes occurred for all participants (experimental
and control subjects) from pretest to posttest. All the changes in the
stress measures held up through the second posttest, while changes on
healthy eating measures were maintained on three of the five measures.
As hypothesized, there were virtually no differences between
experimental and control groups on the stress and healthy eating
measures: Participants showed similar, significant improvement
regardless of the presence of the substance abuse prevention material.

On measures of substance abuse, the stress management participants
showed significant improvement at initial posttest on the three
attitude/perceptions measures, regardless of whether they were in the
experimental or the control group. Similarly, both experimental and
control groups in the stress management program showed significant
decreases in alcohol and other drug use from pretest to posttests. In
some contrast, the healthy eating participants in the experimental group
showed improvement on two of the three attitude/perceptions measures,
improvements which were held through second posttest; the control group
showed no such improvements. Neither experimental nor control
participants in the healthy eating program exhibited significant
reductions in their consumption of alcohol or other drugs. These
findings indicate that workers will change important attitudes,
perceptions and practices regarding substance abuse if they are exposed
to stress management sessions \-- regardless of whether explicit
substance abuse prevention materials are presented to them. Participants
in healthy eating sessions (and perhaps other health promotion
offerings) will also change substance abuse attitudes and perceptions,
but only if they receive the substance abuse prevention materials.

Improvements in substance use attitudes and behavior seemed to occur as
a result of learning healthful stress management practices as much as
\-- perhaps more than \-- exposure to explicit substance abuse
prevention materials, results that are congruent with findings from the
stress management literature.

[Stree Management Programs.]{.underline} For the past several years,
Snow and Kline have been testing the effects of preventive interventions
in the workplace on a variety of psychiatric outcomes, focusing mainly
on abilities to cope with stress, psychological outcomes (anxiety,
depression and somatic complaints), as well as alcohol and tobacco use
(Kline and Snow, 1994; Snow and Kline; 1995). Their approach is based on
stress and coping theories (e.g., Lazarus and Folkman, 1984; Pearlin and
Schooler, 1978) and has typically taken the form of 10-15 hour-long
training sessions designed to teach workers a wide range of adaptive
strategies for coping with stress. Although the sessions have covered a
wide range of stress coping topics and strategies, they have not
explicitly addressed substance abuse issues. Until recently their
subject samples have been mainly female workers. Their research has been
marked by methodological strengths, including careful conceptualization
and measurement, randomized designs, attrition analysis, and long term
follow-ups (6 months and 22 months). Results have generally been
positive, showing impact on some stress coping skills, psychological
symptoms and tobacco and alcohol use (Kline and Snow, 1994; Snow and
Kline, 1995). Snow recently tested his coping skills intervention
approach on a sample of 468 male and female workers from three company
sites, randomly assigned to a coping skills intervention condition or a
control group, and assessed at four points in time (although only
pretest, posttest, and 6 months results are currently available).
Effects were largely concentrated in the coping measures, although the
intervention impact on alcohol (number of drinks per month) was
significant at posttest and, for a subsample of higher alcohol users
only, at six months. This program of research has consistently shown
that interventions that teach workers skills for coping with stress can
have impact on alcohol and tobacco use.

[Worker Health Counseling.]{.underline} In a program of research
spanning more than two decades, the Worker Health Program at the
University of Michigan has conducted a number of rigorous, illuminating
studies assessing the impact of a variety of health and wellness
interventions on worker health (e.g., Foote & Erfurt, 1984; Heirich et
al., 1993). Most of these interventions have focused on physical health,
such as blood pressure control. Recently, however, this group tested the
effectiveness of a cardiovascular wellness program as a route to
preventing alcohol abuse (Heirich & Sieck, 2000). Based on a social
learning model, their approach emphasizes raising the salience of
alcohol abuse as a potential health risk, developing one's confidence to
make successful behavior changes, providing social support for making
the changes, and providing information on alternative health behaviors.
(In this respect, the approach of Heirich and Sieck is rooted in much
the same theoretical framework as that of Cook and his colleagues.) They
assessed the effectiveness of a cardiovascular risk reduction education
program that included unsafe drinking as a cardiovascular risk,
comparing a classroom-based approach with individualized, proactive
follow-up counseling. In a worksite of 4,000 employees, 2,000 employees
were recruited for initial screening, then randomly assigned to the
proactive counseling or the health education classes. One-half (1,000)
of this sample were followed up for rescreening. At rescreening, 43% of
employees who had been identified as at-risk drinkers were either
abstemious or had reduced their consumption to safe levels. In addition,
overall health risks improved among all study groups as well. The
proactive counseling intervention was more effective than health
education classes in reducing the proportion of heavy drinkers (and
smokers) from initial screening to rescreening. Heirich and Sieck
believe that the worksite corporate culture, initially not receptive to
efforts to promote health or examine drinking practices, changed during
the intervention period, as evidenced by widespread requests to continue
the wellness counseling. The authors attribute much of the success of
the counseling approach to the highly visible, proactive outreach of the
program, as well as the individualized nature of the counseling. The
authors also point out that this type of intervention is labor intensive
and costly, although they believe it to be more cost effective (as well
as more effective) than health education classes.

# Workplace Substance Abuse Prevention in the Managed Care Era: The WMC Study

In 1997, the Center on Substance Abuse Prevention initiated the
Workplace Managed Care (WMC) study, awarding nine grants designed to
document best practices in workplace substance abuse prevention as
conducted by workplaces and their managed care organizations. The study
also includes a cross-site analysis designed to identify trends in
findings across the nine research projects. The WMC study (still
ongoing) includes approximately 25 highly varied work sites nationwide
and provide interventions to more than 52,000 employees (Galvin, 2000).
A wide variety of interventions are represented across the nine
grantees, including health promotion programs, health risk assessments,
parenting programs, drug testing, peer counseling, specialized videos,
interactive web sites, and enhanced EAP services. The methodologies
employed are characterized mainly by quasi-experimental and time series
designs, and because most of the projects are assessing intervention
impact on medical claims utilization and costs, the medical claims data
from the managed care organizations form a dependent variable data set
of central interest. As noted by Hersch and her colleagues (2000), this
kind of "real world" research faces numerous methodological challenges,
from threats to the validity of substance self-reports to difficulties
in accessing and analyzing medical claims data (Hersch et al., 2000).
Nonetheless, significant early findings are beginning to emerge.

Baseline data on substance abuse collected by several of the WMC
projects indicates that substance abuse rates are substantial across a
variety of workplaces. A random sample survey of employees at a major
university indicates that substance abuse is a significant problem for
approximately 20% of the employees, yet less than 3% of the work force
use the EAP. A baseline survey of 705 employees at an insurance company
found that approximately 15% of the work force engages in heavy
drinking, and nearly one-half of the work force reports using alcohol to
relieve stress.

Retrospective studies conducted by two WMC grantees indicate that
substance abuse preventive interventions can have a significant impact
on injuries and costs in the workplace. In a 12-year retrospective study
of injury rates at a transportation workplace, reductions in injury
rates and costs were found to be associated with the introduction of a
substance abuse prevention program that involves peer counseling. A
follow-up analysis of medical claims of insurance company employees
found that participants in a workplace health promotion program were
more likely to seek subsequent treatment for behavioral health problems
than a matched sample of workers who did not participate in the program
(Trudeau et al., in press).

Although the WMC study is still mid-stream, these early results suggest
that in the near future the WMC study will generate a variety of
significant findings that will help guide workplace substance abuse
prevention in the managed care era.

# Methodological Issues in Workplace Substance Abuse Prevention

The research on workplace preventive interventions described above
raises certain methodological issues that deserve comment. In addition
to the issue of research designs and the limitations on causal inference
(already discussed above), there is evidence that the field needs to
attend more closely to the two related issues of (a) sample size and
statistical power, and (b) the selection of appropriate outcome
measures. These issues are discussed briefly below.

[Sample size and statistical power]{.underline}**.** Simply stated, the
concept of statistical power refers to the ability of a test statistic
to detect a true difference between two (or more) study groups. Nearly
40 years ago, Cohen (1962) reported that the median statistical power of
studies published in the 1960 volume of the [Journal of Abnormal and
Social Psychology]{.underline} was only 46%. More recently, Lipsey
(1988;1990) found that the average power was still only 45% in nearly
2,000 statistical tests compiled from 39 meta-analyses in various
fields. Comparable power estimates are not available from the workplace
literature, but it appears that research on workplace preventive
interventions is often underpowered, running the risk of Type II error
(e.g., see Cook et al., 1996a). Statistical power is influenced by
several factors, including effect size, the variance of that outcome
variable, and the size of the samples. Among these, only the size of the
samples is readily manipulable by the investigator, and therefore
deserves particular attention. By conducting the appropriate power
analyses \-- for all major outcomes \-- during the planning stages of
the research, investigators can maximize the likelihood that the sample
sizes will generate sufficient power (usually 80%) to detect a specified
effect size.

[Selection of Appropriate Outcome Measures]{.underline}**.** A factor
that influences both the ability to make valid causal inferences and the
ultimate power of studies is the identification and use of appropriate
outcome measures; i.e., adequate coverage of the underlying construct(s)
being studied, and the psychometric properties (i.e., reliability and
validity) of the actual measures.

One of the critical issues in prevention research of all kinds is: what
specifically is it that we are trying to prevent? Answering this
question comprehensively requires a "logic model" (Wholey, 1979) of the
intervention, which is in essence a conceptual description of the causal
mechanisms through which the intervention "works," including
hypothesized mediating and moderating variables and expected outcomes,
along with an operational definition of each of the constructs involved.
Creating a logic model forces investigators to specify more fully their
underlying assumptions and beliefs about the intervention and its
relationship to outcomes (i.e., what specific outcomes are we hoping to
produce?), which has many benefits.

For example, interventions that are applied to individuals who have
never had alcohol are typically aimed at forestalling *onset* of alcohol
use, and therefore we might view (any) use of alcohol in the follow-up
period as the appropriate outcome for evaluating intervention efficacy.
For workplace-based programs, however, substantial proportions of the
workforce already drinks alcohol, at least occasionally, and the
prevention targets may include: (a) to maintain (or reduce further) safe
drinking levels among those whose drinking is moderate or less, (b) to
reduce the drinking levels of those whose drinking is risky, and (c) to
provide treatment for those whose drinking is problematic.

This complicates substantially the problem of specifying the appropriate
outcome. For example, a measure appropriate for target (a) is probably
not appropriate for targets (b) or (c), so there are typically multiple
measures. Development of logic models forces program designers to think
carefully about the intended effects of the intervention, and makes more
obvious the need to select appropriate measures to determine efficacy.
The point is that selection of measures that do not reflect well the
intended outcome is a fundamental design flaw that can lead to erroneous
conclusions about the intervention (i.e., a design-based type II error).

There exists today a relatively large, accumulated literature describing
the psychometric properties of various substance use measures and the
correspondence of measures based on differing methodologies (e.g., self
report vs urine screen). One broad conclusion that can be reached based
on that literature is that none of the currently-available measures is
"perfect"---i.e., none is error-free. Rather, the various measures all
have strengths and limitations. For example, everyone will agree that
self reports of substance use may be subject to a variety of sources of
bias, including potential desires on the part of respondents either to
"fake bad" or to "fake good." Recent findings, however, indicate that
participant reports of participating in a variety of sensitive behaviors
are much higher when the data are collected via computerized methods
rather than face-to-face interviews (Turner et al., 1998). Although it
is reasonable to assume that the technology for collecting such data
will continue to improve, it is unlikely ever to be "perfect."

Currently available biological tests are also not the Holy Grail, in
that neither urinalysis nor hair analysis covers all drugs or all time
periods of interest, questions remain as to what concentrations of
metabolite constitute valid evidence of "use," etc. Although we can
anticipate enhanced technology here as well, we do not expect
"perfection" of these methods on any reasonable horizon.

Although the lack of an "absolute" measure is vexing, some comfort can
be taken in the fact that substance use prevention is not alone in this
regard (Sheps & Schechter, 1984). From the broader perspective of
psychiatric epidemiology, Robins (1985) has argued that the question of
validity is best thought about in the context of *construct*
validity---that is, in terms of the pattern of relationships between the
measures of interest and a broad range of other variables to which they
are hypothesized to be (and not to be) related. These and other
considerations suggest that an appropriate solution is the routine use
of multiple measures, ideally including multiple methods.

#### Future Programming and Research in 

#### Workplace Substance Abuse Prevention

The field of workplace substance abuse prevention is undergoing a period
of both tantalizing promise and frustrating obstacles. The forces
supporting increased attention and activity in workplace substance abuse
prevention are numerous and potent; at the same time, the obstacles
impeding such activity are not insubstantial. Indeed, the forces working
against the implementation of workplace substance abuse prevention
programs remain formidable. Despite the significant costs associated
with work force substance abuse, the costs of substance abuse medical
claims are typically small relative to other disorders, and thus do not
receive the level of attention reserved for more costly physical
disorders. It is seldom recognized that these substance abuse cost
estimates are artificially suppressed by the limitations imposed on
treatment services and by ignoring the broader effects of substance
abuse on general health costs and worker productivity. The perceived
role of alcohol and other drugs in our society \-- the stigma of
substance abuse and the ingrained acceptance of social uses of alcohol
\-- also pose a continuing obstacle to workplace substance abuse
prevention.

Yet there is clearly an array of potentially powerful forces supporting
increased substance abuse prevention in the workplace; these are
summarized below:

-   *The growing popularity of workplace health promotion and disease
    prevention* *programs.* A wide variety of health promotion and
    disease prevention activities, from stress management to fitness,
    have become increasingly accepted and visible in workplaces and
    occupations, as employers and their managed care organizations
    recognize that these activities can improve the health of employees
    and the bottom line of the organization. Such recognition is
    accelerated by the publication of studies showing that health
    promotion and disease prevention/disease management programs
    directed toward the work force are effective and provide excellent
    return on investment (Goetzel et al., 1999). Although most
    workplaces do not yet include substance abuse prevention as part of
    these programs, the implied legitimacy of employers' attempts to
    shape employee health practices that affect productivity and health
    care costs would appear to create a climate in which employers might
    more easily address issues of alcohol and other drug use.

-   *Evidence that events and forces in the workplace, from substance
    use policies to specially developed interventions, can have an
    impact on employee substance abuse.* Little more than decade has
    passed since the first series of workplace studies began
    accumulating empirical evidence supporting the potential efficacy of
    prevention interventions. The work of Ames and colleagues indicates
    that workplace alcohol policies that are clearly communicated and
    well enforced might be effective in controlling rates of
    work-related drinking. The results of several field tests from our
    research group (Cook, 2000; Cook et al., in press) and the findings
    of Heirich and Sieck (2000) provide evidence that substance abuse
    can be an effective part of broader health promotion programs in the
    workplace. As yet, there is no indication that large numbers of
    workplaces are adopting these strategies, but as managers become
    more aware that these approaches are available, reasonable (not a
    modern temperance movement), and effective, they may be more likely
    to embrace such interventions.

-   *The growth and promise of programs for working parents.* The
    importance of parenting and family strengthening in the prevention
    of adolescent substance abuse has gained renewed attention in recent
    years. If it can be demonstrated that workplace parenting programs
    result in improvements in the health and productivity of the work
    force -- and if workplaces and their managed care organizations
    recognize and act upon these demonstrated benefits -- the workplace
    could become a powerful force in substance abuse prevention. As
    employers compete for a scarce labor pool, they are increasingly
    concerned with establishing themselves as "employers of choice;"
    i.e., employers whose appeal to prospective employees goes beyond
    traditional compensation and benefits to include a genuine and
    meaningful concern for the health and well-being of employees and
    their families. Such concerns should foster increased activity of
    workplaces in programs designed to prevent substance abuse and
    related disorders.

-   *The use of computer-based substance abuse prevention programs.*
    Computer-based interventions -- web-based, CD-ROM, etc. \-- offer
    unique advantages for the presentation of substance abuse prevention
    programs directed at the work force. They can be made interactive
    and self-paced, providing an individualized learning experience.
    Unlike the traditional approaches that herd employees together at
    particular location at an appointed hour, computer-based programs
    can be accessed at the user's convenience and are not fixed in time
    or place. And with increases in power and bandwidth, engaging
    multi-media programs are becoming more feasible on the web as well
    as on CD-ROM. Since it is possible for an employee to access a
    program with a good degree of privacy and anonymity, the weakening
    effects of substance abuse stigma are virtually eliminated.
    Preliminary data from web-based stress reduction and alcohol
    prevention program in a university setting (one of the Workplace
    Managed Care projects) indicates that employees will seek assistance
    for alcohol problems by anonymously accessing an interactive web
    site (Matano et al., 2000). Cook and his colleagues are currently
    developing and testing two computer-based (CD-ROM and website)
    programs for use in the workplace. *Parent Power* is designed to
    provide working parents with improved skills for communicating with
    their children about alcohol and other drug use. *Pathways to
    Health* is designed to help working adults achieve a more healthful
    diet, avoid harmful alcohol consumption, and stop smoking.
    Preliminary data from focus group assessments of prototype programs
    indicate that users find them interesting, appealing and motivating;
    controlled field tests are now underway to assess the impact of the
    programs (Cook and Back, 1998; Cook & Hersch, 2000).

Research on substance abuse prevention interventions in the workplace
has made significant strides in the past decade. However, although it is
no longer in its infancy, the field has still not progressed far beyond
the toddler stage. Much more research is needed on feasible, effective
workplace interventions -- interventions that not only reduce the
likelihood of work force substance abuse, but which can be practically
implemented, embraced by management and sustained by the organization.
To date, studies focused on the work environment (e.g., alcohol
policies, workplace norms, etc.) and those assessing specific
interventions (integrating substance abuse prevention into workplace
health promotion) have proceeded on virtually independent tracks. Field
tests of comprehensive strategies that include both environmental/policy
variables and specific interventions seem long overdue. Substance abuse
researchers could benefit from collaborations with health promotion
practitioners, managed care organizations, benefits administrators, and
human resource managers -- and associations that represent these key
professions. Prevention strategies crafted in consultation with people
responsible for the essential human resource functions of the
organization are more likely to widely embraced and implemented. The
field needs to more frequently employ the more powerful methodologies
discussed above -- the use of more randomized designs, the application
of more sophisticated analytic techniques (e.g., structural modeling),
and ensuring ample power for detecting major effects. Studies that are
able to wed more comprehensive interventions to more rigorous
methodologies should be instrumental in improving the infrastructure of
substance abuse prevention in the workplace.

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