RESEARCH ANALYSIS

and

UTILIZATION SYSTEM

Preventing Adolescent

Drug Abuse:

Intervention Strategies

U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service • Alcohol, Drug Abuse, and Mental Health Administration
Preventing Adolescent

Drug Abuse

Intervention Strategies

Editors:

Thomas J. Glynn, Ph.D.

Carl G. Leukefeld, D.S.W.

Jacqueline P. Ludford, M.S.

National Institute on Drug Abuse

NIDA Research Monograph 47

A RAUS Review Report

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Alcohol, Drug Abuse, and Mental Health Administration

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, Maryland 20857

For sale by the Superintendent of Documents, U.S. Government Printing Office

Washington, D.C. 20402
NIDA Research Monographs are prepared by the research divtsrons of the

National lnstitute on Drug Abuse and published by its Office of Science. The

primary objective of the series is to provide critical reviews of research problem

areas and techniques, the content of state-of-the-art conferences, and

integrative research reviews. Its dual publication emphasis is rapid and targeted

dissemination to the scientific and professional community.

Editorial Advisors

MARTIN W. ADLER, Ph D.

Temple University School of Medicine

Philadelphia, Pennsylvania

SYDNEY ARCHER, Ph.D.

Rensselaer Polytechnic lnstitute

Troy, New York

RICHARD E. BELLEVILLE, Ph.D.

NB Associates, Health Sciences

Rockville, Maryland

KARST J. BESTEMAN

Alcohol and Drug Problems Association

of North America

Washington, D.C

GILBERT J. BOTVIN, Ph.D.

Cornell University Medical College

Now York. New York

JOSEPH V. BRADY, Ph.D.

The Johns Hopkins University School of

Medicine

Baltimore, Maryland

THEODORE J. CICERO, Ph. D.

Washington University School of

Medicine

St. Louis, Missouri

SIDNEY COHEN, M.D

Los Angeles, California

MARY L. JACOBSON

National Federation of Parents for

Drug Free Youth

Omaha, Nebraska

REESE T. JONES, M.D.

Langley Porter Neuropsychiatric Institute

San Francisco, California

DENISE KANDEL, Ph.D.

College of Physicians and Surgeons of

Columbia University

New York, New York

HERBERT KLEBER, M.D.

Yale University School of Medicine

New Haven, Connecticut

RICHARD RUSSO

New Jersey State Department of Health

Trenton, New Jersey

NIDA Research Monograph Series

CHARLES R. SCHUSTER, Ph.D.

Director, NIDA

JEAN PAUL SMITH, Ph.D.

Acting Associate Director for Science, NIDA

Acting Editor

Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857
Preventing Adolescent

Drug Abuse

Intervention Strategies
ACKNOWLEDGMENT

This monograph is based upon papers and discussion from the RAUS

Review Conference on strategies for prevention of adolescent drug

abuse, held April 14 and 15, 1983, in Rockville, Maryland,

sponsored by the Office of Science, National Institute on Drug

Abuse. Editor Thomas J. Glynn, Ph.D., who served on the staff of

the NIDA Division of Clinical Research, is now with the National

Cancer Institute.

COPYRIGHT STATUS

The National Institute on Drug Abuse has obtained permission from

the copyright holders to reproduce certain previously published

material as noted in the text. Further reproduction of this

material is prohibited without specific permission of the copyright

holders. All other material in this volume except quoted passages

from copyrighted sources is in the public domain and may be used or

reproduced without permission from the Institute or the authors.

Citation of the source is appreciated.

Opinions expressed in this volume are those of the authors and do

not necessarily reflect the opinions or official policy of the

National Institute on Drug Abuse, or any other part of the U.S.

Department of Health and Human Services.

The U.S. Government does not endorse or favor any specific

commercial product or commodity. Trade or proprietary names

appearing in this publication are used only because they are

considered essential in the context of the studies reported herein.

Library of Congress catalog card number 83-600601

DHHS publication number (ADM)86-1280

Printed 1983 Reprinted 1985, 1986

NIDA Research Monographs are indexed in the Index Medicus. They

are selectively included in the coverage of American Statistics

Index, Biosciences Information Service, Chemical Abstracts, Current

Contents, Psychological Abstracts and Psychopharmacology Abstracts.

iv
Preface

The Research Analysis and Utilization System (RAUS) is designed to

serve four functions:

Collect and systematically classify the findings of all

intramural and extramural research supported by the

National Institute on Drug Abuse (NIDA);

Evaluate the findings in selected areas of particular

interest and formulate a state-of-the-art review by a

panel of scientific peers;

Disseminate findings to researchers in the field and to

administrators, planners, instructors, and other

interested persons;

Provide a feedback mechanism to NIDA staff and planners so

that the administration and monitoring of the NIDA

research program reflect the very latest knowledge gleaned

from research in the field.

Since there is a limit to the number of research findings that can

be intensively reviewed annually, four subject areas are chosen

each year to undergo a thorough examination. Distinguished

scientists in the selected field are provided with copies of

reports from NIDA-funded research and invited to add any

information derived from the literature and from their own research

in order to formulate a comprehensive view of the field. Each

reviewer is charged with writing a state-of-the-art paper in his or

her particular subject area. These papers, together with a summary

of the discussions and recommendations which take place at the

review meeting, make up a RAUS Review Report in the NIDA Research

Monograph series.

v
“Preventing adolescent drug abuse” was chosen as a subject for a

comprehensive RAUS review in FY 1983 because a large body of

knowledge has developed relative to preventing tobacco smoking in

youth and the time seemed propitious for review of the

state-of-the-art in light of its possible applicability to the

prevention of other forms of drug abuse. The results of this

review are presented in this monograph.

vi
Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Executive Summary

Jacqueline P. Ludford . . . . . . . . . . . . . . . . . . . .

The Role of Mass Media in Preventing Adolescent Substance Abuse

Brian R. Flay and Judith L. Sobel . . . . . . . . . . . . . .

Social-Psychological Approaches

Alfred L. McAlister . . . . . . . . . . . . . . . . . . . . .

Doing the Cube: Preventing Drug Abuse Through Adolescent

Health Promotion

Cheryl L. Perry and Richard Jessor . . . . . . . . . . . . .

Comprehensive Community Programs for Drug Abuse Prevention:

Implications of the Community Heart Disease Prevention Programs

for Future Research

C. Anderson Johnson and Julie Solis . . . . . . . . . . . . .

Prevention of Adolescent Substance Abuse Through the Development

of Personal and Social Competence

v

1

5

36

51

76

Gilbert J. Botvin . . . . . . . . . . . . . . . . . . . . . . 115

Alternatives to Drug Abuse: Some Are and Some Are Not

John D. Swisher and Teh-Wei Hu . . . . . . . . . . . . . . . 141

Empirical Foundations of Family-Based Approaches to

Adolescent Substance Abuse

Brenna H. Bry . . . . . . . . . . . . . . . . . .. . . . . 154

A Value Approach to the Prevention and Reduction of Drug Abuse

Milton Rokeach . . . . . . . . . . . . . . . . . . . . . . . 172

vii
Prevention of Adolescent Substance Abuse Through Social

Skill Development

Mary Ann Pentz . . . . . . . . . . . . . . . . . . . . . . . 195

Preventing Adolescent Substance Abuse Through Drug Education

Joel M. Moskowitz . . . . . . . . . . . . . . . . . . . . . . 233

Discussion and Recommendations

Carl G. Leukefeld and Joel M. Moskowitz . . . . . . . . . . . 250

List of NIDA Research Monographs . . . . . . . . . . . . . . . . 256

viii
Executive Summary

Jacqueline P. Ludford, M.S.

From a public health view, the prevention of drug abuse among

adolescents is an enormous and pressing problem. Recognizing that

it was time to review prevention strategies which have been used

with a certain degree of success in the tobacco smoking area and

evaluate their applicability to drug abuse prevention strategies,

NIDA convened a RAUS meeting on “Preventing Adolescent Drug Abuse”

on April 14-15, 1983. The presentations included:

Media Approaches to

Adolescent Substance

Abuse Prevention

Social Psychologically-Based

Approaches to Adolescent

Substance Abuse Prevention

Health Promotion Approaches

to Adolescent Substance

Abuse Prevent ion

Community-Level Interventions

in the Prevention of

Adolescent Substance Abuse

Prevention of Adolescent

Substance Abuse Through

Life Skills Development

Provision of Alternative

Activities as an Adolescent

Substance Abuse Prevention

Approach

Family-Based Approaches to

Adolescent Substance Abuse

Prevent ion

Dr. Brian Flay

University of

Southern California

Dr. Alfred McAlister

University of Texas

Dr. Cheryl Perry

University of Minnesota

Dr. Richard Jessor

University of Colorado

Dr. C. Anderson Johnson

University of

Southern California

Dr. Gilbert Botvin

Cornell University

Medical College

Dr. John Swisher

Pennsylvania State

University

Dr. Brenna Bry

Rutgers University

1
Value Approaches to Adolescent Dr. Milton Rokeach

Substance Abuse Prevention Washington State Univ.

Prevention of Adolescent Dr. Mary Ann Pentz

Substance Abuse through University of Tennessee

Social Skill Development

Prevention of Adolescent Dr. Joel Moskowitz

Substance Abuse through “The NAPA Project”

Drug Education

Dr. Richard Jessor, of the University of Colorado, and Dr. Thomas

Glynn, of the Division of Clinical Research, NIDA (now at the

National Cancer Institute), served as cochairmen for the meeting

and led the discussions.

Dr. Flay discussed the role of mass media campaigns in drug abuse

prevent ion. He emphasized the importance of media in the lives of

children and suggested that campaigns must not only give

information but also give skills to resist other media influences

such as “models,” anti- versus pro-social programming, and the

effects of TV advertizing. His prescription for an ideal

prevention campaign would combine mass media programming with

another major national or regional media event (e.g., the Surgeon

General’s report), involvement of families, and training of

teachers. Further conditions for a successful campaign include the

provision for a complete cohort (whole school or whole town) and

the addition of a complementary effort such as a smoking cessation

program for those already addicted.

Dr. McAlister discussed and categorized general and specific

influences on health behavior from the perspective of societal

influences, family, peers, school, and individual psychology. A

correlational construct is presented relative to beliefs of

potential drug users, and the results of research about beliefs are

discussed.

Drs. Perry and Jessor approached prevention from the standpoint of

four domains of health: physical, psychological, social, and

personal. Health promotion in each of these categories may be

categorized as focused on either health-enhancing or

health-compromising behavior. Finally, the strategies can be

focused at the level of the environment, the personality, or the

behavior. Thus, a three-dimensional model--a cube--was presented.

In the second half of the paper, the youth education component of

the Minesota Heart Health Program was described.

Dr. Johnson described several community prevention projects in

heart disease (the Multi-Risk Factor Intervention Trial, the

Stanford Three Community Study, and the North Karelia Project),

evaluated them, and discussed their possible implications for drug

abuse prevention programs. Consideration was given to possible

design criteria for research in community approaches to drug abuse

prevention.

2
Dr. Botvin stressed the interplay of social, personality,

cognitive, attitudinal, behavioral, and developmental factors in

drug abuse prevention. He presented his own research which

involves a prevention strategy focused on the enhancement of

personal competence through basic life skills training and the

acquisition of problem-solving skills and resist nce skills. He

presented preliminary results of an ongoing study which indicate a

50 percent reduction in numbers of new cigarette smokers with this

prevention method, the effects being evident up to one year after

completion of the program.

Dr. Swisher reviewed the research on alternative programming as a

prevention strategy. He cited research to support the hypothesis

that some alternatives (academic, sports, and religious activities)

minimize drug abuse, whereas some (social, entertainment, and

vocational) contribute to the use of various substances. He called

for more scientifically planned and evaluated research in this area.

Dr. Brenna Bry reported on her research with school/parent groups

and their effectiveness. She found low religiosity, poor school

performance, distance from parents, poor self-image, psychological

disturbance, and/or drug use before 12 years of age to be

predictive of heavy drug use, especially if four or more of these

factors were present. She recommended multiple prevention

strategies to counter these multiple risk factors. She stated that

we need educational approaches using media, social interventions

involving the whole environment, modeling the “saying no” approach,

encouraging parent influence, family effectiveness and

communication training, emphasis on religious training, and,

finally, therapy for troubled young people.

Dr. Rokeach addressed the values of drug abusers from the

perspective of belief system theory. He indicated that changes in

values result in changes in behavior and that humans behave in a

manner which reflects their values and self-esteem. Dr. Rokeach

reviewed the available research on the values of addicts vs the

values of nonaddicts. In general, addicts care more for personal

values than for social values, and this appears to be a persuasive

difference.

Dr. Pentz evaluated social skills training for adolescents as a

possible approach to preventing drug abuse. Training approaches

are reviewed and the results indicate that improving social skills

reduces substance use and such related behaviors as aggression,

withdrawal, truancy, and stealing. Outcome was enhanced by the

inclusion of modeling in the training.

Dr. Moskowitz pointed out that there is a long-standing belief that

education can solve social problems based on the assumption that

knowledge gained will positively affect values and social skills.

He discussed the considerable disagreement among experts about the

type of education which is most effective or, in fact, about

whether the basic assumption is correct.

3
In a final chapter, Drs. Carl Leukefeld and Joel Moskowitz

summarize the discussions which took place at the meeting and the

recommendations of the participants for future research efforts.

AUTHOR

Jacqueline P. Ludford, M.S.

Coordinator

Research Analysis and Utilization System

Office of Science

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, Maryland 20857

4
The Role of Mass Media

in Preventing Adolescent

Substance Abuse

Brian R. Flay, D. Phil.

and Judith L. Sobel, Ph.D.

Discussion of the role of mass media in drug abuse prevention must

reflect, to some extent, the history of drug education in general.

Early approaches to drug education were based on moral objections

to the use of drugs or alcohol and advocated temperance. We know

that such moral approaches to education did not work. Even the

outlawing of a substance is not an effective deterrent to its use.

A second phase in the history of drug education involved the use of

fear approaches. If people could not be exhorted to avoid recreational drugs, perhaps they could be made afraid to do so. Again,

we know that such approaches did not work. In fact, the use of

fear does not appear to lead to appropriate behavior change unless

specific actions are recommended that will overcome or reduce the

fear that is aroused (Leventhal 1970). Subsequently, drug educators

came to believe that an appropriate message was one that emphasized

the objective facts about the physical properties of drugs, and the

consequences (usually long-term health consequences) of using them.

These programs did not work well either (Goodstadt 1976). In fact,

sometimes they even led to "boomerang" effects (Swisher et al. 1971),

possibly because the information provided served only to increase

adolescents' curiosity about the substances described, or possibly

because adolescents may have, as a result of the viewing environment,

become aware of perceived grou norms, and shifted attitudes accordingly (Feingold and Knapp 1977).

We have elsewhere (Flay et al. 1980; Flay 1981) provided a socialpsychological analysis of why information-based programs do not

work well. Basically, it is because changes in knowledge, which

such programs sometimes do accomplish well, are only at the beginning of a long probabilistic chain, and many other factors must be

examined if behavior is to be changed. One of these other factors

concerns values -- and values clarification and decisionmaking

approaches dominated the fourth phase in the history of drug education. The majority of attempts using these so-called "affective"

approaches were also unsuccessful, probably because they also failed

to address many of the major determinants of adolescent drug use.

5
In recent years, there has been increasing recognition that the

primary influences on adolescent drug use are social, particularly

peer and family influences. Recent prevention programs that make

students aware of social influences and provide them with the

social skills with which to resist or cope with such influences

have been more successful (see other chapters in this collection).

Although the mass media are also thought to be a source of social

influence on adolescent drug use, direct effects have been much

more difficult to document. In this paper, we will a) discuss

briefly the pervasiveness of media influences to use drugs, b)

review past attempts to utilize mass media for drug education, c)

provide an analysis of mediators of successful and unsuccessful

uses of the mass media, d) argue that the principles found to be

effective in classroom programming can and need to utilize mass

media to be disseminated widely and, therefore, to have maximum

effects, e) describe an example where this was done, and f) close

with some research recommendations. We argue that despite the many

past failures in the use of mass media for drug abuse prevention,

the recent successes of classroom-based drug abuse prevention

programming, coupled with communication research principles and our

recent success at using mass media for cigarette smoking

prevention, give us confidence that mass media have a valuable role

to play in solving the very important problem of increasing

adolescent drug abuse.

IMPORTANCE OF MEDIA

Television is the preeminent mass medium among adolescents. The

typical American child will spend more time watching television

than he or she will spend at any other single activity, including

going to school or interacting with friends. All this time spent

watching television undoubtedly provides adolescents with many

learning opportunities. Much research suggests that behavioral

learning does occur during viewing (Pearl et al. 1982; Roberts

1983).

Content

Adolescents observe and listen to drug use, particularly alcohol

drinking, being modelled and discussed as a natural and everyday

event on prime-time television. Reviews by Barcus and Janowski

(1975) and Winick and Winick (1976) document the pervasiveness of

drug content in all forms of entertainment media, including

television, radio, magazines, and records, particularly those

preferred by adolescents. Alcohol is the most frequently depicted

drink in television programming, and it is usually depicted as a

"social" drug with generally positive consequences resulting from

its use (McEwen and Hanneman 1974).

Among the illicit drugs, it has been suggested that marijuana use,

while rarely depicted, has become a trivial matter and is commonly

regarded with humor as a harmless escape. Other illicit drugs are

rarely shown and fairly consistently associated with bad

consequences (McEwen and Hanneman 1974).

6
Very few depictions of cigarette smoking appear on television as

compared with character counterparts of the 60's and early 70's.

In fact, a similar change may be just beginning with respect to

alcohol use. Negative consequences and dependence associated with

use are more prevalent than they were even a few years ago. As a

result of some academic and other interest groups, several

prime-time shows have even incorporated episodes dealing with the

problems of drinking (e.g.,

(e.g., "Different Strokes," "Quincy").

"MASH," "All in the Family") and drugs

Advertising of cigarettes, alcohol, and proprietary drugs may be

responsible for more adolescent exposure to drug use than all the

entertainment and news programming combined. With the exception of

cigarette ads on television, alcohol, tobacco and proprietary drug

advertisements are pervasive throughout the mass media.

The predominant message of advertisements is that use of

recreational drugs, or frequent use of proprietary drugs, is not

only acceptable, but is even desirable (Milavsky et al. 1975).

Recently, a new concern in mediated exposure to drug use has been

directed to the possible effects of approaches to drug coverage on

TV news. Drug problems (busts) are popular human interest stories,

Scripts for these segments are written quickly with little thought

to their effect on adolescents. It has been suggested that more

care be taken with these reports: to dramatize the drugs less and

report actual legal consequences.

Overall, when we add up these various influences, we find the mass

media environment to contain many pro-drug-use messages. The

anti-drug or prevention-oriented content of mass media appears to

be minute compared to the pro-drug-use content noted above. The

number of prevention-oriented PSA's, *for example, is outnumbered

many times by the number of pro-drug commercial advertisements.

The number of prevention-oriented portrayals in entertainment

programming is also small compared to pro-drug, especially

pro-alcohol, portrayals. There may, however, be a real effort

being made by society (e.g., Breed and Defoe's 1981, alcohol

interest group) to change the nature and extent of drug usage in

the media. The decrease in characters smoking cigarettes is clear,

and alcohol appears to be next. It also seems that there are

increasing attempts to provide more anti-drug messages within

entertainment programming. However, while no detailed analysis is

yet available, these do seem to rely fairly heavily on the

information (objective facts) and fear approaches -- and so will

probably not be very effective as preventive influences.

Effects

Studies have found that non-users of drugs identify the mass media

as one of their most important sources of information about drugs

(Hannemhn 1973). Further, two studies found that mass media was

designated as an important place for adolescents to learn about

drugs, and was perceived by them as a trusted and influential

source of information, irrespective of individual drug use (Fejer

and Smart 1971; Sheppard 1980). Yet, while there is increasing

* public service announcements 7
evidence that anti- and pro-social behaviors are learned, at least

in small part, from seeing them modelled on television (Pearl et

al. 1982), relatively little research has been done on the effects

of viewing, reading, or hearing drug use messages. This is

surprising in that a) drug use/abuse is of major concern to parents

and schools, and b) there is a significant amount of social

modelling of drug use on television.

Research on the behavioral influence of ads on adolescents is also

limited, but some studies suggest that over time proprietary drug

ads do affect proprietary drug use, at least when adolescents are

also exposed to those drugs at home (Milavsky et al. 1975).

Rossiter and Robertson (1980) found that adolescents exposed to

proprietary drug ads had generally more favorable though still

moderate dispositions toward products than those not exposed. As a

result of similar research, Atkins (1978) suggested that

"children's beliefs about the efficacy of medicine and illness in

society were affected by (exposure to) drug advertising" (p. 76).

Proprietary drug exposure has not been shown to affect illicit drug

use among adolescents (Milavsky et al. 1975). There is, of course,

evidence that commercials aimed at children affect children

(Roberts 1983). Adolescents are more likely to want to have the

attractive products they see advertised, and this increases sales

(Atkins 1982).

While no causal relationship has been established between viewing

drug use on television and subsequent drug use by adolescents, four

considerations make such a relationship highly likely. The four

considerations are: a) learning theory principles (which have been

empirically validated in other behavioral domains), b) documented

effects of anti- and pro-social programming on children's

behaviors, c) documented effects of advertising on children's

consumer behavior, and d) the finding that adolescents not yet

using drugs seek information on them from mass media.

Conclusions

Our current understanding of the determinants of drug use has led

to prevention programming that a) provides ways of resisting social

influences, and b) makes positive use of those influences.

Similarly, our belief that mass media can influence adolescent drug

use leads us to suggest that prevention programming should a) provide ways of resisting media influences, and b) make positive use

of mass media for prevention. There is some progress in both directions -- the former is reviewed briefly immediately below, and

the latter is reviewed in more detail in the next major section.

Some progress has already been made in teaching adolescents how to

resist media influences. Some studies have shown that adolescents

can be taught to recognize and develop counterarguments against

false claims of advertisements (Goldberg et al. 1979; Ward et al.

1977). This approach has already been used in most

social-psychologically derived smoking prevention programming.

8
There is growing and consistent evidence that shared viewing and

directed interaction with adolescents about what they view can

affect the influence of a program dramatically. Verbal labelling

and role-playing have both been used successfully in studies of

mediated behavioral learning. This technique can be used either to

enhance the effects of a program or to counteract the effects of

viewing antisocial behaviors (Friedrick and Stein 1975). It has

been suggested that parents and teachers must be aware of the media

environment and effectively "counter-educate" adolescent viewers by

offering superior alternatives. There is even evidence that the

real-life meaning derived from television by children can be

tempered by teaching them about the production process and by

teaching them a healthy skeptism (Singer et al. 1980).

USE OF MASS MEDIA FOR PREVENTION

Health Promotion In General

In making the transition from assessing the influence of "natural"

media such as entertainment, advertising, and news, to an

examination of the effects of media campaigns, one is struck with

the very poor record of evaluated mass media health promotion

programs. It seems somewhat paradoxical that when we are not

trying to affect behavior some behavior change has been observed,

but when a concerted effort is made to affect behavior, significant

change often fails to occur. The preponderance of failed campaigns

must, however, be placed in historical perspective. Greater

success has been achieved by some more recent programming.

The history of the use of mass media for pro-social objectives in

general, and health promotion in particular, closely parallels the

history of drug education research (see Blane 1976 and Wallack 1980

for more detailed surveys). Early campaigns were based on

providing information or avoiding fear. They were often successful

at changing knowledge, less often successful at changing attitudes,

and rarely successful at influencing behavior change (Atkin 1979;

Cartwright 1949; Flay 1981; Flay et al. 1980).

Over 30 years ago Cartwright (1949) outlined three stages that a

campaign must go through to influence behavior: i) create an

appropriate cognitive structure (i.e., what people know and

understand), ii) create an appropriate motivational structure

(i.e., what people want to do), and iii) create an appropriate

action structure (i.e., what people actually do and how this can be

facilitated). Our more complex model that incorporates theories

from many different areas of psychology is based on that same

underlying structure (Flay 1981). It is noteworthy that the

histories of both drug education and the use of mass media follow

these steps -- from providing facts, to arousing fear, to altering

action structures -- with the latter occurring only very recently.

It is also clear that the most successful mass media health

promotion programs have included the development of action

structures. We shall see below that this is also true in the use

of mass media for drug abuse prevention.

9
In addition to message structure, other factors that have been

emphasized by reviewers of the use of mass media for health

promotion include, but are not limited to (e.g., Atkin 1979; Blane

and Hewitt 1977; Flay et al. 1980; Griffiths and Knutson 1960;

Mendelsohn 1968, 1973; Solomon 1982; Wallack 1981): a) the need

for more careful planning of media products, and for more formative

evaluation during product development; b) program or campaign

dissemination issues -- no effects can be expected if the audience

is not reached, yet many PSA campaigns fail to do so; c) the use

of multiple channels, including supplementation of media

programming with other campaign activities; d) audience selectivity

(Klapper 1960; Sears and Freedman 1967) and interpersonal

communication (Katz and Lazarsfeld 1955) as mediators of media

effects; and e) the need for more frequent and improved summative

evaluation (Ball 1976; Flay et al. 1980; Flay and Cook 1981;

Haskins 1970; Towers et al. 1962; Wild 1975). Again we will see

that these same issues arise with respect to mass media drug abuse

prevention programming.

Most studies of the use of mass media for drug abuse prevention

concern drug and/or alcohol PSAs. These will be reviewed

immediately below. In a subsequent sub-section, we will review a

few studies that involved more than PSAs such as testing the

effectiveness of 90-minute shows, comparing media-only and media

plus community mobilization interventions, and investigating the

role of interpersonal communication in mediating the effects of

films on PSAs.

Studies Of Drug And Alcohol PSAs

In a study of drug information sources among college students,

Hanneman (1973) found trustworthy, personal informants to be more

important sources of drug information than media, among users,

Media were found to be one of the most important sources among

non-users. In an attempt to at least partially explain this

finding, the author analyzed the content of drug information

television programming. Out of 500 hours of viewing analyzed, 37

minutes were devoted to PSAs about drug abuse, 80% contained no

factual information, and most were nonspecific and broadcast during

the least popular viewing periods. Hanneman suggested that the

PSAs were minimally effective on a high risk audience not only

because of PSA content and timing problems, but also because drug

abuse education is an information-sharing process, subject to the

information flow between opinion leaders and followers.

Two weeks of drug abuse appeals on television were content analyzed

by Hanneman (1973). Of 85 appeals observed, only 18% were

youth-oriented. Almost half were broadcast between the hours of

10:00 a.m. and 3:00 p.m. Another one-third were broadcast before

10:00 a.m. and after 10:30 p.m. No appeals were broadcast between

7:00 p.m. and 10:30 p.m. Twenty-two percent of the messages relied

heavily on a presentation of the harmful social effects of drug use

and 20% showed a heavy reliance on the presentation of the harmful

physical effects. A total of 40% used fear as the motivation for

10
the prescribed behavior change, and it was concluded that most were

neither directed toward, nor specific to, the needs of any one

subpopulation.

Capalaces and Starr (1973) reviewed anti-drug abuse PSAs over the

five-year period preceding 1973. They found that PSAs relied

heavily on creating anxiety and fear in the audience. They

suggested that the PSAs were ineffective because a) scare tactics

were used which were not "concordant with subjective reality"

(e.g., all adolescents who take drugs don't overdose as some PSAs

implied), b) target audiences were rarely identified, c) station

managers (gatekeepers) were not well informed and, therefore,

allotted haphazard energy and effort to scheduling, and d)

appropriate audiences were not "reached."

Goldstein (1974) content analyzed published and unpublished

research papers in the fields of broadcast-mediated drug

education between 1968 and 1972. The author concluded, based

on the quantitative review, that television is the most effective

medium with which to promote drug abuse prevention. Further, the

message was most effective if the source had credibility, was

knowledgeable and was someone with whom the audience could

identify. The most effective content was educationally

oriented material (based on scientific fact) with minimal

reference to fearful consequences, but provoking some discomfort

and stating clear cut suggestions for alternative behaviors.

Hanneman and McEwen (1973) reported that during NIAAA's 1972

campaign, many of the youth-oriented PSAs were aired during

day-time hours when most youth would be in school. About 2% of

those recalling any exposure wrote to the advertised address for

further information. Drinkers were more likely to recall one or

more messages (approximately 60%) than non-drinkers (approximately

40%). A central finding was that the "market" is heavily

segmented, with different messages appealing to different segments.

Harris and Associates (1974) evaluated a NIAAA alcohol prevention

PSA campaign to assess the penetration and recall of the campaign,

attitudes toward PSAs, and beliefs about trends regarding the

nature and extent of alcohol abuse. Sixty-four percent of those

surveyed recalled seeing at least one advertisement while only 22%

recalled seeing four or more. Older and less educated subjects

recalled fewer messages. Heavy drinkers were less likely to

remember seeing ads than light drinkers, and the ads most commonly

recalled were those involving drinking and driving.

Rappaport et al. (1975) tested the public's perceptions of 12 ads

used in the NIAAA PSA campaign of the early seventies. While

60-70% of respondents recalled seeing PSAs "in the past few

months," a maximum of 39% recalled one theme ("don't drink and

drive"), less than 12% recalled any one other theme, and about 40%

of respondents did not recognize any of the NIAAA messages.

11
The Public Sector Research Group (1978) evaluated the 1978 national

prevention campaign sponsored by NIDA. While there was some

evidence that beliefs about the nature of drug abuse were changed,

there was no evidence that the campaign increased participation in

prevention activities or feelings of efficacy and personal

responsibility about prevention.

Plant et al. (1979) evaluated a media campaign, begun in 1976 in

Scotland, that utilized television and newspaper ads in an attempt

to encourage individuals who abuse alcohol to seek help. A complex

evaluation design was used to assess the effect of the campaign on

knowledge about alcoholism, knowledge of services available, use of

treatment agencies, and individual alcohol consumption. Surveys

were conducted by household and through national and local newspapers. No exposure (the control), two-month, six-month, and

eight-month exposure periods determined the intervals between

surveys. In addition, contacts with agencies about ads and letters

received in response to the campaign were reported. The exposure

group was significantly better able to recall the messages than the

no-exposure group. After two months of exposure there was a small

significant difference between the treatment and control groups in

their belief that problem drinkers could be helped. The older

(over 45) respondents recalled more information about alcoholism in

the exposure group than the control. No difference was found in

the number of agencies contacted by each group.

After eight months of exposure, respondents were significantly more

likely to recall seeing the films and to recall specific contents

of the messages than the six-month exposure group. In both groups,

respondents were better able to name agencies and believe problem

drinkers could be helped than those not seeing the messages. Older

respondents (over 45) felt they could advise persons with alcohol

problems better if they had seen the message than if they had not.

Television segments reached more individuals than the newspaper

ads. The authors concluded that penetration was reaehed, and

knowledge was realized, after months of exposure for older

audience members. The young were unaffected by this campaign.

Viewers were about 10 percent better informed about alcohol, and

there appeared to be an increase in referrals in several agencies

in the target communities.

Field et al. (1983) report an evaluation of the implementation of

the NIAAA 1982 Alcohol Abuse Prevention Campaign. This campaign

consisted of 12 PSAs targeted at women and youth, with special

attention to Fetal Alcohol Syndrome and drinking and driving among

youth. Several of the spots emphasized the negative social

consequences of drinking to excess, and others modelled socially

acceptable ways of resisting offers or social pressures to drink.

PSAs could have reached 85% of TV households an average of 45 times

per day (across all stations). However, only 6% of these airings

were during prime time (8:00 p.m. - 11:OO p.m.) and only 20%

between 5:00 p.m. and 11:30 p.m. Even these lead to overestimates

of likely viewership, in that only local stations aired 20% between

5:00 p.m. and 11:30 p.m.; the networks aired only 3% during this

12
time period. Thus, local stations aired more PSAs during prime

time, but national networks tended to have most of the audience

during those hours. These data point up rather dramatically the

low coverage obtained by PSA campaigns in the United States.

Primary findings from the Field et al. (1983) evaluation concern

program dissemination. Effective dissemination was associated

with:

a) well-planned and carefully executed approaches to media gatekeepers (public service directors at each station); and

b) extensive community involvement -- which involved volunteers,

State authorities, the private sector, schools, political and

government leaders, experts/celebrities, and other media.

One of the few evaluations of the cost-effectiveness of a campaign

was conducted by Hu and Mitchell (1981) on data from an outcome

evaluation of the 1978 NIDA drug abuse prevention media campaign

intervention (Public Sector Research Group 1978). Data were

assessed on intervention costs, PSA play-time, and subsequent audience effects at eight treatment and two control sites. The average

cost of a PSA spot was determined to be $92. It was estimated that

10.4% of respondents between 12 and 65 years of age, who had viewed

a PSA, could recall it when surveyed. The cost was estimated at

11¢ per viewer. Two models were tested in regression analyses

involving socio-demographic variables, time spent watching

television, site, concern about the issue, number of PSAs played,

number of PSAs remembered, and involvement in prevention activities.

Model I proposed that the ability to recall the PSA was a function of

socio-demographics, the amount of television viewed, and the number of

PSA spots. Model II proposed that concern about, and involvement with,

the prevention of drug abuse was a function of demographics, location,

and recall. Results of model I analyses indicated a greater likelihood of being able to recall the PSA when more PSAs were played,

when more television was viewed, when the respondent was from a lower

educational background, and when the respondent was neither black

nor white. Model II analyses indicated that concern about alcohol

abuse was likely to be greater if the respondent was older, less

educated, female, black, unemployed, or residing in a few specific

cities around the country. In addition, a respondent who

remembered the PSA was most likely to be highly concerned.

Involvement in drug abuse prevention was greatest among younger,

highly educated, and black respondents. Ability to recall the PSA

was also positively associated with level of involvement.

In one of the few reported attempts to experimentally evaluate the

effectiveness of a PSA campaign, Morrison et al. (1976) used a

non-equivalent control group design with program and control cities

to study the effects of radio and TV alcohol and drug abuse PSAs.

There were no differences between cities in the proportion of

people who had heard an alcohol or drug abuse commercial, partly

because other organizations were airing such PSAs at the same time

in both cities. Furthermore, however, there were no differences in

knowledge or attitudes between those who had heard a commercial and

those who had not.

13
In another quasi-experimental investigation of the effectiveness of

a PSA campaign, Delaney (1978, 1981) evaluated a two-year radio,

television and newspaper campaign in Florida that attempted to

increase public awareness about the effects of alcohol abuse.

Three counties constituted the treatment communities and three

other counties acted as matched controls. Stratified sampling

using phone survey methods before and at the end of one year

revealed a 13% decrease in the mythical belief that a drunk person

will become sober with cold showers and hot coffee compared to a 3%

change in the control communities.

Anti-drug campaigns have sometimes had "boomerang" effects. For

example, the anti-chewing tobacco campaign of the early 1900's

seems to have contributed to an increase in cigarette smoking;

anti-barbiturate publicity in the 1940's was followed by more

wide-spread use; anti-speed campaigns of the early 1960's may have

alerted a new generation of young people to its pleasures and

perils; anti-marijuana, anti-LSD and anti-glue sniffing campaigns

were followed by increases in the uses of these substances (Brecher

1972). Media sensationalism and scare tactics can glamorize some

risky behaviors and lead to increased experimentation among young

people (Kinder 1975).

Studies Involving More Than PSA Campaigns

In this section we review laboratory-style investigations of

anti-drug message characteristics, an evaluation of the effects of

a full-length film treatment of drug issues, studies of the value

of purchasing or legally mandating counteradvertising, and two

examinations of the role of interpersonal communication.

Three studies provide examples of laboratory-style investigations

of anti-drug message characteristics. Smart and Fejer (1974)

studied the effects of high and low fear appeals about drug abuse.

With an interesting twist, the first study consisted of presenting

one in a series of messages incorporating various levels of threat

to randomly assigned 9th, 11th and 13th grade classes. From

questionnaire data regarding drug use, attitudes, and intentions, no

association was found between intentions and anxiety levels. In

the second study, the authors examined the same variables after

students viewed one in a series of presentations about an unknown

(fictitious) drug called M.O.T. It was suggested that few

extraneous influences would affect attitudes about this drug. The

effects of levels of fear in the presentation were very

significant. High fear appeals were far superior to low fear

appeals. It was suggested that in the case of a new drug high

levels of fear will discourage use. Those students who received

the high threat appeal were less likely to want to try the drug and

more likely to believe that possession should be illegal.

Feingold and Knapp (1977) randomly assigned 10 high school English

classes to one in a series of 60-second anti-drug commercial

14
presentations in which three variables were manipulated: a) the

threat of serious versus minimal harm, b) the use of explicit

versus implicit conclusions, and c) presentation in monologue or

dialogue format. Twenty-five Likert Scales were used to ascertain

attitudes about the specific drugs discussed pre- and post-viewing.

Results across groups showed that threat of serious harm was no

more effective than that of minimal harm. However, the explicit

conclusion was more effective than the implicit conclusion, and

dialogue was found to be significantly more effective than

monologue format. Results from within-group comparisons showed a

significant shift in attitudes in the direction opposite to the

intent of the message.

In an elaborate three-study design, Ray and Ward (1976) extensively

pretested three anti-drug programs on specific populations under

specific conditions to determine their acceptability and overall

effectiveness. The design included tightly controlled laboratory

settings as well as more naturalistic field settings. Eighty

treatment conditions were identified after manipulating

environmental, socio-demographic, and program format variables.

Self-administered questionnaires given pre- and post-presentation

to juniors, seniors, and parents in the first study, and to adults in

the second and third studies, provided data on recall of

information, attitudes about drugs, and interest in the

presentation. Responses elicited during the presentations in the

first and second study also provided data on the extent and nature

of cognitive responses. The authors conclude that when pretesting

material, researchers must evaluate more than just attitudes about

the program issues or program format; they must assess all manner

of environmental and situational conditions in which the program

will be viewed, as well as the specific responses which those

conditions elicit, in order to fully assess the effectiveness of

the program in question.

Only one study has examined the effects of publicly broadcast,

full-length,anti-alcohol programming. Dickman and Keil (1977)

studied the effects of weekly 90-minute PBS programs on

alcoholism. Using a random sample of 1200 people in Pennsylvania,

they found a) very low exposure (2.3% of the sample) to the

programs, as would be expected given their placement on PBS, b)

many more people with an alcohol problem were familiar with the

program, and c) less than one quarter of those with a problem who

were familiar with the program said the program had stimulated them

to take some corrective action.

In an attempt to overcome a major problem with PSAs (that is, reaching the audience), several studies report evaluation of Purchased

counteradvertising. For example, Goodstadt (1977) reported on an

evaluation of a paid public alcohol information campaign in

Ontario, Canada. The campaign was successful in reaching its

audience, but the majority of those surveyed were unable to recall

any content of the messages.

15
The California Medicine Show (Hanneman et al. 1977, 1978), a

project designed to alter behavior regarding prescription and

over-the-counter drugs, was tested using three test sites. One

site was subjected to a purchased and public service advertising

campaign plus community mobilization techniques. One site received

the total media campaign without community mobilization, and one

site received only the public service announcements. Six-month

data indicated that behavioral change occurred at the sites where

media saturation was utilized. Results of another California

campaign that used purchased time in an effort to alter drinking

behavior were not as encouraging (Wallack 1978, 1979).

One way to ensure that PSAs reach their intended audience is to

have them legally mandated. O'Keefe (1971) studied the effects of

the radio and TV anti-smoking counter-advertising of the late

1960's. During the time of the study, between 80 and 100

anti-smoking ads appeared on television each week. Among samples

of students and adults in Florida, almost 90% reported seeing at

least one commercial, and 50% could remember the message of at

least one commercial. Nonsmokers and smokers already predisposed

to quit smoking perceived the counterads to be much more effective

than did confirmed smokers. No influence on behavior was detected,

although later analyses of cigarette sales suggest strongly that,

over the long term at least, counteradvertising did reduce

cigarette consumption (Hamilton 1977; Warner 1977, 1980; Warner and

Murt 1982).

Interpersonal communication is thought to be important to a)

diffuse messages (Katz and Lazarsfeld 1955; Katz 1980) and b)

increase their saliency to the exposed audience (McCombs and Shaw

1972). Two studies of mass media drug messages address this issue.

Trager (1976) tested the effects of four drug education (heroin)

films on adolescents' subsequent discussions with their families or

peers. He found that 10% of exposed adolescents, as compared to

only 5% of a control (unexposed) group, reported discussing any of

the films with their parents, with females three times more likely

to (15%) than males (5%), and with such interaction more likely to

occur in "pluralistic" or "laissez-faire" homes (16% and 18.5%

respectively) than "protective" or "consensual" homes (4% and 4.5%

respectively). Students were almost four times as likely to

discuss the films with their peers (38%), with females again more

likely to do so (52%) than males (25%).

Wong and Barbatsis (1978) tested the level of knowledge and

attitude change caused by educational television drug information

programs and group discussion. Viewers self-selected themselves to

study in groups or alone. While the program produced significant

knowledge and attitude change, no significant differences were

observed for the group versus alone comparison. These negative

results could, however, have been due to self-selection -- with

those individuals judging that they would do better in a group

choosing to join one and others choosing not to.

16
Conclusions

Any conclusions about the effectiveness of past drug abuse

prevention programming must be prefaced by some remarks regarding

the quality of the reported evaluations. Most consist of simple

cross-sectional surveys, that is, a single-group, post-test-only

design (c.f. Campbell and Stanley 1966; Cook and Campbell 1979).

Accordingly, results must be interpreted with great caution.

Results from the two controlled studies demonstrate the importance

of control groups. For example, one of the treatment and

comparison group studies (Morrison et al. 1976) was seriously

flawed in that the comparison community seemed to have received as

many messages as the treatment community. This might not have been

determined without a control group. Studies involving more than

PSAs are too few, and also of too problematic quality. to allow any

firm conclusions to be drawn on the basis of this review alone.

Despite the above shortcomings, however, this review, together with

theory and reviews of mass media effects in other domains, does

allow us to reach some conclusions. The first major conclusion, of

course, is that more and better research is required, but we will

leave a detailed discussion of that issue until later in the paper.

An overwhelming majority of mass media drug abuse prevention

programs have failed to change behavior. One obvious major reason

for this is that most PSA campaigns literally fail to even reach

the audience. Obviously, a campaign cannot affect peoples'

behavior if it doesn't even reach them. Advertisers believe that

it requires an average of three exposures for an advertisement to

affect purchase behavior (Hersey et al. 1982). It probably takes

even greater exposure to influence health behavior. Yet most

evaluations report the proportion of a surveyed sample who recall

seeing any ads. Even those studies of purchased counteradvertising

drug and alcohol campaigns (Goodstadt 1977; Hanneman 1977, 1978;

Wallack 1978, 1979) did not report the proportion of their audience

reached by their ads three or more times. Given the low budgets

compared to alcohol and cigarette advertisers, the mediocre effects

of these paid counteradvertising campaigns might still be explained

by low exposure. The one counteradvertising campaign that has been

found to be effective was, of course, the anti-smoking campaign of

the late 1960's. That involved one counterad for every three to

five cigarette ads and definitely reached a large portion of the

target audience.

Another major reason for the failure of most PSA campaigns has

probably been heavy reliance on information and fear messages. We

need not dwell again on the reasons for the ineffectiveness of

information-oriented programs at changing behavior. Regarding

fear-based messages, teenagers are particularly likely to

counterargue against threatening messages (Atkin 1979).

Another problem with anti-drug-abuse campaigns was the tendency for

PSAs to be directed to unidentifiable audience segments (Capalaces

and Starr 1973; Hanneman et al. 1973; Rappaport et al. 1975).

17
Adolescents are clearly an easily defined segment that can be

reached with relevant messages.

The studies on the role of interpersonal communication do not

suggest any firm conclusions. Indeed, the lack of studies in this

area suggests a focus for future research.

MACRO-LEVEL MEDIATORS OF SUCCESS AND FAILURE

We have seen that attempts to use mass media for health promotion

in general and drug abuse prevention in particular have often

failed and only occasionally succeeded. In previous papers (Flay

et al. 1980; Flay 1981) we have focused on traditional

micro-level, source, message, and channel characteristics of media

products that are related to success and failure. Utilizing social

psychological theories, we developed an integrative model of the

attitude and behavior change process, and identified a large number

of ways in which media messages could be improved to increase

attitude and behavior change. There seems to be some evidence in

our review that at least some of the most recent messages are

incorporating more of those suggestions. For example, the most

recent NIAAA and NBC1 campaigns included modelled ways of saying no

to social pressures to drink or do drugs. There is certainly ample

evidence, reviewed by others in this volume, that we now know a

good deal about how to design classroom programs that incorporate

our suggestions for successful behavior change and that

successfully prevent at least cigarette smoking and probably also

more general drug abuse. The few successful media campaigns have

demonstrated that those principles found successful in the

classroom also can be incorporated into media campaigns. However,

even with the best-designed media messages, there remain three

major factors that limit the success of a mass media campaign. The

remainder of this paper will focus on these.

Program Dissemination

Many past campaigns, particularly PSA campaigns, probably have

failed precisely because they were not well disseminated. Airing

of PSAs outside of prime time and/or on non-commercial stations,

and then only infrequently, cannot lead to the levels of reach and

frequency necessary to ensure adequate exposure.

The best example of a successful PSA campaign was the corrective

advertising against cigarette smoking. That campaign consisted of

spots on prime time, one for every three to five cigarette ads, for

an extended period of time (several years), with many different

spots being produced and used (thus ensuring some novelty).

Several analyses demonstrate that such an approach was effective at

reducing the level of cigarette smoking while it was in effect,

though this effect may have been reduced once all advertising was

removed from television (Hamilton 1977; Warner 1977, 1980; Warner

and Murt 1982).

18
All other effective mass media programs also had demonstrably high

levels of exposure because of good dissemination. For example, the

CBS Driver's Test (Bush 1965; Mendelsohn 1973) was shown

nation-wide on a national network during prime time. The Stanford

Heart Disease Prevention Project involved the use of multiple media

over an extended period of time, as did the Finland study.

Pechacek et al. (1983) recently ensured high exposure for a smoking

cessation program by promoting it through existing community

organization channels set up for the larger Minnesota Heart Health

Project.

Obviously, there must be successful dissemination of a program

before any intended effects can be expected. Primary mediators of

successful program dissemination are media "gatekeepers."

Television and radio station managers, and newspaper and magazine

editors, are the most obvious and most proximal examples of

gatekeepers. Politicians, trade union representatives,

Parent-Teacher Associations, consumer protection groups, etc., are

less obvious and more distal, but equally powerful gatekeepers.

Media gatekeepers determine, to a large extent, what is and is not

acceptable for media presentation. As such, they are the first

that must be convinced of the worth of a media product or campaign

if it is ever to be disseminated adequately.

We need not be pessimistic about the attitude of media gatekeepers

toward drug abuse prevention material. First, at least some

gatekeepers in the broadcast industry have already discovered that

certain treatments of health tssuesin general, and the drug problem

in particular, are not only acceptable to audiences, but may be

desired. KABC-TV in Los Angeles believes strongly that Dr. Art

Ulene's health program, "Feeling Fine," helps their ratings, and

his treatment of smoking and drug problems provide no exception.

Cable Health Network seems to be signing up cable distributors and

advertisers at a rate better than anybody ever expected. NBC's use

of the First Lady to inject a drug education message into a prime

time entertainment program obviously would not have been done if it

was thought to jeopardize ratings. NBC's recent "Don't Be A Dope"

program provides another demonstration of media commitment to

solving the drug problem. This program obviously overcame program

dissemination problems because it was initiated by the media

gatekeepers themselves. Thus, they aired PSAs during prime time,

they advertised in local newspapers, they showed some of their

programming (five 5-minute segments) during the early evening news

hour and aired a 30-minute program ("The Drug Abuse Test") during

prime time (7:30 p.m.).

Selectivity

Klapper (1960) and Katz (1980), among others, have suggested that a

second major mediator of media effects concerns individual

selectivity; that is, individual predispositions to attend or not

attend to messages on particular issues. While it has been

difficult for social psychologists to demonstrate this phenomenon

in laboratory studies (Sears and Freedman 1967), it is readily

19
observable in more sociologically oriented field studies (Atkin

1973; Katz 1968). It is known, for example, that women are, on the

average, more likely to attend to health information (Feldman

1966). Drinkers are more likely to attend to and recall

drinking-related messages than are nondrinkers (Dickman and Keil

1977; Rappaport et al. 1975). Several studies have demonstrated

that heavy smokers are less likely to attend to information about

the health consequences of smoking, and more likely to develop

counterarguments to such information, than light smokers or

non-smokers (O'Keefe 1971). Uses and gratifications research seems

to provide the best explanation of this phenomenon (Blumler and Katz

1974) -- with considerable buttressing from value and

value-expectancy theories of psychology (Palmgreen and Rayburn

1982). In essence, these theories, and the research data

underlying them, suggest that individuals are more likely to attend

to a program orcampaignif it meets a salient need or value that they

have. For example, a drug education program can be successful at

gaining and holding the attention and involvement of adolescents if

they can see that it might help them become more socially adept or

improve their self-esteem or independence from adults in some other

way.

Problems of selectivity are probably minimized when there is a

focus on prevention rather than cessation. Users of drugs are less

likely to attend to a program that tells them why they should stop

or how to stop using drugs than non-users of drugs are to attend to

a program that provides them with the skills necessary to remain

non-users. Parents, even smoking and drug-using parents, are

perhaps even more likely than children to attend, and to try to get

their children to attend, to a prevention-oriented program than a

cure or cessation program. Thus, one of the major ways of

increasing interpersonal communication, working with families,

probably also decreases selectivity. In addition, reduced

selectivity and therefore increased attention would also lead to

increased agenda setting.

Focus on selectivity as a problem might also lead health educators to pay more attention to the needs of their potential

audience. This problem has been minimized somewhat for drug

educators because they believed that they had a captive audience in

school students. Distributing drug prevention programs to a

non-captive audience will demand that greater attention be given to

audience needs and values. Fortunately, analyses of media content

suggest that there is already an accelerating move toward prevention of drug use or abuse, and a corresponding demand for such

programming by viewers, particularly parents. Adolescents' needs

will still need to be considered carefully, however, and drug

prevention programming promoted as social skills development and

health promotion rather than as drug prevention.

The problem of selectivity is of particular concern for

media-based drug prevention programming. The crucial question is,

"How do you get high-risk adolescents to attend to and participate

in drug abuse prevention programming?" Adolescents at high risk of

20
becoming drug users are those who a) have drug-using parents, b)

have drug-using friends, c) have low opinions of themselves (i.e.,

low self-esteem, poor performance in school), and/or d) are

generally rebellious against parental/adult authority. Under what

conditions are such adolescents likely to view media programs on

drug abuse prevention? Not many, but a few do come to mind.

Favorite music groups advocating non-drug use might sway even those

adolescents whose friends are users -- and may even influence some

of their friends to quit. Admired stars or sports heroes may also

be effective. We believe, however, that media programs alone may

never be as effective as those that include complementary elements

such as school-based curricula or community organization designed

to increase interpersonal communication. Such combinations of

program elements stand a greater chance of reaching high risk

adolescents than those that rely on media alone. In addition, such

programs increase the speed of agenda setting and diffusion and

ultimately the adoption of new norms.

Interpersonal Communication

Cartwright (1949) and Katz (1980; Katz and Lazarsfeld 1955) have

also identified level and direction of interpersonal communication

among the target audience as being major mediators of mass media

program effectiveness. Early social psychological and

communications research studies support the notion that

interpersonal communication, particularly group discussion,

increases the effectiveness of media messages (Lewin 1947, 1965).

Johnson (1983; Johnson and Ettema, in press) provides a more recent

and children-based example. Children who viewed and discussed a TV

series in the classroom evidenced more changes than children who

did not have the opportunity of discussion after viewing the same

TV series in the classroom. The diffusion of messages or adoption

of innovations (Rogers and Shoemaker 1971) also relies on interpersonal networks.

To the extent that an issue is already salient, people will be

discussing it with each other, and any new information or program

is likely to be attended to and also discussed. To the extent that

an issue is not already salient, the ultimate effectiveness of a

mass media program will be enhanced if it gets people talking to

each other about the issue (i.e., agenda setting -- McCombs and

Shaw 1972). Interpersonal communication then spreads the message,

or reactions to it, to a wider audience. Diffusion of an issue may

lead, in turn, to demands for more information on it or for new

policies or laws.

The issue of drug use seems to be fairly salient these days, with

pro and con points of view receiving treatment by the media. The

existence of both points of view on the media should, in turn, lead

to increased interpersonal communication about the issue. Trager

(1976), for example, found that viewing drug education films

encouraged a small amount of discussion with peers and parents.

21
Many of the most successful campaignsand programs of the past have

included conditions that increased the probability of interpersonal

communication. For example, the TV-based smoking cessation

programs of Best (1980) and Danaher et al. (1982) explicitly

instruct participants to obtain the support of their spouse or a

friend. The face-to-face condition of the Stanford Heart Disease

Prevention Project (Maccoby and Farquhar 1975) naturally involved

interpersonal communication. In addition to increasing diffusion

and the possibility of attitude and behavior change, interpersonal

communication is probably also important for ensuring the

maintenance or persistence of induced changes (Cook and Flay 1978).

Cost-benefit issues become important when face-to-face programming

is recommended to ensure or enhance the effectiveness of mass media

programming. One of the great arguments for using mass media is

its potential cost-effectiveness, its ability to reach many

people at a relatively low cost per person reached. Adding

face-to-face elements is likely to increase unit costs. However,

judicious selection of methods of increasing interpersonal

communication can keep costs down and does not necessarily reduce

cost-benefit ratios. Intensive clinics, such as the smoking or

weight loss clinics offered to high risk individuals in one

condition of the Stanford Three Community Study, are very

expensive. Use of school-based curricula that encourage family

interactions may still be as much as double the cost of television

programming alone. However, this is much less expensive per unit

than face-to-face clinics, particularly as schools want to, or are

mandated to, offer drug education anyway. Some forms of community

organization, particularly those that make heavy use of existing

organizations, many of which may be voluntary, might also be

cost-effective alternatives.

Agenda setting and diffusion of new ideas each serve to increase

interpersonal communication still further, which, in turn, is likely

to influence media gatekeepers. Thus, interpersonal communication

is seen to be important not only in mediating media influence on

individuals, but also on the media's acceptance of issues for

further exposure.

An Example Of A Program That Overcame The Above Problems

In this section, we describe an example of an evaluated smoking

prevention program that incorporates many of the suggestions made

above for improving program dissemination, selectivity, and

interpersonal communication (more details on this study can be

found in Flay et al. in press).

Targeted primarily at junior high school students and their

families, the USC/KABC-TV Smoking Prevention and Cessation Program

consisted of the following elements:

1) Five 5-minute TV segments on smoking prevention on the

early evening news hour -- these commenced the same day as

the 1982 Surgeon General's Report was released (February

22nd)

22
2) A coordinated 5-day classroom curriculum for junior

high school students -- modelled after those reported from

Houston (Evans et al. 1978), Minnesota (Hurd et al. 1980),

and Waterloo (Flay et al. 1983), utilizing same-age peerled group activities with an emphasis on training social

skills with which to resist social influences (peer,

family, and media)

3) Home/Family activities -- homework assignments included

viewing the TV segments and discussing them and/or

completing an assignment with an adult

4) Five 5-minute TV segments on smoking cessation on the

early evening news hour the following week, and

5) A written guide to quitting provided to all parents of

participating students and any other adults who requested

it directly from KABC.

The classroom program was provided to over 50,000 students in 153

schools in the L.A. viewing area by 600 teachers. An additional

30,000 people requested the written materials from the TV station.

Sixty-three percent of students in program schools viewed at least

one of the prevention segments (67% of them with someone else),

while only 8% of control students saw any of the segments. In the

second week, adults from 42% of homes of program students that

included one or more smokers viewed some of the cessation

programming, compared to only 13% from control students' homes.

In terms of effects, we found that a) knowledge, attitudes, social

normative beliefs, and behavioral intentions were changed for

program students, but only knowledge changed for control students

(who were exposed to traditional health education programs), b)

only half as many program students (7%) as control students (14%)

tried their first cigarette in the two month period between

pre-test and post-test, c) 14% of smokers in program students'homes

(or 35% of those viewing any cessation segments), but only 4% of

smokers in control students'homes (29% of these viewing) were not

smoking at one-month follow-up, and d) 12% of other adults who

requested program materials directly from KABC were not smoking at

a two-month follow-up.

The above viewership patterns and program effects compare favorably

with results from classroom-based smoking prevention programming

(reviewed by others in this volume) and more than favorably with

results from previous TV-based smoking cessation programs (see Flay

1983, for a review). We believe that the success of this program

is attributable to factors implemented to overcome the three

factors identified above -- program dissemination, selectivity, and

interpersonal communication. This program was able to reach a

large portion of the target audience because it: a) was

coordinated with a classroom program (note the difference between

program and control school students' viewership patterns), b) was

aired at a popular viewing time, c) appeared coincident with the

release of a new Surgeon General's Report that linked cigarette

smoking to many more cancers, d) got students talking to their

parents, thus influencing parents to tune in the second week, and

23
e) provided free information (booklets). Selectivity problems were

reduced because a) students are a relatively captive audience for

the classroom program, b) the classroom program was involving

anyway because of its novelty, c) the program provided adolescents

with social skills they desire, d) students were encouraged to get

their parents involved, e) the Surgeon General's Report generated

widespread discussion, and f) smokers were provided with tools for

solving a problem that had been made salient. Interpersonal

communication was increased a) among students because of the

coordinated media and classroom program, b) between students and

parents because of the built-in homework assignments, and c) among

adults because i) parents sometimes talk to each other about the

activities of their children, ii) quitters were encouraged to seek

social support from spouses, friends, and other quitters, and iii)

the Surgeon General's Report generated considerable media attention

and discussion.

By utilizing the best technology available for classroom prevention

programming and smoking cessation, and by encouraging family

involvement, we successfully utilized mass media to reach large

numbers of adolescents and their families with effective smoking

prevention and cessation programming. It would appear that other

successful mediated health campaigns also: a) maximized

opportunities for individual exposure to the message (by using

various media), b) made special efforts to attract individuals for

whom health innovations were more salient (e.g., opinion leaders

and high-risk individuals), and c) incorporated group meetings to

increase expert and social interaction in order to increase

salience and information flow in the community. Clearly, these

mediating factors can explain, to a great extent, the difference

between success and failure in media campaigns.

DISCUSSION

The Appropriate Role Of Mass Media In Drug Abuse Prevention

Lazarsfeld and Merton (1948) identified three conditions one or

more of which they believed to be necessary for mass media programs

to be effective at behavior change. The first was monopolization

(i.e., lack of counterpropaganda). Prevention-oriented programming

will never monopolize the mass media. Indeed, commercial interests

come closer to monopolizing them than prevention interests ever

will. However, the current shift toward more prevention-oriented

coverage will help to break that monopolization -- probably a

necessary step if we are ever to succeed in prevention. The second

condition identified by Lazarsfeld and Merton was canalization

(i.e., moving existing attitudes into action).

works this way--.

Most advertising

by channeling people from one brand to another.

Smoking cessation programs probably owe part of their success to

canalization. Many smokers want to quit -- they are just waiting

for the right program to reach them at the right time. Prevention

programming can utilize canalization to the extent that it helps

adolescents maintain a desired status quo. Increasing their

awareness of social pressure and giving them skills with which to

resist it probably does this.

24
The third condition identified by Lazarsfeld and Merton was

supplementation. This is the area where we believe the greatest

advances can be made in the use of mass media for drug abuse

prevention. Supplementation involves supplementing media

programming with other activities such as school programs, small

group discussion, community organization, face-to-face clinics, and

changes in laws or their enforcement. Obviously, the most

successful health promotion campaigns to date utilized the

supplementation principle. The analysis we provide in this paper

also suggests that supplementation is most important because it

increases the effectiveness of media programming by: a) increasing

the likelihood of program dissemination, by increasing the speed of

agenda setting and diffusion and thus exerting pressure on

gatekeepers, b) increasing interpersonal communication, because the

issue is made salient to more people in different ways, and

c) decreasing selectivity, by i) increasing access to captive

audiences or ii) breaking down selection barriers by increasing

interpersonal communication. Thus, we conclude from our analysis

that the most appropriate role for mass media in preventing drug

abuse is to increase the dissemination of program technologies

found to be effective in other settings such as classrooms and

clinics.

Research Implications

Research recommendations derived from our review and analysis are

at three levels. First, there is a need for basic research on the

effects of exposure to the "national" media. Second, there is an

obvious need for a great deal of research on ways of improving

program dissemination, decreasing selectivity, and increasing

interpersonal communication. Third, focus on the above issues

suggests a need for a greater emphasis on formative and implementation evaluation than on outcome evaluation, or more than has

been accorded mass media drug abuse prevention programs in the

past.

We provided a brief review of studies of the effects of viewing,

reading, or hearing the many drug use messages in the "natural"

media such as entertainment programming, news, and advertising.

While there are many studies on the content of the natural media,

and the extent of adolescents' exposure to it, there are few

studies on the effects of such exposure. It is not yet possible

to establish a causal relationship; more basic research is

recommended. The studies by Smart and Fejer (1976) and Feingold

and Knapp (1977) reviewed earlier, provide good examples of this

level of research.

We have suggested many ways in which program dissemination may be

improved, selectivity may be decreased, and interpersonal

communication may be increased. However, minimal empirical

data exist on the relative effectiveness or cost-effectiveness of

these suggestions. The history of media effects illustrates

dramatically the foolishness of relying on "common sense," or even

"expert judgement," in reaching decisions about the relative

25
cost-effectiveness of alternatives. Because it was widely believed

that media caused big effects (the "hypodermic" or "bullet" model

of communication). it was also widely believed that mass media

would be the most cost-effective way of influencing the behavior of

large audiences. Many reviews should by now have put these beliefs

to rest, yet many practitioners still promote the false economy

of the low cost of mass media products per member of the target

audience. At this time, the relative cost-effectiveness

of various ways of disseminating otherwise effective programming

remains a researchable issue. Similar arguments apply to the

issues of selectivity and interpersonal communication. Obviously,

however, those approaches or methods that simultaneously address

two or three of these issues, or even make them act synergistically, will probably have the greatest payoff in the long

term.

In our previous writings on evaluation of mass media programs (Flay

and Cook 1981; Flay et al. 1980), we have focussed on impact or

outcome evaluation. The findings of this paper make it quite

clear, however, that to focus on evaluation of the ultimate effects

of mass media drug abuse prevention programs would be ill advised

in many instances. The need to minimize selectivity and maximize

interpersonal communication suggests that much research effort

needs to be expended during product or campaign development. In

particular, formative research of message concepts and trial

products (e.g., Office of Cancer Communication 1979), and

small-scale tests of the finished product, need to be emphasized.

At each stage, there needs to be a concern with the acceptability

to the target audience of the concept, message, or product. That

is, can the product gain and hold the attention of the target

audience? This can be assessed inexpensively by exposing a captive

audience to the product within the context of a set of other media

material designed to represent the real-world exposure context.

The question being answered is, "Within the context of competing

media messages, does the target audience attend to the being

tested?" Thus, this type of formative evaluation also addresses

the issue of selectivity directly.

The potential effectiveness (i.e., efficacy) of media product

also needs to be assessed before program dissemination. This can

be accomplished by testing exposed and unexposed (control) groups

for relevant knowledge, attitudes, norms, and intentions. Tests of

efficacy are concerned with the question of, "How effective will

this product be if it reaches the intended audience and they

attend to it?" Thus, relatively small-scale and inexpensive tests

of the responses of samples of the target audience to the media

products in a "captive" situation are appropriate. The suggested

testing of acceptability and efficacy is comparable to the

procedure developed at the Health Message Testing Service of NCI

and NHLBI. Only after it has been established that an efficacious

communications product has been developed, is it worth disseminating

it. Then, the success of the dissemination implementation needs to

be assessed. Implementation evaluation is concerned with determining

things such as how and how well a program or campaign has been

26
disseminated, where and how often a PSA has been aired, and where

and to whom a pamphlet or other written material has been

distributed.

Finally, there is a great need for more high quality outcome

evaluation of mass media campaigns. However, only when it has been

established that an efficacious product has reached the intended

target audience with sufficent frequency is it worth the expense of

attempting summative evaluation. It is at this stage that the

choice between the three major paradigms discussed by Flay and Cook

(1981) becomes relevant.

To conclude, we have suggested that more research is needed on ways

of optimizing mass media drug abuse prevention program dissemination, minimizing selectivity, and maximizing interpersonal communication. This research is needed at both the basic and applied

(evaluation) levels.

FOOTNOTES

1

KNBC in Los Angeles, and some other NBC stations nation-wide, ran

an anti-drug-abuse campaign, "Don't Be A Dope," during April of

1983. It consisted of PSAs, a reasonable number of which appeared

during prime viewing times, one week of five-minute segments during

the early evening news hours, a half-hour information program

presented in a test format, "The Drug Abuse Test," and other

activities.

REFERENCES

Atkin, C.K. Instrumental utilities and information seeking. In:

Clarke, P., ed. New Models for Mass Communication Research.

Vol. 2 Beverly Hills: Sage Publications, 1973.

Atkin, C.K. Research evidence on mass mediated health

communication campaigns. In: Nimmo, D., ed.

Communication Yearbook 3. New Brunswick: Transaction, 1979.

Atkin, C.K. Television advertising and socialization to consumer

roles: In: Pearl. D.; Bouthilet. L.; and Lazar, J., eds.

Television and Behavior. Washington D.C.: NIMH Technical

Reviews, 1982.

Atkin, C.K. Effects of drug commercials on young viewers.

Journal of Communication, 28:71-96, 1978.

Ball. S. Methodological problems in assessing the impact of

television programs. Journal of Social Issues, 32(4):8-17,

1976.

27
Barcus, F.E., and Janowski, S.M. Drugs and the Mass Media.

The Annals of the American Academy, A.A.P.S.S. 417(1):86-100,

1975.

Best, J.A. Mass media, self management and smoking modification.

In Davidson, P.O. and Davidson, S.M., eds. Behavioral Medicine:

Changing Health Lifestyles. New York: Bruner/Mazel, 1980.

Blane, H.T. Education and mass persuasion as preventive

strategies. In: Room, R., and Sheffield, S., eds.

The Prevention of Alcohol Problems: Report of a conference.

Sacramento, California: California State Office of Alcoholism,

255-288, 1976.

Blane, H.T., and Hewitt, L.E. Mass Media, Public Education and

Alcohol: A State-of-the-Art Review. Prepared for National

Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse

and Mental Health Administration, Rockville, Maryland, February,

1977.

Blumler, J.G., and Katz, E. The Use of Mass Communication Beverly

Hills: Sage, 1974.

Brecher, E.M. (and the editors for Consumer Reports) Licit and

illicit drugs. Boston: Little, Brown, and Co., 1972.

Breed, W., and De Foe, J.R. Effecting Media Change: The role of

cooperative consultation on alcohol topics. J Commun,

32(2):88-99, 1982.

Bush, W.V. The National Drivers Test. Columbia Broadcasting

Service, New York: Random House, 1965.

Campbell, D.T., and Stanley, J.C. Experimental and

Quasi-Experimental Designs for Research. Chicago: Rand

McNally, 1966.

Capalaces, R., and Starr, J. The negative message of anti-drug

spots: Does it get across? Public Telecommunications Review

1:64-66, 1973.

Cartwright, D. Some principles of mass communication: Selected

findings of research on the sale of United States war bonds.

Human Relations, 11(3):253-267, 1949.

Cook, T.D., and Campbell, D.T. Quasi-experimentation: Design

and Analysis Issues for Field Settings, Chicago: Rand McNally,

1979.

Cook, T.D., and Flay, B.R. In persistence of experimentally induced

attitude change. In: L. Berkowitz, ed. Adv Exp Soc Psychol.

Vol. 11. New York: Academic Press, 1978.

28
Danaher, B.;, Berkanovic, E.; and Gerber, B. Media-based quit

smoking program. In: Final Report: Community Cancer Control

of Los Angeles. Report to NCI, July, 1982.

Delaney, R.W. Comparison Impact of Two Approaches to Primary

Alcoholism Prevention in Florida -- 1978. Sarasota, Florida:

Department of Health and Rehabilitative Services, Alcohol Abuse

Prevention Project, 1978.

Delaney, R. Florida study looks at effects of media messages

NIAAA Information and Feature Service 5, 1981.

Dickman, F.B., and Keil, T. J. Public television and public health:

The case of alcoholism. J Stud Alcohol, 38(3):584-592, 1977.

Evans, R.I.; Roselle, R.M.; Mittelmark, M.B.; Hansen, W.E; Bane,

A.L.; and Havis, J. Deterring the onset of smoking in children:

Knowledge of immediate physiological effects and coping with

peer pressure, media pressure, and parent modeling. J Appl Soc

Psychol, 8:126-135, 1978.

Field, T.; Deitrick, S.; Hersey, J.C.; Probst, J.C; and Theologus,

G.C. Implementing Public Education Campaigns: Lessons from

Alcohol Abuse Prevention. Summary Report to NIAAA. Washington,

D.C.: Kappa Systems, 1983.

Feingold, P., and Knapp, M. Anti-drug abuse commercials. J Commun,

27:20-28, 1977.

Fejer, D.; Smart, R.G.; Whitehead, P.C.; and La Forest, L. Sources

of information about drugs among high school students. Public

Opinion Quarterly, 35(2):235-241, 1971.

Feldman, J. J. The Dissemination of Health Information. Chicago:

Aldine, 1966.

Flay, B.R. On increasing the chances of mass media health

promotion programs causing meaningful changes in behavior. In:

Meyer, M. ed. Health Education by Television and Radio.

Munich: Saur, 1981.

Flay, B.R. State-of-the-art in mass media and smoking behavior.

Presented at NCI Workshop on the role of mass media in smoking

prevention and cessation. Washington, D.C., February, 1983.

Flay, B.R., and Cook, T.D. The evaluation of mass media prevention

campaigns. In: Rice, R.R. and Paisley, W., eds. Public

Communication Campaigns. Beverly Hills, California: Sage,

1981.

Flay, B.R.; d'Avernas, J.R.; Best, J.A; Kersall, M.W.; and Ryan,

K.B. Cigarette Smoking: Why young people do it and ways of

preventing it. In: McGrath, P.J. and Firestone, P., eds.

Pediatric and Adolescent Behavioral Medicine. New York:

Springer, 1983.

29
Flay, B.R.; deTecco, D.; and Schlegel, R.P. Mass media in health

promotion: An analysis using an extended information-processing

model. Health Education Quarterly, 7(2):127-147, 1980.

Flay, B.R.; Johnson, C.A.; Hansen, W.B.; Ulene, A.; Grossman, L.M.;

Alvarez, L.; Sobol, D.F.; Hochstein, G.; and Sobel, J.L.

Evaluation of a mass media enhanced smoking prevention and

cessation program. In: Baggaley, J.P. and Sharpe, J., eds.

Experimental Research in Televised Instruction. Vol. V. St.

John's, Newfoundland: Memorial University Press, In Press.

Friedrich, L.K., and Stein, A.H. Prosocial television and young

children: The effects of verbal labelling and role playing on

learning and behavior. Child Development, 46:27-38, 1975.

Goldberg, M.E.; Gorn, G.J.; and Gibson, W. TV messages for snack

and breakfast foods: Do they influence children's preferences?

J Consumer Res, 5(2):73-81, 1979.

Goldstein, H.K. Guidelines for drug education through electronic

media. J of Drug Education, 4(1):105-110, 1974.

Goodstadt, M.S. Drug education - Where do we go from here? In:

Ostman, R.E., ed. Communication Research and Drug Education,

California: Sage, 1976.

Goodstadt, M.S. An Evaluation of the Ontario (1975-1976) Alcohol

Education Program: TV and Radio Exposure and Initial Impact.

Toronto: Addiction Research Foundation, Substudy, #847, 1977.

Griffiths, W., and Knutson, A.L. The role of mass media in public

health. Am J Public Health, 50(4):515-523, 1960.

Hamilton, J. L. The demand for cigarettes: Advertising, the health

scare, and the cigarette advertising ban. Review of Economics

and Statistics, 54:401-411, 1972.

Hanneman, G.J. Communicating drug abuse information among college

students. Public Opinion Quarterly, 37(2):171-191, 1973.

Hanneman, G.J.; Eisenstock, B.A.; Hunt, M.F.; and Weinbeck, W.L.

The Medicine Man Message. Vol. I. Los Angeles: Center for

Communications Policy Research, Annenberg School of

Communications, University of Southern California, 1977.

Hanneman, G. J., and McEwen, W.J. Televised drug abuse appeals: A

content analysis. Journalism Quarterly, 50(2):329-333, 1973.

Hanneman, G.J.; McEwen, W.J.; and Coyne, S.A. Public service

advertising on television. J of Broadcasting, 17:387-404, 1973.

30
Hanneman, G.J.; Weinbeck, W.L.; Goldman, R.; Svenning, L.; Nicol,

J.; Quattlebaum, C.T.; and Scoredos, J. The Medicine Man

Message. Vol. 3. Los Angeles: Center for Communication Policy

Research, Annenberg School of Communications, University of

Southern California, 1978.

Harris, L., and Associates. Public Awareness of the NIAAA

Advertising Campaign and Public Attitudes Toward Drinking and

Alcohol Abuse. The National Institute on Alcohol Abuse and

Alcoholism: Report #2352, 1974.

Hersey, J.C.; Field, T.A.; Probst, J.C.; and Theologus, G.C.

Evaluating Public Health Education: A Decision-Making Approach.

Submitted to office of Communications and Public Affairs,. NIDA.

Washington, D.C.: Kappa Systems, 1982.

Hu, T., and Mitchell, M.E. Cost Effectiveness Evaluation of the

1978 Media Drug Abuse Prevention Television Campaign. A final

report submitted to the Prevention Branch, National Institute on

Drug Abuse, 1981.

Hurd, P.D.; Johnson, C.A.; Pechacek, T.; Bast, L.P.; Jacobs, D.R.;

and Luepker, R.V. Prevention of cigarette smoking in seventh

grade students. J Behav Med, 3(1):15-28, 1980.

Johnson, J. Using television to change stereotypes. In:

Spratkin, J., Swift, C., and Hess, R., eds. Rx Television:

Enhancing the Preventive Impact of TV. New York: Haworth

Press, 1983.

Johnson, J., and Ettema, J. An Experiment in Children's Television.

Beverly Hills: Sage, In Press.

Katz, E. On conceptualizing media effects. In McCormack, ed.

Studies in Communication, Vol. 1. JAI, 1980.

Katz, E. On reopening the question of selectivity in exposure to

mass communication. In Abelson et al., eds. Theories of

Cognitive Consistency. Chicago: Rand McNally, 1968.

Katz, E., and Lazarsfeld, P.F. Personal Influence: The Part

Played by People in the Flow of Mass Communications. Glenco,

Illinois: The Free Press, 1955.

Kinder, B.N. Attitudes toward alcohol and drug abuse: II.

Experimental data, mass media research, and methodological

considerations. Int J Addict, 10:1035-1054, 1975.

Klapper, J.T. The Effects of Mass Communication. Glencoe,

Illinois: The Free Press, 1960.

31
Lazersfeld, P.F., and Merton, R.K. Mass communication, popular

taste and organized social action. Reprinted from The

Communication of Ideas. New York: Institute for Religious and

Social Studies, 1948. In: Schramm, W., ed. Mass

Communications (Second edition, third printing). Urbana,

Illinois: University of Illinois, Press, 1975.

Leventhal, H. Findings and theory in the study of fear

communications. In: Berkowitz, L., ed. Adv Exp Soc Psychol.

Vol. V. New York: Academic Press, 1970.

Lewin, K. Group discussion and social change. In: Proshansky, H.

and Seidenberg, B. eds. Basic Studies in Social Psychology.

New York: Holt, Rinehart and Winston, 1947, 1965.

Maccoby, N., and Farquhar, J.W. Communication for health:

Unselling heart disease. J Commun, 25:114-126, 1975.

McCombs, M.E., and Shaw, D.L. The agenda-setting function of the

media. Public Opinion Quarterly, 36:176-178, 1972.

McEwen, W.J., and Hanneman, G.J. The depiction of drug use in

television programming. J Drug Educ, 4(3):281-293, 1974.

Mendelsohn, H. Which shall it be: Mass education or mass

persuasion for health? Am J Public Health, 58:131-137, 1968.

Mendelsohn, H. Some reasons why information campaigns can succeed.

Public Opinion Quarterly, 37(1):50-61, 1973.

Milavsky, R. J.; Bekowsky, B.; and Stipp, H. TV drug advertising and

proprietary and illicit drug use among teenage boys.

Public Opinion Quarterly, 39: 457-481, 1975.

Morrison, A.F.; Kline, F.G.; and Miller, P. Aspects of adolescent

information acquisition about drugs and alcohol topics. In:

Ostman, R., ed. Communication Research and Drug Education.

London: Sage Publications, 1976.

Office of Cancer Communications. The Health Message Testing

Service. Washington, D.C.: National Cancer Institute, Draft

Booklet, 1979.

O'Keefe, M.T. The anti-smoking commercials: A study of

television's impact on behavior. Public Opinion Quarterly,

35(2):242-248, 1971.

Palmgreen, P., and Rayburn, II, J.D. Gratifications sought and

media exposure. Commun Res, 9(4):561-580, 1982.

Pearl, D.; Bouthilet, L.; and Lazar, J. Television and Behavior:

Ten Years of Scientific Progress and Implications for the

Eighties. Alcohol, Drug Abuse and Mental Health Administration,

Technical Reviews. Vol. II. DHHS Pub. No. (AOM) 82-1196.

National Institute of Mental Health Rockville, Maryland, 1982.

32
Pechacek, T.F.; Madden, M.; Wackman, D.; Pirie, P.; Rocella, E.;

and Fruetel, J. Estimating the impact of a televised cessation

program. Presented at American Psychological Association annual

meetings. Anaheim: August, 1983.

Plant, M.A.; Pirie, F.; and Kreitman, N Evaluation of the

Scottish Health Education Unit's 1976 campaign on alcoholism.

Social Psychology, 14:11-24, 1979.

Public Sector Research Group. Evaluation of the 1978 Drug Abuse

Prevent Campaign - Final Report. Washington, D.C.: National

Institute on Drug Abuse, Contract No. 271-12, Fall, 1978.

Rappeport, M.; Labow, P.; and Williams, J. The Public Evaluates

the NIAAA Public Education Campaign: A Study for the U.S.

Department of Health, Education, and Welfare, Public Health

Service, Alcohol, Drug Abuse, and Mental Health Administration.

2 Vols. Princeton, New Jersey: Opinion Research Corp., 1975.

Ray, M., and Ward, S. Experimentation for pretesting public health

programs: The case of the anti-drug abuse campaigns.

Adv Consumer Res, 3:278-286, 1976.

Roberts, D.F. Children and commercials: Issues, evidence,

interventions. In: Sprafkin, J., Swift, C., and Hess, R., eds.

Rx Television: Enhancing the Prevention Impact of TV. New

York: Haworth Press, 1983.

Rossiter, J.R., and Robertson, T.S. Children's dispositions toward

proprietary drugs and the role of television drug advertising.

The Public Opinion Quarterly. 33:316-329, 1980.

Sears, D.O., and Freedman, J.L. Selective exposure to information:

A critical review. Public Opinion Quarterly, 31:194-213. 1967.

Sheppard, M.A. Sources of information about "drugs." J Drug Educ,

10(3):257-262, 1980.

Singer, D.G.; Singer, J.L.i Zuckerman, D.M. Teaching Television:

How to Use TV to Your Child's Advantage. New York: Dial Press,

1980.

Smart, R.G., and Fejer, D. The effects of high and low fear

messages about drugs. J Drug Educ, 4:225-235, 1974.

Solomon, D.S. Health campaigns on television. In: Pearl, D.,

Bouthilet, L., and Lazar, J., eds. Television and Behavior.

Washington, D.C.: NIMH Technical Reviews, 1982.

Swisher, J.D.; Crawford, J.L.; Goldstein, R.; and Yura, M. Drug

education: Pushing or preventing? Peabody J Educ, 49:68-75,

1971.

33
Towers, I.M.; Goodman, L.A.; and Zeisel, H. A method of measuring

the effects of television through controlled field experiments.

Studies in Public Communication. University of Chicago Press,

4:87-110, 1962.

Trager, R. Adolescent reactions to educational media messages

regarding drug education. In: Ostman, R.E., ed. Communication

Research and Drug Education. Vol. III. London: Sage

Publications, 1976.

Wallack, L.M. An Assessment of Drinking Patterns, Problems,

Knowledge and Attitudes in Three Northern California

Communities. Prepared for the California Office of Alcoholism.

Berkeley, Social Research Group, 1978.

Wallack, L. The California Prevention Demonstration Program

Evaluation: Description, Methods and Findings. Berkeley,

California: Social Research Group, School of Public Health,

University of California, Berkeley, 1979.

Wallack, L.M. Mass media campaigns: The odds against finding

behavior change. Health Education Quarterly, 8(3):209-260,

1981.

Ward, S.; Wackman, D.;, and Wartella, E. How Children Learn to Buy:

The Development of Consumer Information Processing Skills.

Beverly Hills: Sage, 1977.

Warner, E. The effects of the anti-smoking campaign on cigarette

consumption. Am J Public Health, 67(7):645-650, 1977.

Warner, K.E. Cigarette smoking in the 1970's: The impact of the

anti-smoking campaign on consumption. Science, 211:729-731,

1981.

Warner, K.E., and Murt, H.A. Impact of the anti-smoking campaign

on smoking prevalence: A cohort analysis.

J Public Health Policy, December, 1982.

Wilde, G.J.S. Evaluation of effectiveness of public education and

information programmes relating to alcohol, drugs and traffic

safety. In: Israelstam, S. and Lambert, S., eds. Alcohol,

Drugs and Traffic Safety. Toronto: Addiction Research

Foundation, 813-823, 1975.

Winick, C., and Winick, M.P. Drug education and the content of mass

media dealing with "dangerous drugs" and alcohol. In: Ostman,

R.E., ed. Communication Research and Drug Education. Vol. IV.

London: Sage Publications, 1976.

Wong, M.R., and Barbatsis, G.S. Attitude and information change

effected by drug education through broadcast TV and group

viewing. J Drug Educ, 8(2):161, 1978.

34
AUTHORS

Brian R. Flay, D.Phil., is Assistant Professor and Assistant

Director of the Health Behavior Research Institute, University

of Southern California, 1985 Zonal Avenue, Los Angeles,

California 90033.

Judith L. Sobel, Ph.D., is a Post-doctoral Fellow and Research

Associate at the Health Behavior Research Institute, University

of Southern California.

35
Social-Psychological Approaches

Alfred L. McAlister, Ph.D.

This paper provides an overview of what I believe to be the most

important social-psychological variables influencing substance

abuse behaviors. To stimulate our understanding of how social policy

can influence substance use, I will present social-psychological

notions in the context of larger, structural and normative influences

on behavior. Most research is organized by differentiating categories

based upon diagnostic or pharmacological concepts. I believe the key

challenge to progress in this field is the development of schemata

for classifying the causes of disparate phenanena across conventional

categories of research. One way is to begin by categorizing causal

variables as specific or general. Specific causes are those which

have a clear relationship with a specific substance use behavior,

but which do not directly influence other such behaviors. For

example, the availability and advertising of tobacco may influence

smoking behavior, but the marketing of cigarettes does not directly

influence other substance use behaviors (although profits fran

cigarette sale may be invested in the marketing of alcohol). General

causes are those which my influence several specific behaviors.

For example, low sociceconomic status seems to increase many behavioral risks, from smoking to diet. Although this is an oversimplification, the specific/general concept my be seen to

distinguish between two realms of research on the social psychology

of drug abuse, i.e., between specific "belief/skill" and general

"personality/environment" orientations. The concept also my be

used to argue for the usefulness of considering drug abuse as part

of some more fundamental sociocultural phenomena.

The significance of distinguishing between specific and general

approaches is most evident when causes of behavior are categorized

according to level of analysis: At the "macro" level are the

broadest societal influences. The "meso" level is the direct social

communication between individuals and their family and community.

At the "micro" level are the psychological processes which control

individual behavior. This categorization scheme does not necessarily

imply a causal hierarchy in either direction, but a bidirectional

flow with environments influencing individuals and individuals

influencing their environments. When specific and general influences

are differentiated first at the societal level, the implications of

differences in underlying "meso" and "micro" processes are magnified.

36
"SPECIFIC" BELIEFS AND SKILLS

Possible specific influences at the societal level are not difficult

to identify. Price, availability, and pranotion of unsafe or unhealthy

products such as handguns or substances such as cigarettes must bear

some relationship with adolescent violence or smoking. Governmental

legislation and regulation may also influence risk-taking behavior,

e.g., lowered legal drinking ages (Smart and Goodstadt 1977).

Another societal factor is the presentation of role models in mass

media and other channels of cultural transmission. These structural,

"macro" influences can become very powerful. For example, China's

policy of harsh punishment for opium trafficking (death penalty for

repeated offense) curbs opiate use while modeling and marketing

tobacco led to steeply divergent trends in use of the two specific

substances (Lowinger 1972).

Of course, these specific structural factors most be applied at the

local level - particularly in the case of substances which can be

easily grown in moderate climates. The enforcement of sanctions and

the marketing of products depend upon the direct efforts of police

and sales personnel. Furthermore, local schools, churches, ethnic

group, and other formal and informal organizations are often

independent sources of specific influence on the behavior of children

and youth (Sherif and Sherif 1974). Group norms are enforced both

through explication of rules and implication of social desirability,

and the two may contradict. Further diversity is introduced at the

level of primary group, where families, teachers,and peer groups

create environments which enforce nom and model behaviors idiosyncratically and are often resistant to external pressures. Parents

and peers are the most proximal specific influences on the behavior

of young people, e.g., for diet, snoking, violent behaviors. All

social influences are themelves a product of the interaction between

individual learning histories and larger forces in the community and

society, i.e., marketing, and media models (Bandura 1977).

Behavior-specific influences at the level of individual psychology

me the learned expectations and skills regarding specific behaviors.

These probably can be understood in the context of current theories

of "reasoned" cognition and learning (Fishbein and Ajzen 1975).

For example, individuals smoke when they expect relatively immediate

positive outcomes (admiration of peers, relief fran anxiety,

increased alertness) and when they know how to acquire and use

cigarettes. Individuals choose not to smoke when they do not expect

rewarding consequences to outweigh negative short- or long-term

effects, and when they have the ability to resist specific social

pressures toward smoking. These beliefs and skills are learned from

direct and mediated observation and from experience. For any

specific health behavior, it is theoretically possible to identify

the behavior-specific cognitive structures associated with specific

patterns of response. The most powerful process relating these

variables to excessive use of drugs may be fueled by the perceived

psychoactive effects of substances like alcohol and tobacco on

affective-emotional experience (Wister 1979). Alcohol is an

effective sedative in large doses. Tobbacco may make it easier to

37
endure stress or remain alert. The process reviewed earlier

involved primarily social factors and are indisputably indicated

in "social" drug-taking habits - i.e., those which produce no more

compulsion or excess than the interpersonal circumstances demand.

The interaction of the direct effects of substances like tobacco

and alcohol with individual psychological factors my underly the

establishment and persistence of chronic self-abusive drug-using

behaviors (e.g., Cahalan and Roan 1974).

To study the social and psychological processes involved in

cigarette and marijuana smoking adoption we developed measures of

four specific influences from four models: friends' smoking, parents' snaking, siblings' smoking, and parents' instructions regarding

smoking (McAlister et al. 1982). We also developed measure of four

clusters of beliefs about the consequences of smoking and three more

general social-psychological factors which we thought might modify

the influence of social factors. These variables were measured by

multiple choice questionnaire items which were included in the

larger base line survey reported above. The items were selected

after direct observational studies and exploratory factor analyses

from a prelimanary survey. We identified three independent belief

clusters: Social desirability Enjoyment, and Punishment. Health

beliefs did not appear to be an organized factor, but an item

measuring health beliefs was included in our analyses ("How often

can a person smoke without it hurting their health?"). A confirmatory factor analysis was conducted on the baseline survey data

using a maximum likelihood estimation procedure. The results are

presented below. Anticipation of enjoyment was found to be the

strongest cross-sectional predictor of smoking.

TABLE 1. Beliefs about Specific Consequences of Smoking:

Factor and Item Loadings (n=1758)

item loading

Social Desirability

If I smoked, older kids would like me more. 0.693

If I smoked, I would have more friends. 0.644

Smoking cigarettes makes you look cool. 0.605

Anticipation of Enjoyment

Kids who smoke have more fun.

If I smoked, I would feel more relaxed.

0.594

0.582

Punishment

If I smoked, I would feel more uptight.

If I smoked, I'd be afraid of getting caught.

Correlation Matrix

0.768

0.392

Enjoyment Punishment

Social Desirability 0.532 -0.014

Anticipation of Enjoyment -0.219

38
"SPECIFIC" APPROACHES TO PREVENTION

Modification of these substance-specific variables my be

hypothesized to influence the probability that young adolescents

will adopt substance-use habits. There is evidence that sharp

increases in penalties for illicit drug use in adult populations

can strongly influence long-term behavior patterns. Lowinger's

(1972) finding that heroin use virtually disappeared from China

when revolutionary law mandated harsh penalties can probably be

attributed to a modification of beliefs about punishnent similar to

those expossed in table 1. But in our culture,the social and

health costs of incarceration have led to a search for more enlightened approaches to prevention. Political values in the United

States often favor efforts to reduce the need for prosecution and

punishment through educational program, although the balance

between expenditures for educational and penal system remains

unsteady. Confidence in educational strategies is low because

studies have shown that providing unbiased, factual information

about the nature of psychoactive, dependence-producing substances

does not reliably prevent abuse and may lead to increased experimentation (e.g., Stuart 1974). Perhaps that findings can be

explained by the tendency for adolescents to be more influenced by

beliefs about short-term enjoyable effects than by beliefs about

long-term health consequences (Evans et al. 1979). Publicized

herbicide spraying my be understood as an attempt to enhance the

salience of beliefs about short-term health consequences in order

to overcome the attraction of what some find to be subjectively

enjoyable effects that are natural properties of psychoactive

substances. Of course, the wisdom of such policies is highly

debatable. In any case, most efforts to find specific educational

solutions to the problem of drug abuse have been disappointing

(Schaps et al. 1981).

As the social psychology of adolescent behavior is more fully

considered, a number of more pranising recent studies have investigated the effects of school-based efforts to alter the perceived

social desirability of substance use and to "psychologically

inoculate" non-users by training subvocal and interpersonal skills

for resisting specific peer pressures toward particular behaviors

(e.g., McAlister et al. 1980). Most studies have concentrated only

on cigarette Smoking behavior (Evans et al. 1979; Perry et al. 1980;

Hurd et al. 1980; Schinke 1981; Puska et al. l982).and evidence is

accumulationg which shows these methods to be highly promising as at

least short-term deterrents to adolescent cigarette use. However,

all current studies have suffered fran two major methodological

flaws: Nonrandom assignment to treatment and failure to use schoolwide data as the unit of statistical analysis. Thus, although

evidence so far is quite encouraging, one must be cautious in

promoting the inference that such education programs can be effective

(Fisher 1980).

To more fully assess the extent to which we can be confident in

recommending the specific social-desirability-belief/peer-pressureresistance-skill approach represented in the work cited above,

39
we identified pairs of comparable junior high (grades 7 and 8) or

middle schools (grades 6-8) in five administrative districts in

Massachusetts and California (McAlister et al. 1982). The schools

in each pair were randomly assigned to treatment or control

conditions in a "matched-pair" design. Because the behavior of

students within schools cannot be considered statistically

independent, schools were the units of observation. Cooperation was

obtained by providing parent and school representatives with detailed

information about the preventive program and its experimental nature,

and insisting that for one school to benefit both must agree to

participate. Randamization was achieved by a coin flip in the

presence of the two principals and their district representatives.

Our research raised issues of privacy, and permission to measure

student's behavior and their perceptions of family and friends'

behavior was given on the condition that students not be uniquely

identified by name or traceable code number. Without that provision,

most of the students could not have participated in our research.

The "treatment" program was based upon previous research and our own

experience. The cigarette smoking prevention component consisted of

a two-year program of 12,45-minute sessions for junior high and

middle school students (ages 11 to 15) which were conducted by high

school students (ages 15 to 18) under the leadership of our research

team. The sessions were designed to interfere with the social

influences which we hypothesized to cause adolescent smoking. Our

objective was to train young nonsmokers to counter-argue subvocally

against both overt and implied persuasive influences toward smoking

and to behave comfortably in situations which include peer pressures

to smole. We assumed that adolescents respond to opportunities to

engage in specific acts primarily because of anticipated social

consequences, e.g., to impress friends by appearing "cool" Ihrough

the use of older nonsmoking peer models, the program was also

intended to create new influences which would reduce the perceived

social desirability of specific behaviors. We accepted the notion

that psychopharmacological effects of nicotine play a role in the

maintenance of smoking behavior, but we did not believe that beliefs

about such effects were important to the ll- or 12-year-old students

toward whom the program was directed.

The curriculum was based on pre-tested material developed during a

pilot study (McAlister et al. 1980). Intervention sessions consisted

of question-answer sessions, films, role plays, and simple contests.

We also distributed buttons and stickers which were written by

students, e.g., "I'm too cool to smoke." We encountered numerous

administrative difficulties. Schedules were sometimes shifted

unexpectedly because of heavy snowfall or teacher strikes. Classes

were often too large or otherwise umnanageable, especially in the

larger schools. Of course, many of these problems; are typical of

any school-based program of health education. Even when implementation was disrupted, the novelty of our peer-led program seemed to

catch students' attention at least as well as most of the other

educational efforts to which they were exposed. Because of organizational and structural problems, implementation of the research

protocol was uneven across the five sites. Most sessions concerned

40
with marijuana were not conducted in the California schools. In

the largest California schools, very large classes and associated

disruption of sessions was a severe constraint on program implementation. To a similar degree, the same problem was encountered

in the two large schools in one of the urban Boston sites. In the

suburban Boston site, a community group helped the control school

to implement a smoking prevention program very similar to the one

that was introduced to the experimental school. The most successful

applications of protocol were achieved at the two smaller sites,

were principal investigators were most frequently involved. These

factors clearly introduce "noise" into the experimental design of

the present study, but they are typical problems that represent the

"real world" in which educational programs are applied.

Data were gathered in classroom settings with self-administered,

anonymous questionnaires in 45-minute sessions led by trained

graduate and undergraduate students fran Harvard and Stanford. To

increase the veracity of students' self-reports of smoking we

conducted a "bogus pipeline" procedure in which saliva and sane

breath samples were collected and identified as a potential accuracy

check (Evans et al. 1977). Measurements in the ten schools were

taken four times:

May 1981.

October 1979 (baseline); May 1980; October 1980;

Of the students enrolled and eligible for the study, 5%

to 10% were absent fran measurement sessions. School administrators

estimate that between the first and last survey periods approximately

30% of the students transferred to other schools. Fluctuations in

sample sixes introduce error to our estimation of trends in the

different populations. But they are random with respect to treatment

and do not threaten the internal validity of our inferences. In the

inner city and California Valley schools with the greatest attrition,

one-third of the original cohort participated in the complete study

or about two-thirds of the total "possible" cohort, i.e., those who

remained in the age-grades and schools that were being studied. The

research sites were highly diverse: The two inner city districts

consisted of middle schools which contained a majority of black

students and were significantly lower in socioeconomic status than

other sites. The two California sites included junior high schools

with a large proportion of Hispanic students in the Valley district.

The suburban district also contained junior high schools, and these

were almost exclusively white. Students there were significantly

higher in socioeconomic status than the California and inner city

districts.

To test the effectiveness of the "treatment" program we compared

changes in the proportion of self-reported smokers in each of the

five pairs. In table 2 the percentage of self-reported regular

smokers (monthly or more often) is presented for each school at

baseline (October 1979) and follow-up (May 1981) for the sample of

respondents who were matched across those two survey points (n=1150).

In two of the sites there is an indication of markedly higher tobacco

smoking onset rates in the control schools than in the treatment

schools. In the third pair, there is a smaller difference in that

direction, while in two remaining pairs there are modest differences

in the opposite direction. Overall, the differences in follow-up

41
smoking rates within pairs can be conservatively tested with a

matched-pair t-test. For tobacco smoking, differences in followup

rates between treatment and control units were at the borderline of

statistical significance (t4=2.69, p < .07 with one-tailed test).

For marijuana smoking, the pattern of differences within pairs is

not systematic. Smoking rates and rates of change are more variable

than was expected, and whatever effects the experimental program

might have had are difficult to distinguish with tests based on

four degrees of freedom.

TABLE 2.

Urban Boston I

experimental

control

Self-Reported Tobacco Smoking

at Baseline and Follow-up (%)

n Baseline Follow-up

37 16.2 7.6

38 10.5 20.5

Urban Boston II

experimental

control

N. Calif. Valley

experimental

control

101 8.0 11.9

66 10.6 20.0

254 7.0 10.2

215 14.0 11.2

56 7.2 3.8

100 4.0 15.3

N. Calif. Coast

experimental

control

Suburban Boston

experimental

control

Some variability among the pairs can be interpreted in the context

of variability in the implementation of the experimental program.

The senior author participated in all phases of implementation in

the smaller urban site and was often directly involved in problemsolving to overcome threats to effective program application in

both urban sites in Boston. In the Northern California Valley

site, organization and administrative constraints led the program

to be delivered in very large classes (40-50). project staff

assigned to that site reported numerous disruptions and other

problem and were not satisfied with the implementation. The

decrease in smoking in the California Valley control school is not

easily interpreted. In the suburban Boston site, the similar trends

in both treatment and control schools can perhaps be attributed to

the control school's unexpected access to aggressive preventive

activities similar to the experimental program. In general, the

variability of outcomes must be seen as a sign that results fran

mall-scale studies my not be too hastily generalized and that

complex experimental program may not be easily disseminated.

150 3.3 11.3

133 5.3 12.2

42
"GENERAL" PERSONALITY AND ENVIRONMENT

More general influences on health behavior are less well understood,

and there are few data to guide theorization (e.g., Mechanic and

Cleary 1980). Little is known about whether or how superficially

dissimilar health behavior problems are related. But sate logical

connections can be hypothesized and fitted into the framework that

organizes my presentation. Based on broad theories of social

psychology, one my hypothesize several factors which might generally

influence health behaviors (McAlister 1980). For example, the

absence of future orientation should bias decisions toward immediate

effects and decrease the extent to which long-term health consequences

are taken into account. Low self-esteem might have a similar effect.

Poor stress-coping skill is another individual factor which may

influence different health behavior problems, e.g., by increasing

the salience of temporary psychological relief gained by making,

drinking or overeating, or by limiting the capacity to make rational

decisions. To the extent to which learning of a variety of health

behaviors depends upon the quality of a child's relationship with

family and school, alienation fran those institutions can be expected

to generally influence the development of diverse health behavior

problems (Jessor and Jessor 1977). These general factors are

important objects of research and were included in the study described

above. The three general social-psychological factors were developed

in a parallel fashion and the results of confirmatory analyses are

presented in table 3. The factors were Self-Image, Family Relationship, and School Relationship. The findings suggest that disturbed

relationships at home and at school are related, but independent;

and that self-image is related to family relationship more than to

school relationship.

To investigate whether the specific processes which seemed to be

important in adolescent-king are modified by these general

social psychological variables, we followed recently specified

procedures for comparing structural coefficients. Results showed

that friends' snokingwas a much stronger influence on the smoking

behavior of students with disturbed family (unstandardized

coefficient = 1.95; p < .005) or school (coefficient = 1.78; p < .025)

relationships than it was on the behavior of the students who were

close to their parents (coefficient = 1.22) and teachers (1.16).

However, we did not observe significantly different effects in the

corresponding groups of students with low or high estimtes of

self-image. These findings do not support the notion that selfimage plays an indirect role in the onset of stroking, but do support

the idea that alienation fran parents and teachers is an indirect

influence toward smoking.

43
TABLE 3. Social-Psychological Factors

and Item Loadings (n=1772)

Self-Image

Things get so rough, I feel I can't win.

I'm nervous when I meet new people.

item loading

0.697

0.547

It's hard to tell if people like me. 0.421

Family Relationship

I follow my parents

When my parents tell

I'm more comfortable

friends.

teachings. 0.715

me to do something, I obey, 0.501

with my family than with my

0.443

School Relationship

I do things just to bother my teacher.

I enjoy doing things I shouldn't do.

Teachers pick on me.

Correlation Matrix

0.688

0.567

0.466

Self-image

Family School

0.296 0.115

Family Relationship -0.384

These kinds of general, social-psychological qualities are themselves

a product of general influences at the level of family and community.

For example, Pratt (1976) has advanced the concept of the "energized

family" to account for variations in the learning of diverse health

behaviors, and lack of parental interest is associated with low

self-esteem. The quality of schooling is another community-level

variable with broad influence. Mechanic (1980) found low educational

attainment to be associated with low rating of physical health,

reports of emotional problems, failure to use seat belts, smoking and

a sedentary life-style. Although many questions remaian, there is

growing evidence that a variety of health behavior problems are part

of a broader pattern of disturbances in family, school and community)

relationships. These disturbances may themselves be the product of

even larger forces, e.g., deterioration of economic conditions or

international relations.

44
"GENERAL" APPROACHES TO PREVENTION

Efforts to intervene in these more general domains may be dismissed

as naive, and problem such as unemployment or the threat of nuclear

war certainly raise political issues that are more complex than

those surrounding specific disease-related policies (Mechanic 1979).

On the other hand, our society my be greatly in need of unifying

concepts that can help focus fragmented disease- or substancespecific concerns and pressures on questions about how society

can meet its most basic and pressing challenges. Furthermore, if

interventions can be found which do alter general health-related

variables, the broad impact on multiple health problem may be

worth the cost of actions more fundamental than the substancespecific programs described in the preceding section.

There is evidence that some basic components of self-efficacy can

be improved and generalized in order to reduce the onset of diverse

problem behaviors. The most relevant area of research is on the

teaching of social skills and competencies related to resistance to

persuasion (McGuire l968; Schinke 1981; Sarason 1981). Botvin and

colleagues (e.g., Botvin et al. 1980) have conducted a series of

studies testing the effects of broad social skills training and

related self-esteem and coping enhancement activities on the onset

of cigarette smoking. Cigarette-specific skills training is included

in the program. This study has methodological shortcomings omitting

attribution of effects to the edification of general socialpsychological factors. But it points with promise toward a high

priority area for future research. Perhaps the most important

question is whether behavioral education can produce enduring

improvements in self-esteem and efficacy without more difficult

alterations in family and neighborhood environments. Even the most

sophisticated educational program directed toward young people may

fail in the face of family disturbance or early failure at school

(Kellm et al. 1982).

There is great challenge and promise in efforts to improve family

and school relationships. A large accumulation of evidence indicates

that alienation fran family and school is a general predisposing

factor toward multiple substance use and other problem behaviors

(e.g., Jessor and Jessor 1977). But few investigators have been

bold enough to intervene to reduce such alienation as a method of

preventing drug abuse. An exception to this is the work of Bry and

colleagues(Bry l982; Bry and George 1980). These stimulating

reports suggest that intensive efforts to improve school attendance

and achievement may be successful. However, the mall number of

subjects and short time-span of these and related studies are

weaknesses which reduce confidence in their implications. Very

recently, The National Institute of Drug Abuse has supported more

extensive investigations of efforts to modify general socialpsychological variables. The most promising is a randomized study

of family relationship improvement1 that is being conducted by

Szapocznik and colleagues at the Spanish Family Guidance Center in

Coral Cables, Florida. Another important study2

 is being conducted

by Gersick and colleagues at the Connecticut Mental Health Center

45
in New Haven, Connecticut. These studies represent ambitious efforts

to test the effectiveness of general approaches to substance abuse

prevention. They illustrate a high priority area for further and

more rigorous empirical study. The cost of programs designed to

address the basic school/family relationship may be great. But if

they can act as a general deterrent of multiple health-related

behaviors, the investment may be highly worthwhile.

Of course, it may not be possible to improve family and school

relationships to any significant degree in conditions of high

unemployment or other sources of stress and social deterioration.

Despite the magnitude of such pressing structural problems, they

are not necessarily beyond the scope of social-psychological analysis

or intervention. Although it may be nearly impossible for the entire

range of specific public health benefits to be evaluated, social

scientists should not avoid opportunities to use their shills to

address the "macro" issues which they believe to be of most general

concerns.

In a recent study in Boston, an effort was made to investigate the

short-term psychological impact of altering an important structural

variable: Eighth grade students were randomly assigned to receive

enhanced opportunity for summer employment related to long-term

career goals (McAlister and Edwards 1983). The study design was

implemented in an inner-city, minority setting of high youth

unenployment where the number of government-sponsored summer jobs

had been sharply cut. All study students completed an interview at

the beginning andendoftheir 8th grade school year. The interview

included measures of future orientation, self-esteem,and coping

styles. Experimental subjects participated in a series of weekly

classroom sessions and field trips designed to increase social

support and self-esteem and to improve coping skills. The summer

jobs were a very salient part of the intervention: There was

anecdotal evidence of short-term increased attendance when the

special forms were passed out. Self-esteem was enhanced by direct

social approval and by identification of positive qualities. Coping

shills were trained by actual problem-solving in all groups were

students were urged to express their most pressing problems, to

discuss solutions and to apply possible solutions experimentally.

All sessions more led by a group of Harvard undergraduates with a

cultural background similar to that of the study participants.

Follow-up differences between self-reports of relevant variables

are presented in table 4. The experimental subjects tend to develop

more positive future-orientation and greater self-esteem and selfefficacy. The difference is significant (p < .05) for futureorientation and at the borderline of significance (p < .10) for

self-efficacy, according to the Kolmogrov-Smirnov test (one-tail

test). The trend for self-esteem is not significant. Data were

not available from about one-third of the participants, with no

differences in attrition between groups. These are, of course,

short-term findings and probably do not indicate stable differences.

Furthermore, the experimental methods are probably not generalizable. Nevertheless, these tentative data point toward what may be

46
an important direction for future, more substantial studies. If

important, general variables related to "'personality and environment" can be altered, some pranising possibilities are encountered.

By concentrating efforts on the most generally important or central

factors, diverse improvements in specific behaviors my be facilitated. Although behavior-specific preventive measures my be

easier to identify and fund, generalized approaches may be the

most fruitful in the long-term. "General" factors may be the most

resistant to change, but their importance probably merits a coalition

of interests broader than those formed by current research organization.

TABLE 4. Follow-up Group Differences

in Future-Orientation and

Self-Esteem

Future Orientation

Do you "look forward"

to your future?

n(%)

experimental control

Yes 27(90) 18(58)

Undecided 3(10) 9(29)

No O(O) 4(13)

Self-Esteem

Do you "like" yourself?

Yes

Undecided

No

31(100) 26(81)

O(O) 4(13)

O(O) 2(7)

Self-Efficacy

Could you "do something

about" a recent problem?*

Yes

Undecided

No

15(65) 12(52)

6(26) 2(9)

2(9) 9(39)

*For those reporting a recent problem.

CONCLUSION AND RECOMMENDATIONS

The most important conclusion is a familiar one: methodological

problems must he overcome before we can confidently make inferences

about how substance abuse can be prevented. Variability among

schools or other settings is sufficient to require that aggregated

data from such settings be viewed as the proper unit of analysis.

Large-scale research with large numbers of schools will be needed

to rigorously assess the effects of experimental prevention programs.

47
Effective tracking procedures are also needed. To assure the

accuracy of outcome data, 'bogus-pipeline" or, ideally, actual

physiological or observational measures are necessary.

Researchers should concentrate on experimental, rather than

correlational, studies. Much is already known about the kinds of

variables which predict substance use. Much less is known about

how those variables can be modified and whether such modification

can influence rates of substance abuse. Only experimental studies

can produce strong causal inferences and clear implications for

policy.

Pranising approaches to "specific" belief- and skill-based

prevention have been identified and these are ready for large-scale

field trials. Smoking prevention strategies based on peer leadership and psychological "inoculation" appear to have at least shortterm effects. Whether these strategies may be usefully applied to

the prevention of marijuana smoking or alcohol abuse rains in

question. The long-term effects of such programs are not known.

promising "general" approaches are emerging more slowly, but should

be considered as an equally high priority for snaller-scale

experimental studies. There is evidence that generally important

social skills can be trained and that family and school relationships can be improved. It is important to learn whether such

improvements can be achieved on a large scale in order to prevent

diverse problem behaviors. General approaches to prevention my

require substantial and sophisticated investments in socialization

systems. But if general approaches effectively prevent the mortality,

morbidity and other social costs associated with a range of negative

health behaviors, the investment may be worthwhile,

FOOTNOTES

1. Family Effectiveness Training, NIDA Grant No. RO1 DA 02694.

2. NIDA Grant No. R01 DA 02721. Contact NIDA or Dr. Kelin Gersick,

Department of Psychiatry, Yale University School of Medicine,

34 Park Street, New Haven, Connecticut 06519.

REFERENCES

Bandura, A. Social Learning Theory. Englewood Cliffs, N.J.,

Prentice-Ball, 1977.

Botvin, G., Eng, A., and Williams, C., Preventing the onset of

cigarette smoking through life skills training, Prev Med, 9:

135-143, 1980.

Bry, B.H., and George, F.E. The preventive effects of early intervention upon the attendance and grades of urban adolescents.

Prof Psych, 11:252-260, 1980,

48
Bry, B.H. Reducing the incidence of adolescent problems through

preventive intervention: One- and five-year follow-up. Am J

Comm Psychol, 10:265-276, 1982.

Cahalan, D., and Roan, R. Problem drinking among Amrican men.

Monograph No. 7. New Brunswick, N.J., Rutgers Center of Alcohol

Studies, 1974.

Evans, R.I.; Hansen, W.B.; and Mittelmark, M.B. Increasing the

validity of self-reports of behavior in a smoking in children

investigation. J Appl Psychol, 62:521-523, 1977.

Evans, R.I.; Henderson, A.H.; Hill, P.; and Raines, B.E. smoking in

children and adolescents: Psychosocial determinants and prevention

strategies. In: Smoking and Health: Report of the Surgeon

General. Washington, D.C., Government Printing Office, 1979.

Fishbein, M., and Ajzen, I. Belief, Attitude, Intention and Behavior.

Reading, MA, Addison-Wesley, 1975.

Fisher, E.B. Progress in reducing smoking behavior. Am J Public

Health, 70:678-679, 1980.

Hurd, P.D.; Johnson, C.A.; Pechacek, T.; Bast, L.P.; Jacobs, D.R.;

and Luepker, R. Prevention of cigarette smoking in seventh grade

students. J Behav Med, 3:15-28, 1980.

Jessor, R., and Jessor, S. Problem Behavior and Psychosocial

Development. New York, Academic Press, 1977.

Kellam, S.G.; Brow, C.H.; and Fleming, J.P. Social adaptation to

first grade and teenage drug, alcohol, and cigarette use. J Sch

Health 52:301-306, 1982.

Lowinger, P. The politics of drugs. Soc Policy, 3:41-43, 1972.

McAlister, A,; Perry, C.; Killen, J.; Slinkard, L.; and Maccoby, N.

Pilot study of smoking, alcohol and drug abuse PreventiOn. Am J

Public Health, 70:719-721, 1980.

McAlister. A.L. Social and environmental influences in health

behavior. Health Educ Q, 8(1):25-31, 1980.

McAlister, A., and Edwards M. General Coping Skills to Promote

Adolescent Health and Responsibility. Report to the W.T. Grant

Foundation, May, 1983.

McAlister, A. Smoking, Alcohol, and Drug Abuse: Onset and Prevention,

in Surgeon General's Report on Health Promotion and Disease Prevention

Background Papers. DHHS, 1979.

McAlister, A.L.; Gordon, N.P.; Milburn, M.; Krosnick, J.; Maccoby,

N.; Perry, C.; Kearney, S.; Telch, M,; Killen, J.; and Carmen, D.

"Experimental and Correlational Tests of a Theoretical Model for

Smoking Prevention." Invited paper presented at Society for

Behavioral Medicine annual meeting, Detroit, Michigan, March, 1982.

McGuire, W.J. Personality and susceptibility to social influence.

In: Borgatta, E.F., and Lambert, W.W., eds. Handbook of Personality

Theory and Research. Chicago: Rand McNally, 1968. pp. 1130-1187.

Mechanic, D. Future Issues in Health Care. New York, The Free

Press, 1979.

Mechanic, D. Education, parental interest, and health perceptions

and behavior. Inquiry, 17:331-38, 1980.

Mechanic, D., and Cleary, P.D. Factors associated with the

maintenance of Positive health behavior. Prev Med, 9:805-814, 1980.

Perry, C.L.; Killen, J.; Slinkard, L.A.; and Danaher, B.G. Modifying

smoking behavior of teenagers: A school-based intervention. Am J

Public Health, 70, 1980.

Pratt, L. Family Structure and Effective Health Behavior: The

Energized Family. Boston, Houghton-Mifflin, 1976.

49
Puska, P.; Vartiainen, E.; Pallonen, U.; Salonen, J.; Poyhia, P.;

Koskela, K.; and McAlister, A. The North Karelia Youth project:

Evaluation of two years of intervention on health behavior and

CVD risk factors among 13- to 15-year old children. Prev Med,

11:550-570, 1982.

Samson, B. Tbe dimension of social competence: Contributions fran

a variety of research areas. In: Wine, J.D. and Smye, M.D., eds.

Social Competence. New York: Academic Press, 1981.

Schaps, E.; DiBartolo, R.; Moskowitz, J.; Palley, C.S.; and Churgin,

S. A review of 127 drug abuse prevention program evaluations.

J Drug Issues, 11:17-43, 1981.

Schinke, S.P. Interpersonal skills training with adolescents. In:

Hersen, M., Eisler, R.M., and Miller, P.M., eds. Progress in

Behavior Modification. Vol. II. New York: Academic Press, 1981.

Sherif, M., and Sherif, C.W. Reference Groups: Exploration into

Conformity and Deviation of Adolescents. New York, Harper and Row,

1974.

Smart, R.G., and Goodstart, M.S. Effects of reducing the legal

alcahol purchasing age on drinking and drinking programs: A

review of empirical studies. J Stud Alcohol, 38:1313-1323, 1977.

Stuart, R. Teaching facts about drugs: Pushing or preventing?

J Educ Psychol, 66:250-255, 1974.

AUTHOR

Alfred L. McAlister, Ph.D.

Associate Professor

University of Texas Health

Science Center at Houston

Center for Health Promotion

P.O. Box 20708

Houston, TX 77025

50
Doing the Cube: Preventing

Drug Abuse Through Adolescent

Health Promotion

Cheryl L. Perry, Ph.D., and

Richard Jessor, Ph.D.

Drug abuse among adolescents has become a major health concern

in American society. The relation of drug abuse to motor

vehicle mortality and morbidity, to long-term chronic diseases,

and to other risk-related behaviors such as precocious or

unprotected sexual intercourse is now generally recognized.

With earlier onset, wider prevalence, and heavier involvement

in health-compromising behaviors (especially tobacco, alcohol

and marijuana use) has come broader interest in the possibilities for interventicn. Over the past decade, interest has also

grown in the concepts of health and of health promotion. The

conceptual linkages that unite these two interests, the prevention of drug abuse and the promotion of health, are the key

concerns of this paper.

The first major aim of the paper is to help clarify the meaning

of health promotion as an intervention modality. The sketching

out of a conceptual framework from which to view health promotion makes it possible to examine its aims, its structure, and

its approach in a more logical fashion. The major health promotion prgrams that have included a drug abuse prevention component are then reviewed by employing that conceptual framework; that is the other major aim of the Paper.

Among the variety of intervention options and programtatic components, it is necessary to stress at the outset that it is not

currently possible to assert what is really effective empirically. The reason for this is not that the health promotion

projects to date have not been innovative and insightful, but

that health promotion research and the complexities of such

large-scale projects have yielded, thus far, only partial

results, and their outcomes have been compelling.

Still, health promotion has gained considerable momentum and

support; the pragrams have achieved greater specification of

key intervention elements; and some promising results are

beginning to emerge. In exploring how adolescent health promo51
tion can have logical relevance for the preventionof drug

abuse within these programs, this review may also serve to

illuminate the larger potential of that approach.

TOWARD A CONCEPTUAL FRAMEWORK FOR HEALTH PROMOTION

It seems necessary, first, to provide some conceptual clarification of the notions of "health" and "health promotion." Each

carries a range of meanings that have differing personal,

social, and political significance. The terms health and

health promotion are generally used without explicit definition

and with an assumption that there is broad consensus on their

meanings. Clearly, that is not the case.

The Concepts of Health and Health Promotion

With respect to health, most definitions tend to emphasize

variation in illness. Historically, health has been defined as

a residual category, that is, as the absence of disease. More

recently, definitions such as that of the World Health Organization have a more positive character: health is a "state of

complete physical, mental, or social well-being and not merely

the absence of disease or infirmity" (WHO, 1958). Other definitionshave emphesized effective social functioning, adequate

role or task performance, realistic personal aspirations, the

ability to cope and adapt, or sinqly extended longevity

(Baranwski 1981). Then-ore recent definitional literature on

health, while still not providing explicit criteria for health,

or the specific competencies required to be labelled "healthy,"

doesalertthe reader to damains of health other than merely

physical. In so doing, it provides us with a more positive

definition than just the absence of disease.

The concept of health promotion remains even less fully

explored. Its usage overlaps considerably with the notion of

disease prevention, largely reflecting, again, aviewofhealth

as the absenceofdisease. Health promotion is generally associated with changing particular health practices or healthrelated behaviors. In Healthy People (1979) for example,

health promotion is used in relation to cessation of smoking,

reduction of alcobol and drug we, control of stress,modification of unhealthy diet, and increase of exercise. Such a

listing of what are mainly behavioral deletions is quite

characteristic of most definitions of health promotion. Something similar appears in the Canadian Lalonde Report (1974) and

is also evident in the wall known list of health practices

suggested by Belloc and Breslow (1972).

52
In more recent publications, the concept of health promotion

has been elaborated to be more broadly encompassing. Thus, it

now includes health education and related organizational,

environmental, and economic interventions designed to support

behavior conducive to health" (USDHHS 1981), and "efforts to

reduce unhealthy behaviors, improve preventive services, and

create a better social and physical environment" (McAlister

1982). These definitions, as well as those of others (Taylor

1991; Rootman 1982), make clear that health promotion is concerned with more than the reduction or deltion of specific,

health-compromising behaviors, that it may involve a variety of

methods to instigate the adoption of alternative behavior, and

that it can extend to include environmental changes that would

serve to support such adoption.

From our own view point, the concept of health encompasses at

least four interrelated domains. As may be seen in Figure 1,

these include physical health, psychological health, social

health, and finally, what we call personal health. Physical

health refers to processes of physical and Physiological

functioning and their adequacy and efficiency. An indicator of

at least minimal health in this domain would be the lack of

dysfunction, with other indicators (e.g. blood pressure,

cholesterol measures, resting heart rate, carbon nonoxide) used

to assess varying degrees of physical health. Psycological

health refers primarily to a subjective sense of well-being, a

self-appraisal of how one generally feels. It involves such

areas as a self-concept of personal competence, the sense of

fitness and energy, feelings of wall-being, and, internal

locus-of-control. An indicator of a state of minimal

psycological health might be not being depressed. The third

domin of health, social health, refers to a person's social

effectiveness: the ability of the individual to fulfill tasks,

perform roles, and learn necessary skills for adaptive

functioning within the social setting. An indicator of at

least a minimal state of health in this domain might be the

ability to carry cut the basic tasks and skills of assigned

roles. Personal health is the final health domain. By

personal health, we mean that goes beyond a adequate or

effective functioning in the other three domains. By speaking

of health of the person, we want to emphasize the possibility

of inner capabilities, resources, and talents of an individual

that may be not be tapped or elicited by the ordinary circmstances of everyday life. A concern with personal health

implies that, within the individual, there is potential for

fulfillment of other dimensions of the person, ones that are

not necessarily instrumental, and that permit the full

53
FIGURE 1

Domains of Adolescent Health
development of what a person can become. A minimal indicator

of personal health might be a viable interest in activities and

experiences that enable the person to transcend the status quo.

The relevance of these multiple domains for defining health

becomes obvious when considering drug abuse as behavior that is

health-compromising for adolescents. If only physical parameters are used, then concern about the health-compromising consequences of drug abuse would be limited primarily to drugrelated accidents and injuries and in the long term, to

chronic disorders and morbidity. But this would exclude fran

consideration the compromising consequences of drug abuse in

the other domains of health; Figure 2 provides examples of

some of these.

We should make it explicit here that our use of the term "drug

abuse" refers to that level of drug use (either frequency or

intensity) that impairs healthy functioning in at least one of

the health domains. At the same time, it is important to

recognize that more moderate levels of drug use may not compromise the health of the user and, in some instances, could conceivably be health-enhancing.

Health promotion can now be seen, follwing this definition of

health, as the implementation of efforts to foster improved

health and well being in all four domains of health.

Complementary Strategies for Health Promotion

Efforts to pramote health can be divided into two main types:

those that are oriented toward weakening, reducing, and eliminating behaviors that compromise health; and those that are

oriented toward introducing, strengthening, and reinforcing

behaviors that enhance health and that may, in addition, be

incompatible with health-compromising behavior. Empheasizing

both of these complementary strategies for health promotion

makes it clear that health enhancement cannot be seen simply

as a residual outcomes of reducing health-compromising behavior.

Neither can it be seen as including cnlydirect efforts to

advance health tile ignoring the necessity of reducing healthcompromising behavior at the same time. A comprehensive

approach to health promotion should represent the optimal

balance of attention to strengthening health-enhancing behavior

and, simultaneously, to reducing health-compromising activities

(see Figure 3).

In any discussion of such categories of behavior as healthcompromising and health-enhancing, it is important to under55
FIGURE 2

Adolescent Drug Abuse

As Health-Compromising Behavior
FIGURE 3
stand the relations among the behaviors in each category and

between the categories. Thus, it is already clear that there

is strong evidence for covariation among at least- subset

of health-compromising behaviors , e.g., drug and alcohol abuse,

smoking, precocious sexuality, and delinquency, and that they

may constitute a sydrome (Jessor 1983a). Evidence for similar

cwariation among health-enhancing behaviors is, at this point,

slim. Evidence for an inverse relationship between healthenhancing and health-compromising behavior is essentially non

existent. Yet these possible patterns of relationship among

health-related behaviors would have enormous significance for

the kind of complementary health promotion approach emphasized

here. In cur view, this is an area that warrants immediate and

extensive researchattention. Irrespective of the ultimate

findings about covaration with and between these two categories, however, health promotion, as an apprcach, should be

seen as logically encompassing both strategies.

Foci of Intervention

Given both strategies, the next issue is just how to implement

then, that is, how to intervene to strengthen health enhancing

and,at the same time, to diminish health-compromising

behavior? In short, what is really being asked is a more

general question, namely, how to achieve change in social

behavior, especially health-compromising behavior such as drug

abuse?

Answering that question requires reliance on theory about the

kinds of factors that are related to and can influence the

occurrence of behavior. In the last decade or two, a number of

formulations have been developed that are relevant to our concern with health-related behavior and behavioral change.

Although our perspective is most directly influenced by one of

those, namely Problem-Behavior Theory (Jessor and Jessor 1977),

it is a perspective that is shared by a number of different

social-psychological approaches. What is common to them is a

concern with three major levels of analysis; (1) the level of

behavior, (2) the level of personality, andq (3) the level of

environment, and an awareness that efforts to change behavior

can be focused at any one, or all, of these levels (Bandura

1977; Fishbein & Ajzen 1975).

The possibility that Problem-Behavior Theory can be apposite to

the domain of health-compramising behavior as well derives from

a consideration of the overlap that exists amomg three conceptually different categories of behavior: problem-behavior,

58
health-compromising behavior, and psychopatholcgical behavior.

As can be seen in Figure 4, there is a substantial intersection

of these three realms. That intersection includes a number of

the behaviors that have been dealt with in the past by

Problem-Behavior Theory and that are of concern to us

because they can be seen simultaneously, and unequivocally, to

be health-compromising.

Further elaboration of the implications of Problem-Behavior

Theory for behavioral health can be found elsewhere (Jessor

1983b); our present aim is to incorporate into our health

promotion conceptualization the three levels, behavior,

personality, and environement, at which interventions can be

directed in efforts to promote health.

Health-related interventions at the level of behavior would

focus on weakening or elimininating parrticular healthcompromising behaviors. Smoking cessation programs and alcohol

moderation campaigns exemplify such efforts, directly focused

as they are on the behavior of concern.

Still at the level of behavior, interventions can also focus on

introducing or strengthening other behaviors that can serve as

substitutes for or alternatives to the behaviors of concern,

and may also be incompatible with drug use,such as running

vis-a-vis smoking, new hobbies or social activities that serve

psychological functions similar to those of drinking and drug

use.

Health-related interventions at the level of personalilty would

focus on reducing the strength of particular personality dispositions that sustain health-compromising behaviors including

drug use, for example, risk-taking orientation, tolerance of

deviance, or sensation-seeking tendencies.

Still at the level of personality, health-related interventions

can also focus on introducing or strengthening other personality dispositions that could increase the likelihood of

health-enhancing behavior, such as increasing personal value on

health and fitness, strengthening internal locus-of-control

about health, or teaching the importance of a sense of social

responsibility.

At the level of the environment, health-related interventions

would focus on eliminating or weakening those aspects of the

environment that support to permit engagement in healthcompromising behaviors, for example, access to health59
FIGURE 4

Behavioral Domains Relevant to

Adolescent Health Promotion

PROBLEM

BEHAVIOR

PSYCHOPATHOLOGY-ROLE FAILURE

HEALTHCOMPROMISING

BEHAVIOR
compromising materials such as drugs, exposure to influential

models for health-comprmising behavior, and social support for

engaging in such behavior.

Still at the level of the environment, interventions can also

focus on providing access to, or creating opportunities for

alternative health-enhancing behavior, promoting exposure to

influential models who exhibit health-enhancing behavior, and

making available reinforcement for positive changes in

behavior.

Interventions at any of these levels, and by either major

strategy, should be judged succesful,we would argue, to the

extent that they reverberate across all four domains of health.

The more domains that an intervention impacts, the greater the

effect would be on health. In designing, selecting, or implementing particular intervention efforts or options (whether at

the level of behavior, personality, environment, or any conbination of these levels), consideration should be given to the

breadth of their impact across fourd domains of health.

Interventions that impact more of the domains are obviously to

be preferred.

To review, the major emphases that we have discussed in conceptualizing health promotion can be seen constituting as three

dimensions. One dimension involves the four domains of health:

physical, psychological, social, and personal; the second

dimension includes the two strategies for health promotion:

weakening or eliminating health-compromising behavior, and

introducing or strengthening health-enhancing behavior: and the

third dimension consists of the three foci of intervention:

behavior, personality, and the enviroment. These various considerations generate a three-dimensional model that can be

represented as a cube (see Figure 5).

The fundamental position taken in this paper is that a

comprehensive approach to drug abuse prevention through health

promotion would require "Doing The Cube."

MAJOR HEALTH PROMOTION PROGRAMS

Using the health promotion framewo rk provided by the cube, we

can turn more systematically to the literature that focuses on

health promotion adololescent drug abuse interventions. We

have restricted our puview to those major programs of intervention research that have making, drinking, or marijuana use

by adolescents as dependent measures, yet have health as an

61
FIGURE 5

Doing the Cube:

A Three-Dimensional Model of

Adolescent Health Promotion
intervention focus. Most other kinds of intervention

approaches can also be mapped onto the cube conceptually.

However, since they are, for the most part, aimed more at drug

abuse prevention than at health promotion, wa have excluded

them from this review. Because the first author is responsible

for youth education for the Minnesota Heart Health Program, it

seems appropriate to begin with a description of that pogram

and to present somewhat more detail and program description

about it than will be possible with the other programs.

The Minnesota Heart Health Program is a community-based

demonstration project to enhance cardiovascular health and to

reduce morbidity and mortality from cardiovascular diseases

(heart attack and stroke) in three northern midwestern communities. The approach involves a nine-year education program

in the communities, annual risk factor assessments cm a sample

of the adult populations in three "educated" and three comparison communities, and morbidity and mortality surveillance.

The education program is aimed at the entire community,

including children, adolescents, and the elderly. Significant

changes in smoking prevalence, eating patterns, physical activity levels, and hypertension management are targeted objectives (Blackburn et al. 1983; Mittelmark et al. 1983).

Youth are viewed as a specific target group within the larger

educational program (Perry and Murray 1982). Interventions for

youth parallel the organizational designofthe adult education

program and reflect the special expertise of the youth working

group. Three types of intervention modalities are used:

health behavior campaigns, educational interventions, and

community-organization programs (see Figure 6).

Health behavior campaigns focus on changes at the larger,

impersonal environmental level. These emphasize awareness,

knowledge, motivation, trial behavior, and larger environmental

charges. An example of a campaign around smoking is the

recent community-wide quite and Win contest (Pechacek 1983).

The contest encouraged adult smokers to and Win by providing drawing for a prize (a trip to Disneyworld funded by

the local community to contestants who quit smoking and

remained non-smokers throughout the month of January.

Adolescents also became involved in this effort through their

initiation of Kwit Smoking This Year (KSTY) interviews about

smoking with adults in the community. The leading adolescent

KSTY interviewer, that is, the student who had interviewed the

most adults, was recognized and rewarded with a 10-speed

bicycle. Children in elementary schools were also involved

63
FIGURE 6

Minnesota Heart Health Program:

INTERVENTION MODALITIES
directly by being instructed by Mickey Mouse, in a visit to

their classrooms, on how to encourage their parents or other

relatives to join the Quit and Win contest.

Educational interventions are the second modality, and their

focus is on changes in the immediate, personal environment of

individuals in the comnunity and of targeted subgroups. They

include behavioral screening centers and special classes aimed

at changing health behavior. Targeted subgroups include, among

others, health professionals, physicians, restauranteurs,

grocers, church attendees, and employees in articular organizations. The programs for youth tend to be school-based,

skills training, behavior change programs. Hearty Heart and

Friends, for example, is a twenty-hour pragrann designed to

change eating and exercise patterns among third and fourth

grade students. It includes a slide-tape cartoon adventure

series depicting health-enhanced and health-compromised

archetypal characters, food selection and cooking skills,

regular aerobic physical activity, and homwork which involves

skills practice assigmnents.

Community-organization programs, the third modality, focus on

charnges in the social enviroment through the identification

and education of key community leaders, organization of task

forces on the overall porgram, smoking, eating, exercise, and

hypertension, and community-initiated projects such as

community-wide walks (Volksmarching) and changes in grocery

store food product labeling. students in junior high school

are elected as health camcil representatives. They are

trained as peer leaders to conduct our junior high school

drug abuse prevention program, "Keep It Clean," and initiate

their own projects, such as health newpapers or cross-age

teaching al health.

All of these activities are designed to promote behavior

change. To accomplish that, we feel it is necessary, theoretically, to: provide health-related information, change values

on health, develope new norms for health-related behavior, promote models for health-enhancing behaviors, enlarge the health

skills reperotire, create opportunities and support for trial

behavior, remove barriers to behavior change, provide social

support and reinforcement for change, and develop new individual group, and organizational expectations for behavior (see

Figure 7).

What is expected, as the outcome of the youth intervention

activities seeking to effect these environmental, behavioral,

65
FIGURE 7

Minnesota Health Program:

EDUCATIONAL PROGRAM
and personality level changes, is the adoption of certain

health-enhancing behaviors (healthy eating, regular physical

activity, sufficient sleep, seat belt use) and the reduction of

certain health-compromising behaviors (salt and fat consumption, tobacco smoking, excessive drinking, and marijuana use).

These specific intended outcomes are being measured at a

community-wide level with targeted adolescent cohorts in both

the intervention and the comparison commities to assess the

overall impact of these efforts. Outcomes are also being

measured within the intervention communities, to assess the

relative effectiveness of particular intervention strategies.

Since the project is still in an early stage, empirical

findings are not yet in hand, and no evaluation of the success

of the approach can be made at this time.

Although it is not possible to provide a description and

analysis of all the other health promotion program at this

level of specificity, this overview of our program should help

to clarify how particular theoretical constructs suggested by

the cube can be implemented within a health promotion program.

What has been left out of even this discussion, however, ought

not to be minimized, namely, the enourmous time: cost,

ingenuity, and effort that are required to translate theory

into specific strategies and programs within a given community.

It is precisely these more pragmatic considerations that

ultimately have decisive influence on the effectiveness of any

health promotion program.

The other program to be reviewd are all large-scale health

promotion projects that have, as one outcome goal, the reduction of adolescent smoking, drinking, or drug use. Programs

that meet these criteria include: the Stanford Heart Disease

Prevention Program, the Pawtucket Heart Health Program, the

Chicago Heart Health Program, the North Karelia Project, the

Oslo Youth Study, and the International Know Your Body Program.

The Stanford, Pawtucket, and North Karelia Projects are all

concerned with improving cardiovascular health and reducing

orbidity and mortality from cardiovascular disease at the

community level. Each also includes a youth component. The

Oslo Youth Study, the Know Your Body Program, and the chicago

Heart Health Program are concerned with the prevention of

chronic diseases such as cancer and heart disease, and are

targeted solely toward youth. In this presentation, we will

restrict our description to the youth events of the various

projects and their outcomes, especially in regard to drug abuse

prevention.

67
The North Karelia Youth Project included an educational intervention in four schools within the tarqeted county in Finland

(Vartianinen 1962). Two schools were involved in intensive

interventions directly involving project staff. Two other

schools participated in the intervention but relied on regular

school staff. Two schools in the reference county served as

controls. The interventions were conducted over a two year

period with 13-to-15-year-old students. The intervention consisted of reduced fat and salt in the cafeteria offerings,

classroom instruction on nutrition and health, home visits with

high-risk students by a nutritionist, risk factor screening and

review (using a Health Passport), parent meetings on health

education, and a peer-led smoking prevention program. At the

end of two years, students in the intensive intervention

schools reported significant decreases in fat consumption and,

for girls, there was a reduction in cholesterol levels compared

to students in the control schools. No significant changes in

blood pressure or salt use were noted. With regard to cur

present concern with drug abuse prevention, students in the

intensive intervention program had a lower smoking prevalence

rate than students in the control schools, according to their

self-reports.

The Stanford Heart Disease PreventionP rogram included smoking

and drug use prevention interventions for junior and senior

high school students as the youth commponent of the Program.

Two junior high schools and four high schools received

educational interventions. For the junior high intervention,

two junior high schools within the target communities served as

control schools. The junior high intervention was conducted

over a two year period with l3-to-15-year-old students. The

intervention consisted of a peer-led drug abuse prevention

program involving social skills training sessions, school

environment changes (including P.A. announcements, posters, and

T-shirts), and an alternatives program involving health

education and exercise for high-risk students. The high school

smoking `intervention employed a within-schools design to compare

three intervention approaches. The program involved classman

teachers and college students who taught social skills,

demonmstrated physiolcgical effects of smoking, and introduced

cessation methods to students in health education classes. At

the end of twm years, students in the intensive junior high

program had a lower self-reported smoking prevalence rate than

did students in the control schools(McAlister,personal

communication.) At the end of the first year, students in all

of the high school programs showed significant reductions in

smoking rates, as indicated by their self-reports (Perry 1983).

68
The Pawtucket Heart Health Program includes school district

curriculum revisions in health education and some intensive

interventions (Rosenberg 1983). Programs in grades 3, 6, and

9 involve classroom instruction in heart health, nutrition, and

physical activity. An intensive peer-led smoking prevention

program is currently being implementedd in schools. At the

end of the first year of the study, no data on behavioral

outcomes related to drug use are as yet available.

The Oslo Youth Study includedand educational intervention in

three schools Oslo, Norway. All three schools received

intensive interventions directlyinvolvingproject staff; three

additional schools in Oslo serves as control. The

interventions were conducted over a two-year period with

13-to-15-year-old students. The intervention components were

essentially the same as those described for the North Karelia

Youth Project (Tell 1982). At the end of two years, students

in the intensive intervention schools reported significant

decreases in fit consumption and,correspondingly, increases in

consumption of complex carbohydrates. Males in the intervention schools also demonstrated increased levels of physical

activity. With regard to drug abuse prevention, students in

the intensive program had a lower smoking prevalence rate than

students in control schools, according to students selfreports (Tell, personal communication).

The International Know Your Body Program involved 17, 150

students, ages 13-to-15, in fifteen countries. Each country

designed its own within-country research project. (The North

Karelia and Oslo Youth projects were, incidentally, part of the

Know Your Body Program.) The interventions are conducted in

Schools. They consist of a general screening of health habits

and risk factors, feedback to students on their risk profile

via a Health Passport, and teacher-facilitated classroom

activities in nutrition, making, drug use, and pyhsical

activity. At the end of-year, risk factor screeninq and

student feedback was completed for all fifteencamtries

(Wynder et al. 1981). Results of the interventions in North

Karelia and Oslo are reported above, although both projects

added a smoking prevention intervention. Recent intervention

activities in New York with fifth grade students in three

school districts yielded lower fat consumption, increases in

health knowldge, increases in fitness levels, and lower saliva

thiocyanate levels (Arnold 1982). With regard to our concern

with drug abuse prevention, very little can be concluded at the

present time about the efficacy of the Know Your Body Program

for reducing eventual drug use.

69
The Chicago Heart Health Curriculum Project involves inerventions with sixth grade students in 34 classes in the Chicago

public schools (Sunseri et al. 1982). Five sixth grade classes

same as controls. The intervention consists of fifteen

sessions of a curriculun called "Body Power" and involves five

health modules. The modules include anatomy and Physiology,

nutrition, physical activity, and risk reduction. One additional studuent is aimed at smoking. At the end of the first

year of intervention, students reported increased knowledge in

all five areas covered by the curriculum and improved attitudes

toward nutrition as compared to students in the control

classes. These effects were augmented by direct parental

involvement in heart health classes. With regard to drug abuse

prevention, students in the intervention program demonstrated

less interest than control students in buying cigarettes; no

effect on actual smoking behavior was reported.

Several other major health promotion program currently underway are in the implementation stage , or their evaluations are

not as yet completed. In Sweden and in Canada, for example,

health promotion efforts include nation-wide campaigns to prevent adolescent cigarette making, and to minimize drinking and

drug we. Both nations are using mss media and intensive,

provincial, school-based interventions (Tibbin 1980). other

health promotion programs, such as the one in Galveston, do not

include a focus on adolescent drug-related interventions.

CONCLUSIONS

Several generalizations can be made from this review of

programs that emphesize health promotion. All of them give

attention to health-enhancing as well as to health-compromising

behavior. Characteristically, the attention to healthenhancement focuses on increased physical activity and healthy

eating patterns. The attention to reducing health-compromising

behavior has almost exclusively been focused on cigarette

smoking, with hypertension as a secondary concern. Almost no

attention has been given to the moderation of alcohol use or to

diminution of illicit drug use such as marijuana. The domain

of health that is implicated in these programs is, in almost

every case, Physical health. Originally, their main focus of

intervention has been behavioral: secondary attention has been

given to the environment, and personality has not received much

attention at all in any of these programs.

Considering the nunber of programs reviewed, the magnitude of

resources invested in them, and the scope and intensity of

70
effort involved, it is unfortunately the case that little

information can be gleaned from them about the unique efficacy

of health promotion as an approach to adolescent drug abuse 

prevention. What has emerged- from most of the studies is that

adolescent cigarette smoking can be affected, either by

delaying its onset or by reducing its prevalence. While this

is an important outcome of the overall intervention approach,

it is not possible to attribute that outcome to the promotion

of health-enhancing behavior; rather, it seems to reflect

primarily the very direct focus on reducing making behavior.

Indeed, none of the research designs permits the disentangling

of intervention components in a way that enables specific

causal inference. It is clear, then, that an adequate test of

health promotion and its complemantary strategies has not

yet been accomplished.

Future research on health promotion as an approach do drug

abuse prevention should, nevertheless, be able to benefit from

the pioneering work accomplished by the programs we have

described. It should also be able to benefit fran the conceptual clarification that is now actively underway in the health

promotion field (Kickbusch 1983). Already, however, there

seems to be a sufficient basis for making a half-dozen general

recommendations

First, and not surprisingly, it seems time for adolescent

health-on interventions to be guided by and logically

derived from a theoretical framework relevant to adolescent

drug use and to adolescent development. The relative paucity

of theoretical elaboration ought no longer to be acceptable

given the size of investment generally involved.

Second, health promotion interventions should seek to implement, simultaneously, both complementary strategies: the

introduction or strenghtening of health-enhancing behavior and

the elimination or wakening of health-compromising behavior.

In this regard, research designs are needed that will permit

the specification of the relative contribution of each strategy, and of their interaction.

Third, health promotion interventions need to encompass more

than their custanary focus on behavior alone. More attention

to environmental change clearly seems to be warranted,

including the larger environment of the social norms and social

supports that regulate the occurrence of behavior, whether

health-enhancing or health-compramising. Attention to changing

personality attributes, both those proximal to specific health

71
behaviors, such as value on fitness, and. those more distal,

such as a general sense of personal competence, seems long

overdue as well.

Fourth, the level of behavior, itself, would seem to warrant

more conceptually oriented research within health promotion

programs for drug abuse prevention than there has been in the

past. Recognition of the well-established co-variation among a

number of health-compromising behaviors makes it essential to

have interventions that focus on multiple behavior targets and

are able to assess multiple behavioral outcomes. Further,

knowledge is needed about the possible co-variation among

health-enhancing behaviors as well, and about their relationship to health-compromising behavior. Research on the

functions or meanings of the behaviors in both of these categories would permit much more sensitive efforts at interventions seeking to substitute less health-compromising behavioral

alternatives that can serve similar psychological functions or

have similar meanings for an adolescent.

Fifth, health promotion interventions would be strengthened by

orienting them toward all of the health domains more explicitly, and including social and personal health. This

suggests, at the very least, the promotion of opportunity for

self-improvement through, for example, access to employment,

education, and recreation, and the opportunity to explore

potential aptitudes and undevelpoed talents.

Finally, as these recomendations all seem to indicate, a

salutary develoment in future healt promotion interventions

to prevent adolescent drug abuse would be an increase in more

comprehensive programs that could rightfully claim that they

are: "Doing The Cube."

REFERENCES

Arnold, C.B. Coronary risk factor intervention in childhood.

NIH Research Progress Support. Rockville, Maryland: CRISP

system. Washington, D.C.: U.S. Government Printing Office,

1982.

Bandura, A. Social Learning Theory. Englewood, NJ:

Prentice-Hall, 1977.

Baranowski, T. Toward the definition of concepts of health and

disease, wellness and illness. Health Values, 5: 246-256,

1981.

72
Belloc, N.B., and Breslow, L. Relationship of physical health

status and health practices. Preventive Medicine, 1:

409-421, 1972.

Blackbum, H.; Carleton, R.; and Farguhar, J. The Minnesota

Heart Health Program: A Research and Demonstration Program

in Cardiovascular Heart Disease Prevention. In Matarazzo,

J.D.: Weiss, S.M.: Herd, J.A.: Miller, N.E.: and Weiss,

S.M.. (eds.) Behavioral Health: A Handbood of Health

Enhancement and Disease Prevention. New YorK: Wiley, in

press.

Fishbein, M., and Ajzen, I. Belief, Attitude, Intention, and

Behavior: An Introduction to Theory and Research. Reading

MA: Addison-Wesley, 1975.

Jessor, R. A psychosocial perspective on adolescent substance

use. In Litt, I.F.(ed.) Adolescent Substance Abuse:

Report of the Fourteenth Ross Roundtable. Colombus, Ohio:

Ross Laboratories, in press.

Jessor, R. Adolescent development and behavioral health. In

Matarazzo, J.D.; Weiss, S.M.: Hard, J.A.; Miller, N.E. and

Weiss, S.M. (eds.) Behavioral Health: A Handbook of Health

Enhancement and Disease Prevention. New York: Wiley,

in press.

Jessor, R., and Jessor, S.L. Problem Behavior and Psychosocial

Develpoment: A Longitudinal Study of Youth. New York:

Academic Press, 1977.

Kickbusch, I. "Health Promotion: An Overview." Unpublished

paper. WHO Regional Office for Europe. Copenhagen,

Denmark, 1983.

LaLonde, M. A New Perspective on the Health of Canadians.

Minister of Supply and Services Canada, Cat. No. H31-1374.

Ottawa, Canada: National Health and Welfare, 1974.

McAlister, A.L. Theory and action for health promotion:

Illustrations from the North Karelia Project. American

Journal of Public Health, 72: 43-49, 1982.

Mittelmark, M.; Blackburn, H.; Luepker, R.; Jacobs, D.; Kline,

F.G.; Jefferey, R.; Murray, D.; Carlaw, R.; Bracht, N.;

Pirie, P. for the Minnesota Heart Health Program Research

Group. Initial Experiences in Community-Based CVD Risk

73
Factor Education: The Minnesota Heart Health Proqram.

University of Minnesota, in preperation.

Pechacek, T. Quit and Win: Report of a Community Smoking

Campaign. Minnesota Heart Health Program working document

Laboratory of Physiological Hygiene, University of

Minnesota, 1983.

Perry, C.L.; Telch, M.J.; Killen, J.; Burke, T.; and Maccoby, N.

High school smoking prevention: The relative efficacy of

varied treatments and instructors. Adolescence, in press.

Perry, C.L., and Murray, D.M. Enhancing the transition years:

The challenge of adolescent health promotion. Journal of

School Health, 52: 307-311, 1982.

Rootman, I. A Conceptual Framework for a National Health

Promotion Survey. Health Promotion Directors working

document. Ottawa, Canada: Health and Welfare Canada, 1982.

Rosenberg, P, Youth working group summary. In Stone, E. (ed.)

Report of the Communtiy Deomonstration Programs Second Annual

Meeting. Bethesda, MD: NHLBI, in press.

Sunseri, A.J.; Alberti, J.M.; and Scbenberger, J.A. Children

as Reinforcers of Adult Health Education.

Health Curriculum Program Report, Chicago Heart Association

Chicago Heart

1992.

Taylor, R.B. Health promotion: Can it succeed in the office?

Preventive Medicine, 10;258-262, 1981.

Tell, G. Factors influencing dietary habits: Experiences of

the Oslo Youth Study. In Coates, T.J.; Petersen, A.C.; and

Perry, C. (eds.) Promoting Adolescent Health:

Research and Practice. New York: Academic Press, 1982

Tibbin, G. Raising a smoke-free generation in Sweeden. In

Lauer, R.M., and Shekkelle, R.B. (eds.) Childhood Prevention of Atherosclerosis and Hypertension. New York: Raven

Press, 1980.

U.S. Department of Health, Education and Welfare. Healthy

People, The Surgeon General's Report on Health Promotion and

Disease Prevention, Background Papers. DHEW (PHS) Pub. No.

79-5507lA. Washington D.C.: U.S. Government Printing

Office, 1979.

74
Government Printing Office, 1981.

Vartiainen, E. "Changes in Cardiovascular Risk Factors During

a Two-Year Intervention Programme Among 13 to 15 Year Old

Children and Adolescents." Unpublished dissertation.

University of Kuopio, Finland, 1982.

Wynder, E.; William, C.L.; Laakso, K.: and Levenstein, M.

Screening for risk factors for chronic disease in children

from fifteen countries. Preventive Medicine, 10; 121-132,

1981.

AUTHORS

Cheryl L. Perry, Ph.D. Richard Jessor, Ph.D.

Division of Epidemiology Institute of Behavioral Science

University of Minnesota

Minneapolis, MN 55455

University of Colorado

Boulder, CO 80309

75

U.S. Department of Health and Human Services. Strategy for

Promoting Health for Specific Populations. DHHS (PHS)

Publication No. 81-50169. Washington, D.C.: U.S.
Comprehensive Community

Programs for Drug Abuse

Prevention: Implications of the

Community Heart Disease Prevention

Programs for Future Research

C. Anderson Johnson, Ph.D.,

and Julie Solis, M.S.W.

Prevention of cigarette smoking and alcohol and drug

abuse in whole populations through community action may

now be achievable. There are reasons to be optimistic.

First, unhealthy lifestyles consist of behaviors which

are acquired early in life through example and social

reinforcement, these unhealthy behaviors are maintained

through periodic social reinforcement, environmental

cues, and in some cases physiological reinforcement.

Second, research in smoking prevention, which has

considered the role of social psychological factors in

promoting the onset of cigarette smoking, has repeatedly

demonstrated that relatively short interventions can

reduce the incidence of cigarette smoking in young

adolescents by one half or more, and that these effects

can have sustained action (Johnson 1982a; Evans 1982;

Perry 1983). Recent research has demonstrated that the

same approaches can be useful for preventing the onset

o f alcohol and marijuana use (McAlister et al. 1982;

Johnson in press: Botvin, this volume). The social

psychological variables important to onset of alcohol,

marijuana, and other drug use, and probably dietary

practices and activity patterns as well are much the

same as for cigarette smoking (Flay et al. 1983).

Social psychological interventions to countermand these

negative influences have also been reviewed elsewhere

(Johnson 1982b; McAlister, this volume). Briefly,

important social psychological determinants of

acquisition and maintenance of drug use and other

unhealthy practices include: vicarious learning from

observing the behavior of others (role models),

consensual validation of specific behavior, perceptual

errors regarding behavioral norms, attributional errors

about causation or responsibility, social reinforcement,

social and environmental cues which trigger specific

behaviors, perception of behavioral options and

self-efficacy regarding these options, and effectiveness

of preferred behavioral options in achieving valued

outcomes. Successful intervention programs are those

which have taken into account at least some of these

social psychological and behavioral variables and taught

76
cognitive and behavioral skills useful in resisting

social and environmental influences to smoke, use drugs,

and engage in other unhealthy practices. These

intervention strategies have tended to focus on youth

who by and large have not yet acquired the lifestyle

patterns targeted for prevention and, largely out of

convenience, have been implemented through the schools.

THE CASE FOR COMPREHENSIVE COMMUNITY PREVENTION PROGRAMS

There are several reasons why sustained, highly

integrated, multi-component community programs should be

preferable to single component programs or campaigns.

Despite successful developments in social

psychologically and behaviorally based school programs

in substance use prevention, the potential of any solely

school-based program is severely limited by a number of

factors.

The majority of a youth's day is spent outside

of school. Even in school, attention to drug

abuse prevention consumes only a small amount

o f curriculum time. In addition, most drug

use occurs outside of school.

The major portion of a young adolescent's time

is still spent in the home (as much as 17

hours per day, more on weekends) and in front

of the television set (four to six hours on

the average per day). The potential

influences of family and mass media are

enormous.

Substantial time is spent by the young person

in predictable out-of-school locations, such

as diners, movie theaters, and video arcades.

These could be sources of considerable

positive influence instead of negative

influence on drug use.

The young people at highest risk to drug use

onset are the least likely to be at school on

the days that prevention programs are

delivered. Absenteeism and dropout rates are

known to be highest among drug users.

Significant onset of drug and alcohol abuse

also occurs atother identifiable times beyond

the school years, e.g., adulthood and late

adulthood.

77
For these reasons, an optimal prevention proqram would

utilize not only school systems for delivery, but also

families, mass media, and community organization. Any

such program should be comprehensive and highly

integrated, with each component contributing according

t o its unique potential. Every intervention component

should be soundly based on theory and research findings.

Little is known, however, about how to apply the

principles of behavioral change developed in

school-based prevention research to other community

settings, and about which community components can

contribute most effectively and in what combination, to

prevention. Research in these matters is needed.

Recent research in community programs for heart disease

prevention provides important clues about how research

for community drug abuse prevention might best be

carried out. The findings from these heart programs are

reviewed in the pages that follow and their implications

for community drug abuse prevention research are

discussed.

COMMUNITY PROGRAMS FOR HEART DISEASE PREVENTION

In recent years community programs for heart disease

prevention have been developed and tested in the United

States and elsewhere. The lessons from community heart

disease prevention are relevant to drug abuse prevention

in several important ways: 1) many of the behavioral

objectives are the same, 2) problems in community

organization are similar, 3) the same general strategies

for community stratification and assignment to

experimental conditions are appropriate to both kinds of

programs, 4) many of the measurement problems and their

solutions are the same, and 5) the scope of both types

of programs is similarly large and demanding in terms of

organizational requirements.

A t the same time there are ways that community drug

abuse prevention programs ought to differ from the heart

disease prevention programs conducted to date. First,

the primary target group for the heart programs has been

middle-aged adults (ages 30-59), especially males. This

age group would also be targeted in an optimum drug

abuse prevention program, both to prevent onset of abuse

in mid and later life (a substantial problem), and to

reach young people more effectively through their

parents, adult role models, and gatekeepers of community

resources. However, the primary target group of a

community drug abuse prevention program probably should

be youth, ages 10-17 approximately. Recent community

heart health programs have had substantial youth

components, some of which have been quite successful -

most notably the school-based smoking prevention

78
programs. Still, these have been either secondary

programs or attached only loosely to the heart programs,

rendering them somewhat different from the optimum drug

abuse prevention strategy.

A second difference between drug abuse prevention

programs and heart programs is their different outcome

objectives. The heart programs have been preoccupied -

understandably so - with heart disease mortality and

morbidity, and biological risk factors for heart

disease. Drug abuse prevention programs by comparison

are concerned with the direct effects of interventions

on behavior. The biological and social sequelae (e.g.,

reduced incidence of cirrhosis of the liver and poor

school performance) would be important secondary

outcomes, However, drug abuse prevention programs

should be considered as successful or not primarily in

terms of their impact on the behaviors targeted, i.e.,

use and abuse of specific substances in the population.

A third difference is that the emphasis on drug abuse

prevention should be on preventing onset of abuse in

youth, rather than trying to bring about changes in well

developed lifelong patterns of behavior (i.e., smoking,

dietary practices, sedentary lifestyles, etc.).

Research in cigarette smoking would suggest that

prevention of smoking is far easier and more cost

effective than programs for cessation. As has been the

case with heart health programs targeted largely at

adults, drug abuse prevention programs might well

contain behavior change components for older audiences,

but the greatest impact will probably come through

primary prevention of abuse in youth.

A fourth difference is that heart health programs have

typically utilized existing medical resources in the

community. Many drug abuse prevention programs would

probably rely less heavily on medical resources, and

take advantage of existing community resources that are

already concerned with drug abuse. Generally the

involvement of physicians, nurses, pharmacists, etc., in

these organizations is minimal. This potential

difference should not minimize the potential, however,

of a public health approach to drug abuse prevention

wherein avoidance of drug abuse is considered as an

important element of healthy living. This approach

could be very appealing.

Fifth, the measurement requirements of the two types of

programs might be quite different. Drug abuse

prevention programs might not require the extensive

anthropomorphic measures called for in heart health

programs. At the same time, the measurement of drug

79
abuse is probably somewhat more socially sensitive than

the measurement of heart health, creating other

assessment problems.

With these differences in mind, it is useful to consider

what behavioral changes the community heart programs

have accomplished, how these accomplishments were

brought about, and their relevance to drug abuse

prevention.

Four community programs for heart disease prevention are

reviewed here. These programs include: The Multi-Risk

Factor Intervention Trial (MRFIT). The Oslo study, the

Stanford Three Community Study, and the North Karelia

Project in Finland. They vary in a number of ways,

including the populations targeted for intervention;

intensity and duration of the programs; the specific

behavioral, biological, and disease objectives, and the

number of those objectives; community channels through

which programs were implemented: strategies for

community organization; social and psychological models

guiding program implementation: and program outcomes

reported. Different community programs for heart

disease prevention have emphasized different features in

their plans and reports. Hence, equally complete

information is not available about all components from

all of the programs. Nevertheless, much can be learned

from careful consideration of these programs for

community drug abuse prevention.

The Multi-Risk Factor Intervention Trial (MRFIT)

Although not a comprehensive community study, MRFIT

(Sherwin et al. 1981; Benfari 1981; Caggiula et al.

1981; Hughes et al. 1981; Cohen et al. 1981; Multiple

Risk Factor Intervention Trial Research Group 1982) is

important to consider because it represents the largest

study ever reported of efforts to change the smoking and

dietary behaviors of a specified population. Several

features of MRFIT should be made clear in order to

understand which features of the study and its outcomes

are relevant to primary prevention of drug abuse.

First, the study emphasized the effects of interventions

o n mortality and morbidity. Secondary emphasis was on

the calculated risk of cardiovascular disease (the

Framingham risk function or the Keyes equation).

Behavioral outcomes have been of only tertiary

importance in reports of the program's successes and

failures to date.

Second, MRFIT included for study only persons at high

risk of coronary heart disease. Criteria for inclusion

were: male, ages 35-59, and having one or more of three

80
risk factors - a mean baseline diastolic blood pressure

greater than 95/140 mm Hg, a serum cholesterol level

greater than 220, and cigarette smoking.

Third, the intermediate goals of MRFIT were to change

behavior (stop or reduce smoking, cut back on intake of

animal fats, etc.), not to prevent behavior, as is the

case for drug abuse prevention.

Fourth, MRFIT would not qualify as a community study in

any sense directly relevant to drug abuse prevention.

There was no attempt to work through existing community

resources such as schools, churches, community

organizations, media, etc., except for the purpose of

recruiting participants. Still, it did become a

community event of some magnitude and as such received

at least the implicit sanction of 27 host communities.

Recruitment was from the general community and eligible

individuals were assigned randomly to receive the

program. These were components of the program that were

highly relevant to community prevention, including

involvement of whole families in the secondary

prevention efforts.

With these restrictions in mind, it is worthwhile to

consider the objectives, interventions, and outcomes of

MRFIT for their implications for community drug abuse

prevention research. The program may be described

briefly as follows. From 1974 to 1976, 361,662 men were

screened at 27 centers, and 12,886 were found to meet

acceptance criteria. Those selected were assigned

randomly to either a special intervention (SI) or a

usual care control (UC) group. A program of

interventions was designed for the SI group to reduce

three cardiovascular risk factors: smoking,

hypertension, and hypercholesterolemia. The UC group

members were referred to their ongoing sources of care

for traditional treatment. All participants were

followed for at least six years and an average of seven,

or until death for those dying during the study.

The special intervention program was designed to reduce

risk by sequentially increasing awareness, bringing

about behavior changes, and eventually effecting risk

factor changes. Immediately after randomization to the

SI group, study physicians delivered simple messages

regarding nutrition and weight as appropriate to the

participants. Smokers were counseled more extensively

regarding cessation by a study physician. Involvement

of the participant's wife or homemaker in the

intervention program was also solicited at this time.

Within 3 to 5 weeks after randomization, a 10-week group

intervention program for the simultaneous modification

81
of all three risk factors was initiated. Approximately

10 men were assigned to each group in order of

recruitment. The group met on a weekly basis for 1 1/2

t o 2 hours per session. The integrated group

intervention program presented the current state of

knowledge regarding the three risk factors. Principles

o f behavior modification were applied to bring about

dietary changes, the cessation of smoking, and adherence

t o antihypertensive medication. The initial sessions

included audiovisual and printed materials to enhance

awareness. Subsequent group sessions focused on

activities directed to the participant and his partner

for initiating and sustaining behavior change. The

group method was the usual mode of intensive

intervention, although a small number of participants

opted for an individualized approach. The wives of

about three-quarters of the married participants

attended at least some of the group sessions. The last

session of the intensive group program usually occurred

at the time of the first four-month followup visit.

Upon completion of the group program, participants who

had reduced one or more risk factors were placed on a

maintenance program. The general approach to maintenance

in all three risk factor areas was individual

counseling, planned and executed by an intervention

team. Exceptions included the use of a stepped-care

system for monitoring hypertensives and the development

of group modalities for the smokers at some sites.

Participants in the SI groups were seen at least every

four months for intervention purposes. The process

varied considerably across the different implementation

centers.

Most relevant to considerations for future research in

drug abuse prevention is the finding, validated by

biochemical analyses, that cigarette smoking was

significantly affected by the interventions. Figure 1

reveals that the proportion of men reporting cigarette

smoking fell steadily in both groups over the six years.

The decrease was more abrupt, however, in the first year

for those in the treatment group, and differences

remained significant for all six years. Adjusting

estimates of proportions of those who smoked by serum

and plasma thiocyanate determinations revealed a similar

pattern of results (Figure 2). Differences between the

two groups remained highly significant. By self-report,

43% of smokers in the SI group had quit by one year, and

50% by six years. This compared to 14% at one year and

29% at two years for controls. Estimates corrected by

thiocyanate determinations were 31% at one year and 46%

at six years for those in the SI group, and 12% and 29%

for those in the UC group. The smoking cessation

program was clearly successful. Six-year differences

82
Figure 1. - Self-reports of cigarette smoking by year of

follow-up in the MRFIT trials. Multiple Risk Factor

Intervention Research Group. Multiple Risk Factor

Intervention Trial, Risk Factor Changes and Mortality

Results. Journal of the American Medical Association,

248(12):1465-1477, 1982. © 1982, The American Medical

Association. Reprinted by permission.

Figure 2. - Thiocyanate-adjusted reports of cigarette

smoking by year of follow-up in the MRFIT trials. Multiple

Risk Factor Intervention Research Group. Multiple Risk

Factor Intervention Trial, Risk Factor Changes and

Mortality Results. Journal of the American Medical

Association, 248(12):1465-1477, 1982. © 1982, The

American Medical Association. Reprinted by permission.

83
between treatment and control groups were considerably

better than program objectives, according to both

self-report and thiocyanate criteria.

Cigarette smoking is a behavior that should be targeted

in any drug abuse prevention program because tobacco is

believed to have great addictive potential, because

smoking is the single behavior with the most adverse

consequences for public health, and because smoking is

closely associated with other drug use. The smoking

results from MRFIT are most encouraging and are

consistent with other data in indicating that smoking

can be effectively controlled with good behavioral and

social psychological programs.

Other findings from MRFIT that are also relevant for

drug abuse prevention are those for dietary practices.

Although dietary practices might not necessarily be a

part of any drug abuse prevention campaign, they are

conceptually relevant since diet represents deeply

ingrained habits and preferences. At this writing, sixyear followup data on dietary practices have not yet

been published. However, data for dietary sequelae

which are considered risk factors, serum cholesterol and

blood pressure, are available. At six-year followup,

treatment effects on those outcomes were significant

(p<.01, See Figures 3 and 4). Mean serum cholesterol

and blood pressure levels were significantly less in the

treatment group from the one-year followup on. At this

time, dietary results have been published for three- and

four-year followup in the SI group, but not the UC group.

Measured by 24-hour dietary recall, the proportion of

total caloric intake through saturated fats was reduced

28% by the third year. Total dietary cholesterol was

reduced 42%, and polyunsaturated fats in the diet were

increased 36%. All of these accomplishments met the

program's published dietary objectives. In addition,

there was a small decrease in alcohol intake reported

(reduction of alcohol intake was suggested to

participants as a means for reducing total caloric

intake). Individual changes in serum cholesterol levels

and body weight support the validity of these selfreport measures.

The mortality and morbidity results of the trial are

equivocal. It is not clear from these results that

interventions so late in the arteriosclerotic process

(age 35-59) can have meaningful effects on mortality and

morbidity. Resultant mortality from coronary heart

disease and cerebrovascular disease was somewhat lower

in the SI group than the UC group (4.7% and 7.1%

respectively), but those differences were not

significant. Cardiovascular mortality rates in both

groups were considerably lower than expected from

84
Figure 3. - Mean serum cholesterol levels by year of

follow-up in the MRFIT trials. Multiple Risk Factor

Intervention Research Group. Multiple Risk Factor

Intervention Trial, Risk Factor Changes and Mortality

Results. Journal of the American Medical Association,

248(12):1465-1477, 1982. © 1982, The American Medical

Association. Reprinted by permission.

Figure 4. - Mean diastolic blood pressure by year of

follow-up in the MRFIT trials. Multiple Risk Factor

Intervention Research Group. Multiple Risk Factor

Intervention Trial, Risk Factor Changes and Mortality

Results. Journal of the American Medical Association,

248(12):1465-1477, 1982. © 1982, The American Medical

Association. Reprinted by permission.

85
base-line risk factors. In addition, there was an

unanticipated reduction in all risk factors in the

control group, although they were exceeded in the

treatment group. Because of the unexpected reduction of

risk factors in the control group, differences between

the groups on blood pressure and serum cholesterol -

while significant - fell short of program objectives.

It is not relevant to the discussion why the behavioral

changes observed and total risk factor reduction

achieved in the MRFIT trials have not yet resulted in

significant reduction in cardiovascular mortality. It

is important, however, to note that the behavioral

objectives of the program were all met successfully.

Substantial reduction in cigarette smoking and

considerable changes in dietary practices were achieved

despite the fact that these must have been deeply

ingrained practices for this middle-aged population.

The methods used in bringing about those changes should

be examined carefully by drug abuse prevention

researchers for their potential relevance to drug abuse

prevention research.

The Oslo Study

The Oslo Study (Leren et al. 1975; Holme et al. 1980;

Hjermann et al. 1981; Holme et al. 1981a,b; Holme et al.

1982) was an experimental epidemiological study of the

effects of informative advice on the dietary and smoking

habits of healthy, middle-aged men at high risk of

coronary heart disease, and the effects of these

interventions on mortality and morbidity. All men aged

40-49 were invited for screening of coronary risk

factors at the Oslo Department of Health during 1972-73.

A response rate of 65% was achieved. Of 16,202 men

screened, 1,232 men who manifested the primary risk

factors (e.g., smoking, hypertension, etc.) were

selected and randomly assigned to the intervention group

o r the control group. The participants were followed

for a five-year period to assess the effect of the

intervention program on the lowering of serum lipids,

the cessation of smoking and the subsequent reduction of

coronary heart disease incidence.

The intervention program consisted of advice given in

individual and group formats. Initially, 10 to 15

minutes were spent in one-to-one discussions of the risk

factor concept and the purpose of the study. Another 30

minutes were spent in delivering individualized dietary

advice based on the person's body weight, serum

cholesterol and triglyceride levels, and his general

background. Anti-smoking advice was also given

individually to all the smokers. The wives of the

program participants were invited to groups with their

86
husbands for diet and smokinq counselinq information.

The groups ranged in size from 30 to 40 people. Follow

ups regarding eating and smoking habits were conducted

every six months in the intervention group and every 12

months in the control group. Only 14 intervention group

subjects and three control group subjects were lost

during the course of the study, due to refusal or

relocation.

The Oslo study is conceptually very similar to MRFIT and

the same comments regarding the relevance of program

outcomes, participant population, specific behaviors

targeted, etc., apply here.

Cigarette consumption (mean number of cigarettes per

day) declined significantly more in the intervention

condition than the control condition, and the difference

was maintained for the five years (see Figure 5).

Cholesterol and triglycerides, presumably determined in

part by dietary practices, also decreased more for those

in the intervention condition (Figures 6 & 7). Although

measures of diet were taken, those results have

not been reported to date.

Figure 8 reveals that despite the smaller N when

compared to MRFIT, program effects were found for

coronary heart disease mortality and morbidity combined.

After four years the incidence of fatal and non-fatal

myocardial infarctions and sudden death combined was

less in the intervention condition than the control

condition (p<.03).

The Oslo study corroborates the findings from MRFIT that

cigarette consumption can be reduced in middle aged men

and, in this case, with relatively minimal intervention.

Although the relationship between triglycerides and

dietary intake was not reported for the Oslo study, the

finding of reduced triglyceride levels in the

intervention group following dietary recommendations

suggests that meaningful behavioral changes may have

been accomplished there as well.

The Stanford Three Community Study

The Stanford Three Community Study (Meyer and Henderson

1974; Maccoby 1976; Stern et al. 1976; Farquhar et al.

1977; Maccoby et al. 1977; Farquhar 1978; Maccoby and

Alexander 1979, 1980; Meyer et al. 1980a; Maccoby and

Solomon 1981; Farquhar et al. 1981; Solomon 1982) made

several important advances in community prevention

research. Unlike MRFIT and the Oslo Heart Study where

middle-aged men at high risk of coronary heart disease

were targeted for interventions through medical clinics,

the Three Community Study targeted the general public

87
Figure 5. - Intervention effects on smoking in the Oslo

Study. I. Hjermann, I. Holme, K. Velve Byre, P. Leren.

Effect of Diet and Smoking Intervention on the Incidence

of Coronary Heart Disease. Report from the Oslo Study

Group of a Randomused Trial in Healthy Men. The Lancet,

December 12, 1981, pp. 1303-1309. © 1981, The Lancet Ltd.

Reprinted by permission.

Figure 6. Intervention effects on serum cholesterol in

the Oslo Study. I. Hjermann, I. Holme, K. Velve Byte,

P. Leren. Effect of Diet and Smoking Intervention on the

Incidence of Coronary Heart Disease. Report from the Oslo

Study Group of a Randomised Trial in Healthy Men. The

Lancet, December 12, 1981, pp. 1303-1309. © 1981,

The Lancet Ltd. Reprinted by permission.

88
Figure 7. - Intervention effects on triglycerides in the Oslo Study.

I. Hjermann, I. Holme, K. Velve Byre, P. Leren. Effect of Diet and

Smoking Intervention on the Incidence of Coronary Heart Disease.

Report from the Oslo Study Group of a Randomised Trial in Healthy

Men. The Lancet, December 12, 1981, pp. 1303-1309. © 1981,

The Lancet Ltd. Reprinted by permission.

Figure 8. - Life table analysis of CHD in intervention and control

groups in the Oslo study. I. Hjermann, I. Holme, K. Velve Byre,

P. Leren. Effect of Diet and Smoking Intervention on the Incidence

of Coronary Heart Disease. Report from the Oslo Study Group of a

Randomised Trial in Healthy Men. The Lancet, December 12, 1981,

pp. 1303-1309. © 1981, The Lancet Ltd. Reprinted by permission.

89
for intervention via mass media. However, measures were

collected only from persons 35-59 years old. Males and

females were equally represented in the sample. Media

and individual interventions differed from the previous

heart studies in being well grounded in theory and

research findings from the behavioral sciences.

Media campaigns and evaluations were designed with five

elements or objectives in mind: agenda-settinq -

drawing the public's attention to the campaign issues;

informing - providing to the recipient a logical set of

propositions that make the issues relevant and set the

stage for action; motivating - providing positive

incentives for behavior change: training - teaching

skills in how to modify risk behaviors and how to deal

with barriers and personal costs; and promoting

self-maintenance - providing skills relevant to

maintenance, and environmental cues to support

maintenance of behavior changes.

Two intervention towns (Gilroy and Watsonville) and a

measurement-only control town (Tracy) were chosen on the

basis of demographic comparability, the absence of major

health education programs, reasonable proximity to

Stanford, and the sharing of radio and television

channels by Watsonville and Gilroy, but not by Tracy.

The Three Community study conducted a multimedia

campaign from 1972 to 1975 in two of the California

communities (Gilroy and Watsonville). In Watsonville the

media campaign was supplemented with an intensive

instruction program for high risk subjects. This

previously untested combination of intervention

approaches was designed to achieve maintained reduction

of coronary heart disease risk factors through the

simultaneous modification of smoking, exercise, and

dietary behavior.

Probability samples of 500 persons between the ages of

35 and 59 were drawn from each community's approximate

population of 15,000. The high-risk cohort was obtained

by selecting the top quartile of those at risk at

baseline in each town sample. In Watsonville, the 169

high-risk subjects were assigned randomly to either an

intensive face-to-face instruction program (n=113), or

to the media-only campaign (n=56). High risk groups in

the media-only town (Gilroy) and the control town

(Tracy) served as comparison groups for the intensive

intervention town (Watsonville).

The media campaigns in Gilroy and Watsonville focused on

providing knowledge and skills to enable behavior

changes. Media intervention began two months after the

baseline survey. Over the three-year period, there were

more than 150 radio and television spots, over 3 hours

90
of radio and television programming, weekly newspaper

columns, advertisements, and material mailed to persons

in the random samples. A bilingual campaign was

implemented in areas with sizeable Spanish-speaking

populations. The campaign was conducted intensively for

the first two years with a shift in emphasis to

maintenance activities in year two. The intensity of

the campaign was considerably reduced in year three.

The face-to-face instruction program was initiated

through invitations mailed to the randomly selected

Watsonville subjects and their spouses to attend a

recruitment consultation. Ninety-five percent of the

subjects (107 of 113) and virtually all of the spouses

agreed to participate. Fifty-nine percent (63 subjects)

chose to join one of four instruction groups; the

remaining 41% (44 subjects) preferred individual

treatment sessions at home. Due to death,

out-migration, and dropout, about one-third of the highrisk participants were lost to followup (77 of the 107

subjects remained by the end of year two).

The face-to-face instruction program incorporated

techniques derived from social learning theory and

behavioral self-control principles. These included

self-monitoring, modeling, and a token reward system to

simultaneously affect diet, smoking, and physical

activity. The dietary interventions included having

participants keep a record of food consumed on a menu

plan for the first four weeks of instruction.

Appropriate meal preparation and food storage were

modeled live and via videotape. Points were awarded for

success with eight out of 10 recommended dietary

improvements.

Treatment procedures in smoking cessation consisted of

activities designed to identify and change the

antecedents of smoking. Goal-setting for the gradual or

complete reduction of smoking over a five-week period

was instituted. Similarly, prescribed physical activity

levels were self-monitored and supplemented by

suggestions. Points were assigned for weight loss of

one pound or more. Group progress on diet and physical

activity was charted on a wall graph.

To enhance maintenance of new behaviors, fading of

instructional support began after the sixth session in

both the group and home programs. The token reward

system was eliminated, and the self-monitoring and

modeling procedures became less complex. Time intervals

between group sessions were increased from one week to

two or three weeks. Gradual reductions in instruction

time occurred. Instruction shifted from a modeling and

reinforcement focus to problem-solving regarding

maintenance.

91
The intensity and duration of the face-to-face

interventions were as follows. The four instruction

groups each met nine times from 1 1/2 to 3 1/2 hours per

session over a 2 1/2 month period in community settings.

Group size ranged from 24 to 28 subjects and spouses.

During the same period project counselors made eight

home visits, each from 1 to 1 1/2 hours in length, to

each participant. Smokers in the home program received

five or six additional visits by smoking cessation

counselors. During the second year, the intensity of

the home and group programs gradually diminished to

virtually no activity by the third year. Near the end

of the third year, letters were sent to all the media

and intensive instruction participants, concluding with

small gatherings in subjects' homes.

Results from the Three Community Study have been

reported for total risk reduction, specific risk-factor

reduction, and targeted behavioral changes. Figure 9

reveals changes in total risk from baseline over the

three-year period. Risk reduction was greatest and best

maintained in the Watsonville intensive instruction

condition. At three years, risk reduction was greater

among Watsonville intensive intervention subjects than

Tracy control and Gilroy media-only subjects. It may be

that Watsonville media-only subjects benefited by

association with those who received intensive

instruction; evaluations indicate that there were high

levels of communication about prevention between these

two groups of Watsonville residents. Figure 10 shows

that knowledge gains over the three-year period roughly

mirrored risk reduction. The least gain occurred in the

Tracy control condition; intermediate gains occurred in

the two media-only conditions: and the greatest gain

occurred in the intensive instruction condition.

The most dramatic result, and the one most relevant to

drug abuse prevention, was sustained reduction in

cigarette smoking in the Watsonville intensive

intervention group. Reductions in smoking were

significantly greater for the Watsonville intensive

intervention group than for any other group at all but

the first followup measures (Figure 11). The

Watsonville intensive intervention group experienced a

50% cessation rate and a 51% reduction in cigarettes

smoked per day. If intensive instruction participants

lost to followup are included in the analysis and

assumed to have continued as smokers, the three-year

followup cessation rate was still 32%. These findings

are highly consistent with those for MRFIT and the Oslo

study.

92
Figure 9. - Percentage of change from baseline (0) in risk of

cardiovascular disease after the three annual follow-up surveys:

The Stanford Three-Community Study.

Figure 10. - Percentage of change from baseline (0) in knowledge

of cardiovascular disease risk factors at three annual follow-up

surveys: The Stanford Three-Community Study.

Figures 9 and 10: A.J. Meyer, J.D. Nash, A.L. McAlister,

N. Maccoby, and J.W. Farquhar. Stanford Heart Disease Prevention

Program, Stanford University School of Medicine. Skills Training

in a Cardiovascular Health Education Campaign. Journal of

Consulting and Clinical Psychology, 48(2):129-142, 1980.

© 1980. The American Psychological Association, Inc. Reprinted

by permission.

93
Figure 11. - Comparison of cessation rates among smokers

in communities subjected to varied intensity of education:

The Stanford Three Community Study. John W. Farquhar, Paul

F. Magnus, Nathan Maccoby. The Role of Public Information

and Education in Cigarette Smoking Controls. Canadian

Journal of Public Health, 72:412-420, 1981. © 1981, The

Canadian Public Health Association. Reprinted by permission.

94
Next to smoking, the most relevant findings for drug

abuse prevention were the dietary modifications. Table

1 reveals that both media-only groups achieved

significantly greater reduction in dietary cholesterol

intake than did Tracy controls. Dietary change in the

Watsonville intensive instruction condition was

consistently greater than for the other conditions, but

significantly so only for the first followup comparison

with Watsonville media-only subjects. Reductions in

dietary saturated fat for all three treatment groups

were significantly greater than those for Tracy controls

throughout the study, except for the Watsonville

media-only group which began to differ from controls

only at the third followup. No effects were realized

for changes in activity levels.

Biological outcomes are one step removed from behavioral

changes. However, they are useful as validators of

behavior change as can be seen in Table 2, changes in

plasma cholesterol levels were significantly greater for

the Watsonville intensive intervention group than the

Tracy control cohort at all three followup surveys.

Reductions in plasma cholesterol were greater for the

Watsonville media-only group than for the Tracy group at

the first and second followups, and were greater for

Gilroy than for Tracy at the second followup only.

Apparently, media effects on plasma cholesterol were

difficult to maintain. Changes in plasma triglycerides

were similar to those for plasma cholesterol levels.

Changes in systolic blood pressure were significant for

all three treatment cohorts when compared to the Tracy

controls at all three followup surveys (Table 3), and

all cohorts except Gilroy media-only manifested a

reduction in diastolic blood pressure, The difference

in systolic blood pressure between the Watsonville

intensive instruction group and the Gilroy media-only

group was significant at all three followup measures.

Evaluations of the Stanford Three Community Study

present a consistent pattern of results that support the

feasibility of well-designed media and family-oriented

intensive intervention for risk-reducing behavior

change. The results for behaviors most relevant to drug

abuse prevention were particularly impressive; sizeable

effects were achieved and maintained for three years on

cigarette smoking cessation and dietary practices.

Serum cholesterol and triglyceride changes support the

reported changes in dietary behavior. Significant and

sustained changes in blood pressure are particularly

interesting in this study, since the primary

recommendations for changes in media campaigns were salt

restriction, weight reduction, and exercise. Since no

lasting effects were found for weight reduction and

95
Treatment

Measurement

Watsonville

intensive

instruction

Watsonville

media only

Gilroy

media

Only

Tracy

control

Diet

Dietary cholesterol (mg/day)

Baseline

Follow-up 1

Follow-up 2

Follow-up 3

Dietary saturated fat (g/day)

Baseline

Follow-up 1

Follow-up 2

Follow-up 3

460.9 492.4 607.2 510.7

-40.7 -26.1 -29.8 -10.1

-37.1 -22.9 -31.8 -6.5

-42.3 -27.2 -38.6 - 13.4

33.4

-33.4

- 30.5

- 36.4

36.1 40.8 34.5

-20.9 -25.8 -11.1

- 17.0 -30.1 -5.1

-23.9 -38.4 -7.0

Table 1. - Mean Values at Baseline and Percentage of Change

from Baseline at Three Follow-Up Surveys for Dietary

Cholesterol and Saturated Fat: Stanford Three Community

Study. Anthony J. Meyer, Joyce D. Nash, Alfred J. McAlister,

Nathan Maccoby, and John W. Farquhar. Stanford Heart Disease

Prevention Program, Stanford University School of Medicine.

Skills Training in a Cardiovascular Health Education Campaign,

Journal of Consulting and Clinical Psychology 48(2):129-142,

1980. © 1980, The American Psychological Association, Inc.

Reprinted by permission.

Treatment

Measurement

Watsonville Gilroy

intensive Watsonville media Tracy

instruction media only Only control

Overall physiologic indicators

Plasma cholesterol (mg/100 ml)

Baseline

Follow-up 1

Follow-up 2

Follow-up 3

Plasma triglyceride (mg/100 ml)

Baseline

Follow-up 1

Follow-up 2

Follow-up 3

233.9 235.6 238.4 232.5

-5.3 -3.6 -.6 1.5

-1.5 -1.7 -1.8 3.0

-3.1 -.2 .1 2.3

180.7 182.8 174.5 139.6

-9.5 -7.1b2.8 17.6

-6.4 3.9 -9.8 6.4

- 17.4 -3.4 -1.8 -3.2

Table 2. - Mean Values at Baseline and Percentage of Change from

Baseline at Three Follow-Up Surveys for Plasma Cholesterol and

Triglycerides: Stanford Three Community Study. Anthony J. Meyer

Joyce D. Nash, Alfred L. McAlister, Nathan Maccoby, and John W.

Farquhar. Stanford Heart Disease Prevention Program, Stanford

University school of Medicine. Skills Training in a Cardiovascular Health Education Campaign. Journal of Consulting and

Clinical Psychology 48(2):129-142, 1980. © 1980, The American

Psychological Association, Inc. Reprinted by permission.

96
exercise, the blood pressure effects achieved in the

general population may have been due largely to

restrictions in salt intake. Data directly related to

this point have not yet been reported. No data are

available from the Three Community Study on changes in

actual mortality and morbidity rates.

Leventhal and his colleagues (1980) in their critique of

the Stanford Three Community Study have made a number of

conceptual and design suggestions which should be useful

for future community drug abuse prevention research.

Another published critique by Kasl (1980) is also very

useful. In light of recent publications by the Stanford

group (Meyer et al. 1980a), including direct responses

to the Leventhal et al. and Kasl critiques (Meyer et al.

1980b), these useful commentaries would not appear to

diminish the importance of this study. It is especially

important, however, that drug abuse prevention

researchers pay heed to Leventhal et al.'s

recommendation to consider community components for

their individual effects and to focus carefully on

behavioral outcomes, and to Kasl's recommendations about

exploring covariate relationships between reported

behaviors and biological changes. The Stanford Three

Community Study was the first to assess, albeit

quasi-experimentally, differential effects of media and

face-to-face interventions. To their credit they have

taken care to report relevant behavioral outcomes.

The North Karelia Project

The North Karelia Project (Salonen et al. 1979; Puska et

al. 1979 and 1981a,b,c,d; McAlister et al. 1980, 1982)

was the first comprehensive community program for heart

disease prevention conducted on a large scale and with

adequate data collected to evaluate program effects. In

addition to the mass media and individual instruction

approaches used in the Stanford Three Community Study,

the North Karelia Project included restructuring the

health delivery system, community organization,

interventions into the workplace and shopping place,

school - based programs for youth, and a variety of

consumer training programs available for all persons in

the community, not just those at high risk. The North

Karelia Project differed from those before it in not

singling out persons at high risk for particular

attention. The appeal was to the general public to

bring about constructive behavioral changes.

Unlike the Stanford study, intervention strategies and

their coordination were not based on a clearly

articulated theoretical framework. Nor were they

obviously guided by data from the behavioral sciences.

Instead, the various components of the program seem to

97
have been developed piecemeal depending on interests of

various segments of the community. In fairness, it

should be pointed out that late in the program,

behavioral scientists from the United States and

elsewhere were brought in to help design specific school

and media programs.

Like most other heart disease prevention programs,

primary emphasis in the North Karelia Project has been

o n evaluating disease outcomes, secondary emphasis has

been on changes in risk factors. Very little in the way

of systematic evaluation of behavior and behavior change

has been reported.

The North Karelia Project was conceived as a prevention

service program, somewhat of an emergency program,

called for by local Finnish inhabitants and politicians

in the face of an epidemic of cardiovascular mortality

and morbidity in the region. Growing local concern

regarding the county's exceptionally high cardiovascular

disease rates triggered this monumental effort between

1972 and 1977 to reduce the levels of the major coronary

heart disease risk factors. The North Karelia Project

was not conceived as a research project and, hence,

evaluation has suffered somewhat. The effect of the

program was assessed through comparison with a reference

county, Kuopia, which matched North Karelia's mortality

and morbidity rates and socioeconomic characteristics.

Despite its limitations as a controlled study, the North

Karelia Project is the best example to date of a

comprehensive community intervention study for which

outcome data are available.

The major elements of the intervention included

individual and group services, general health education,

training, community organization, and environmental

changes. During the five-year period, the project

organized 17 seminars for physicians and 22 seminars for

public health nurses and other health personnel, with an

average attendance of 50 persons per seminar.

Buttressed by media and community organization efforts,

the proportion of male hypertensives under appropriate

treatment in North Karelia increased from 13% in 1972 to

45% in 1977.

Information campaigns regarding the coronary heart

disease risk factors were successful in attracting high

levels of support from the news media in the region.

Over the project period, local newspapers printed 1,509

articles related to coronary heart disease risk factors,

their management, and program activities. Over one-half

million bulletins, posters, and other educational

materials were distributed. About 250 general meetings

reaching over 20,000 community members were held in

98
work, school, and community settings. As a result, North

Karelians showed a 10% to 15% increase in knowledge and

understanding of coronary heart disease risk factors.

A variety of consumer training programs was also

implemented. A cooking course which incorporated

involvement of the whole family was conducted in

conjunction with a local housewives' association. Three

hundred forty-four sessions of "Parties for a Long

Life" were held, with about 15,000 participants. At the

1976 followup survey, 18% of the women and 9% of the men

had been involved at least once in the activity.

Smoking cessation classes were also held, culminating in

a comprehensive smoking cessation program televised

nationally in 1978. The four-week televised program

consisted of seven, 45-minute, sessions with a studio

group of ten smokers.

Community organization included activities for

mobilizing the support of opinion leaders and informal

social networks. The support of prestigious

organizations and famous national figures was obtained;

in addition, a "lay leaders" program recruited locally

influential people. Over a four-year period more than

1,000 lay leaders participated in a weekend program of

training leading to involvement in community and

environmental changes for heart disease prevention. In

addition, support from the family was enlisted to

promote maintenance of smoking cessation and adherence

to anti-hypertensive regimens.

Environmental change efforts included pressure on

proprietors to promote and increase the availability of

low-fat foods, to restrict smoking indoors, and to

remove tobacco advertisements from the marketplace.

Upon discovering that the majority of North Karelians

would buy low-fat milk if it was available, the largest

dairy in the county agreed to produce it. National

legislation, in 1977 and 1978, which was stimulated by

the North Karelia Project ensured the availability of a

special soft butter to all Finns and prohibited the

promotion of tobacco products.

After completion of the original five-year

community-based intervention program, in 1978, program

activities were extended to North Karelian youth (Puska

et al. 1981d). The two-year program focused on the

seventh grade populations (13-year-olds) of three

matched pairs of schools. About one-third of the 1000

subjects in the sample received intensive direct

interventions to reduce coronary heart disease risk

factors. The intervention program consisted of student,

teacher, and parent education regarding coronary heart

disease risk factors, including an anti-smoking program

99
using peer leaders in the schools, changes in school

nutrition programs, a project magazine issued four to

six times a year, and parent meetings regarding changes

in the home diet to suit the child's needs. The

intensive program is being compared to two schools

implementing a general countywide intervention and two

schools in the reference county.

Reports of program effects on specific risk factors and

risk behaviors are spotty and incomplete. Table 4

presents to our knowledge the only published risk factor

results to date. Significant reductions were found

among North Karelian males between 1972 and 1977 in

cigarettes smoked per day, serum cholesterol, systolic

blood pressure, diastolic blood pressure, and total risk

score. Risks tended to increase in the control county,

but not significantly. Similar effects were found among

women in North Karelia and the control county for

systolic blood pressure, diastolic blood pressure and

total risk score: but not for cigarettes per day, and

serum cholesterol. It is not possible to compare

smoking results directly with the Stanford, Oslo, or

MRFIT studies since cessation rates are not reported.

No direct data about changes in dietary practices have

been published to date. It is plausible, but not

demonstrated, that reductions in cholesterol levels

among males and diastolic and systolic blood pressures

among both sexes were facilitated by restrictions in

animal fat and sodium intake.

Particularly important was the finding from a nationally

televised anti-smoking campaign that 10,000 of 40,000

smokers who participated in the campaign were not

smoking six months later. This 25% viewer cessation

rate is similar to those reported elsewhere for

televised smoking cessation campaigns (McAlister 1976;

Farquhar et al. 1977; Dubren 1977; Best 1978; Flay et

al. 1983). Almost twice as many smokers viewed the

nationwide broadcast in North Karelia as in the control

commmunity (9.0% vs 4.8%), and roughly the same ratio

were not smoking at one-month (3.9% and 2.0%) and

six-month (2.3% and 1.3%) followups. However, the

sample size was insufficient to detect significant

differences in cessation rates between the "organized"

and the "unorganized" communities.

The finding of a higher total cessation rate in the

organized community (North Karelia) when compared to the

unorganized community and a national sample (1.1%)

suggests that the effects of community interventions may

be synergistic.

Results of the North Karelia Project between 1972 and

1977 are promising if somewhat ambiguous for morbidity

100
Treatment

Measurement

Watsonville

intensive

instruction

Watsonville

media only

Gilroy

media

only

Tracy

control

Systolic blood pressure (mm Hg)

Baseline

Follow-up 1

Follow-up 2

Follow-up 3

Diastolic blood pressure (mm Hg)

Baseline

Follow-up 1

Follow-up 2

Follow-up 3

Overall physiologic indicators

148.1 148.2 147.9 138.4

-6.4 -3.2 -4.4 1.2

-7.6 -8.5 - 10.8 -2.1

-6.6 -8.9 -8.7 -2.0

88.4 91.6 83.5 86.3

-5.7 -4.3 1.8 -4.0

-4. I -4. I 1.7 -2.7

-3.9 -6.2 2.5 -5.4

Table 3. - Mean Values at Baseline and Percentage of Change

from Baseline at Three Follow-Up Surveys for Systolic and

Diastolic Blood Pressure: Stanford Three Community Study.

Anthony J. Meyer, Joyce D. Nash, Alfred L. McAlister, Nathan

Maccoby, and John W. Farquhar. Stanford Heart Disease

Prevention Program, Stanford University school of Medicine.

Skills Training in a Cardiovascular Health Education Campaign.

Journal of Consulting and Clinical Psychology, 48(2):129-142,

1980. © 1980, The American Psychological Association, Inc.

Reprinted by permission.

Table 4. - Mean Risk Factor Levels for Men and Women in

North Karelia and Reference Area in 1972 and 1977.

Alfred McAlister, Pekka Puska, Jukka T. Salonen, Jackko

Tuomilehto, Kaj Koskela. Theory and action for Health

Promotion: Illustrations from the North Karelia Project.

American Journal of Public Health, 72:43-50, 1982. © 1982, The

American Public Health Association. Reprinted by permission.

101
and mortality outcomes. The strongest findings were

among the younger aged persons (30-54 years) of both

sexes (a finding that may have relevance for MRFIT).

The incidence of acute myocardial infarctions (AMI) fell

24% in men and 36% in women from 1972 to 1977. In the

same age group there was a reduction of 52% in men in

the incidence of cerebral stroke, and 68% in women. The

effects for older persons were in the same direction,

but weaker. During 1977 the incidence of AMIS for both

men and women of all ages in the study (30-64) was

significantly different in North Karelia (11.1/1000 for

males and 2.8 for females) and the control community

(12.8/1000 for males and 3.8 for females). Changes in

rates from baseline were not different, however.

Although this may be due to the availability of poorer

quality data early in the study, this non-significant

finding raises some ambiguity about the effects of the

community program on cardiovascular morbidity in the 30

and older population.

Summary of the Heart Disease Prevention Trials

Examination of Table 5 allows a quick comparison of

major features of the target audience, program content,

campaign objectives, and important outcomes of each of

the major heart disease prevention programs. Target

audience characteristics may be summarized as follows.

Two of the programs (MRFIT and Oslo) targeted for

intervention only the minority of persons who were found

t o be at high risk to coronary heart disease (middleaged or older males with two or more established risk

factors present). The other two programs directed

interventions to the entire population, although the

Stanford program also developed special interventions

for a sample of high-risk persons in one community. It

should be noted that, whatever the target audience for

the campaign, all programs restricted major surveys to

mature adults (30+).

Two of the programs (those directed exclusively at

high-risk males) relied entirely on medical or allied

medical personnel working largely out of medical

clinics. The Stanford program operated completely

independently of medical facilities. The North Karelia

program included, among other components, the

reorganization of certain health care services. The two

campaigns directed at the general public included

broadcast television and other media. The Stanford

program was predominantly media based. Only North

Karelia formally involved school interventions, and

North Karelia was the only program to attempt community

organization for heart disease prevention. All programs

included a family-involvement component, and all

provided individual as well as group instruction.

102
Table 5 - Comparison of the Community Heart Disease Prevention Programs
Although it is not apparent in Table 5, all programs

attempted to teach skills in effective strategies for

heart disease prevention. The intensity of each

campaign, except the one in Oslo, was at least

moderately high, and the intensity of the North Karelia

Project was very high.

Only the two programs directed exclusively at high risk

persons had truly randomized designs. The two involving

whole-population interventions had single communities

assigned (not altogether randomly) to the experimental

and control conditions. Hence, MRFIT and the Oslo study

provide important conceptual replications with

randomized experimental designs, of the quasiexperimental community programs at Stanford and North

Karelia. Only the Stanford program did anything in the

way of testing the effectiveness of individual program

components (mass media for the whole community and

individualized instruction for persons at high risk).

Although both Stanford and North Karelia developed their

interventions to reach very young people as well as

adults, they collected outcome measures only from mature

adults (30 years or older). This seriously limits one's

ability to draw direct conclusions about the potential

of these approaches for drug abuse prevention. Another

limiting factor was the emphasis placed in the campaigns

and measures on smoking cessation and dietary changes,

t o the exclusion of preventing onset of smoking and

unhealthy dietary practices. These latter objectives

are most relevant to drug abuse prevention.

Effects of programs on targeted behaviors were uniformly

positive. Most encouraging were the consistent positive

effects on smoking cessation and cessation maintenance.

Also important was the finding in the three studies

where it was reported, that lasting dietary changes were

achieved. Positive changes in blood lipids and blood

pressure, which occurred in all the studies, are

consistent with positive behavioral changes, as is the

consistent effect of interventions on total risk score.

Findings regarding program impact on mortality and

morbidity rates are mixed, but since they are at least

two steps removed from the objective of producing

lasting behavior changes, they are of little consequence

for drug abuse prevention.

One advantage of comprehensive community prevention

programs that is clearly demonstrated by the heart

studies is that they provide continuity in a way that

any single-component progam introduced into the

community by a peripheral organization, such as the

university, cannot. Continuity is important. All of

the experimental community heart disease prevention

campaigns reviewed above lasted for at least three

104
years, and at least one lasted as long as seven years.

The positive findings for the three-year Stanford media

campaign stand in sharp contrast to findings from the

usual single-shot television campaigns (Flay and Sobel,

this volume).

The heart trials also provide evidence that

multi-component programs are more effective than

single-component programs. In the Stanford Three

Community Study, smoking cessation rates were higher and

better maintained in the community where some of the

high-risk persons received individual instruction as

well as the mass media presentations available to

everybody. Similarly, in a study reported by Flay et

al. (1983) an integrated school-television program was

much more effective in reaching smoking parents than a

television program alone, and resulted in a far greater

rate of smoking cessation at one year followup.

Viewership of a nationally televised smoking cessation

series was higher in the North Karelia Project where

community organization for heart disease prevention had

occurred, than in the rest of Finland where it had not.

One-month and six-month cessation rates appear to have

been higher where community organization occurred as

well. In summary, television programs for smoking

cessation appear more effective when supported by other

activities to promote cessation-relevant interaction

within the family or community.

DESIGN CONSIDERATIONS FOR COMMUNITY DRUG ABUSE

PREVENTION RESEARCH

The new qeneration of community heart disease prevention

proqrams. Four recently developed community research and

demonstration programs in heart disease prevention have

greatly improved upon the program and design limitations

of previous studies. These limitations have been

reviewed elsewhere by Farquhar (1978), Leventhal et al.

(1980)

community

and Kasl (1980). The second generation of

heart disease prevention programs will be

reviewed briefly here for their several contributions.

They include: The Stanford Five Cities Study, begun in

1978 (Farquhar 1978; Farquhar et al. 1981; Maccoby and

Solomon 1981; Maccoby 1983, in press); the Minnesota

Heart Health Program, begun in 1980 (Luepker et al. 1982;

Luepker 1983, in press); the Pawtucket (Rhode Island)

Heart Health Program, begun in 1982 (Elder et al. 1982;

Abrams et al. 1982; Abrams and Elder 1983, in press);

and the Community Health Improvement Program of Lycoming

County, Pennsylvania, begun in 1980 (Felix 1983).

The major features of these programs are: mass media

campaigns, community-based organization, adult

education, youth education, health professional

105
education, and mass screening or health medical

services. The following discussion will examine the

differences in program focus for each study.

The Stanford and Minnesota Programs have been designed

to institutionalize the community's role in prevention,

in a manner resembling the mobilization effort in North

Karelia. The eight-year-long Stanford Five City Project

will provide the necessary "software" and training to

community leaders who will then facilitate the provision

of the program by existing local groups now and beyond

the study. Similarly, the nine-year Minnesota program

will incorporate the involvement of opinion leaders and

other key leadership throughout the project term to

establish community staffing and support in the long

run. Minnesota staff members are consistently more

involved in day-to-day implementation in participating

communities than is the Stanford group. The development

of cost effective prevention models which can be

replicated in other communities is one vital community

organization function which is the focus of these

programs (Farquhar 1978; Farquhar et al. 1981; Maccoby

and Solomon 1981; Luepker et al. 1982).

In contrast, the Rhode Island and Pennsylvania programs

have to date focused on an "organizational approach" to

community prevention programs. In the six-year-long

Pawtucket program, gaining support from organizational

gatekeepers provides the basis for the development of

risk factor reduction programs which are coordinated by

task forces of organizational members where feasible

(Elder et al. 1982). Compared to the Minnesota program,

there is much less involvement of doctoral level

researchers in organizational efforts, and greater

reliance on subprofessional personnel recruited from the

community to carrry out program implementation. The

five -year -long Pennsylvania Program has been highly

successful in developing an extensive worksite program

in private industry (Felix 1983). Researchers in both

the Pawtucket and Lycoming County programs have

field-tested their worksite, behavioral, weight

reduction programs with very promising results (Stunkard

and Brownell 1980; Abrams and Follick 1983; Brownell et

al. in press). This form of community organization

focuses more on "proximal" approaches to behavior change

- both at the individual and small group levels - than

o n more "distal" community-wide interventions such as

media campaigns and medical professional interventions.

The new generation of community heart disease prevention

programs provides an excellent opportunity for gaining

insight into youth-oriented approaches to prevention.

The Minnesota and Rhode Island Programs target youth

between the ages of six and eighteen, and the Stanford

106
Program focuses on youth from twelve to eighteen years

of age. The Pennsylvania program has developed a Peer

Helpers component which trains youth to discourage

smoking by their parents. These programs have taken the

view that youth involvement is an important component of

a total prevention program.

Several design improvements have been built into these

studies. In each case, there are at least two

intervention communities and paired control communities.

The Minnesota design provides multiple replications in

three pairs of towns that differ in size, urban

characteristics, and media patterns. All appear to be

interested in collecting quality data on behavioral as

well as biological endpoints, and behavioral data are

collected from young people (as young as age six at

Minnesota and 12 at Stanford) as well as adults. In

these projects, considerable attention is given to

preventing and measuring the onset of cigarette smoking,

unhealthy dietary practices, and sedentary lifestyles in

youth.

This second generation of heart disease prevention

research is still limited in one important way. None

has planned a rigorous test of the relative

effectiveness of different program components. In

fairness, it should be pointed out that this limitation

was imposed by the primary objective of increasing

overall power to detect effects on mortality/morbidity.

In community drug abuse prevention research, this

restriction does not hold. Drug abuse prevention

researchers should be encouraged to explore, within

limits of power and characteristics of communities for

assignment, the relative efficacy for drug abuse

prevention of various community components and

intervention strategies.

CONCLUSIONS

There is reason to be optimistic about the potential of

comprehensive community programs for drug abuse

prevention. The potential for productive research in

community prevention is great. Behavioral technologies

for prevention, strategies for community organization,

and methodologies for community research design and

assessment are now sufficiently well developed for

productive research in community drug abuse prevention

to take form.

Several promising community-based programs for drug

abuse prevention are underway, including those in San

Francisco (Wallack and Barrows 1981); Charlotte, N.C.

(Kim 1981a, b and 1982; Ventura, California (National

Institute on Drug Abuse, 1982a, b; Skager, no date); and

107
Seattle, Washington (Resnik 1982; NIDA 1982c).

Unfortunately, except for the programs in San Francisco

and Charlotte, it is not clear that any meaningful

evaluation of any of these projects will be forthcoming.

Project SMART at USC is an experimental drug abuse

prevention program that is being rigorously evaluated

(Johnson and Graham 1983; Graham et al. 1983). It

compares alternative approaches to prevention derived

from successful smoking prevention strategies and

relevant social psychological and behavioral theory and

findings. Although this program has community research

implications (it involves diffusion throughout the

second largest school system in the country, and takes

preliminary steps towards mobilizing and assessing the

effects of family involvement), it is nothing like a

comprehensive community prevention research program. We

view comprehensive community research as the next

logical step in the development of drug abuse prevention

research.

REFERENCES

Abrams, D.B.; Elder, J.P.; and Lasater, T.M. Principles

of health promotion: A review and integration

across levels of intervention. Paper presented at

the annual convention of the Association for

Advancement of Behavior Therapy, Los Angeles: 1982.

Abrams, D.B., and Elder, J.P. Organizational health

promotion: A n integrated approach. Paper

presented at the annual convention of the Society

for Behavioral Medicine, Baltimore: 1983.

Abrams, D.B., and Follick, M.J. Behavioral weight loss

intervention at the worksite: Feasibility and

maintenance. J Consult Clin Psychol, 51:226-233,

1983.

Benfari, R.C. The multiple risk factor intervention

trial (MRFIT) III. The model for intervention.

Prev Med, 10(4): 426-442, 1981.

Best, J.A. Effectiveness of self-help mass media clinics

for smoking cessation. Unpublished report, Health

Studies Program, University of Waterloo, Canada,

1978.

Brownell, K.D.; Stunkard, A.J.; and McKeon, P.E. Weight

reduction at the work site: A promise partially

fulfilled, in press.

Caggiula, A.W.; Christakis, G.; Farrand, M.; Hulley,

S.B.; Johnson, R.; Lasser, N.L.; Stamler, J.; and

Widdowson, G. The multiple risk factor intervention

trial (MRFIT) IV. Intervention on Blood Lipids.

Prev Med, 10(4):443-475, 1981.

108
Cohen, J.D.; Grimm, R.H.; and McFate Smith, W. The

multiple risk factor intervention trial (MRFIT) VI.

Intervention on blood pressure. Prev Med,

10(4):501-518, 1981.

Dubren, R. Evaluation of a televised stop-smoking

clinic. Public Health Reports, 1977, 92, 81-8

clinic Public Health Reports, 92:81-84, 1977.

Elder, J.P.; Artz, L.M.; Carleton, R.A.; Knisley, P.M.:

Peterson, G.S.; Rosenberg, P.E.; and Snow, R.C.K.

Establishing cost-efficient member-owned heart

health programs in organizational settings. Paper

presented at the annual convention of the Society

of Behavioral Medicine, Baltimore: 1982.

Evans, R.I., and Raines, B.E. Control and Prevention of

Smoking in Adolescents: A psychosocial

perspective. Coates; A. Petersen; C. Perry

(Eds) In: Promoting Adolescent Health, A dialog on

research and practice. Academics Press, New York

1982, pp 101-129.

Farquhar, J.W.; Maccoby, N.; Wood, P.D.; Alexander,

J.K.; Breitrose, H.; Brown, B.W.; Haskell, W.W.;

McAlister, A.L.; Meyer, A.J.; Nash, J.D.; and

Stern, M.P. Community education for cardiovascular

health. Lancet, I: 1192-1195, 1977.

Farquhar, J.W. The community-based model of life style

intervention trials. Am J Epidemiol, 108(2):

103-111, 1978.

Farquhar, J.W.; Magnus, P.F.; and Maccoby, N. The role

of public information and education in cigarette

smoking controls. Can J Public Health, 72(6):

412-420, 1981.

Felix, M.R.J. The Pennsylvania County Health

Improvement Program (CHIP), unpublished project

description, 1983.

Flay, B.R.; d'Avernas, J.R.; Best, J.A.; and Kersell,

M.W. Prevention of smoking onset in children: A

review and some new data. Pediatric Behavioral

Medicine Conference, University of Ottawa (Invited

theme paper), 1981.

Flay, B.R.; Hansen, W.B.; Johnson, C.A.; and Sobel,

J.L. The influence of a school-based smoking

prevention program on the response of smoking

parents to a TV-based smoking cessation program.

5th World Conference on Smoking and Health,

Winnipeg, Canada, July 1983.

Graham, J.W.; Flay, B.R.; Johnson, C.A.; and

Hansen,W.B. Ensuring the comparability of

experimental groups with small numbers of

aggregated units: A multiattribute utility

measurement approach. Evaluation Review (in press)

Hjermann, I.; Holme, E.I.; Byre, K.V.: and Leren, P.

Effect of diet and smoking intervention on the

incidence of coronary heart disease. Report from

the Oslo study group of a randomized trial in

healthy men. Lancet, II(8259): 1303-1309, 1981.

109
Holme, E.I.; Helgeland, A.; Hjermann, I.; Leren, P.; and

Lund-Larsen, P.G. Four and two-thirds years

incidence of coronarv heart disease in middle aaed

men: The Oslo Study. An J Epidemiol, 112(1);

149-160, 1980.

Holme, E.I.; Helgeland, A.; Hjermann, I.; Leren, P.; and

Lund-Larsen, P.G. Physical activity at work and at

leisure in relation to 5 coronary risk factors and

social class. A 4-year mortality follow-up. The

Oslo Study. Acta Med Scand 209:277-283, 1981a.

Holme, E.I.; Enger; Helgeland, A.: Hjermann, I.;

Leren,P.; Lund-Larsen, P.G.; Solberg, L.A.; and

Strong, J. P. Risk factors and raised

atherosclerotic lesions in coronary and cerebral

arteries. Statistical analysis from the Oslo

Study. Arteriosclerosis, 1(4):250-256, 1981b.

Holme, E.I.; Helqeland, A.: Hjermann, I.; and Leren, P.

Socio-economic status as a coronary risk factor:

The Oslo Study. Acta Med Scand, Suppl. 660:

147-151, 1982.

Hughes, G.H.; Hymowitz, N.; Ockene, J.K.; Simon, N.; and

Vogt, T.M. The multiple risk factor intervention

trial (MRFIT) V. Intervention on smoking. Prev

Med, lO(41: 476-500, 1981.

Johnson, C.A. Prevention in Adolescence: Initiation and

cessation. The Health Consequences of Smoking:

Cancer A Report of the Surgeon General, 289-304,

1982a.

Johnson, C.A. Project SMART: A Social Psychological

approach to Drug Abuse Prevention for the School

and Community. Paper presented at ADAMHA Community

Prevention Research Technical Review, Rockville,

MD. June, 1983b.

Johnson, C.A. Untested and erroneous assumptions

underlying anti-smoking prevention programs.

T. Coates; A. Petersen and C. Perry (Eds) In:

Promoting Adolescent Health, A dialog on research

and practice. Academic Press, New York, 1982c, pp

149-165.

Johnson, C.A. Intervention in public schools using

informational, teacher and peer strategies. In:

Interdisciplinary Analysis of Strateaies in Drug

Abuse Prevention, Grabowski, J., and Glynn, T. (Eds),

National Institute on Drua Abuse. Rockville

Research Monograph (in preparation) 1983d.

Johnson, C.A., and Graham, J.W. Standard measures in

smoking prevention. Invited presentation at the

Fifth World Conference on Smoking and Health,

Winnipeg, July 1983.

Kasl, S.V. Cardiovascular risk reduction in a community

setting: Some comments. J Consult Clin Psychol,

48(21: 143-149, 1980.

Kim, S. How do we know whether a primary prevention

program on drug abuse works or does not work? Int

Addict, 16(2):359-365, 1981a.

110
Kim, S. An evaluation of ombudsman primary prevention

program on student drug abuse. J Druq Educ,

11(1):27-36, 1981b.

Kim, S. Feeder area approach: an impact evaluation of a

prevention project on student drug abuse. Int J

Addict, 17(2): 305-313, 1982.

Lasater, T. The Pawtucket Heart Program. Paper

presented at ADAMHA Community Prevention Research

Technical Review, June 1983.

Leren, P.; Askevold, E.M.; Foss, O.P.; Froili, A.:

Helqeland, A.: Hjermann, I.; Holme, E.I.;

Lund-Larsen, P.G.; and Norum, K.R. The Oslo Study.

Cardiovascular disease in middle-aged and young

Oslo men. Acta Med Scand, Suppl. 588:1-38, 1975,

Leventhal H.; Clearly.; Safer, M.A.: and Guttman M.

Cardiovascular-risk modification by community-based

programs for life-style change: Comments on the

Stanford Study. 1980.

Luepker, R.V. The Minnesota Heart Health Program. Paper

presented at ADAMHA Community Prevention Research

Technical Review, June 1983.

Luepker, R.V.; Blackburn, H.; Mittelmark, M.; Jacobs,

D.R.; and Cline, F.G. A community research and

demonstration project on the prevention of

cardiovascular diseases: The Minnesota Heart

Health Program. Paper presented at the Ninth World

Congress of Cardiology, Moscow: 1982.

McAlister, A. Toward the mass communication of

behavioral counseling. Unpublished doctoral

dissertation, Stanford University, 1976.

McAlister, A.: Puska, P.; Koskela, K.; Pallonen, V.: and

Maccoby, N. Mass communication and community

organization for public health education. Am

Psychol, 35(41:375-379, 1980.

McAlister, A.; Puska, P.; Salonen, J.T.; Tuomilehto, J.;

and Koskelia, K. Theory and action for health

promotion: Illustrations from the North Karelia

Project. Am J Public Health, 72(l): 43-50, 1982.

Maccoby, N. The Stanford Heart Disease Prevention

Program. Paper presented at ADAMHA, Community

Prevention Research Technical Review, June 1983.

Maccoby, N. The Stanford heart disease prevention

program. In: Newman, I.M., ed. Consumer Behavior

in the Marketplace.

Nebraska:

Symposium proceedings.

Nebraska Center for Health Education.

1976. pp. 31-44.

Maccoby, N.; Farquhar, J.W.; Wood, P.O.; and Alexander,

J. Reducing the risk of cardiovascular disease:

Effects of a community-based campaign on knowledge

and behavior. J Community Health, 3(2): 100-114,

1977.

111
Maccoby, N., and Alexander, J. Reducing heart disease

risk using the mass media: Comparing the effects

o n three communities. In: Munoz, R.F., Snowden,

L.R., and Kelley, J.G. and Associates, eds. Social

and Psychological Research in Community Settings.

San Francisco: Jossev-Bass-Publishers. 1979.

pp.69-100.

Maccoby, N., and Alexander, J. use of media in

lifestyle programs. In: Davidson, P.O., and

Davidson, S.M., eds. Behavioral Medicine:

Chanqina Health Lifestyles, New York: Brunner/Mazel

Publishers, 1980. p. 351-370.

Maccoby, N., and Solomon, D.S. Heart disease

prevention: Community studies. In: Rice, R.E.

and Paisley, W.J., eds. Public Communication

Campaiqns, Beverly Hills: Sage Publications,

1981. p. 105-125.

Meyer, A. J., and Henderson, J. B. Multiple risk factor

reduction in the prevention of cardiovascular

disease. Prev Med, 3:225-236, 1974.

Meyer, A.J.; Nash, J.D.; McAlister, A.L.; Maccoby, N.;

and Farquhar, J.W. Skills training in

cardiovascular health education campaign. J

Consult Clin Psychol, 48(2): 129-142, 1980a.

Meyer, A.J.; Maccoby, N.; and Farquhar, J.W. Reply to

Kasl and Leventhal et al. J Consult Clin Psychol,

48(2): 159-163, 1980b.

Multiple Risk Factor Intervention Trial Research Group.

Multiple risk factor intervention trial. Risk

factor changes and mortality results. J Am Med

Assoc, 248(12):1465-1477, 1982.

National Institute on Drug Abuse. A chronology of

growth: How the parent movement evolved. Prev

Resources, 6(1): 11-12, 1982a.

National Institute on Drug Abuse. Networking: Allies

in prevention/parents and youth. Prev Resources,

6(2): 4-6, 1982b.

National Institute on Drug Abuse.

Primary Prevention:

Teaching Tools for

A Guide to Classroom

Curricula, DHHS Publ No. (ADM) 81-4907. Rockville,

MD: NIDA Prevention Branch, 1982c, 93pp.

Perry, C. Smoking Interventions for Adolescent

Populations. Paper presented at ADAMHA Community

Prevention Research Technical Review, Rockville,

MD. June, 1983.

Puska, P.; Koskela, K.; McAlister, A.; Pallonen, U.;

Vartiainen, E.; and Homan, K. A comprehensive

television smoking cessation programme in Finland.

Int J Health Educ, Suppl. to 22(4): 1-29, 1979.

Puska,P.; Vienola, P.; Kottke, T.E.; Salonen, J.T.; and

Neittaanmaki, L. Health knowledge and community

prevention of coronary heart disease. Int J Health

Educ, Suppl. to 24(2): 1-10, 1981a.

112
Puska, P.; Neittaanmaki, L.; and Tuomilehto, J. A

survey of local health personnel and decision

markers concerning the North Karelia Project: A

community program for control of cardiovascular

diseases. Prev Med, 10:564-576, 1981b.

Puska, P.; McAlister, A.; Pekkola, J.; and Koskela, K.

Television in health promotion: Evaluation of a

national programme in Finland. Int J Health Educ,

24(4):238-250, 1981c.

Puska, P.; Vartiainen, E.; Pallonen, V.; Ruotsalainen,

P .; Tuomilehto, J.; Koskela, K.; Lahtinen, A.; and

Norppa, J. A community-based intervention study on

CVD risk factors among 13-to-15-year old children:

Study design and preliminary findings. Prev Med,

10:133-148, 1981d.

Resnik, H.S. It starts with people - II. Drug abuse

prevention programs for the 1980's. Lafayette, CA:

Pyramid, unpublished paper, 1982.

Salonen, J.T.; Puska, P.; and Mustaniemi, H. Changes in

morbidity and mortality during comprehensive

community to control cardiovascular

diseasesprogrammeduring 1972-77 in North Karelia. Br Med

J, 2:1178-1183, 1979.

Sherwin, R.; Kaeber, C.T.; Kezdi, P.; Kjelsberg, M.D.;

and Thomas, H.E. The multiple risk factor

intervention trial (MRFIT) II. The development of

protocol. Prev Med, 10(4):402-425, 1981.

Skager, R. Substance use among students in the Conejo

Valley unified school district - Report on thesecond annual survey, May 1982. Thousand Oaks, CA:

Conejo Valley Unified School District, unpublished

paper, no date.

Solomon, D.S. Health campaigns on television. In:

Pearl, D.; Bouthilet, I., and Lazar, J., eds.

Television and Behavior: Ten Years of Scientific

Progress and Implications for the Eighties. Vol.

2: Technical Reviews. Washington, D.C.: National

Institute of Mental Health, 1982. pp. 308-321.

Stern, M. P.; Farquhar, J.W.; Maccoby, N.; and Russell,

S.H. Results of a two-year health education

campaign on dietary behavior. Circulation,

54(5):826-833, 1976.

Stunkard, A.J., and Brownell, K.D. Worksite treatment

for obesity. Am J Psychiatry, 137(2):252-253,

1980.

Wallack, L.M., and Barrows, D.C. Preventing Alcohol

Problems in California: Evaluation of the Three

Year "Winners Program". California Department of

Alcohol and Drug Programs. Contract A-0345-8.

Berkley: Social Research Group, 1981. 197 pp.

113
ACKNOWLEDGMENT

AUTHORS

Preparation was

National

supported in part by grants from the

Institute on Drug Abuse, 08-R8DA03076A, and

5-RO1-DAO2941-03

C.A. Johnson, Ph.D.

Health Behavior Research Institute

University of Southern California

1985 Zonal Avenue

Los Angeles, California 90033

Julie Solis, M.S.W.

Health Behavior Research Institute

University of Southern California

1985 Zonal Avenue

Los Angeles, California 90033

114
Prevention of Adolescent

Substance Abuse Through the

Development of Personal and

Social Competence

Gilbert J. Botvin, Ph.D.

INTRODUCTION

Experimentation with a wide variety of substances for many

adolescents appears to have become an integral part of the coming

of age in America. Unfortunately, early experimentation often

leads to regular use and, for all too many individuals, this may

result in compulsive patterns of use characterized in many cases

by both psychological and physiological dependence. Treatment

programs designed to either help individuals achieve total

abstinence, or modify their pattern of use, appear to be only

moderately effective, with virtually all programs being plagued

by high rates of recidivism. As a consequence, the prospect of

developing effective substance abuse prevention strategies holds

a great deal of appeal. However, until recently the development

of effective substance abuse prevention programs has remained

only an illusive goal.

In this chapter an argument is made for a more comprehensive

approach to substance abuse prevention than has been utilized

previously. The type of approach being suggested focuses on both

the enhancement of personal competence through the development of

basic “life skills” and the acquisition of problem-specific

skills and knowledge designed to increase adolescent stability to

resist the various forms of social pressure to smoke, drink, or

use drugs.

The first three sections of this chapter deal with issues

concerning the etiology of adolescent substance use. The next

three sections briefly summarize traditional educational

approaches to substance abuse prevention and the more recent

psychosocial approaches which have been tested primarliy on

cigarette smoking, and a re-examlnation of some of the underlying

assumptions of these approaches. Two sections are devoted to

conceptual issues which can help provide a framework for

preventive interventions along with specific implications for

developing effective prevention strategies. The next three

115
sections summarize general strategies for enhancing personal

competence as well as highlighting the kind of problem-specific

skills and knowledge that are likely to facilitate substance

abuse prevention. This material is followed by a section which

describes a prevention program called Life Skills Training. This

program incorporates the kind of generic life skills and

problem-specific skills suggested by the preceding sections of

this chapter. The chapter ends with a section which provides

summary and conclusions and a final section which outlines some

recommendations for future research.

INITIATION AND EARLY STAGES OF USE

The initiation and early stages of tobacco, alcohol, and drug use

typically occur during adolescence (Botvin and McAlister 1981).

The initial use of most substances tends to be confined to social

situations, with solitary use being relatively uncommon. Indeed,

it has been suggested that the use of tobacco, alcohol, or drugs

may provide a major focus for group interaction and identity

(Becker 1967; Jessor 1975). While psychosocial factors appear to

be primarily responsible for the initiation of substance use, as

use becomes more regular, psychopharmacological factors become

increasingly important in reinforcing and maintaining regular

patterns of use (Meyer and Miran 1979; Oakley 1972). Despite

warnings from parents, teachers, and the media, most adolescent

substance users [particularly during the early stages of use)

exhibit a remarkable absence of concern about the dependency that

may result from the frequent use of tobacco, alcohol, and certain

drugs, and they tend to overestimate their ability to avoid

personally destructive patterns of use. Adolescent cigarette

smokers, for example, typically believe that they can quit

smoking any time they want (Botvin 1978). It is not until they

have actually made a serious effort to quit smoking that they may

gain a real appreciation of the extent to which they are both

psychologically and physiologically dependent on tobacco.

The sequence of experimentation and regular use of psychoactive

substances observed in most individuals suggests what has been

referred to as a substance use hierarchy (Hamburg et al. 1975;

Kandel et al. 1978). Individuals typically begin with the use of

tobacco and alcohol, followed later by the use of marijuana.

Some individuals may eventually progress to the use of

depressants, stimulants, and psychedelics. Generally, the use of

opiates and cocaine appears towards the end of this progression,

although for some sociocultural groups experimentation with

opiates may occur just after the initial use of alcohol.

Given the fact that most adolescents stop at particular points in

this sequence, controversy exists concerning the extent to which

“soft” substances (e.g., tobaco, alcohol, and marijuana) lead to

the use of other more dangerous “hard” substances (Goode 1974).

Although many individuals do not go on to use “hard” drugs, it

has been pointed out that without the prior use of tobacco,

alcohol, and even coffee, there would be no progression (Blum and

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Richards 1979; Hamburg 1975). Furthermore, the experience of

altering or controlling consciousness or mood with a psychoactive

substance, if perceived as positive, may provide the impetus for

experimentation with stronger substances.

DETERMINANTS OF SUBSTANCE USE

The available evidence suggests that a number of factors may

promote and/or facilitate the initiation of substance use [Blum

and Richards 1979; Braucht et al. 1977; Jessor 1975; Wechsler

1976). Among these are pro-substance-use social influences

coming from the family, the peer group, and the media;

psychological factors such as an external locus of control, low

self-esteem, low self-satisfaction, a greater need for social

approval, low social confidence, high anxiety, low assertiveness,

impuisivity, rebelliousness, and an impatience to assume adult

roles; and developmental factors, particularly those related to

cognitive and social development, which may tend to increase

adolescents’ susceptibility to pro-use social pressures.

Moreover, knowledge about the health, social, and legal

consequences of use along with negative attitudes toward

substance use might logically be expected to deter use. However,

while there may be a relationship between knowledge, attitudes,

and use, this relationship is complex and poorly understood.

Finally, substance users and nonusers have been found to differ

along several behavioral dimensions, suggesting a difference with

respect to orientation, values, and aspirations. In general,

individuals who smoke, drink, or use drugs tend to get lower

grades in school, do not participate in organized

extra-curricular activities such as sports or clubs, and are more

likely than nonusers to engage in antisocial behavior such as

lying, stealing, and cheating (Demone 1973; Jessor et al. 1972;

Wechsler and Thurn 1973). Furthermore, high intercorrelations

exist between a variety of substances so that, for example,

adolescents who smoke cigarettes are also likely to drink or

smoke marijuana.

Interestingly, the use of tobacco, alcohol, and drugs has also

been found to be associated with other health-related behaviors

such as premature sexual activity and delinquency. According to

Jessor , “one of the clearest facts to have emerged from the past

decade of research is that there is substantial covarlation among

many of these health-related behaviors, that is they tend to

occur together within the same adolescent.” The correlations

between these behaviors may be quite substantial and are evident

for both males and females. Furthermore, in addition to highly

significant intercorrelations among various health-compromising

behaviors, they “correlate in a similar way with a large number

of personality and environmental measures of psychosocial risk”

(Jessor 1982, p.453). In other words, a number of problem

behaviors appear to be caused by the same underlying factors. As

a consequence, related health-compromising behaviors may most

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usefully be viewed as a syndrome rather than as separate or

idiosyncratic behaviors.

SUBSTANCE USE AND ADOLESCENT DEVELOPMENT

Adolescence is a period of great physical and psychological

change. During adolescence, indlviduals experiment with a

variety of behaviors and lifestyle patterns as part of the

natural process of separating from parents. developing a sense of

autonomy and independence, establishing an Identity, and

acquiring the skills needed to function effectively in an

increasingly adult world.

Profound cognitive-developmental changes occur during the

beginning of adolescence which significantly affect adolescents’

views of the world, and the manner in which they think. In

contrast to the pre-adolescent’s concrete operational mode of

thinking which is rigid, literal, and grounded in the “here and

now, " adolescent thought is more relative, abstract, and

hypothetical [Piaget 1932). This enables adolescents to conceive

of a wide range of possibilities and logical alternatives, to

accept deviations from established rules, and to recognize the

frequently irrational and inconsistent nature of adult behavior.

Changes also occur with respect to the relative influence of

peers and parents. As individuals approach adolescence, there is

a progressive decline in parental influence and a corresponding

increase in the influence of peers and other socializing agents

[Utech and Hoving 1969). Furthermore, adolescents tend to have a

heightened sense of self-consciousness--referred to as

“adolescent egocentrism “--about their appearance, personal

qualities, and abilities (Elkind 1976).

These and other developmental factors increase adolescents’ rlsk

of yielding to the various direct and indirect pressures to

smoke, drink, or use drugs. The use of some substances (e.g.,

cigarettes and alcohol) is age-graded and, therefore, is

proscribed for children and adolescents while viewed as

acceptable for adults. Thus, engaging in these behaviors may be

an attempt to lay claim to adult status. Similarly, since the

use of illicit substances is legally proscribed for both

adolescents and adults, their use may serve as a means of

establishing solidarity with a particular reference group,

rebelling against parental authority, establishing a sense of

identity, and so forth.

Moreover, while the combination of adolescent egocentrism and

increased reliance on the peer group may tend to promote

substance use in some individuals, the cognitive developments

occurring prior to and during this period may also serve to

undermine previously acquired knowledge relating to the potential

risks of using these substances. For example, the adolescent’s

new cognitive orientation may enable him to discover

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inconsistencies or logical flaws in arguments belng advanced by

adults concerning the risks of substance use or to formulate

counter-arguments permitting rationalizations for ignoring these

risks--particularly if substance use is perceived to have social

or personal benefits. Thus, a recognition of the developmental

tasks, issues, changes, and pressures motivating adolescent

behavior is necessary to fully understand the etiology of

substance use/abuse.

EDUCATIONAL APPROACHES TO SUBSTANCE ABUSE PREVENTION

For the most part, substance abuse prevention programs have been

almost completely informational. Tobacco, alcohol, and drug

prevention programs have been largely based on the assumption

that increased knowledge about these substances and the

consequences of their use would be an effective deterrent

(Goodstadt 1978). Smoking education programs typically provide

students with factual information about the long-term health

consequences of smoking (Thompson 1978). Similarly, alcohol and

drug education programs have primarily attempted to increase

students’ knowledge about the legal, pharmacological, and medical

aspects of using these substances (Goodstadt 1978). More

recently, a variety of other types of prevention strategies have

been implemented. These programs have attempted to enrich the

personal and social development of students by developing

programs designed to increase self-esteem and interpersonal

skills, and foster participation in alternative activities.

A number of reviews have been published concerning the

effectiveness of substance abuse prevention programs (Berberian

et al. 1976; Braucht et al. 1973; Dorn and Thompson 1976;

Coodstadt 1974; Pyramid 1976; Richards 1969; Schaps et al. 1981;

Swisher and Hoffman 1975). The general consensus of these

reviews is that most substance abuse prevention programs do not

contain adequate evaluation components. Some programs reviewed

which had sound evaluation designs did not contain any measures

of drug use behavior. For example, Schaps et al. (1981) found

only four relatively well-designed studies out of the 127 program

evaluations they reviewed which utilized substance use measures.

Of these, only two showed a positive impact on behavior.

Evaluations of programs which focused on providing factual

information as their main strategy clearly indicate that

increased knowledge has virtually no impact on drug use or on

intentions to use drugs. On the other hand, although some

studies which contained cognitive and affective components have

produced at least some positive results (e.g., Carney 1972;

Swisher et al. 1973), in general affective education approaches

appear to have placed too little emphasls on the acquisition of

the kind of skills that are likely to increase general personal

competence and enable students to cope with the various

Interpersonal and intrapersonal pressures to begin using tobacco,

alcohol, or drugs. Unfortunately, the inescapable conclusion to

119
be drawn from the existing substance abuse prevention literature

is that few studies have demonstrated any degree of success in

terms of actual substance abuse prevention.

PSYCHOSOCIAL PREVENTION STRATEGIES

Potentially effective approaches to substance abuse prevention

are suggested by recent research in the area of smoking

prevention. Several research groups around the country have

demonstrated the efficacy of prevention stragegies focusing on

the psychosocial factors believed to be involved in the

initiation of cigarette smoking (Botvin et al. 1980; Evans et al.

1978; Hurd et al. 1980; McAlister et al. 1979). Ail these

approaches are similar in that they have their roots in social

learning theory (Bandura 1977) and problem behavlor theory

(Jessor and Jessor 1977), although differences exist with respect

to both their emphasis and modes of implementation. For example,

some approaches place prlmary emphasis on increasing students’

awareness of pro-smoking pressures, teaching specific techniques

for resisting such pressures; while others emphasize the

development of more general coping skills and take a broad

spectrum approach by attempting to target several of the most

significant underlying determinants of cigarette smoking. These

two types of prevention program have produced reductions in new

smoking by approximately 50%.

THE ASSUMPTIONS OF EDUCATION/PREVENTION STRATEGIES

A closer look at some of the basic assumptions of traditlonal

substance abuse education programs as well as the more recent

psychosocial prevention strategies, in light of what is known

about the cognitive, attitudinal, social, personality, and

developmental factors which appear to play Important roles in the

initiation and early stages of substance use/abuse, suggests the

need for a broader approach to substance abuse prevention.

First, most traditional educational approaches are based on the

assumption that individuals begin to smoke, drink, or use drugs

because they are unaware of the potential risks. However, given

the diversity of variables associated with substance use, it

seems evident that substance use/abuse is not simply a problem

rooted in an absence of knowledge about the health, social, and

legal risks--although this certainly may be a contributing factor

for some individuals.

Second, some of the more recently developed psychosocial

prevention strategies (e.g., Evans et al. 1978; Evans et al.

1981) are based on the assumption that the principal reason

adolescents begin to smoke, drink, or use drugs is “peer

pressure.” As a consequence, this type of prevention strategy

has focused almost exclusively on providing students with tactics

for resisting peer pressure. While high correlations have been

found consistently between individuals’ substance use and that of

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their friends, it is unclear to what extent these associations

are the result of peer pressure rather than a process of mutual

self-selection. Another point which is frequently overlooked is

that since most adolescents do not smoke or use drugs, the peer

pressure experienced by most individuals would be in a direction

consistent with non-use rather than use. Finally, reliance on

strategies which focus exclusively on teaching adolescents

pressure resistance tactics may be inadequate since they

implicitiy assume that all individuals who begin using drugs do

so because they lack the necessary skills to resist pro-substanceuse pressures. However, individuals who perceive substance use

as desirable for whatever reason will not be prevented from

substance use by merely teaching them pressure resistance skills,

since some individuals may actually want to engage in these

behaviors.

A CONCEPTUAL FRAMEWORK FOR PREVENTIVE INTERVENTIONS

In view of the number of factors which have been associated with

substance use among adolescents, it seems clear that no one

factor is both necessary and sufficient to cause these behaviors.

Rather, it appears that adolescent substance use/abuse is the

result of the complex interplay of a diversity of factors.

Indeed, a number of multivariate models have been posited to

explain how the various social, personality, cognitive,

attitudinal, and behavioral factors interact to produce use

and/or abuse (e.g., Flay et al. 1981; Jessor and Jessor 1977).

Although theories concerning the etiology of substance abuse are

plentiful (Lettieri et al. 1980). few of these appear to have any

direct relevance to the development of effective prevention

strategies. However, despite the vast array of substance abuse

theories and the lack of a single unified theory concerning the

initiation of substance use and abuse, both social learning

theory (Bandura 1977) and problem behavior theory (Jessor and

Jessor 1977) provide a useful conceptual framework for

understanding the etiology of substance use. From this

perspective, substance use is conceptualized as a socially

learned, purposive, and functional behavior which is the result

of the interplay of a diversity of social (environmental) and

personal factors.

Some individuals may seek out other individuals who smoke, drink,

or use drugs or may be motivated to engage in those behaviors

themselves as a way of coping with expected failure, or as an

alternative way of achieving some specific goal (e.g., some

adolescents may begin to smoke, drink, or use drugs in response

to the fact that they are not doing well academically and as an

alternative means of achieving popularity, social status, or selfesteem). The use of tobacco, alcohol, and certain other drugs

may also be used to cope with anxiety, particularly that induced

by social situations. Other individuals may begin smoking,

drinking, or using drugs as a result of the social influence

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process. That is to say, they may be influenced to begin using

one or more substances after repeated exposure to high status

models engaging in these behaviors, or as the result of

persuasive appeals made by advertisers or peers. Differential

susceptibility to social influence appears to be mediated by

personality, with individuals who have low self-esteem, low

autonomy, low self-confidence, and an external locus of control

being more likely to succumb to these influences (Bandura 1969;

Rotter 1972). Thus, adolescents may begin smoking, drinking, or

using marijuana for a variety of different reasons, suggesting

not one but several different pathways to substance use.

IMPLICATIONS FOR PREVENTION

One obvious implication from this type of conceptual model is

that substance use/abuse might be prevented by intervening on the

environmental level, i.e., eliminating the social influences to

become a smoker, drinker, or drug user. This might be

accomplished in the case of cigarette smoking, for example, by

eliminating cigarette advertising and smoking role models, by

increasing the visibility of attractive high status nonsmoking

role models, and by decreasing the social acceptability of

smoking. However, such changes are difficult and may take years

to achieve.

Alternatively, substance use and abuse might be prevented by

intervening on the personal level. This might be accomplished by

(a) increasing students* ability to deal with direct

interpersonal pressure to smoke, drink, or use drugs, and (b)

reducing intrapersonal pressures to use these substances.

The students’ abillty to deal with interpersonal pressures to

become users may be increased by making them aware of the various

social pressures to use these substances and by teaching them

specific skills to counter these pressures (e.g., interpersonal

skills to resist peer pressure).

Furthermore, students’ susceptibility to intrapersonal influences

might be reduced by increasing their self-esteem, sense of

personal control, self-confidence, self-satisfaction, and ability

to cope with anxiety. While this may not appear to be an easy

task, there is evidence to suggest that this might be

accomplished by improving personal competence and increasing

general adaptive behavior (Hjeiie 1974; Marlatt et al. 1976;

Parks et al. 1975; Percell et al. 1974). Thus, as an alternative

(or In addition) to intervening upon the school or community

environment, a logical approach to substance abuse prevention

might involve both teaching students pressure resistance tactics

to deal with explicit interpersonal pressure to use drugs, and

fostering the improvement of general personal competence as a

means of reducing Intrapersonal pressures.

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SOCIAL COMPETENCE AND SOCIAL SKILLS TRAINING

The acquisition of adequate social skills may well play an

important role in psychological adjustment and psychosocial

development. Basic interpersonal skills are necessary for

confident, responsive, and mutually beneficial relationships and

are perhaps among the most important skills that an individual

must learn. Inadequate social skills may cause problems in

interpersonal relationships or may interfere with optimal

functioning in school, work, or recreational situations (Coombs

and Slaby 1977). More importantly, a lack of social competence

may lead to rejection and social isolation which may result in

poor psychological adjustment.

The acquisition of social skills begins during childhood, and as

individuals mature, they generally become more socially adroit.

By the time individuals become adolescents they are expected to

have acquired a repertoire of social skills such as those

involved in communicating effectively, initiating and maintaining

conversations, giving and receiving compliments, asking someone

out for a date, denying unreasonable requests, expressing

feelings, etc. For the most part, social skills are learned

through a combination of imitation and reinforcement. However.

the development of these skills is dependent upon having the

opportunity to observe and practice them.

For a variety of reasons, many individuals do not sufficiently

master these skills. Over roughly the last decade there has been

considerable interest on the part of researchers and clinicians

concerning the development of effective strategies for helping

people improve their social competence. Numerous studies have

been reported involving attempts to teach a variety of social

skills to adult psychiatric patients, college students,

adolescents, and children. Social skills tralning has been

applied to a number of different areas involving interpersonal

interaction. For example, social skills training has been used

to decrease anxiety and enhance social skills involved in dating

(Curran 1976; Curran and Gilbert 1975), to improve the

interpersonal behavior of adolescent offenders (Thelan et al.

1976), to teach conversational skills to pre-delinquent girls

(Minkin et al. 1976) and socially isolated children (Whitehill

1978), and to teach problem-solving and communication skills to

parents and adolescents (Robin et al. 1977).

However. bv far the most common application of social skills

training -involves teaching people to be more assertive, that is,

to express their feelinas, needs. preferences. or opinions

directly and honestly. Although assertive difficulties were

initially viewed from the perspective of social anxiety, more

recently they have been viewed as behavioral deficits independent

of the attendant anxiety (Hersen et al. 1973; McFall and

Twentyman 1973).

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Assertiveness training focuses on both verbal and nonverbal

(paralinguistic) assertive behaviors. Verbal assertive skills

involve learning what to say (no-statements, requests, refusals),

whereas nonverbal assertive skills include eye contact, loudness

of voice, facial expressions, distance, and body expression.

Assertive skills are typically taught using a combination of

instruction, modeling, feedback, social reinforcement, and

behavior rehearsal.

A number of studies have tested the effectiveness of social

skills training for increasing assertiveness. Studies using

individual subjects (Eisler et al. 1974; Hersen et al. 1975) and

control group designs (Goldsmith and McFall 1975) have

demonstrated the effectiveness of assertive training for

Improving both the behavior and subjective feelings of comfort in

social situations of psychiatric patients. Although the results

of these studies generally only provide evidence of short-term

effectiveness, some studies have found these results to be

relatively stable (Hersen et al. 1975).

Studies conducted with college students have also demonstrated

the effectiveness of social skills training procedures for

increasing assertive behaviors (McFall and Twentyman 1973; McFall

and Marston 1970; McFall and Lillesand 1971; Wolfe and Fodor

1977). Not only do these studies demonstrate the short-term

effectiveness of social skills training, but they have shown that

significant improvement may be achieved with very brief treatment

(McFall and Twentyman 1973; Schinke et al. 1979). and even

without practice (McFall and Lillesand 1971). While practice has

generally been found to maximize the effects of social skills

training, the practice does not necessarily have to be overt.

For example, Kazdin (1974) found that even covert practice could

facilitate the learning of these skills.

Assertive behaviors have also been taught to children. Bower et

al. (1976) taught passive fourth grade girls to be more assertive

using a combination of instruction, modeling, discussion,

feedback, and practice. The results were judged to generalize to

real-life situations as was evidenced by an increase in the use

of assertive tactics in the classroom. Bornstein et al. (1977)

trained unassertive children using instruction, behavior

rehearsal, modeling, and feedback. The results indicated large

increases over baseline levels for both trained and untrained

role-play scenes, and these levels were maintained at two- and

four-week follow-ups.

Several excellent reviews of adolescent social skills training

have been published (e.g., Gilchrist 1981; Goldstein et al. 1979;

Pentz and Tolan 1983; Rotheram and Armstrong 1980; Schinke 1981).

Although much of the early social skills training research which

has been conducted focuses on the remediation of existing

deficits, more recently there has been a shift toward the use of

social skills training with normal adolescent populations as a

means of enhancing personal competence. In a review of 117

124
adolescent social skills training studies, Pentz and Tolan (1983)

found that while most of the studies they reviewed were of the

deficit remediation type, there was a general emphasis on the

development of positive social skills such as prosocial behavior,

assertiveness, and initiating conversations. Perhaps most

importantly, over 93% of the studies they reviewed reported total

effectiveness with better results being associated wIth training

conducted in school or community settings among normal adolescent

populations. Finally, as Pentz noted in this volume, there is

recent evidence to suggest that social skills training may have a

positive impact on substance abuse prevention.

ANXIETY REDUCTION TECHNIQUES

Several different techniques have been used to help individuals

cope with anxiety. These techniques fail into two categories:

relaxation training and cognitive restructuring. The most widely

used relaxation technique is called progressive deep muscle

relaxation and was initiaiiy developed by Jacobsen (1938). This

technique, as it is currently used, involves the systematic

tensing and relaxing of specific muscle groups. The main

objective of progressive relaxation is to make patients aware of

the presence of even mild tension and to provide them with a

means of eilminating it. This technique may be beneficial in two

ways. First, it can be used to generally lower physiological

arousal throughout the day. Second, it can be used to respond to

specific environmental stressors.

The effectiveness of progressive relaxation for reducing

physiological arousal has been documented by a number of

researchers (Lehrer 1972; Matthews and Gelder 1969; Paul 1969).

In one study (Israel and ieiman 1977), live and taped progressive

relaxation training was compared with self-relaxation using

measures of physiological arousal (heart rate, respiration rate,

and muscle tension) and subjective measures of tension. The

relaxation training was conducted in three 30-minute sessions.

The results showed significant in-treatment reduction of

physiological arousal for all groups. Furthermore, all

relaxation treatments led to significantly reduced levels of

subjective tension; however, the live progressive relaxation

training was more effective than either taped progressive

relaxation or self-relaxation.

Borkovec and Sides (1979) recently reviewed 25 well-controlled

studies of progressive relaxation to determine the extent to

which progressive relaxation produced physiological changes and

under what conditions. Examination of these studies indicated

that there is little uniformity in the teaching of progressive

relaxation. Some training procedures involved many sessions,

others involved very brief training (one or two sessions); some

used a pre-recorded tape, others used live procedures that could

be paced to individual subjects. Borkovec and Sides concluded

that although some studies using a brief or taped training

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procedure produced significant relaxation effects when used with

a normal population, multi-session subject-controlled (live)

procedures are generally more effective, particularly when used

with clinical populations.

Indeed, many studies have demonstrated the ability of relaxation

training to decrease anxiety both during treatment and beyond the

treatment session (Lazarus 1958; Weil and Goldfried 1973).

Analysis of posttreatment questionnaires in several

well-controlled outcome studies indicated that the people who

benefited from the treatment reported that they used relaxation

as an active coping skill (Bootzin and Kazdin 1972; Sherman

1972). In addition, Sherman (1972) found that subjects

desensitized to fear of water were able to utilize their newly

acquired ability to relax to cope with other situations creating

anxiety such as taking tests and public speaking.

Goldfried (1971) suggested that systematic desensitization

indirectly teaches individuals how to use relaxation to cope with

anxiety and modified the traditional desensitization procedure so

that emphasis was placed on teaching relaxation as an active

coping skill. The effectiveness of self-control relaxation was

tested on 27 college students who had difficulty with speech

anxiety (Goldfried and Trier 1974). Subjects were trained via

standard relaxation training and self-control relaxation. in the

latter, the relaxation technique was presented as an active

coping skill which could be used to alleviate tension in a

variety of situations causing anxiety, including public speaking.

Moreover, the subjects were encouraged to apply their relaxation

skills to real-life situations inducing anxiety. The treatment

consisted of five weekly one-hour live sessions and an additional

two sessions per week using a tape. The results demonstrated the

effectiveness of the self-control relaxation procedure for

reducing speech anxiety as well as other types of anxiety not

focused on during training. In addition, the students in the

self-control group expressed greater satisfaction with the

procedure than those who saw it as a passive procedure. In a

separate study (Chang-Liang and Denny 1976), self-control

relaxation was also found to be an effective treatment for test

anxiety. The evidence, therefore, indicates that presenting

relaxation as an active coping skill can increase its

effectiveness above that of the traditional approach.

Anxiety reduction strategies that are even more cognitive than

those described above involve what has been referred to as

cognitive restructuring. Ellis (1962) has noted that much

anxiety is the result of irrational thinking and has suggested

that such problems can be solved if changes are made in one’s

internal dialogue (e.g., if negative self-statements are replaced

by positive ones). Several studies have largely supported Ellis’

hypothesis. For example, Meichenbaum et al. (1971) found that

cognitive restructuring based on Ellis’ rational-emotive therapy

did result in significant reductions in speech anxiety. In

another study (Meichenbaum 1972), the effectiveness of a

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cognitive modification package was compared with traditional

desensitization. Subjects having problems with test anxiety

participated in an eight-session group treatment utilizing

cognitive restructuring and modified desensitization. Included

in the program were relaxation training and discussion of

potential irrational thoughts underlying test anxiety. Subjects

were given imaginal practice in coping with test anxiety by means

of relaxation and self-instructions to focus on the test itself.

The cognitive modification procedure resulted in greater

reductions in test anxiety than the traditional desensitization

procedure (based on subjective ratings, performance on an

analogue task, and school grades).

Cognitive restructuring has also been applied to the problem of

social anxiety. For example, DiLoreto (1971) taught socially

anxious undergraduates to re-evaluate the consequences of their

behavior in various social situations and eliminate their

irrational thoughts. The results demonstrated the effectiveness

of the rational-emotive approach and showed that it was at least

as effective as systematic desensitization. Kanter and Goldfried

(1976) compared cognitive restructuring, self-control

desensitization, and both combined. All three conditions

produced significant reductions in social anxiety (using

behavioral and subjective measures) at the end of training. But

two months after training, the students in the cognitive

restructuring group did better in terms of anxiety reduction than

the students in the other groups. These findings are consistent

with those of Holroyd (1976) who found cognitive restructuring to

be superior to a combination of cognitive restructuring and

desensitization.

Taken together, the evidence discussed above supports the use of

relaxation training and cognitive restructuring as a means of

reducing several types of anxiety. Progressive relaxation

produces in-treatment physiological changes and lowers anxiety

when used within the context of systematic desensitization both

during and, In many cases, after treatment. However, teaching

relaxation as an active coping skill increases its effectiveness

and facilitates transfer to other anxiety-provoking situations.

Cognitive approaches to anxiety reduction involving specific

strategies to eliminate irrational thoughts or replace negative

self-statements with positive ones also have been effective in

reducing different types of anxiety. Moreover, cognitive

restructuring also tends to transfer to situations other than the

one targeted during training, and long-term results show that it

is at least as effective as self-control relaxation.

PROBLEM-SPECIFIC SKILLS AND KNOWLEDGE

Several recently developed prevention strategies targed at one

or more substances have focused almost exclusively on providing

adolescents with skills and knowledge directly related to the

problem being addressed by the particular preventive

127
intervention. To a large extent, this type of approach has been

based on the pioneering work conducted by Evans and his

colleagues at the University of Houston (Evans et al. 1978; Evans

et al. 1981) which involved the application of social

psychological principles to the problem of adolescent cigarette

smoking. Films were developed to make students aware of the

various social pressures to smoke which they might be likely to

encounter during their junior high school years in order to

“inoculate” them against these pressures. In addition to

teaching students about social pressures to smoke--particularly

that coming from peers--suggestions were made concerning tactics

which might be used to resist such pressures.

Other investigators have elaborated on this model, placing more

emphasis on the actual training of junior high school students in

the use of pressure resistance tactics to deal with peer and

media pressures to smoke, drink, or use drugs (Hurd et al. 1980;

McAlister et al. 1979; McAllster et al. 1980). Specially trained

peer leaders have been utilized to demonstrate the application of

these pressure resistance tactics to common situations in which

adolescents might find themselves. Moreover, role plays were

organized to provide an opportunlty for structured practice and

feedback in the classroom. Students have also been taught how to

identify and formulate counter-arguments against advertising

appeals to smoke or drink.

Although there is a growing recognition that abstract knowledge

about the negative consequences of substance abuse is of marginal

value as a prevention strategy, certain types of knowledge about

the use of tobacco, alcohol, and drugs may be a useful component

of substance abuse prevention programs. For example, since many

observers have noted that adolescents typically overestimate the

prevalence of smoking, drinking, and the use of certain drugs,

all of the psychosocial prevention strategies (e.g., Evans

et al. 1979; Hurd et al. 1980; McAlister et al. 1979) have

attempted to correct normative expectations of high substance use

in the hope of reducing the perceived social support for these

behaviors. Furthermore, since the perceived social benefits of

smoking, drinking, or using other drugs may override concern for

any potential negative consequences (particularly more distant

long-term ones), an effort has been made in many of these

prevention strategles to focus on some of the more immediate

negative consequences of use which may serve as social

liabilities (e.g., nicotine stains on teeth, bad breath, etc.).

In sum, the inclusion of program components designed to teach

pressure resistance skills, knowledge concerning the various

social pressures to smoke, drink, or use drugs, knowledge

concerning the more immediate negative consequences of using

these substances. and knowledge about the actual levels of use

among both adults and adolescents appears to enhance the

effectiveness of prevention programs.

128
LIFE SKILLS TRAINING AND SUBSTANCE ABUSE PREVENTION

Our own research has involved the development and testing of a

broad-spectrum prevention strategy called Life Skills Training

(LST). The main purpose of this approach is to facilitate the

development of general personal and social skills, with

particular emphasis being placed on the development of skills for

coping with pro-substance-use social influences. As such, the

LST program utilizes several cognitive-behavioral techniques

found to be effective in treating a variety of problems.

However, within the context of this program, these techniques are

being used educationally in order to enhance students* ability

to, for example, cope more effectively with anxiety or function

more competently in social situations.

Some of the general cognitive-behavioral techniques incorporated

into the LST program include cognitive strategles for enhancing

self-esteem (e.g., goalsetting, behavior change techniques,

replacing negative self-statements wlth positive ones);

techniques for resisting persuasive (advertising) appeals (e.g.,

identifying persuasive appeals, formulating counter-arguments);

cognitive-behavioral self-management techniques for coping with

anxiety (e.g., relaxation trainlng, mental rehearsal); verbal and

nonverbal communications skills; and a variety of social skills

(e.g., initiating social interactions, conversational skills,

heterosociai (“dating”) skills, complimenting, verbal and

nonverbal assertive skills). These skills are taught using a

combination of instruction, modeling, rehearsal, feedback and

reinforcement, and extended practice through homework

assignments.

In addition to providing students with general life skills, this

prevention strategy also involves teaching skills and knowledge

more directly related to the problem of substance abuse.

For example, in addition to teaching students general assertive

skills (i.e., the use of "no" statements, requests, and the

assertive expression of rights), students are taught how to use

these skills to resist direct interpersonal pressure to smoke,

drink, or use marijuana. Thus, students are not only taught a

wide range of personal and social skills in order to improve

thelr general competence and reduce potential motivations for

using one or more substances, but are also taught the application

of these skills to situatlons in which they may experience

pro-substance-use social pressure.

Conceptually, the intervention can be divided into five major

components: (1) a cognitive component designed to present

information concerning the short- and long-term consequences of

substance use, prevalence rates, social acceptability, onset

process, habit development, etc.; (2) a decision-making component

designed to foster the development of critical thinking and

responsible decision-making; (3) a component designed to provide

students with techniques for coping with anxiety (i.e., cognitive

and behavioral self-control strategies); (4) a social skills

129
training component, including both general coping skills and

assertiveness techniques which can be used to effectively resist

direct interpersonal pressures to smoke, drink, or use drugs; and

(5) a self-improvement project designed to provide students with

the basic principles of behavior change and to enhance selfesteem.

EVALUATION OF THE LIFE SKILLS TRAINING APPROACH

The initial pilot research with this psychosocial prevention

strategy (Botvin et al. 1980) tested its short-term effectiveness

for preventing the onset of cigarette smoking when implemented by

outside health professionals. This study was conducted with 8th,

9th. and 10th graders (N = 281) from two different schools in

suburban New York. Both schools were comparable with respect to

SES and baseline smoking rates. Schools were randomly assigned

to experimental and control conditions. One school participated

in a IO-session prevention program (LST) and the other served as

a no-contact control group.

The results of this study indicated that significantly fewer

students in the experimental group (4%) began smoking than in the

control group (16%) at the time of the initial posttest.

Follow-up data (Botvin and Eng 1980) collected three months after

the initial posttest indicated that there still were fewer

students in the experimental group beginning to smoke than in the

control group (6% vs. 18%). Overall, the LST prevention strategy

produced a 75% reduction in new cigarette smoking over the three

months between the pretest and posttest, which decreased over the

three months between the posttest and the follow-up to a 67%

reduction.

The second study with this approach involved testing the efficacy

of the LST prevention program when implemented by older (11th and

12th grade) peer leaders. The program was tested on 7th graders

(N = 426) from two public junior high schools in suburban New

York City. Schools were randomly assigned to experimental and

control conditions. Furthermore, saliva samples were collected

prior to administration of the self-report questionnaire in a

variant of the “bogus pipeline” procedure used by Evans and his

co-workers (Evans et al. 1977) and to provide an objective

measure of smoking status (saliva thiocyanate). Once again the

results indicated that there were significantly fewer new smokers

in the experimental group (8%) than in the control group (19%).

These results were corroborated by the results of the saliva

thiocyanate (SCN) levels [indicating increased smoking) for the

students in the control group and no significant increase for the

students in the experimental group.

One year later these students were posttested again and the two

groups compared. Although there were still differences between

130
the experimental (24%) and control groups (32%) with respect to

all new smoking, these differences were no longer significant.

However, when more regular cigarette smoking (weekly or daily)

was examined, significant differences were evident between the

experimental group (11%) and the control group (25%). This study

demonstrated a 58% reduction in new smoking at the initial

posttest and a 56% reduction in more regular smoking at the one

year follow-up.

The third study with this prevention approach (Botvin et al. in

press) was designed to provide a "real-world” test of this type

of smoking prevention strategy when implemented by regular

teachers under conditions relatively typical of most classrooms.

Seventh grade students from seven suburban New York schools

(N = 902) were randomly assigned to three conditions: a treatment condition which involved conducting the LST prevention

program once a week for 15 weeks, a treatment condition which

involved conducting the LST program several times a week for

about 5 weeks, and a control condition. Two schools were

assigned to each treatment condition and three schools were

assigned to the control group. As in the previous study, saliva

samples were collected in order to ensure high quality selfreport data.

Comparison of the combined experimental group and the control

group revealed significant differences in the proportion of new

smokers (6% vs. 13%). No significant differences between the two

scheduling formats were apparent at the initial posttest.

However, at the one year follow-up it became clear that the more

intensive approach was more effective for ail measures (monthly,

weekly, and daily) of smoking status. Furthermore, comparison of

the combined experimental group indicated that it resulted in

significantly fewer new smokers using the monthly recall measure

(15% vs. 22%), the weekly measure (8% vs. 15%), and the daily

measure (6% vs. 11%). Finally, the results indicated that

providing students with additional “booster” sessions can help to

maximize the effectiveness of the prevention program. Thus, for

example, while the best non-booster group had an onset rate for

regular smoking of 5% (compared to a 15% rate for the controls),

the booster group had an onset rate of only 2%.

Therefore, based on the most inclusive measure of new smoking

(monthly smoking), the prevention program resulted in a 50%

reduction in new cigarette smoking at the end of the first year

and a 55% reduction at the end of the second year for the

intensive format condition. Furthermore, new regular smoking was

reduced by 87% at the end of the second year for the students who

participated in the additional booster sessions.

Research is currently underway to test the impact of the LST

prevention strategy on alcohol and marijuana use. Since tobacco,

alcohol, and marijuana use not only appear to be promoted by the

same etiologic factors but also occur at roughly the same point

In the developmental sequence of substance use behavior, it was

131
hypothesized that this type of broad spectrum prevention strategy

would also have an impact on alcohol and marijuana use. A

secondary goal is to test the relative effectiveness of this type

of prevention program when implemented by either older (10th and

11th grade) peer leaders or regular classroom teachers.

The study includes approximately 1200 7th grade students from 10

suburban New York junior high schools. The students in these

schools are from predominantly white middle-class families. Two

schools were assigned to each of the following five experimental

conditions: (1) teacher-led prevention curriculum, (2) peer-led

prevention curriculum, (3) teacher-led prevention curriculum plus

booster sessions, (4) peer-led prevention curriculum plus booster

sessions, and (5) control.

Students in conditions 1-4 participated in the LST prevention

program. For two of the four treatment conditions, the

prevention program was implemented by regular classroom teachers,

whereas older ( 10th, 11th and 12th grade) peer leaders conducted

the prevention program with the students in the other two

treatment conditions. Approximately four months after the

pretest, all students were posttested by questionnaire and saliva

samples were once again collected. In addition, one of the

teacher-led conditions and one of the peer-led conditions are

participating in an eight-session “booster” program during the

1982- 1983 school year. At the conclusion of the school year,

students will once again be posttested by questionnaire, and

saliva samples will be collected.

Results of the first year of this study (Botvin et al. 1983)

indicate that the prevention program had a significant impact on

tobacco, alcohol, and marijuana use. The students in the

peer-led condition reported drinking significantly less alcohol

per occasion than either the students in the control condition or

the teacher-led condition. Perhaps most dramatic was the impact

of the prevention program on marijuana use. Not only were there

significantly fewer students reporting marijuana use with respect

to both the monthly and the weekly recall measures, but the

magnitude of these differences was quite substantial. Comparing

the proportion of students reporting marijuana use in the

peer-led condition with the control condition, the prevention

program reduced total marijuana use by 71% and regular (weekly or

daily) marijuana use by 83%. As was the case in the previous

studies, significant changes were also evident with respect to

selected cognitive, attitudinal, and personality variables in a

direction consistent with non-substance use.

SUMMARY AND CONCLUSIONS

The initiation of substance use typically begins during

adolescence and appears to be the result of the complex interplay

of social, personality, cognitive, attitudinal, behavioral, and

developmental factors. Traditional smoking, alcohol, and drug

132
education programs have attempted to increase students’ knowledge

of the risks associated with using these substances in the hope

that this would deter use. Other programs have attempted to

enrich the personal and social development of students through

what has been referred to as “affective” education.

Unfortunately, the inescapable conclusion to be drawn from the

substance abuse prevention literature is that few of these

programs have demonstrated any degree of success in terms of the

actual prevention of substance use/abuse. Traditional

educational approaches to substance abuse prevention appear to be

inadequate because they are based on faulty assumptions and are

too narrow in their focus. The “affective” education approaches,

on the other hand, appear to have placed too little emphasis on

the acquisition of the kind of skills that are likely to increase

general personal competence and enable students to cope with the

various interpersonal and intrapersonal pressures to begin using

tobacco, alcohol, or drugs.

From the perspective of social learning theory (Bandura 1977) and

problem behavior theory (Jessor and Jessor 1977). substance use

is conceptualized as a socially learned, purposive, and

functional behavior which is the result of the interplay of

social (environmental) and personal factors. One potentially

effective approach to substance abuse prevention might Involve

enhancing general personal competence and teaching adolescents

the kind of problem-specific skills and knowledge which will

increase their ability to resist the various forms of

pro-substance-use social pressure. Brief reviews of the social

skills training literature and the literature related to

techniques for coping with anxiety not only provide evidence for

the feasibility of teaching these kinds of skills, but also

provide guidelines concerning the most effective approaches to

use. Similarly, several of the most successful smoking

prevention programs have included components designed to

increase adolescents’ ability to resist the various pro-use social

pressures, particularly pressure from their peers.

Our own research has involved testing a broad-spectrum prevention

strategy which focuses both on the enhancement of personal

competence through the development of basic “life skills” and the

acquisition of problem-specific skills and knowledge designed to

increase adolescents’ ability to resist the various forms of

social pressure to engage in the use of one or more substances.

Results of evaluation studies conducted thus far indicate that

this type of prevention strategy can significantly reduce new

cigarette smoking by 50% or more, with the effects of the

prevention program being evident up to one year after completion

of the program. Furthermore, the preliminary results of an

ongoing study, designed to determine the applicability of this

prevention strategy to alcohol and marijuana use, indicate that

it can significantly reduce excessive drinking as well as regular

marijuana use. Finally, in all of the studies conducted to date,

this type of prevention program has produced significant changes

133
on selected cognitive, attitudinal, and personality variables in

a direction consistent with non-substance use.

RECOMMENDATIONS FOR FUTURE RESEARCH

The results of research with this type of broad-spectrum approach

to substance abuse prevention are extremely encouraging.

However, a number of important issues need to be examined

further. First, some effort should be made in future studies to

measure the actual impact of this type of prevention program on

the skills being targeted in order to determine, for example, the

extent to which students can be effectively taught how to cope

with anxiety. Second, virtually all of the substance abuse

prevention research, including our own, has been conducted with

predominately white middle-class populations; future research

needs to be conducted to determine the extent to which this type

of program is also applicable to minority populations who are

likely to be at high risk for becoming substance abusers. Third,

future research should attempt to identify the “active

ingredients” of this type of prevention strategy in order to

determine whether or not the kinds of general coping skills

taught actually contribute significantly to program

effectiveness. Fourth, future research should attempt to

identify the factors that can either positively or negatively

affect program effectiveness. Fifth, this type of prevention

strategy should be tested against other competing substance abuse

prevention models. Sixth, once one or more effective prevention

models have been identified, it will be necessary to learn more

about how to insure successful implementation. Finally, once

these questions have been answered satisfactorily, it will be

necessary to conduct large scale “clinical” trials to determine

the effectiveness of this type of prevention strategy when it is

implemented with a broad range of students.

REFERENCES

Bandura, A. Social Learning Theory. Engiewood Cliffs, N.J.,

Prentice Hail, 1977.

Bandura, A. Principles of Behavior Modification. New York,

Holt, Rinehart and Winston, 1969.

Becker, H.S. History, culture and subjective experience: An

exploration of the social basis of drug-induced experiences.

J of Health and Social Behavior, 8:163-176, September 1967.

Berberian, R.M.: Gross, C., Lovejoy, J., and Paparelia, S. The

effectiveness of drug education programs: A critical review.

Health Education Monoqraphs, 4(4):377-398, Winter 1976.

Bium, R., and Richards, L. Youthful drug use. In: DuPont, R.I.,

Goldstein, A., and O’Donnel, J., eds. Handbook on Drug Abuse.

DHEW and Office of Drug Abuse Policy, Executive Office of the

President, National Institute on Drug Abuse, 1979, pp. 257-267.

Bootzin, R.R., and Kazdin, A.E. A comparison of systematic

desensitization with systematic habituation for fear of

134
heights. Paper presented at the Midwestern Psychological

Association, 1972.

Borkovec, T.D., and Sides, J.K. Critical procedural variables

related to the physiological effects of progressive relaxation:

A review. Behavior Research and Therapy, 17: 119-125, 1979.

Bornstein, M.; Bellack, A.; and Hersen, M. Social skills

training for unassertive children: A multiple baseline

analysis. J of Applied Behavioral Analysis, 10:183-195, 1977.

Botvin, G.J. The ethnography of teenage cigarette smoking. Paper

presented at the annual meeting of the American Public Health

Association, Los Angeles, October 1978.

Botvin, G.J.; Baker, E.: Renick, N.; Donohue, A.D.; and Botvin,

E.M. A cognitive behavioral approach to the prevention of

marijuana use. Submitted for publication, 1983.

Botvin, G.J., and Eng, A. A comprehensive school-based smoking

prevention program. J of School Health, 50:209-213, 1980.

Botvin, G.J., and Eng, A. The efficacy of a multicomponent

approach to the prevention of cigarette smoking. Preventive

Medicine, 11:199-211, 1982.

Botvin, G.J.: Eng, A.; and Williams, C.L. Preventing the onset of

cigarette smoking through life skills training. Preventive

Medicine, 9: 135-143, 1980.

Botvin, G.J., and McAlister, A. Cigarette smoking among children

and adolescents: Causes and prevention. In: Arnold, C.B.,

ed. Annual Review of Disease Prevention. New York: Springer,

1981.

Botvin, G.J.; Renick, N.; and Baker, E. The effects of scheduling

format and booster sessions on a broad-spectrum psychosocial

approach to smoking prevention. J of Behavioral Medicine,

in press.

Bower, S.; Amatea, E.; and Anderson, R. Assertiveness training

with children. Elementary School Guidance and Counselinq,

4:236-245, 1976.

Braucht, G.N.; Gollingstad, D.; Barkarsh, D.; and Berry, K.L.

Drug education: A review of goals, approaches and

effectiveness, and a paradigm for evaluation. Q J Stud

Alcohol, 34:1279-1292, 1973.

Carney, R.E . An evaluation of the Tempe, Arizona 1970-71 drug

abuse prevention education program. Unpublished report of

E.S.E.A. Title ill Project, Grant No. 12-71-0021-0. Tempe

Elementary School District #3, Tempe, Arizona, 1972.

Chang-Liang, R., and Denney, D.R. Applied relaxation as training

in self-control. J of Counselinq Psychology, 23:183-189, 1976.

Coombs, M.D., and Slaby, D.S. Social skills training with

children. In: Lakey, B., and Kazdin, A., eds. Advances in

Clinical Child Psychology, Volume 1, New York: Plenum Press,

1977 pp. 161-201.

Curran, J.P. Social skills training and systematic

desensitization in reducing dating anxiety. Behavior Research

and Therapy 7:453-462, 1976.

Curran, J.P., and Gilbert, F.S. A test of the relative

effectiveness of a systematic desensitization program and an

interpersonal adjustment of delinquents. Behavior Therapy,

6:510-521, 1975.

135
Demone, H. W. The nonuse and abuse of alcohol by the male

adolescent. In: Chafetz, M., ed., Proceedings of the Second

Annual Alcoholism Conference, DHEW Pub. No. (HSM) 73-9083,

1973.

DiLoreto, A.O. Comparative Psychotherapy: An Experimental

Analysis. Chicago, Aidine-Atherton, Inc., 1971.

Dorn, N., and Thompson, A. Evaluation of drug education in the

longer term is not an optional extra. Community Health,

7:154-161. 1976.

Eisier, R.M.; Hersen, M.; and Miller, P.M. Shaping components of

assertive behavior with instructions and feedback. American J

of Psychiatry, 131: 1344-1347, 1974.

Elkind, D. Understanding the young adolescent. Adolescence,

8(49):127-134, 1978.

Ellis, A. Reason and Emotion in Psychotherapy. New York, Lyle

Stuart, 1962.

Evans, R.I.; Hansen, W.B.; and Mittlemark, M.B. Increasing the

validity of self-reports of smokinq behavior in children.

J of Applied Psychology, 62:521-523, 1977.

Evans, R.I.; Henderson, A.H .; Hill, P.C.; and Raines. B.E.

Current psychological, social, and educational programs in

control and prevention of smokinq: A critical methodological

review. In: Gotto and Paoletti, eds. Atherosclerosis Reviews,

6:203-243. 1979.

Evans, R.I.; Rozelle, R.M.; Maxwell, S.E.; Raines, B.E.: Dill,

C.A.; Guthrie, T.J.; Henderson, A.H.; and Hill, P.C. Social

modelinq films to deter smokina in adolescents: Results of a

three year field investigation. J of Applied Psychology,

66(4):399-414, 1981.

Evans, R.I.; Rozelle, R.M.; Mittlemark, M.B.; Hansen, W.B.; Bane,

A.L.; and Havis, J. Deterring the onset of smoking in

children: Knowledge of immediate physiological effects and

coping with peer pressure, media pressure, and parent modeling.

J of Applied-Social Psycholoqy, 8:126-135, 1978.

Flay, B.R.; d’Avernas, J.R.; Best, J.A.; Kerseil, M.W.; and Ryan,

K.B. In: Firestone, P. and McGrath, P., eds. Pediatric

Behavioral Medicine. New York: Springer-Verlig, 1981.

Gilchrist, L.D . Social competence in adolescence. In: Schinke,

S.P., ed. Behavioral Methods in Social Welfare. New York:

Aldine, 1981.

Goldfried, M.R. Systematic desensitization as training in

self-control. J of Consulting and Clinical Psycholoqy,

37:228-234, 1971.

Goldfried, M.R., and Trier, C.S. Effectiveness of relaxation as

an active coping skill. J of Abnormal Psychology, 83:348-355,

1974.

Goldsmith, J.B., and McFall, R.M. Development and evaluation of

an interpersonal skill training program for psychiatric

inpatients. J of Abnormal Psychology, 84:51-58, 1975.

Goldstein, A.P.: Sparfkin. R.P.: Gershaw. N.J.; and Klein, P.

Skill-Streaming the Adolescent: A Structured Learning Approach

to Teaching Prosocial Behavior. Champaign, IL, Research Press,

1979.

136
Goode, E. Marijuana use and the progression to dangerous drugs.

In: Miller, L.L., ed. Marijuana Effects on Human Behavior.

New York: Academic Press, 1974.

Goodstadt, M.S. Myths and methodology in drug education: A

critical review of the research evidence. In: Goodstadt ,

M.S., ed. Research on Methods and Programs of Druq Education.

Toronto: Addiction Research Foundation, 1974.

Goodstadt, M.S. Alcohol and drug education. Health Education

Monographs, 6(3): 263-279, 1978.

Hamburg, S. Behavior therapy in alcoholism: A critical review

of broad-spectrum approaches. J Studies Alcohol, 36:69-87,

1975.

Hamburg, B.A.; Braemer, H.C.; and Jahnke, W.A. Hierarchy of

drug use in adolescence: Behavioral and attitudinal correlates

of substantial drug use. American J of Psychiatry,

132: 1155-1167, November 1975.

Hersen, M.; Eisier, R.M.; and Miller, P.M. Development of

assertive responses: Clinical, measurement, and research

considerations. Behavior Research and Therapy, 11:505-521,

1973.

Hersen, M.; Turner, S.; Edeistein, B.A.; and Pinkston, S.G.

Effects of ohenothiazines and social skills trainina in a

withdrawn schizophrenic. J of Clinical Psychology, 31:588-594,

1975.

Hjelle, L.A. Transcendental meditation and psychological health.

Perceptual and Motor Skills, 39:623-628, 1974.

Holroyd, K.A. Cognition and desensitization in the group

treatment of test anxiety. J of Consulting and Clinical

Psychology, 44:991-1001, 1976.

Hurd, P.; Johnson, C.A.; Pechacek, T.; Bast, C.P.; Jacobs, D.;

and Luepker, R. Prevention of cigarette smoking in 7th grade

students. J of Behavioral Medicine, 3:15-28, 1980.

Israel, E., and leiman, I. Live versus recorded relaxation

training: A controlled investigation. Behavior Therapy,

8:251-254, 1977.

Jacobsen, E. Proqressive Relaxation. (2nd edition) Chicago,

University of Chicago Press, 1938.

Jessor, R. Predicting time of onset of marijuana use: A

developmental study of hiqh school youth. in: Lettieri, D.J.,

ed. Predicting Adolescent Drug Abuse: A Review of Issues,

Methods and Correlates. National institute on Drug Abuse

Research Issues 11. DHEW Pub. No. (ADM) 77-299. Washington,

D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1976.

pp. 283-298.

Jessor, R. Critical issues in research on adolescent health

promotion. In: Coates, T.; Petersen, A.; and Perry, C., eds.

Promoting Adolescent Health: A Dialog on Research and Practice.

New York: Academic Press, 1982.

Jessor, R.; Collins, M.I.; and Jessor S.L. On becoming a

drinker: Social-psychological aspects of an adolescent

transition. In: Seixas, F.A., ed. Nature and Nurture in

Alcoholism. New York: Annals of the New York Academy of

Sciences, pp. 199-213, 1972.

137
Jessor, R., and Jessor, S.L. Problem Behavior and Psychosocial

Development: A Longitudinal Study of Youth. New York, Academic

Press, 1977.

Kandel, D.B. Convergences in prospective longitudinal surveys of

drug use in normal populations. In: Kandel, D., ed.

Lonqitudinai Research on Druq Use: Empirical Findings and

Methodological Issues. Washington, D.C.: Hemisphere

(Halsted-Wiley), 1978.

Kanter, N.J., and Goldfried, M.R. Relative effectiveness of

rational restructuring and self-control desensitization for the

reduction of interpersonal anxiety. Unpublished manuscript,

State University of New York at Stony Brook, 1976.

Kazdin. A. Effects of covert modeling and model reinforcement on

assertive behavior. J of Abnormal Psychology, 83:240-252,

1974.

Lazarus, A .A. Some clinical applications of autohypnosis.

Medical Preceedings, South Africa, 4:848-850, 1958.

Lehrer, P.M. Physiological effects of relaxation in a

double-blind analog of desensitization. Behavior Therapy,

3:193-208, 1972.

Lettieri, D.J.; Seyers, M.; and Pearson, H.W. Theories on Druq

Abuse: Selected Contemporary Perspectives. National Institute

on Drug Abuse Research Monograph 30. DHEW Pub. No. (ADM)

80-967. Washington, D.C.: Supt. of Docs., U.S. Govt. Print.

Off., 1980.

Marlatt, G.A.; Pagano, R.R.; Rose, R.M.; and Marques, J.K. The

effects of meditation and relaxation upon alcohol consumption

in male social drinkers. Unpublished research, University of

Washington, 1976.

Matthews, A., and Gelder, M.G. Psycho-physiological investigation

of brief relaxation training. J of Psychosomatic Research,

13: 1-12, 1969.

McAlister, A.; Perry, C.; and Maccoby, N. Adolescent smoking:

Onset and prevention. Pediatrics, 63:650-658, 1979.

McAlister, A.; Perry, C.L.; Killen, J.; Slinkard, L.A.; and

Maccoby, N. Pilot study of smoking, alcohol and drug abuse

prevention. American J of Public Health, 70:719-721, 1980.

McFall, R.M., and Lillesand, D.B. Behavioral rehearsal with

modeling and coaching in assertion training. J of Abnormal

Psychology, 77:313-323, 1971.

McFall, R.M., and Marston, A.R. An experimental analysis of

behavior rehearsal in assertive training. J of Abnormal

Psycholoqy, 76:295-303, 1970.

McFali, R.M., and Twentyman, C.T. Four experiments on the

relative contribution of rehearsal, modeling, and coaching to

assertion training. J of Abnormal Psychology, 81: 199-218,

1973.

Meichenbaum, D.H. Cognitive modification of test anxious college

students. J of Consulting and Clinical Psychology, 39:370-380,

1972.

Meichenbaum, D.H.; Gilmore, J.B.; and Fedoravicious, A. Group

insight versus group desensitization in treating speech

anxiety. J of Consultinq and Clinical Psychology, 36:410-421,

1971.

138
Meyer, R.E., Mirin, S.M. The Heroin Stimulus: Implications for

a Theory of Addiction. New York and London, Plenum Medical

Book Co., 1979.

Minkin, N.; Braukman, C.J.; Minkin, B.L.; Timbers, G.D.; Timbers,

B.J.; Fixsen, D.L.; Phillips, E.L.; and Wolf, M.M. The social

validation and training of conversational skills. J of Applied

Behavior Analysis, 9: 127-139, 1976.

Oakley, S.R. Drugs, Society, and Human Behavior. St. Louis,

C.V. Mosby, 1972.

Parks, C.; Becher, W.M.; Chamberlain, J.M.; and Crandell, J.M.

Eliminating self-defeating behaviors and change in locus of

control. J of Psychology, 91:115-120, 1975.

Paul, G.L. Physiological effects of relaxation training and

hypnotic suggestion. Journal of Abnormal Psychology,

74:425-437, 1969.

Pentr, M.A., and Tolan, P. Social skills training with

adolescents: A critical review of time trends, dimensions and

outcome, 1972-1982. Submitted for publication, January, 1983.

Percell, L.P.; Berwick, P.T.; and Biegels, A. The effects of

assertive training on self-concept. Archives of General

Psychiatry 31:502-504, 1974.

Piaget, J. The Moral Judgment of the Child. 4th edition,

London, Routledge and Kegan Paul, 1932.

Pyramid. Primary prevention research. Unpublished report.

Walnut Creek, CA, Pacific Institute for Research and

Evaluation, 1976.

Richards, L.G. Government programs and psychological principals

in drug abuse education. Paper presented at Annual Convention

of American Psychological Association, Washington, D.C.,

September 1969.

Robin, A.L.; Kent, R.; O’Leary, D.; Foster, S.; and Prinz, R. An

approach to teaching parents and adolescents problem-solving

communication skills: A preliminary report. Behavior Therapy,

8:639-643, 1977.

Rotheram, M.J., and Armstrong, M. Assertiveness training with

high school students. Adolescence, 15: 267-276, 1980.

Rotter, J.B . Generalized expectancies for internal versus

external control of reinforcement. In: Rotter, J.B., Chance,

J.E., and Phares, E.J., eds. Applications of a Social Learning

Theory of Personality. New York: Holt, Rinehart, and Winston,

pp. 260-295, 1972.

Schaps, E.; Bartolo, R.D.; Moskowitz, J.; Paliey, C.S.; and

Churgin, S. A review of 127 drug abuse prevention program

evaluations. J of Drug issues, pp.17-43, Winter 1981.

Schinke, S.P. Interpersonal skills training with adolescents.

In: Hersen, M., Eisler, R.M., and Miller, P.M., eds. Proqress

in Behavior Modification. Volume II. New York: Academic Press,

1981.

Schinke, S.; Lewayne, D.; Smith, T.; and Wong, S. Group

interpersonal skills training in a natural setting: an

experimental study. Behavior Research and Therapy, 17: 149-154,

1979.

139
Sherman, A.R. Real-life exposure as a primary therapeutic factor

in the desensitization treatment of fear. J of Abnormal

Psychology, 79: 19-28, 1972.

Swisher, J.D.; Crawford, J.; Goldstein, R., et al. Drug

education: Pushing or preventing? Peabody J of Education,

44:68-75. 1971.

Swisher, J.D., and Hoffman, A. Information: The irrelevant

variable in drug education. In: Corder, B.W., Smith, R.A.,

and Swisher, J.D. eds. Druq Abuse Prevention: Perspectives and

Approaches for Educators. Dubuque, IA: William C. Brown,

pp. 49-62 1975.

Swisher, J.D.; Warner, R.W. Jr.; Spence, C.C.; and Upcraft, L. A

comparison of four approaches to drug abuse prevention at the

college level. J of College Student Perspectives, 14:231-235,

1973.

Thelan, M.H.; Frey, R.A.; Doilinger, S.I.; and Paul, S.C. Use of

videotaped models to improve the interpersonal adjustment of

delinquents. J of Consulting Clinical Psychology, 44:492,

1976.

Thompson, E.L. Smoking education programs. American J of Public

Health. 68:150-157, 1978.

Utech, D., and Hoving, K.L. Parents and peers as competing

influences in the decisions on children of differing ages.

J of Social Psychology, 78:267-274, 1969.

Wechsler H. Alcohol intoxication and drug use among teenagers.

J Stud Alcohol, 37(11):1672-1677, 1976.

Wechsler, H., and Thurn, D. Alcohol and drug use among teenagers:

A questionnaire study. in: Chafetz, M. ed., Proceedings of

the Second Annual Alcoholism Conference, DHEW Publication No.

(HSM) 73-9083, 1973.

Weil, G., and Goldfried, M.R. Treatment of insomnia in an

eleven-year-old child through self-relaxation. Behavior

Therapy, 4:282-284, 1973.

Whitehill, M.B. A conversation skills training program for

socially isolated children: An analysis of generalization.

Unpublished masters thesis, University of Pittsburgh, 1978.

Wolfe, J.C., and Fodor, I.G. Modifying assertive behavior in

women: A comparison of three approaches. Behavior Therapy,

8:567-574, 1977.

AUTHOR

Gilbert J. Botvin, Ph.D.

Assistant Professor

Departments of Public Health and Psychiatry

Cornell University Medical College

411 East 69th Street

New York, N.Y. 10021

140
Alternatives to Drug Abuse:

Some Are and Some Are Not

John D. Swisher, Ph.D.,

and Teh-Wei Hu, Ph.D.

INTRODUCTION

The purpose of this paper is to discuss the current state of the art of

alternatives to substance abuse as one of several approaches to

prevention. This paper defines four different approaches to prevention

that have been proposed and reviews the literature related to each

approach. Two recent studies of alternative programs and activities will

be presented and the paper will conclude with recommendations for

further research.

The concept of alternatives to substance abuse was one of the first

responses to the problem (Wald and Abrams 1972). The early advocates

of this strategy recommended substituting positive experiences for the

experiences reported to be associated with substance abuse. Some early

workers in the field were aware that not all alternatives would automatically provide an acceptable substitute for some of the pleasures sought

and perceived by drug-using and-abusing individuals. For example, Swisher and Horman (1970) discovered, upon completion of a program for

college student leaders, that one individual had been very impressed by

the emphasis on alternatives; and even though he was only an experimenter with some drugs, he decided to pursue a viable alternative--skydiving,

which may have been a greater health risk.

FOUR MODELS OF ALTERNATIVE PROGRAMMING

It is important to begin by outlining the basic approaches that have been

attempted and in some instances evaluated as part of a larger cluster of

programming known as alternatives to substance abuse. First of all,

programs that are variations of forms of treatment and/or incarceration

are not considered to be prevention programs and have not been included

in this paper. This type of treatment is often confused with the concept

of alternatives as it is applied to prevention. It is important in any

discussion on this topic to make a distinction between treatment (after

the fact) and prevention (before the fact). Therefore, alternative programming includes planned-for activities that will prevent individuals

from becoming abusers or substance-dependent users prior to any significant involvement with substances.

The four models of alternative programming relevant to prevention include the following:

141
1. Providing specific activities for young people (e.g., operating a radio

station)

2 . Matching specific types of needs with specific types of activities (e.g.,

sensory needs met through sensory awareness training)

3. Reinforcing participation in existing alternative activities (e.g.,

encouraging individuals to develop, expand and involve others in their

present interests)

4. Facilitating youth-directed groups in the process of initiating selfselected activities (e.g., Channel One)

Specific Activities

The original model for alternatives to substance abuse has no single

identifiable source, but the idea of providing alternative activities for young

people was seen as a consensus among prevention professionals in the early

1970's (Wald and Abrams, 1972). This approach often took the form of

opening a youth center that provided a unique activity or a specified set of

activities for the young people in a community. The assumption behind this

approach was that young people could be provided with real life experiences

that would be as appealing as the use of substances and would in turn

preclude their involvement with substances. Horan (1973) described this

assumption as competing reinforcement hierarchies which are very complex

and must be considered in the context of specific situations along with

interpersonal dynamics.

One of the emphases within this first general model of alternatives was to

change the affective-cognitive state of an individual. Weil (1972) was the

most notable advocate of this emphasis which he labeled “altered states of

consciousness.” Weil argued that drug use was in part a natural outgrowth

of a child’s interest in different states, (e.g., being dizzy). However, one

could argue with equal data that children also thrive on maintaining balance

(e.g., walking the curb).

As an example of providing a specific activity in the context of prevention,

Ventura and Dundon (1974) evaluated an Outward Bound type of program.

Their results did not reveal any statistically significant differences, between

groups or as a result of the pre- and post-test occasions, but the authors

concluded that the participants’ self-reports, and behavioral observations of

the participants revealed positive changes.

Religious participation as an alternative activity has always fared well in

the literature. For example, Bowker (1975), Turner and Willis (1979), and

Yohe (1981) all found that greater participation in religious activities was

associated with lower levels of use of substances. Similarly, Jessor and

Jessor (1977) and Kandel (1978) have also concluded that involvement with

religion is associated with less use of various substances.

142
Matching Need With Alternatives

The second major approach to alternative programming recommended

matching alternatives with unfulfilled needs of individuals. While several

authorities have advocated this approach, Cohen’s model (1971) is the most

well-developed conceptualization in this arena. Figure 1 below illustrates

four of Cohen’s levels of potential unmet needs and alternative activities

that would accommodate those needs. A distinguishing feature of this

approach to alternative programming is the individualization of activities

rather than the provision of a predetermined activity or group of activities.

Cohen’s model also emphasized addressing underlying causes in a manner

that would allow the individuals legitimate expressions of their needs.

Level of

Experience

Corresponding Motives

(Examples)

Possible Alternatives

(Examples)

Physical Desire for physical satisfaction, Athletics, dance, exercise,

physical relaxation, relief from hiking, diet, health, training,

sickness, desire for more ener- carpentry or outdoor work.

gy, maintenance of physical

dependency.

Sensory Desire to stimulate sight, sound, Sensory awareness training,

touch, taste, need for sensual- sky diving, experiencing

sexual stimulation. sensory beauty of nature.

Emotional Relief from psychological pain,

attempt to solve personal perplexities, relief from bad mood,

escape from anxiety, desire

for emotional insight, liberation of feeling, emotional

relaxation.

Competent individual counseling, well-run group therapy, instruction in psychology

of personal development.

Inter- To gain peer acceptance, to Expertly managed sensitivipersonal break through interpersonal ty and encounter groups,

barriers, to “communicate,” well-run group therapy, inespecially non-verbally, defi- struction in social custom,

ance of authority figures, confidence training, socialcement two-person relation- interpersonal counseling,

ships, relaxation of inter- emphasis on assisting others

personal inhibition, solve in- in distress via education,

terpersonal hangups. marriage.

FIGURE 1. Examples of Cohen’s approach to alternatives

143
Barnes and Olson (1977) investigated the remedies junior and senior high

school students used to relieve negative states or achieve positive states.

They gave a questionnaire that listed fourteen remedies (six drug and

eight nondrug remedies) and positive and negative states or moods. The

negative states were anxiety, depression, and hostility and the positive

states were adventure, cameraderie, and pleasure. Their goal was to

identify which alternatives were used to achieve and/or relieve emotional

states. The nondrug alternatives were physical activity, personal contemplation, discussions with friends or parents, counseling, social activities, and risk-taking behaviors.

One of their major findings was that alternatives used to reduce the

negative states were seldom used to achieve positive states and vice

versa (Barnes and Olson 1977). Distracting activities, discussions with

friends, and personal contemplation were used most frequently to relieve

negative states. Social activities, risk-taking behaviors, and physical

activities were used significantly more to achieve positive states. The

authors also found that illicit drugs and alcohol were used significantly

more to achieve positive states than to relieve negative states. They

recommended that alternatives should be paired with the state (need) that

they have the highest likelihood of facilitating.

Chanin (1969), Dohner (1972), Goodwin (1972), and Floyd and Lots of

(1978) also emphasized alternatives as a means for meeting more fundamental needs. They emphasized providing meaningful experiences with a

somewhat avant garde flavor such as: transcendental meditation, sensitivity groups, yoga, creative and esthetic experiences.

While Cohen’s (1971) model has been frequently cited as part of a rationale for alternative programming, there have been no evaluation projects

based on the model. Several methodological problems are inherent in

evaluating an approach that emphasizes individualization of services.

Nonetheless, the need for research on this model remains unfulfilled.

Enhancing Existing Alternatives

The third model of alternative programming involved the application of

reinforcement techniques to encourage and expand existing alternative

activities in small groups (e.g., Swisher et al. 1972). The process involved discussions with students regarding current nondrug activities

which were positively responded to by the group leader. Individuals who

were involved in positive alternatives served as role models for the group

members who were less involved. The assumption was that it would be

possible to increase the overall level of participation in alternatives

which, in turn, would reduce involvement with various substances.

144
This approach was evaluated at the junior high level by Warner et al.

(1973), at the senior high level by Swisher et al. (1972), and at the

college level by Swisher et al. (1973). All of these studies were true

experimental designs with random assignment of students to experimental

and control conditions, random assignment of group leaders to experimental and control conditions and pre- and post-testing with reliable and

valid instruments. However, this first series of studies concluded the

following:

1 . Regardless of approach, the knowledge level of participants significantly increased

2. Regardless of approach, the use levels did not change

3 . Regardless of approach, the attitudes of students did not change

The most positive finding was among the college students who reported

lower levels of use as a function of being in humanistically oriented group

processes.

Another study in this series with junior high students (Warner and Swisher

1976) produced a significant and positive change in the students’ expressed

willingness to try drugs. This particular project involved regular weekly

supervision of the group leaders in order for them to function according

to the prescribed procedures. The college results mentioned above were

also produced as a result of extensive supervision of group leaders. Subsequent attempts to implement this approach without the weekly supervision of group leaders were not successful. The theoretical basis of this

reinforcement model was also contrary to the then dominant affective

education philosophy in the field of prevention.

Self-Directed Youth Alternatives

The most recent model of self-directed youth alternative prevention to

emerge (known as Channel One) follows a seven-step procedure which

culminates in youth-directed special projects. The original Channel One

formed when artist Al Duca, of Gloucester, Massachusetts, hired a small

group of youth to help him with a large statue that he had been

commissioned to produce. This same group of young people subsequently

elected to restore a historic grave yard, with some financial support

from the Gloucester Community Development Corporation. While these

projects were being initiated Al Duca began discussions with Prudential

Insurance Company regarding the involvement of regional sales managers

as consultants to local community groups who would create additional

Channel One groups.

The National Institute on Drug Abuse became interested in further

stimulating the adoption of Channel One groups across the country, and

to accomplish this objective, each Single State Authority was given a

special grant (Resnick and Adams 1981).

145
The Channel One process involves a local prevention professional and a

regional sales manager from Prudential (or a representative from another

business) who meet to identify community needs. Subsequently community leaders are identified and they form a “steering committee” of adult

consultants. The steering committee recruits young people to form “task

forces” (Channel One groups) that have responsibility for initiating alternative activities of their own choosing. This self-directed process assumes that young people will elect responsible courses of action and by

generating meaningful alternatives they will ultimately become less involved with substance abuse.

Resnick and Adams (1981) reported that, as of May, 1981, there were

3,748 youth involved in 132 Channel One task forces in almost every State

in the country. As self-directed groups, 79 have elected vocational skill

projects, 44 alternative projects, 19 social service projects, 14 educational

projects, 11 historic preservation projects and 5 environmental projects.

The Resnick and Adams (1981) survey also revealed that two-thirds of the

groups were assisted by businesses other than the Prudential Insurance

Company. The involvement of the business community has been viewed

as a positive factor in the promulgation of Channel One groups by NIDA.

It is important to point out that 58 of the active 89 Channel One groups

reported that they were having serious financial difficulties. This problem highlights one of the missing ingredients in the total replication

process. The original Channel One groups were actually hourly employees

whereas, the replication groups were assumed to be volunteers. Given the

choice of projects listed above, it appears that the participants would

prefer income producing alternatives and in the absence of this opportunity the groups will probably disband (Resnick and Adams 1981).

EVALUATION OF CHANNEL ONE

Graefe (1981) conducted a comprehensive process evaluation of a Channel

One replication and concluded that the community, parents, and students

had positive attitudes toward their experiences. Some data suggested

reduced truancy among “active” Channel One members. The evaluation

did not include control groups and data on drug use behaviors were not

collected.

Hu et al. (1982) conducted the most recent outcome evaluation of the

Channel One process. The purpose of their evaluation was to determine

the effectiveness and the cost-effectiveness of this type of alternatives

programming. A community-based drug and alcohol agency, currently

conducting Channel One type groups that had received an incentive grant

for the effort, was nominated by a northeastern State as an appropriate

site for the evaluation. Even though several Channel One groups were

presently operating in the community, the local agency decided to initiate

new groups for this project. The groups were initiated at six year-round

146
community recreation centers. Three of the six sites were randomly

assigned to an active status (experimental) and three were assigned to an

inactive status (delayed treatment control). The Channel One program

evaluated by Hu et al. (1982) included the essential components of

natural group formation, group interaction, involvement in alternative

activities, youth-initiated activities, the opportunity for decision-making,

and the necessity for taking responsibility for one’s own decisions. Channel One participants identified their own program activities and goals.

The evaluation focused on the extent to which Channel One increased

participation in alternative activities, improved decision-making and problem-solving skills, improved self-concepts, increased creativity, and reduced substance use.

The outcomes varied across the three sites, with Site 1 becoming significantly more democratic in its group problem-solving. Furthermore, Site 2

became significantly more involved in positive alternatives. There were

no significant changes in self-esteem for any site. There were, however,

negative findings for Sites 2 and 3. In these sites, use of inhalants and

hallucinogens, and the frequency of being drunk increased (Hu et al.,

1982).

The costs of Channel One were calculated by including:

1. Costs to the program, such as personnel, transportation, materials

and supplies

2. Costs to other organizations, such as space, equipment, and supervision

3. Costs to the participants, such as transportation and equivalent hourly wages

Including the potential wages, the cost per participant ranged from $180

to $214. Excluding potential wages, the cost per participant ranged from

$78 to $82. The slight positive findings for improvement in democratic

problem-solving and participation in alternatives are offset by the clearly

significant increases in the use of selected substances. Therefore, the

program was not effective with regard to substance abuse outcomes

although there were some other benefits for the participants. Also the

social costs for all participants must be considered when judging the

program’s effectiveness.

The findings of this evaluation indicate that this particular alternative

program partially achieved the intended effects on the affective goals of

the groups. On the negative side of the ledger, it appears that the

process has a negative effect on the substance use levels of the

participants.

There were many difficulties encountered in starting the groups, collecting the data (e.g., on one test occasion false data were submitted by two

groups members hired to collect the data), and in terms of the adequacy

of experimental and control groups. Furthermore, this single study, while

making a contribution to the literature on costs and effectiveness of

147
alternative types of prevention programming, cannot be construed to be

representative of the 132 Channel One groups that were active at the

time.

A RECENT SURVEY OF ALTERNATIVES TO DRUG USE

During the 1981-1982 academic year, the Pennsylvania Department of

Education, funded by the Office of Drug Abuse Policy (Pennsylvania Department of Health), initiated a school improvement process. All schools

in Pennsylvania were mailed a request for a proposal to participate in a

demonstration project. A review panel was established to select the

demonstration sites and ten geographically dispersed schools were included. Four regional staff members of the Addictions Prevention Network were given training in administration of the questionnaire and they

in turn provided inservice workshops to all of the teachers in the junior

and senior high schools participating in the school improvement process.

The total sample was approximately 14,000 students in grades seven

through twelve.

Instruments

The Primary Prevention Attitude and Usage Scale (PPAUS) consists of

nine subscales as follows:

1 .

2 .

3.

4.

5.

6 .

7 .

8.

9.

Demographic characteristics (four items on age, grade level, sex,

and grade average)

School climate (four items on feelings about teachers, subjects,

classmates, and school in general)

Intentions to use scale (twelve items on situations in which an

individual would be willing to use different substances)

Self-reported use (twelve items on the extent of use of different

substances)

Extracurricular activities (eight items on the extent of participation

in school and community activities)

Social behavior (twenty items on positive and negative social

behaviors)

Prevention variables (eight items on variables that influence use of

substances)

Intervention preferences (ten items on individuals that one would

turn to for help with substance abuse problems)

Location of use (one item describing the typical setting for use of

substances)

The total scale is seventy-seven items in length and requires approximately thirty minutes to complete. Emphasis is given during the administration of the scale to each individual’s right not to answer any offensive

questions. Students are also assured of the anonymous nature of the

procedure and they are allowed to shuffle their answer sheets.

148
Reliability for subscales was established by calculating alpha coefficients

from existing data for various subscales. These data are listed in Table 1

below. Validity has been established by correlating the rank order of

substances reported by students in the norm group with the rank order of

substances reported by a national survey of high school seniors. In

essence, the rank order of substances in both surveys is in nearly perfect

agreement, suggesting high validity for the survey results.

TABLE 1. Reliability for survey subscales

Subscale Mean S.D. R

School Environment

Situational Use

Self-Reported Use

Behavior Scale

Positive

Negative

Total

Prevention

18.4 4.5 .67

26.1 10.4 .89

23.7 11.2 .90

24.5 5.4 .62

45.6 7.0 .84

70.0 9.4 .76

24.3 4.7 .80

A separate analysis was conducted on those students reporting any use of

serotonin. This is a means of detecting individuals who exaggerate their

use of substances or merely are careless in filling out the questionnaire.

The range of inappropriate answers from the various schools in this group

was approximately 3% to 7%.

Table 2 presents the result of a multiple regression analysis for data

collected from the 1981-1982 participating schools. A regression was

calculated for the extent to which the use of that substance is associated

with the types of items found in the questionnaire. For example, all of

the factors listed down the left-hand column are analyzed in terms of

their association with the use of cigarettes. The factors that are significantly (p less than .05) related to use of cigarettes are given a

descriptive label, such as “less.” This would be interpreted to mean that

the less time students spend participating in sports, the more they smoke

cigarettes. In order to understand the chart, it is necessary to verbalize

each statement. In the example above, the statement has a logical

quality and is not difficult to understand. However, some of the statements may require a review of the questionnaire in order to fully understand the interpretation.

149
In all cases, if a word (such as more, less, higher, lower) is present in the

table, it indicates “more use” of the substance under which it is listed. If

there is no word listed, this indicates that the factor was not significant.

However, no individual factor should be considered as extremely important. The weight of each factor is minimal, but if a pattern shows up

(e.g., females consistently listed across the top), this would indicate a

need for focusing on educational materials with a female point of view.

The following conclusions regarding alternatives can be drawn from the

regression model presented in Table 2.

1.

2 .

3 .

4.

5 .

6 .

7 .

8.

Entertainment activities are significantly associated with use of

cigarettes, beer, marijuana, inhalants, depressants, and stimulants.

Academic activities are associated with less use of beer, marijuana,

and stimulants.

Participation in sports is associated with less use of cigarettes,

marijuana, depressants, hallucinogens, and stimulants; however,

sports were significantly associated with more use of beer.

Participation in social activities was associated with more use of

everything.

Involvement in religious activities was associated with less use of

cigarettes, beer, marijuana, and stimulants.

Active hobbies were associated with less use of beer and stimulants.

Participation in extracurricular activities was associated with more

use of cigarettes, beer, marijuana, inhalants, depressants, and

stimulants.

Participation in vocational activities was associated with more use

of all substances in the questionnaire.

150
TABLE 2. Alternative activities and factors influencing use of substances

in 1981-82 school year

Factors Substances

CIG BEER MARJ INH DEP HALL STIM

Gender

Grade

Average

Entertain

Academic

Sports

Social

Religion

Hobbies

Extra

Vocation

Girl

Low

More

Less

More

Less

More

More

BOY

High

More

Less

More

More

Less

Less

More

More

High

Low

More

Less

Less

More

Less

More

More

More

More

More

More

High

More

Less

More

Less

More

More

Less

Less

More

Less

More

More More

More

More

r

2

* .325 .383 .371 .090 .140 .123 .258

N 13,915 13,931 13,946 13,960 13,949 13,949 13,949

*Other variables in the regression model also contributed to the r

2 (e.g.,

how students feel about school).

151
CONCLUSIONS AND RECOMMENDATIONS

One apparent conclusion from this review of research on alternative

programming is that there is a sparse evaluation literature and uneven

correlational literature upon which to base any conclusion. During the

last decade ten thousand studies have appeared in the professional literature involving the MMPI (Anastasi 1980). One is hard pressed to find one

percent of that record for the entire field of prevention.

Schaps et al. (1981), in a comprehensive review of 127 outcome studies of

all types of prevention programs, found only twelve studies of alternative

programming. Seven of the 12 studies reported no program impact on

participants. The other 5 studies had positive outcomes which resulted in

alternative programming being second in positive effects among ten other

approaches to prevention. These successful programs suggest some merit

for the alternative approach, but more importantly they do not represent

an adequate data base for planning.

Programs such as Channel One should be more thoroughly evaluated prior

to mass dissemination efforts. Apparently, neither the initiation nor

termination of Channel One benefited from an adequate data base.

There is a need for additional research in this domain. Instead of

discarding what has been learned, research should further explore what

types of alternatives in what kinds of agencies and institutions have a

constructive effect on what types of individuals. The research cited in

this paper supports the fact that some alternatives detract from drug

abuse (e.g., academic, sports, and religious) whereas, other alternatives

contribute to the use of various substances (e.g., social, entertainment,

and vocational). More basic longitudinal research on underlying psychosocial dynamics needs to be explored regarding these behavioral manifestations.

REFERENCES

Anastasi, A. Psychological Assessment (4th ed.). New York: HoughtonMifflin, 1980. 665 pp.

Barnes, C.P., and Olson, J. N. Usage patterns of nondrug alternatives in

adolescence. J Drug Education, 7(4):359-368, 1977.

Bowker, L. College student drug use: An examination and application of

the epidemiological literature. J College Student Personnel, 16(2):137-

144.1975.

Chanin, A. Understanding adolescence: Alternatives to drug use. Clinical Pediatrics, 8(1):6-10, 1969.

Cohen, A. Y. The journey beyond trips:

Psychedelic Drugs, 3(2):16-21, 1971.

Alternatives to drugs. J

Dohner, V. A. Alternatives to drugs--a new approach. J Drug Education, 2(1):3-22, 1972.

Floyd, J. D., and Lotsof, A.B. Drug education: A cultural perspective,

an educational model and an implementation scheme. J Druq Education, 1978, 8(4):357-368.

Goodwin, L. R., Jr. Drugless alternatives. Unpublished paper, Tallahassee, FL: Department of Health and Rehabilitative Services, Florida

Drug Abuse Program, 1972.

152
Graefe, R. Channel One, Central Falls: Evaluation report. Council for

Community Services, Inc. Providence, RI, 1981.

Hu, T.; Swisher, J.; McDonnell, N.1 and Stein, J. Cost-effectiveness

evaluation: A drug abuse prevention alternatives program. Research

report for the Prevention Branch of the National Institute on Druq

Abuse. Grant No. E07 Da02464-02. 1982.

Horan, J. Preventinq druq abuse throuqh behavior change technoloqy. J

of SPATE, 12:145-152,1973.

Jessor, R., and Jessor, S. Problem behavior and psychosocial development: A longitude study of youth. New York: Acadmeic Press, 1977.

281 pp.

Kandel, D. Longitudinal research on drug use. Washington, DC: Hemisphere Publishing Corp., 1978. 314 pp.

Resnik, H., and Adams, T. Channel One: A government/private sector

partnership for drug abuse prevention. U.S. Government Printing Office, 354-885/9173, Washington, DC, 1981.

Schaps, E.; DiBartolo, R.; Moskowitz, J.; Palley, C.; and Churgin, S. A

review of 127 drug abuse prevention program evaluations. J Drug

Abuse, 11:17-43, 1981.

SWisher, J., and Horman, R. Drug abuse prevention. J College Student

Personnel, 11:337-341, 1970.

Swisher, J. D.; Warner, R. W., Jr.; and Herr, E. L. Experimental comparison of four approaches to drug abuse prevention among ninth and

eleventh graders. J Counseling Psychology, 19(4):328-332, 1972.

Swisher, J. D.; Warner, R. W., Jr.; Spence, C. C.; and Upcraft, M. L.

Four approaches to drug abuse prevention among college students. J

College Student Personnel, 14(3):231-235, 1973.

Turner, C. J., and Willis, R. J. The relationship between self-reported

religiousity and drug use by college students. J Drug Education,

9(1):67-78, 1979.

Ventura, M. R., and Dundon, M. A challenging experience in canoeing and

camping as a tool in approaching the drug problem. J Drug Education,

4(1):123-127, 1974.

Wald, P., and Abrams, A. Drug education. In P. Wald and P. Hutt

(Eds.), Dealing with drug abuse. New York: Praeger, 1972. 356 pp.

Warner, R., and Swisher, J.D. Drug abuse prevention: Reinforcement of

alternatives. In J. Krumboltz, and C. Thoresen, Counselinq methods.

New York: Holt, Rinehart & Winston, 1976.

Warner, R.; Swisher, J.; and Horan, J. A behavioral approach to drug

abuse prevention. NAASP Bulletin, 57:49-54, 1973.

Weil, A. T. Altered states of consciousness. In P. Wald and P. Hutt

(Eds.), Dealing with drug abuse. New York: Praeger, 1972.

Yohe, T. Alternatives to substance abuse. Unpublished Master’s Thesis.

The Pennsylvania State University, University Park, PA 16802, 1981.

AUTHORS John D. Swisher, Ph.D.

Division of Counseling and Educational Psychology

The Pennsylvania State University

309 Cedar Building

University Park, PA 16802

Teh-Wei Hu, Ph.D.

Department of Economics

The Pennsylvania State University

521 Kern Building

University Park, PA 16802

153
ACKNOWLEDGMENT

I wish to acknowledge the contributions of Dr. Coryl Jones to the

conceptual and analytical aspects of the research on which this

paper is based. She served as director of environmental studies

and senior investigator in the NIMH Clinical Infant Development

Program before joining NIDA in 1983.

REFERENCES

Brook, J.W.; Whiteman. M.; and Gordon, A.S. Stages of drug use

in adolescence: Personality, peer, and family correlates.

Developmental Psychology 19:269-277, 1983.

Bruch. H. Eating Disorders: Obesity, Anorexia Nervosa, and the

Person Within. New York: Basic Books, 1973.

Greenspan, S. I. Intelligence and adaptation: An integration of

psychoanalytic and Piagetian developmental psychology.

Psychological Issues, Monograph 47/48. New York: International Universities Press, 1979.

Greenspan, S. I. Psychopathology and Adaptation in Infancy and

Early Childhood: Principles of Clinical Diagnosis and Pre

ventive Intervention. New York: International Universities

Press, Inc., 1981.

Greenspan. S.I., and Lieberman, A.F. Infants, mothers and their

interactions: A quantitative clinical approach to

developmental assessment. In The Course of Life:

Psychoanalytic Contributions toward Understanding Personality

Development, Vol. I: Infancy and Early Childhood (Greenspan,

S.I., and Pollock, G.H., eds.). DHHS Pub. No. (ADM) 80-786.

Washington, D.C.: Govt. Print. Off., Supt. of Docs., 1980.

Greenspan, S.I., and Porges. S.W. Psychopathology in infancy and

early childhood: Clinical perspectives on the organization

of sensory and affective-thematic experience. Child

Development 55:49-70, 1984.

Mahler, M.S.; Pine, F.; and Bergman, A. The Psychological Birth

of the Human Infant. New York: Basic Books, 1975.

Nemiah, J.C. Alexithymia: Theories and Models. Proceedings of

the 11th European Conference on Psychosomatic Research.

Basel, Switzerland: Karger, 1977.

Sorce, J.F., and Emde, R.N. Mother's presence is not enough: The

effect of emotional availability on infant exploration.

Developmental Psychology 17(6): 737-745.

AUTHOR

Stanley I. Greenspan, M.D.

Director, Clinical Infant Research Laboratory

Division of Maternal and Child Health, HRSA, and

National Institute of Mental Health

2340 University Blvd. E.

Adelphi, Md. 20783

154
The Etiology and Prevention of

Substance Use: What Can We Learn

From Recent Historical Changes?

Lloyd D. Johnston, Ph.D.

INTRODUCTION

In this paper, I will review somewhat selectively what we have learned

about trends in the use of illicit drugs among adolescents and young adults

since the mid to early 1970s. I will try to emphasize those aspects which I

believe have particular relevance for the development of primary and

secondary intervention strategies. Some discussion will also be focused on

what we know about trends in surrounding conditions which are potentially

contributory to levels of use.

DATA SOURCES

I will rely primarily on two national data sources for these purposes-the

National Household Survey on Drug Abuse (Miller et al. 1983) and the

Monitoring the Future Study of high school seniors and young adults

(Johnston et al. 1984). Both are based on nationally representative samples

of respective universes within the coterminous United

States-members of households aged twelve and over in the case of the

former study, and high school students nearing completion of their senior

year in both public and private high schools, in the case of the latter. Both

rely upon self-report methods for determining substance use, though the

Household Survey involves face-to-face interviews in the home with

privately completed answer sheets, while the Monitoring the Future Survey

uses self-administered confidential questionnaires, which are groupadministered to about 17,000 seniors in school each year and subsequently

sent by mail to panels of about 1,000 seniors from each of the previous

senior classes for up to ten years past high school.

Perhaps the most important characteristics shared by both studies are that

they are ongoing series, which gives them the capacity to measure trends in

both substance use and potentially related factors and that they encompass

a wide range of substances, both licit and illicit. The National Household

Surveys were begun in 1971 by the President’s Commission on Marijuana

with subsequent national surveys having been conducted in 1972, 1974,

1976, 1977, 1979, and 1982. One is also planned for 1985. The Monitoring

the Future surveys began 4 years later, in 1975, and have been conducted

annually since.

155
FIGURE 2: Relationship between probability of reporting

current substance abuse and number of risk factors exhibited

by individual adolescents in the general population

factors is associated with a four and a half times increase in magnitude of risk, or a 50% chance of reporting substance abuse.

Figure 2 shows the results of a study including all ten of the abovedescribed etiological factors. As you can see, 100% of those subjects who exhibited 5 or 6 risk factors also reported current substance abuse upon cross validation (Bry and Pedraza 1983).

It is important to note that the relationships shown in figures 1

and 2 are not accounted for by one predominant combination of risk

factors. In figure 1, 24 different combinations occurred among the

156 subjects who exhibited 2, 3, or 4 risk factors, and none of the

combinations accounted for more than 20% of the cases.

Table 1 shows that the results of the study whose findings are represented in figure 2 are not accounted for by one set of risk

factors. Among the six exemplary subjects shown, no two subjects

has the same combination of risk factors. The fact that early cigarette use is more highly represented in table 1 than low religiosity does not suggest that one is a more predictive risk factor

than another, for the base rate of early cigarette use is much

higher in the non-substance-abusing population than is low religiosity. These results suggest, as others have hypothesized, that

there may be almost as many salient combinations of etiological

variables as there are substance abusers (e.g., Nathan and Harris

1980).

156
TABLE 1

Combinations of Risk Factors Represented Among Substance Abusers in a Cross-sectional Test of the MultipleText

Risk Factors Hypotesis
in perceived harmfulness than in personal disapproval provides some

substantiation for the first link.

Further evidence of the primacy of health beliefs as determinants for the

recent downturn in regular and occasional marijuana use, may be found in

the reasons given by abstainers and quitters for their nonuse of marijuana.

“Abstainers” here are defined as those who have never tried marijuana;

while “quitters” are defined as those who have used once or more in the

past, but who have not used in the past 30 days, and say they probably or

definitely will not be using in the future. (see Bachman et al. 1984 for the

full questions). Figures 12a and 12b give the frequency with which these

two groups checked each of fourteen pre-specified reasons in the 1983

survey. Note that the two most frequently mentioned reasons deal with

concerns about physical and psychological health effects. Further, an

examination of figures 12c and 12d shows that quitters and abstainers have

been mentioning these two concerns with increasing frequency in recent

years. No other concerns show as sizeable an increase in mentions.

In sum, while the proof is not ironclad, the available evidence is certainly

highly supportive of the notion that the beliefs about how harmful regular

marijuana use is had a lot to do with the changes in use. If we had similar

information on PCP-that is, data on the perceived harmfulness and the

reasons for abstaining and quitting - I am virtually certain that we would

find similar changes accompanying the sharp drop in active PCP use

observed between 1979 and 1982, when annual prevalence dropped by more

than two-thirds (from 7.0% to 2.2%). During that interval the considerable

dangers of using PCP received widespread attention in the media, just as

did the potential hazards of regular marijuana use.

I also believe that the sudden leveling off in cocaine use after a period of

rapid increase in use between 1976 and 1979 had in part to do with changed

beliefs in the population about just how safe that drug was. In fact, the

proportion of seniors stating that regular cocaine use poses a “great risk”

for the user rose between 1979 and 1983 from 69% to 74% (Johnston et al.

1984).

An emphasis on health consequences has not been held in high favor in

recent years by the prevention community, perhaps because the “scare

tactics” sometimes used in schools apparently failed, as did the government

sponsored publicity campaigns of the early 70s through the media. Further,

some suggest that all the evidence in the Surgeon General’s reports on

smoking still have not curtailed smoking.

I would emphasize several different points in response. To take the last

contention first, a lot of people did quit smoking as a fairly direct result of

the Surgeon General’s report and many of the remainder wish to quit. What

must be taken into account in this case is the highly dependence-producing

nature of the drug. Wanting to quit does not translate directly into quitting

once the habit is established. Between 1977 and 1981 we observed nearly a

one-third decrease in the proportion of seniors who smoked daily, and an

examination of their age-at-onset patterns (see figure 10) shows that in the

recent graduating classes, not only are fewer students smoking in senior

year, but fewer of them began smoking regularly at earlier ages. In other

words, good evidence exists of a cohort effect with the differences in

behavior between classes being established at quite an early age. Perhaps

158
cohort differences in underlying attitudes and beliefs were established at a

still earlier age. As figure 14 illustrates, the perceived harmfulness of

smoking was rising with subsequent senior classes up through 1980. These

changed attitudes very likely are “residual” from changes which could have

been observed as early as age ten or eleven. In my opinion, the overall

evidence on smoking strongly suggests that heightened health concerns

have had a substantial effect on both the rates of initiation and quitting.

As far as the apparent failure of the government’s media propaganda

campaign of the early seventies and the scare tactics used in school at that

time are concerned, what they may have had in common was that the

“health” messages came from senders who did not have credibility with the

target audience. Alienation from “the system” was at its peak among youth

in the early 1970s and, in fact, the use of certain drugs--in particular

marijuana and hallucinogens-was an expression of membership and

sympathy with the “counter culture” (Johnston 1973). The President’s

Commission on Marihuana even went so far as to entitle their first report

“Marihuana: A Signal of Misunderstanding.” Clearly the target audience

was not receptive to any messages from the system which cast negative

connotations on such drug use. Further, the senders often depleted

whatever little credibility they might have been able to muster by an

overemphasis on propaganda and an underconcern with accuracy and

balance. No wonder, then, that these early efforts either failed, or perhaps

even backfired.

Different factors are now operant. The sources of the hazard messages--

largely scientists and the media--have credibility with young people. Their

messages can be heard and believed, partly because young people are more

ready to hear and partly because these sources have so far retained

credibility. Further, recent classes may have had more of a chance than

their predecessors for some vicarious learning derived from firsthand

observation of the effects of chronic drug involvement. The commonly

used label of “burnouts” for users of drugs provides some semantic evidence

to this effect.

Causes Of The Overall Downturn

Earlier the beginnings of a downturn in youthful drug use in recent years

was mentioned. Substantiation may be found in both the series of surveys

discussed. Exactly what the causes have been is open to interpretation.

My hypotheses include: (a) the “fad” quality of drug use is beginning to

wear off; it’s becoming “old hat”; (b) the symbolic value of drug use as a

form of rebellion against the system and the adult world has declined as

some of the major historical reasons for that rebellion (in particular, the

Vietnam War) have receded into the past, and as the “shock value” of drug

use has ebbed; (c) drug use is seen as inconsistent with the recent secular

movement toward more healthy lifestyles; (d) young people have become

more able to “hear” the cautions which the system has to tell them about

drugs; and (e) “the system” has become more sophisticated, believable, and

consistent in its communications with youth about drugs. By “the system” I

mean government, the schools, the media, the scientific community, and

parents.

159
Modeling: Behavior is a Function of Others' Behavior

In contrast to the above processes, there is a considerable amount

of understanding about the role modeling can play in human substance use and the conditions that increase and decrease its effects

(Collins and Marlatt 1981). The use patterns of independent models,

particularly of warm active peers, influence amounts of substance

ingestion both in the presence of the model and afterwards. There

is evidence that this effect occurs even when subjects have been

told that an attempt is being made to influence their drinking

behavior (DeRicco and Garlington 1977). Modeling, particularly of

responsible use of the communication skills necessary to say "no,"

of coping with adversity, and of choosing alternative activities,

can be an important process in family-based prevention approaches.

Expectancies: Behavior is a Function of Expectancies Regarding

its Consequences

As Alford (1981) points out, often external stimuli such as reinforcers and models do not directly cause behavior. Instead, they

create conditions under which the adolescent "perceives," through

reinforcement history or anticipatory expectancy, that one course

of action will be more rewarding or less punishing than another.

Expectancies, therefore, are important in the initiation and maintenance of adolescent substance abuse.

Southwick et al. (1978), for instance, found that heavier drinkers

expect greater stimulation and pleasure from alcohol than do lighter

drinkers. Among adolescents, Christiansen and Goldman (1983)

report that, in contrast to social drinkers, young people with

alcohol-related problems are significantly more likely to expect

alcohol to improve their cognitive and motor functioning. They are

significantly more likely to endorse items such as "alcoholic beverages make parties more fun, " "people drive better when they are

drinking alcohol." In another study, Christiansen et al. (1982)

found that adult-like expectancies about alcohol were already established at the beginning of adolescence, before the majority of

young people had experienced alcohol consumption. Such findings

point directly to the family as a potential shaper of expectancies.

FAMILY CONTRIBUTIONS TO THE REDUCTION OF PRECURSORS IN SCHOOL AND

MEDIA-BASED APPROACHES

Given the amount of potential influence that families have upon

adolescent behavior, it is noteworthy how seldom their impacts in

primary prevention have been measured. The following three research

programs, however, all evidence that family involvement is very

important, if not essential, for positive outcomes in programs designed to reduce substance abuse precursors.

160
In a study of the impact of the media on the precursor, cigarette

use, Flay et al. (in press) compared the impact on junior high

students of (a) a combined school and media smoking prevention/

cessation program with written homework assignments to complete

with parents and (b) no special school or family homework component (controls still received traditional health curriculum and

could watch the TV segments). Preliminary results indicated that,

although there were not great differences in knowledge between the

two groups, there were significant differences in beliefs and

behaviors. The full program students were only half as likely as

control subjects to start smoking during the 2 months between the

pre and post tests (7% vs. 14%, respectively). Perhaps equally

as significant, were the findings that of all the smoking parents

who viewed the smoking cessation segments of the program, 69%

attempted to quit or reduce smoking, and 35% quit successfully.

Not only does Flay et al. (in press) report significant reduction

in an important precursor -- cigarette use, they also report, in

another paper (Flay et al. 1982),direct measurement of one of the

processes that has been shown to influence substance abuse -- expectancies. Apparently adolescents usually overestimate how many

other adolescents smoke at least once a week. The actual level is

10%. Before the program, most of both the program and control students overestimated that percentage greatly. After the program, a

significantly lower number of the program students overestimated,

while the controls continued to overestimate. For adolescents in

particular, it is easy to imagine how developing a new expectation

that they will be an "oddball" if they smoke could influence them

to delay or to avoid cigarette smoking altogether.

The other process that may well have been determinant of the

behavioral outcome was not measured -- modeling. Even if all of

the parents who initially quit smoking do not remain abstinent,

they have modeled for their children some at least temporarily

successful methods for coping with an intractible habit. In the

future, it would be interesting to assess more directly the relationship between parental modeling and their children's abstinence

behavior. In addition it would be interesting to investigate the

family involvement separately from that of the special school

program.

Blechman et al. (1981) looked more closely at the impact of

family vs school-only involvement with a dismantling design while

investigating the reduction of another precursor -- low academic

motivation. The researchers identified children in the second

through sixth grades with very inconsistent grades on their math

homework and assigned them to one of three preventive interventions: (a) teacher home notes and family problem-solving training,

161
with an increase in use, while remaining in the parental home is associated

with no change in use. These relationships are little affected, nor is their

explanatory power much augmented, by the inclusion of student status or

employment status.

CONCLUSION

As has been noted throughout this paper, there is rather strong evidence of

a recent secular downturn in the use of a number of illicit drugs (figure 21).

Usage levels still remain very high by historical standards; but this period

of downward movement may prove a particularly opportune one for

achieving prevention results. In my view, those trying to prevent drug

involvement on the part of young people are finally moving with the

current, instead of against it, and the potential for achieving appreciable

results may be better now than at any time in the past 20 years.

REFERENCES

Bachman, J.C.; Johnston, L.D.; and O’Malley, P.M. Monitoring the Future:

Questionnaire Responses From the Nation’s High School Seniors, 1982.

Ann Arbor: Institute for Social Research, 1984.

Bachman, J.C.; O’Malley, P.M.; and Johnston, L.D. Drug use among young

adults: The impacts of role status and social environment. J Per Soc

Psychol, 47 (3), 1984, pp. 629-645.

Johnston, L.D. Drugs and American Youth. Ann Arbor: Institute for

Social Research, 1973.

Johnston, L.D. Frequent marijuana use: Correlates, possible effects, and

reasons for using and quitting. In: deSilva, R.; DuPont, R.; and Russell,

G., eds. Treating the Marijuana Dependent Person. New York: The

American Council on Marijuana, 1981.

Johnston, L.D.; Bachman, J.G.; and O’Malley, P.M. Student Drug Use,

Attitudes, and Beliefs: National Trends 1975-1982. National Institute on

Drug Abuse. DHHS Pub. No (ADM) 83-1260. Washington, D.C.: Supt. of

Docs., U.S. Govt. Print. Off., 1982.

Johnston, L.D.; O’Malley, P.M.; and Bachman, J.G. Drugs and American

High School Students, 1975-1983. Natonal Institute on Drug Abuse,

DHHS Pub. No. (ADM) 84-1317. Washington, D.C.: Supt. of DOCS., U.S.

Govt. Print. Off., 1984.

Miller, J.D.; Cisin, I.H.; et al. National Survey on Drug Abuse: Main

Findings 1982. National Institute on Drug Abuse. DHHS Pub. No. (ADM)

83-1263. Washington, D.C.: Supt. of DOCS., U.S. Govt. Print. Off., 1983.

O’Malley, P.M.; Bachman, J.G.; and Johnston, L.D. Period, age, and cohort

effects on substance use among American youth, 1976-1982. Am J

Public Health, 74 (7), 1984, pp. 682-688.

AUTHOR

Lloyd D. Johnston, Ph.D.

Institute for Social Research

The University of Michigan

P.O. Box 1248

Ann Arbor, MI 48106

162
TABLE 1

Trends in Annual Prevalence of Sixteen Types of Drugs

NOTES: Level of signrficance of difference between the two mat recent classes:

s = .05, ss = .01, sss = .001.

NA indicates data not available.

aData based on four questionaire forms. N is four-fifths of N indicated.

bAdjusted for underrreporting of amyl and butyl nitrates (see text).

cData based on a single questionnaire form. N iS one-fifth of N indicated.

dAdjusted for underreporting of PCP (see text).

eOnly drug use which was not under a doctor’s orders is included here.

fAdjusted for overreporting of the non-prescription Stimulants. Data based on three questionnaire forms.

N is three-fifths of N indicated.

163
FAMILY-BASED APPROACHES TO THE REDUCTION OF PRECURSORS (PRIMARY

PREVENTION)

Parental modeling is specifically programmed in two particular

family-based preventive interventions designed to reduce poor

parental-child relationships. Guerney et al. (1981) compared the

effects of three months of parent and teen-ager communication

skills training in groups (Relationship Enhancement) with an

equated traditional group discussion intervention and no treatment

controls. Whereas the traditional group discussion format increased quality of parent-child relationships over the control

group on three of five measures, only the Relationship Enhancement

training increased (a) quality of parent-child relationships on all

five outcome measures, (b) increased proficiency and satisfaction

in general communication patterns, (c) increased expressive skill

("I" statements), and (d) increased empathic skill in lower class,

non-client volunteer mothers and daughters. Ginsberg (1977)

achieved similar findings with fathers and sons. Modeling and expectancies (re: family relationships) seem to be the salient

processes.

Robin (1981) contrasted the impact of seven sessions of specific

cognitive-behavioral problem-solving and generalization training

with that of traditional family therapy upon number of parent-teen

conflicts at home and specific communication behaviors in mediarecruited parents and adolescents. Both traditional short-term

family therapy and the Problem-solving Communication Training decreased the number of conflicts at home up to 3 months after the

intervention, but only Problem-solving Communication Training

significantly improved problem-solving communication behaviors.

Given the importance of modeling in determining adolescent behaviors,

it is interesting that parents tended to emit a greater proportion

of the problem-solving behavior than the adolescents, even though

parents and adolescents were equivalent in other communications

behavior. It is also significant for the development of prevention

programs, where parents must volunteer to participate vs being

forced, that Robin's parents preferred the problem-solving training

to the short-term family therapy.

For decreasing the precursor of other problem behaviors, familybased approaches have been developed and tested by Patterson (1974)

and Alexander and Parsons (1973). Patterson teaches parents or

teachers of elementary school-aged conduct-disordered boys to reprogram the social environment through contingency contracting so

that the cost associated with problem behaviors exceeds the benefit

for the young person. Both parent reports and objective observations reveal significant improvement in boys so treated. These effects are maintained for at least 12 months, for Patterson and

Fleischman (1979) report that 82-84% of the subjects' behavior is

still within normal range at that time.

164
They also discuss what processes may be involved in such reduction

of a precursor of substance abuse. They suggest that negative

reinforcement will maintain parental behavior changes (just as the

parental behavior changes maintain the boys' behavior changes) as

long as the costs of the child's problem behaviors exceed the cost

to the parent of maintaining consistent contingencies. Patterson

and Fleischman speculate that failures in improvement maintenance

are caused by floods of family crises, such as job loss, separation,

or depression, that together have higher aversive inputs than the

negative behavior of the boy. They also report that expectancies

regarding both family functioning (Patterson and Reid 1973) and

their own self-efficacy improve in trained mothers, suggesting that

changed expectancies play a role too.

Alexander and Parsons (1973) report similar positive effects of

family training in contingency contracting in reducing and preventing behavior problems of adolescents for 6-18 months and 2-1/2 -

3-l/2 years following treatment (Klein et al. 1977). As was true in

the Robin (1981) and Guerney et al. (1981) studies, Alexander and

Parsons (1973) found the effects of a specifically structured family

intervention to be significantly more positive in reducing substance

abuse precursors than were those of traditionally implemented family

therapy. Consequently, the positive results are not merely due to

the inclusion of the family per se, but of, in each case, specific

training to change processes (reinforcement, modeling, and expectancies) that play a role in the development of adolescent risk factors.

FAMILY-BASED APPROACHES TO THE REDUCTION OF EARLY PROBLEM USE

(SECONDARY PREVENTION)

The above technologies are all primary preventions, for they address

substance abuse precursors. As the primary socializing agent, the

family can also be influential and perhaps essential in secondary

prevention, i.e., intervention applied early in the problem development process. Szapocznik et al. (in press) compared short-term

conjoint versus on-person family therapy in reducing early substance

abuse in 37 Miami Hispanic-American adolescents. Both interventions

reduced substance use by the end of treatment, but the one-person

family therapy maintained the gains better at 6 and 12 month followup.

Szapocznik's study is particularly interesting for this discussion

because they examined Processes. They found that the members of the

group whose substance abuse remained low also increased their perception of family cohesiveness, suggesting that Szapoznik's technique of

training the teenager to go home and take actions to improve his/her

family environment reduced substance use, through at least one of

the above-mentioned processes, through increasing the adolescent's

expectancies regarding family closeness.

165
FIGURE 5

Marijuana: Trends in Lifetime Prevalence for Earlier Grade Levels

Based on Retrospective Reports from Seniors

FIGURE 6

Use of Any Illicit Drug Other Than Marijuana or Amphetamines:

Trends in Lifetime Prevalence for Earlier Grade Levels

Based on Retrospective Reports from Seniors

166
FIGURE 7

PCP: Trends in Lifetime Prevaleance for Earlier Grade Levels

Based on Retrospective Reports from Seniors

FIGURE 8

Stimulants: Trends in Lifetime Prevalence for Earlier Grade Levels

Based on Retrospective Reports from Seniors

167
Falk, J.L. Drug dependence: Myth or motive? Pharmacol

Biochem Behav, in press.

Fishman, H.C. ; Stanton, M.D.; and Rosman, B.L. Treating families

of adolescent drug abusers. In: Stanton, M.D., Todd, T.C.,

and Associates. The Family Therapy of Drug Abuse and-Addiction.

New York: Guilford Press, 1982. pp. 335-357.

Flay, B.R.; Johnson, C.A.; and Hansen, W.B. The USC/KABC-TV

smoking prevention/cessation program: Preliminary results.

Los Angeles: Health Behavior Research Institute, University

of Southern California, 1982.

Flay, B.R.; Johnson, C.A.; Hansen, W.B.; Ulene, A. Grossman, L.M.

Alvarez, L. Sobol, D.F. Hochstein, G. and Sobel, J.L. Evaluation of a mass media enhanced smoking prevention and cessation program. In: Baggaley, J.P., and Sharpe, J., eds.

Experimental Research in TV Instruction. Vol. 5. St. John's

Newfoundland: Memorial University, in press.

Ginsberg, B.G. Parent-adolescent relationship development

program. In: Guerney, B.G., Jr., ed. Relationship Enhancement: Skill-training Programs for Therapy, Problem Prevention,

and Enrichment. San Francisco: Jossey-Bass, 1977.

Guerney, B., Jr.; Coufal, J. and Vogelsong, E. Relationship

enhancement versus a traditional approach to therapeutic/

preventive/enrichment parent-adolescent programs. J Consult Clin

Psychol, 49:927-939, 1981.

Helfrich, A.A., and Crowley, T.J. Behavioral approach to cocaine

abuse. Paper presented at the meeting of the American Psychological Association, Washington, DC, August 1982.

Hendin, H.; Pollinger, A.; Ulman, R.; and Carr, A.C. Adolescent

Marijuana Abusers and Their Families. National Institute on

Drug Abuse Research Monograph 40. DHEW Pub. No. (ADM) 81-1168.

Washington, DC: Supt. of DOCS., U.S. Govt. Print. Off., 1981.

Jessor, R., and Jessor, S.L. Theory testing in longitudinal

research on marihuanause. In: Kandel, D.B., ed. Longitudinal

Research on Drug Use: Empirical Findings and Methodological

Issues. New York: Hemisphere, 1978. pp. 41-71.

Kachanoff, R.; Leveille, R.; McCelland, J.P.; and Wayner, M.S.

Schedule-induced behavior in humans. Physiol Behav, 11:395-398,

1973.

Kandel, D.B. Convergences in prospective longitudinal surveys

of drug use in normal populations. In: Kandel, D.B., ed.

Longitudinal Research on Drug Use: Empirical Findings and

Methodological Issues. New York: Hemisphere, 1978. pp. 3-38.

Kandel, D.B.; Treiman, D.; Faust, R.; and Single, E. Adolescent

involvement in legal and illegal drug use: A multiple classification analysis. Soc Forces, 55:438-458, 1976.

Kaplan, H.B. Antecedents of deviant responses: Predicting from a

general theory of deviant behavior. J Youth Adolesc, 6:89-101,

1977.

168
Klein, N.C.; Alexander, J.F.; and Parsons, B.V. Impact of family

systems intervention on recidivism and sibling delinquency:

A model of primary prevention and program evaluation. J Consult

Clin Psychol, 45:469-474, 1977.

Maccoby, N.; Farquhar, J.W.; Wood, P.D.; and Alexander, J.

Reducing the risk of cardiovascular disease: Effects of a

community-based campaign on knowledge and behavior. J Community

Health, 3:100-114, 1977.

Mello, N.K. Control of drug self-administration: The role of

aversive consequences. In: Petersen, R.C., and Stillman, R.C.,

eds. Phencyclidine (PCP) Abuse: An Appraisal. National

Institute on Drug Abuse Research Monograph 21. DHEW Pub.

No. (ADM) 78-728. Washington, D.C.: Supt. of Docs., U.S.

Govt Print. Off., 1978. pp. 289-308.

Nathan, P.E., and Harris, S.L. Psychopathology and Society,

2nd ea. New York: McGraw-Hill, 1980. 524 pp.

Nurco, D.N. Etiological aspects of drug abuse. In: DuPont,

R.I., Goldstein, A., and O'Donnell, J., eds. Handbook on Drug

Abuse. National Institute on Drug Abuse, Washington, D.C.:

of DOCS., U.S. Govt. Print. Off., 1979. pp. 315-324.

Supt.

O'Donnell, J.A., and Clayton, R.R. Determinants of early marihuana

use. In: Beschner, G.M., and Friedman, A.S., eds. Youth

Drug Abuse: Problems, Issues, and Treatment. Lexington, MA:

Lexington Books, 1979. pp. 63-110

Pandina, R.J., and Schuele, J.A. Psychosocial correlates of

adolescent alcohol and drug use. J Stud Alc, in press.

Paton, S.; Kessler, R.; and Kandel, D. Depressive mood and

adolescent illicit drug use: A longitudinal analysis.

J Genet Psychol, 131:267-289, 1977.

Patterson, G.R. Interventions for boys with conduct problems:

Multiple settings, treatments, and criteria. J Consult Clin

Psychol, 42:471-481, 1974.

Patterson, G.R., and Fleischman, M.J. Maintenance of treatment

effects: Some considerations concerninn family systems and

follow-up data. Behav Ther, 10:168-185; 1979.

Patterson. G.R., and Reid. J.B. Intervention for families of

aggressive boys: A replication study. Behav Res Ther,

11:383-394, 1973.

Pervin, L. Affect and addictions. Unpublished manuscript

available from author at Psychology Department, Rutgers University, New Brunswick, NJ 08903, 1981.

Robin, A.L. A controlled evaluation of problem-solving communication training with parent-adolescent conflict. Behav

Ther, 12:593-609, 1981.

Segal, B.; Huba, G.J.; and Singer, J.L. Prediction of college

drug use from personality and inner experience. Int J Addict,

15:849-867, 1980. (a)

Segal, B.; Huba, G.J.; and Singer, J.L. Reasons for drug and

alcohol use by college students. Int J Addict, 15: 489-498,

1980.(b)

169
Here are some reasons people give for not

using marijuana, or for stopping use. If you

have never used marijuana. or if you have

stopped using it, please tell us which

reasons are true for you. (Mark all

apply.)

Concerned about possible

psychological damage

Concerned about possible

physical damage

It’s against my beliefs

My parents would disapprove

Don’t feel like getting high

Concerned about possible loss

of control of myself

It might lead to stronger drugs

I don’t like being with the

people who use it

Concerned about becoming

addicted to marijuana

My friends don’t use it

Concerned about getting arrested

Concerned about loss of

energy or ambition

My husband/wife (or boyfriend/

girlfriend) would disapprove

Not enjoyable, I didn’t like it

Too expensive

I might have a bad trip

Not available

FIGURE 12a

Reasons for Abstaining from Marijuana Use, Class of 1983

(N = 1,347)
Here are some reasons people give for not

using marijuana. or for stopping use. If you

have never used marijuana, or if you hove

stopped using it, please tell us which

reasons are true for you. (Mark all that

apply.)

FIGURE 12b

Reasons for Quitting Marijuana Use, Class of 1983

(N = 1,005)

Concerned about possible

physical damage

Don't feel like getting high

Concerned about possible

psychological damage

Hot enjoyable, I didn't like it

My parents would disapprove

It might lead to stronger drugs

Concered about possible loss

of control of myself

Concerned about getting arrested

It's against my beliefs

Concerned about loss of

energy or ambition

Concerned about becoming

addicted to marijuana

My husband/wife (or boyfriend/

glrlfriend) would disapprove

I don't like being with the

people who use it

Too expensive

My friends don't use it

I might have a bad trip

Not available
A Value Approach to the

Prevention and Reduction

of Drug Abuse

Milton Rokeach, Ph.D.

Are the values of those who abuse drugs any different from the

values of those who do not? If so, can the values of drug abusers

be changed by intervention or therapy, and would changing such

values lead to a reduction or alleviation of drug abuse? And can

the values of the latter--of those who do not abuse drugs--be

strengthened, reinforced, or stabilized in such a way as to

prevent the onset or initiation of drug abuse? My purpose in this

chapter is to present theoretical considerations and to review

research findings that would support the feasibility of a value

approach to drug abuse. Unlike a behavior modification approach,

which would focus attention mainly upon the extinction or

reduction of drug abuse, and unlike an inoculation approach, which

would focus attention mainly upon its prevention, a value approach

attempts to focus attention simultaneously on both prevention and

reduction. This is done by attempting either to change the

strength of those values that are identified as underlying

undesirable behaviors or by attempting to strengthen, reinforce or

stabilize those values that are identified as underlying desirable

behaviors.

BELIEF SYSTEM THEORY

More generally, a value-focused approach may be considered to be a

part of a more comprehensive theoretical conception about the

nature or structure of belief systems, the conditions under which

belief systems will remain stable (because they are functional),

and the conditions under which they will undergo change (because

they are dysfunctional). The point of departure of a value

approach to drug abuse, or to the modification or prevention of

any other behavior considered to be undesirable, is based at least

upon the following four assumptions: first, that a person’s

social behavior is, at least in large part, regulated or

controlled by the structure and content of one’s total belief

system; second, that a person’s values are centrally,

strategically located "deep structures” within one’s total belief

system; third, that a ohange in such “deep structures” will lead

to changes in value-related beliefs, attitudes, and behaviors; and

fourth, that the main functions of individual belief systems are

to maintain, and if possible to enhance, conceptions (to oneself)

and presentations (to others) of the self as a competent and moral

self.

172
All the preceding is, however, too general or abstract to be

scientifically or operationally useful. A more detailed

theoretical statement about a theory of stability and change in

belief systems is presented in a forthcoming volume (Ball-Rokeach

et al. in press) and, given the space limitations imposed upon

this volume, a briefer version of this theory, which provides the

rationale for a value-based approach to the reduction and

prevention of drug abuse, is presented in this introductory

section.

Belief system theory can be viewed as a type of cognitive

consistency theory wherein the main postulated motive is

maintaining and enhancing self-esteem rather than consistency

(Rokeach 1968a, 1973, 1980). Put another way, humans behave in a

manner that is consistent with their need to maintain and enhance

self-esteem rather than in a manner that is consistent with their

need for consistency. Such a view about the central motivational

role assigned to self-esteem maintenance and enhancement is, I

believe, now widely shared not only by other contemporary

consistency theorists (Aronson 1968; Greenwald and Ronis 1978),

but also by social learning theorists (Bandura 1977), and by

symbolic interactionists and self-theorists (Rosenberg 1979; Gecas

1982). The current theory--about the conditions leading to

stability and change in belief systems-- has undergone continual

elaboration and modifications since It was originally proposed

(Rokeach 1968a, 1968b), and it differs from my earlier

formulations, and also from other theoretical formulations, in

that it attempts to be not only a theory of cognitive and

behavioral change, but also of cognitive and behavioral stability.

That is, it attempts to address itself not only to the motivations

that people might have to undergo change, but also to the

motivations they might have to maintain the stability or

continuity of their cognitions and behavior. We thus come to

suggest that both stability and change of belief systems

(organizations of beliefs, attitudes, and values) are motivated by

the same universal need that humans everywhere have for selfmaintenance and self-enhancement. We proceed on the assumption

that a person will voluntarily undergo lasting changes in values,

and in value-related attitudes and behavior, and, moreover, that

he or she will resist such changes for identical reasons, namely,

to maintain or to enhance self-esteem. Maintenance implies a

motivation not to lose whatever level of self-esteem one presently

has, and enhancement implies the presence of a less-thanaltogether-satisfying existing level of self-esteem about one’s

competence or morality, and thus a motivation to improve upon it,

in order to reach some higher level of self-esteem. Thus, whereas

self-maintenance conjures up a model of a human being striving

merely to return to some earlier state of balance, consistency or

homeostasis, self-enhancement conjures up a model of a human being

striving, beyond such states, for what Rogers ( 1961) called

growth, what Haslow (1970) called self-actualization, and what

Goldstein (1963) called self-realization. Thus, our model of

human nature is one that assumes that all humans will attempt to

maintain their self-esteem whenever they are in fear of losing

173
FIGURE 16

Marijuana Cross-age Trends in 30-day Prevalence for Seven Panels

The number used to differentiate each panel in this figure (and figure

17 through 20) is the last digit of the high school class year of the panel.

FIGURE 17

Cocaine: Cross-age Trends in Annual Prevalence for Seven Panels

174
FlGURE 18

Cigaretts:

Cigarettes: Cross-age Trends in 30-day Prevalence for Seven Panels

FlGURE 19

Cross-age Trends in Daily Use of 1/2+ Packs per day for Seven Panels

175
belief system represents a person's cognitive framework (cognitive

map (Tolman 1948)) guiding and regulating all kinds of mental

activities and behavior.

We thus arrive at a view of a human personality not as an

organization of traits, which is inherently much too rigid or

resistant to change, but as an organization of beliefs, attitudes,

and values, a belief system organization capable of maintaining

its stability over time, yet also capable of undergoing continual

change as social circumstances, motivations and changes in life

cycles require, but always with a main eye directed toward the

maintenance and enhancement of self-esteem. The more central are

the components maintaining their stability or undergoing change

(values), the greater will be the likelihood of stability or

change in related beliefs and attitudes within the belief system

organization, and in the behaviors regulated or controlled by the

belief system.

How can people's belief systems, and behaviors regulated by such

belief systems, best be affected by other people? Humans

continually assess whatever they do or say in their everyday lives

for its implications about their own sense of competence and

morality. Such assessments may be correct or incorrect, and more

often incorrect than correct (Nisbett and Ross 1980). But any

information, that a significant other (a teacher, an experimenter,

a therapist) might provide to a person, that is perceived to have

implications for oneself as a competent or moral person will

become especially salient or important to the person. Depending

on the nature of the information provided, the person will

experience Varying degrees Of feelings Of satisfaction or

dissatisfaction with himself or herself. A change in belief

systems and behavior is expected to come about to the extent that

the information provided to the person (about what one believes,

values, or does) leads him or her to become dissatisfied with

self. Self-dissatisfaction is a noxious state and should set into

motion a sequence of cognitive reorganization and behavioral

changes that should lead to the alleviation or reduction of such

feelings of self-dissatisfaction. Conversely, stability, or the

constancy of belief systems and behavior, can result when the

salient information provided to a person about one's competence or

morality leads him or her to feel gratified.

Humans are for the most part unaware about the structure, the

content and the functions served by their belief systems because

belief systems are distinctively "silent organizations" (Scheerer

1954). They are especially unaware about their values, how their

values are arranged into hierarchies, how they determine valuerelated attitudes and behavior, and how their values, attitudes,

and behavior help to maintain and enhance their conceptions and

presentations of themselves. But humans typically have a natural

curiosity to know more about themselves, to know more about their

own belief systems, and to know how their belief systems affect

their everyday behavior. They also have a curiosity about the

176
belief systems and bahavior of significant others, if only to

allow for comparison with others (Festinger 1954).

We, therefore, propose to influence (either to stabilize or to

change) belief systems and behavior by providing a person with

important information about self--with information about one's

behavior and its relation to the structure, content, and

functioning of one's belief systam of which he or she is typically

unaware. More specifically, we focus upon information provided a

person about one's central values, and how such values are

specifically related to one's attitudes and behavior that are

believed to be especially important to the person, and thus to be

especially likely to arouse feelings of satisfaction or

dissatisfaction about oneself. Selective experimental feedback of

such Salient information about oneself should lead some people to

discover that they hold certain values or engage in certain

behaviors that are incompatible with self-conceptions or selfpresentations. This information should lead others to discover

that their values and behavior are compatible, that is, it should

lead them to confirm what they had hoped or thought was true about

themselves. Such selective feadback should lead to feelings

varying in degree of self-dissatisfaction or self-satisfaction

which, in turn, should lead either to changes or to the

stabilization of cognitions and related behavior. Either way,

unidirectional self-maintaining or self-enhancing processes (of

stability or change) should be initiated by such selective

feedback of information about one's self.

There is, however, a danger that must be avoided when providing

such information. Since information presented under conditions of

Self-presentation (to others) is more likely to arouse egodefense, we advocate the method of Self-confrontation rather than

confrontation by significant others when presenting such

information. Important information about self provided under

conditions of privacy, we assume, should be less ego-threatening,

more likely to be faced up to in a rational rathar than

rationalizing manner, and thus more likely to have longer-lasting

stabilizing or destabilizing effects on values, attitudes and

behavior. Those experiencing self-dissatisfaction under

conditions of self-confrontation are expected to take steps to

reduce or eliminate such feelings--by reorganizing their values,

attitudes, and behavior, in directions designed to maintain, and

better yet, to enhance their self-conceptions. In oontrast, those

experiencing satisfaction following the induction of salient

information about self should attempt to perpetuate and extend

such feelings. Thus, it may be conjectured, a person should

maintain the stability of one's values, attitudes and behaviors

insofar as he or She will feel satisfied with the information

provided about oneself, and should change insofar as he or she

experiences dissatisfaction following feedback of such

information.

177
Age of Onset of Drug Use as a

Factor in Drug and Other Disorders

Lee N. Robins, Ph.D., and Thomas R. Przybeck, Ph.D.

Although much has been learned in the last dozen years about the

correlates and frequency of illicit drug use in adolescents and

young adults, gaps remain in our understanding of the causes and

consequences of such drug use. Few studies have provided the

information about the temporal order between onset of drug use and

associated events that could tell us which correlates are causes

of drug use and which are its consequences. In addition, there

has been relatively little effort to distinguish use from problems

arising from use. Indeed, the terms use and abuse have often been

used interchangeably. While the illegal status of drugs may

partly justify this usage, since any use carries the potential for

the user's arrest, in practice few users are arrested and many

users do not appear to suffer serious consequences. Nonetheless,

the consequences are very serious for some users and, therefore,

it is important to distinguish predictors of use from the

predictors of problem use.

The few attempts to explore problem use suggest that the potential

for problems is significantly greater for those who begin use

early in life than for those who begin use later and, therefore,

age of first use appears to be a critical variable. Despite the

predictive power of age of onset, there is little or no

information as to whether the predictors of drug use are different

at different ages of initiation. If they are, predictors of age

of initiation may be what forecasts outcome rather than early use

itself.

Drug use has been increasingly common among the young for about

the last 15 years, a period long enough to allow looking at cohort

differences. Have the causes and consequences of drug use changed

in later cohorts as drug use has become more common?

Finally, there is the issue of the relationship between drug abuse

and dependence and other psychiatric disorders. The problems of

drug abuse have typically been explored independently of other

178
psychiatric disorders, making it difficult to understand how drug

abuse and dependence fit into the general rubric of psychopathology.

An opportunity to address each of these questions arises as a

result of the Epidemiological Catchment Area Program (ECA), a

large-scale study supported by the National Institute of Mental

Health (NIMH), that has investigated the lifetime and current

history of drug abuse and dependence along with other major

psychiatric disorders in adults of all ages living in five sites:

New Haven, Baltimore, St. Louis, North Carolina, and Los Angeles.

The samples in the first three sites were interviewed between 1979

and 1981 initially, and reinterviewed a year later.

Dependence and abuse were assessed according to criteria in DSMIII for six categories of drugs: barbiturates, hypnotics, and

sedatives; opioids; cocaine; amphetamines and other stimulants;

PCP and similar drugs; and cannabis. These criteria require that

the drugs be taken "on one's own." Dependence on prescription

drugs taken according to doctor's orders does not qualify. Dependence requires either tolerance to the drug (needing more to

get the same effect or ability to take much larger quantities than

initially) or withdrawal (symptoms arising from stopping or

cutting down on the amount used) and either social problems or a

pattern of pathological use, such as being unable to control use.

The diagnosis of abuse requires both a social problem from use and

a pathological pattern of use. While DSM-III allows the diagnosis

of both abuse and dependence in one individual, we will divide

subjects into those with dependence (with or without abuse), abuse

only, and neither drug disorder.

The assessment instrument in the ECA program is the Diagnostic

Interview Schedule (DIS), written for this study at Washington

University in St. Louis with the assistance of the principal

authors of DSM-III and, for drug questions, with the consultation of NIDA staff. In addition to covering the specific

symptoms of abuse and dependence listed in DSM-III, the interview

asks whether any illicit drugs have been used, at what age they

were first used, which drugs have been used at least five times,

whether any of four criteria for seriousness of problems have been

experienced (speaking to a doctor about the problem, speaking to

another professional about the problem, taking medication as a

result of the problem more than once, or feeling that the problem

has interfered with one's life or activities a lot), which drugs

have created problems in the last year, and the age at first and

last drug problem.

Similar questions are asked about age of first and last symptom of

other diagnoses, and age of first experience of childhood behaviors: stealing, lying frequently, running away, arrests,

problems as a result of fighting, school expulsion, underachievement at school, and vandalism. These questions make

possible discovering the temporal order between first drug use,

first drug problem, and a number of symptoms and behaviors thought

179
TABLE 1

Median Group Bankings of Terminal and Instrumental Values and Composite Bank Orders for Alcoholics, Addicts,

Combined Alcoholics and Addicts, and the General Population+

Alcoholics Addicts

(N = 42) (N = 43)

Combined

Groups

(N = 85)

Population

(N = 455)

Terminal Values

A comfortable life

An exciting life

A sense of accomplishment

A world at peace

A world of beauty

Equality

Family security

Freedom

Happiness

Inner harmony

Mature love

National security

Pleasure

Salvation

Self-respect

Social recognition

True friendship

Wisdom

9.00 (10)

11.50 (11)

7.00 ( 6)

12.50 (14)

13.50 (16)

11.00 (12)

4.50 ( 3)

8.83 ( 9)

4.50 ( 2)

5.50 ( 5)

7.25 ( 7)

15.41 (18)

12.50 (13)

14.83 (17)

4.06 ( 1)

12.90 (15)

8.33 ( 8)

5.00 ( 4)

12.00 (12)

10.00 (10)

7.67 ( 8)

13.08 (15)

12.92 (14)

11.63 (11)

6.75 ( 5)

7.63 ( 7)

5.42 ( 3)

5.43 ( 4)

6.88 ( 6)

16.82 (18)

12.75 (13)

15.00 (17)

14:88 (16)

8.00 ( 9)

5.20 ( 2)

10.40 (10)

11.11 (11)

7.25 ( 7)

12.94 (14)

13.21 (15)

11.75 (12)

5.75 ( 5)

8.19 ( 9)

5.29 ( 3)

5.44 ( 4)

7.06 ( 6)

16.45 (18)

12.67 (13)

14.88 (17)

4.31 ( 1)

13.57 (16)

8.18 ( 8)

5.11 ( 2)

9.72 (11)

14.34 (l6)***

9.22 ( 8)*

3.22 ( 1)***

12.85 (15)

7.94 ( 5)***

3.93 ( 2)**

4.82 ( 3)***

7.59 ( 4)**

10.97 (13)***

10.59 (12)***”

9.65 (10)***

14.53 (17)*

11.06 (14)**

8.02 ( 6)***

14.91 (18)

9.38 ( 9)

8.55 ( 7)***
Instrumental Values

Ambitious

Broadminded

Capable

Cheerful

Clean

Courageous

Forgiving

Helpful

Honest

Imaginative

Independent

Intellectual

Logical

Loving

Obedient

Polite

Responsible

Self-controlled

5.50 ( 3)

5.00 ( 2)

7.83 ( 7)

10.33 (10)

10.93 (12)

9.83 ( 9)

7.50 ( 6)

10.90 (11)

4.00 ( 1)

15.75 (18)

11.50 (14)

13.00 (17)

11.00 (13)

8.00 ( 8)

13.00 (16)

12.67 (15)

7.00 ( 4)

7.17 ( 5)

8.01 ( 8)

7.00 ( 4)

7.80 ( 6)

12.14 (14)

10.25 (10)

8.00 ( 7)

10.33 (11)

11.60 (13)

4.24 ( 1)

14.13 (18)

7.67 ( 5)*

13.57 (16)

12.25 (15)

8.67 ( 9)

14.13 (17)

11.25 (12)

5.44 ( 2)

5.60 ( 3)

6.38 ( 5)

6.00 ( 2)

7.81 ( 6)

11.55 (13)

10.78 (11)

9.22 ( 8)

9.57 (10)

11.14 (12)

4.25 ( 1)

14.86 (18)

9.40 ( 9)

13.20 (16)

11.60 (14)

8.63 ( 7)

13.60 (17)

5.45 ( 2)

7.40 ( 4)

8.71 ( 6)

11.60 (14)

10.92 (12)

8.41 ( 5)

9.08 ( 8)

9.48 (IO)*

3.38 ( 1)

13.78 (18)

9.08 ( 9)

11.67 (15)

12.11 (16)

10.22 (11)

13.72 (17)

11.54 (13)

5.80 ( 3)

8.74 ( 7)

11.92 (15)

6.13 ( 3)

6.14 ( 4)

+Figures shown are median rankings and, in parentheses, composite rank orders.

*p < .05; **p < .01; ***p < .001

Copyright 1975; reproduced from Toler (1975) with the permission of the author.
The diagnostic criteria for alcohol abuse and dependence parallel

the criteria for drug abuse and dependence. As table 3 shows,

drug dependence and severity are additive in their relationship

to alcohol disorders. Among men with severe drug dependence, 75%

had an alcohol disorder. Dependence has more effect than

severity, but the rate declines steadily as one moves to nonsevere dependence, severe abuse, non-severe abuse, and is lowest

(27%) in those without a drug diagnosis. For women, the

distinction between dependence and abuse is less striking, but

the same regular pattern appears;36% of those severely dependent

on drugs have an alcohol disorder vs. 4% of those with no drug

disorder. The greater number of alcohol disorders among men than

women is visible at every level of drug disorder,

DSM-III criteria for antisocial personality require three conduct

problems (e.g., stealing, truancy, fighting) before age 15 and

four adult symptoms, such as poor work history, fighting, irresponsibility toward spouse and children, and illegal activities.

Drug abuse is counted as a symptom of antisocial personality,

both before 15 and in adulthood, but is not a required symptom.

The pattern of relationships between antisocial personality and

drug abuse and dependence parallels that of alcohol disorders for

men, with rates of antisocial personality ranging from 68% in

those severely dependent on drugs to 8% in those with no drug

disorder. Rates of antisocial personality in women are much

lower, and it is probably for that reason that patterns are less

clear. However, rates of antisocial personality are greatly

elevated in women with all types of drug disorders except nonsevere abuse.

TABLE 2

Lifetime Druq Abuse And Dependence

by Race, Education, And Urbanization

(Three ECA Sites)

NEW HAVEN BALTIMORE ST. LOUIS

N % N % N %

BLACK 334 6.4 1182 7.3* 1158 6.4

WHITE + OTHER 2708 5.7 2299 4.9 1846 5.3

COLLEGE GRADUATE 839 5.2 303 8.2 416 4.5

OTHER 2218 6.0 3174 5.4 2498 5.5

INNER CITY 953 8.1*

SUBURB 1297 5.6

RURAL + SMALL TOWN 740 4.3

* p<.05

182
Diagnostic criteria for the two depressive disorders, major

depressive episode and dvsthvmia, differ in that a major depressive

episode requires the conjunction of low mood and at least four

other symptoms (e.q., insomnia, weiqht loss, fatique, poor

concentration, suicidal ideation) for at least 2 weeks, while

dysthymia requires low mood over most of a 2-year period but

fewer associated symptoms. Criteria for a phobia consist of a fear

which is perceived by the Person afflicted with it as unreasonable

and is so severe that it leads to avoidance of the feared object to

a deqree that results in meeting the severity criteria outlined

above. In women, each of these disorders is most frequent in those

with severe drug abuse but no dependence and next most frequent in

those with severe dependence. Non-severe druq disorder, whether

abuse or dependence, is not stronqly associated with major

depressive episode, dysthymia, or phobia in women. In men, in whom

these disordes are rare, patterns of association are less clearcut.

Major depressive episodes are most common in men with severe

dependence, while dysthymia and phobia are most commnon in men with

severe abuse.

Tobacco dependence is a newcomer to psychiatric nosoloqy. It is

defined as smokinq when medically contraindicated by existent

disease, or sufferinq withdrawal symptoms when attempting to quit

smokinq, or relapsinq to smoking after quittinq. A large proportion of all persons who have been heavy cigarette smokers

TABLE 3

Association Of Drug Disorders With Other Disorders

In Younq St. Louis Adults

Depend., Depend., Abuse only, Abuse only, No drug

severe not sev. severe not severe disorder

(M=25;F=15) (M=32;F=17) (M=8;F=7) (M=17;F=20) (M=249;F=311)

ALCOHOL M

F

ANTISOCIAL M

PERSONALITY F

MAJOR DEPRESSIVE M

EPISODE F

DYSTHYMIA M

F

PHOBIA M

F

TOBACOO M

F

x %

85 75

36 34

68 51

22 28

23 2

51 14

4 0

49 8

21 4

42 14

75 8 2

58 51

183

%

0

64

38

72

30

4

10

18

3

5

52 25 5

77 7 1 1

28 52 32

73 61 33

%

39 27

1 4 4

%

4 9

3 3

42

33

8

2

3

8

2

4
moved to television. First, far greater numbers of people can be

reaohed, and second, television is an ideal medium for providing

people with information about themselves via the method of selfconfrontation.

3. I will also attempt to draw attention to other research now in

progress that I believe will be relevant to drug abuse

researchers.

We have thus far identified 24 experimental studies, carried out

by our own research group and by others, in which a value-based,

self-confrontational approach had been employed to influence longterm stability and change in cognitions and behavior.

The basic paradigm is the same for all such studies.

Via the method of self-confrontation, experimental

subjects are given feedback designed to increase

self-awareness about their own and others’ values,

and how their own and others’ values are related to

specified attitudes and behaviors. In this way,

many experimental subjects discover discrepancies or

contradictions implicating their self-conceptions.

The psychological mechanism that is aroused in such

subjects is a specific state of self-dissatisfaction

that they can identify for themselves. (Rokeach

1980, p. 297)

In nine of these 24 experimental studies, respondents indicated,

immediately following the experimental feedback of objeotive

information about own and others’ values, attitudes, and behavior,

whether they were “satisfied” or "dissatisfied" with the value

rankings they had given prior to the treatment. Without

exception, all nine studies showed larger, statistically

significant value changes, measured weeks and months subsequent to

treatment, among those who were "dissatisfied" than among

3

those

"satisfied” with their rankings given to target values. Yet,

while such findings provide us with convincing evidence about the

central role played by the arousal of feelings of selfdissatisfaction, we do not as yet know whether such feelings are

alleviated following cognitive or behavioral change. This

specific question deserves to be followed up in further research,

and we are doing so in a NIDA-supported project presently underway

on reducing and preventing smoking in adolescents.

Of the 24 studies employing the present paradigm, value changes

were measured, usually weeks or months afterward, in 22 of them.

In 95 percent of these (21 out of 22) the researchers reported

statistically significant changes in one or more of the

theoretically expected values. Value-related attitude changes

were measured in 10 of these studies, and 70 percent of these

studies (7 out of 10) showed statistically significant attitude

changes. Value-related behavioral changes were measured in 14 of

these experiments; 50 percent of these studies (7 out of 144)

showed statistically significant long-term behavioral changes.

184
Moreover, these changes were obtained many weeks or months after

the treatment, and in one experiment, as long as 21 months

afterward (Rokeach 1973).

Thus, the available experimental findings suggest that

investigators using our research paradigm:

. . . . have succeeded in bringing about socially

desirable long-term changes in important values and

in related attitudes and behavior with respect to

such diverse issues as racism, ecology, smoking, and

teacher performance, and that such changes can be

brought about by a single experimental session.

Messages in such a session may be communicated by a

human experimenter, an interactive computer, the

printed word, and closed-circuit television.

Variations in the prestigefulness of source, channel

of communication, or personality of the receiver

(except possibly for locus of control), do not seem

to make much difference since long-term effects are

reported regardless of such differences (BallRokeach et al. in press, p. 4-24 and 4-25).

The above summary of the experimental literature would, however,

be incomplete if I did not also draw attention to several other

major studies which have either been wmpleted recently or which

are presently underway. I believe that our most impressive

findings to date come from a research project (Ball-Rokeach et al.

in press) in which we employed our value approach to produce a

thirty-minute television program entitled "The Great American

Values Test.” This television program was subsequently viewed,

voluntarily, by large numbers of adults in the Tri-Cities area of

eastern Washington, in the privacy of their homes. The television

program, w-hosted by Mr. Edward Asner (of the Lou Grant show) and

Ms. Sandy Hill (ax-anchor woman of ABC’s Good Morning America

show), was shown simultaneously on all three commercial networks

(NBC, CBS, ABC) as a public service program. After a fifteenminute general introduction about what are human values, how

values are measured, and value similarities and differences among

Americans differing in race, sex, age, etc., the program focused

upon three values in particular: freedom, eqauality, and a world

of beauty, and “needled” viewers to increase their regard for

these three values by drawing attention to various wntradictions

that had previously been found to exist in many Americans between

their espousal of such values and their attitudes or behaviors

concerning racism, sexism, and ecology. For instance, Mr. Asner

says:

Americans feel that freedom is very important. They

rank it third. But they also feel that equality is

considerably less important....they rank it twelfth.

Since most Americans value freedom far higher than

they value equality, the question is: What does

that mean? Does it suggest that Americans as a

185
whole are much interested in their own freedom

than they are in freedom for other people? Is there

a contradiction in the American people between their

love of freedom and their lesser love for equality?

By comparing your values with these results, you

should be able to decide for yourself whether you

agree with the average American’s feelings about

freedom and equality.

Since we did not contact the viewers of the program in advance, or

invite their participation, we had to overcome a number of

challenging methodological problems in order to ascertain whether

our television program had any demonstrable effects: Did the

respondents actually watch the program in the privacy of their

homes? Did they watch the program without interruption? How did

we know what their values were prior to watching? How could we

find out whether their values and related attitudes underwent

change as a result of viewing our program? And most important of

all, did their behavior undergo change, and how did we find out

whether it did or didn’t?

While the full details of this television project will be

presented in our forthcoming monograph (Ball-Rokeach et al. in

press), it is possible to summarize here the findings obtained:

Uninterrupted viewers of the television program, when wmpared

with interrupted viewers and with non-viewers, had (1) uniformly

increased their rankings of the three target values, freedom,

eauality, and a world of beauty, and (2) become less racist, less

sexist and more pro-environment in their attitudes. (3) Most

important of all, uninterrupted viewers responded more favorably

than did the other groups to mailed solicitations from three

existing organizations in the state of Washington specifically

dedicated to the advancement of anti-racist, anti-sexist and proenvironmental causes. Table 2 shows the effects of our television

program on the amount of money collected in response to three

solicitations received through the mail by all respondents--two to

three months after the television program had aired. Shown in

table 2 are the average amounts of money donated to all three

solicitations combined, and to each of them considered separately

from uninterrupted viewers, interrupted viewers, and two groups of

non-viewers.

Like most of the two dozen studies using the belief system-valueself-confrontation paradigm, "The Great American Values Test"

focuses upon the question of influencing stability and change in

values, attitudes, and behaviors other than those implicated in

drug abuse. But three experimental studies in particular do focus

upon drug abuse, more specifically, tobacco abuse. Two of these

have been carried out by Conroy (1975) and DeSeve (1975); Conroy

has provided us with a detailed summary of both of these two

researches (1979). Both of these studies were carried out with

adult smokers who, strongly motivated to quit smoking, had

volunteered to undergo treatment at anti-smoking clinics in New

186
TABLE 2

Mean Amounts Contributed by Uninterrupted Viewers, Compared With Interrupted

Viewers and Nonviewers in Experimental and Control City

N Environment Anti -Racism Anti -Sexism All 3 Combined

Uninterrupted Viewers

Interrupted Viewers

Nonviewers,

Experimental City

Nonviewers,

Control City

178 29.2¢ 14.1¢ 25.8 69.1¢

157 7.6¢ .0¢ .0¢ 7.6¢

953 4.9¢ 6.3¢ 5.54 16.7¢

699 5.3¢ 6.4¢ .3¢ 12.0¢

Reproduced from Ball-Rokeach, Rokeach, and Grube, in press, with permission of the authors.
York and Washington. Both focused upon the target value selfcontrol, and provided feedback drawing attention to discrepancies

between smoking, wanting not to smoke, and the low priority the

adult smokers placed on self-control as a value. Both sets of

findings show that value for self-control had increased in

importance in the weeks following the treatment: moreover,

decrements in smoking in experimental groups undergoing the valuebased, self-confrontation treatment were significantly greater

than those manifested by control groups receiving traditional

fear-arousing appeals.

Nonetheless, the effects reported by Conroy and DeSeve dissipate

over time, as they typically do in more traditional treatments.

Thus, the challenge posed by such findings is to find additional

ways to extend the long-term persistence of such effects. Put

another way, the theoretical challenge posed by various approaches

researchers might employ to achieve the reduction of drug abuse is

to shift from demonstrations of statistical significance of

cognitive and behavior change immediately following one or another

treatment (which is relatively easy to demonstrate and which is

more likely to be accepted for publication in refereed journals),

and to find ways to extend the duration or persistence of such

effects. I am generally unimpressed with reports of statistically

significant differences between experimental and control groups

obtained immediately following treatment (whether or not it

concerns value, attitude, or behavior change), because such

findings are extraordinarily vulnerable to alternative

interpretations (Freese and Rokeach 1979).

The third smoking study is one we are presently carrying out with

NIDA support. It enabled us to produce a second television

program entitled “Smoking, Human Values, and You" (co-hosted by

Sarah Purcell and John Barbour of Real People) focusing upon

attempts to influence certain values that previous research

(summarized above) had shown to differentiate between nonsmokers,

smokers, and exsmokers. Its major objective is not only to reduce

and prevent smoking by changing the values underlying smoking or

by stabilizing the values underlying not smoking (a psychological

approach), but also to bolster, maintain and extend such

psychological influences through supplementary "sociological"

social control variables (Gibbs 1982), so that the values and

behavioral effects would persist longer. More specifically, we

are attempting to increase the persistence of the psychological

effects produced by our television program via the social "pulls"

implied by social support (Newcomb et al. 1967) on the one hand,

and the social "pushes" implied by social pressure on the other.

We conceive of social support as a social control mechanism that

attempts to maintain or reinforce socially desirable cognitions

and behavior at existing levels via reward or positive

reinforcement. We conceive of social pressure as another social

control mechanism that attempts to change socially undesirable

cognitions and behavior via social sanctions. For example, a "No

Smoking” sign in a restaurant is an attempt to exert social

pressure to discourage smoking; inviting guests who all smoke (or

188
who all do not smoke) to a dinner party is an example of an

attempt to provide social support; and inviting only one guest who

smokes is a witting or unwitting attempt to exert social pressure.

Summarizing, our present research attempts to extend the

persistence of influence effects (Cook & Flay 1978) by combining

the arousal of psychological processes (the arousal of feelings of

self-satisfaction or self-dissatisfaction) that might encourage

cessation and prevention of smoking with environmental supports on

the one hand and environmental pressures on the other. I believe

that such a combination of psychological and sociological

modalitites will turn out to be a more effective general approach

to bringing about long-term, socially desirable cognitions and

behavior, and the discouragement of long-term socially undesirable

cognitions and behavior.

Our present research is, however, still in progress and our data

are still in the process of being analyzed. We are unable, at

this time, to provide any additional information about the results

of our multi-pronged psychological and sociologioal approach.

I would like to round out this general review of value-based

research by mentioning one other health-related project. It

concerns an attempt to encourage the use of auto safety belts, and

it is being oarried out by Pam Fortin and Michelle Bell of

Dayspring Associates, a Seattle-based research group. Supported

by The Washington Traffic Safety Commission, this research group

has produced a 12-minute film which, using the self-confrontation

method, focuses upon the terminal value family security, which

most people normally rank very high; it also focuses upon the

contradiction existing within many people between their high value

for family security and their failure (and their children’s

failure) to use seat belts. The Seattle Times, (March 6, 1983)

reports that there are “increases in seat belt use up to 40

percent among 3,000 employees in 14 firms." While I have not seen

the final report, I understand (personal communication) that it

will soon be available from The Washington Traffic Safety

Commission in Olympia, Washington.

SUGGESTIONS FOR FUTURE RESEARCH

I would now like to offer several suggestions about future lines

of research that might be fruitful. Nothwithstanding my

contention, expressed at the beginning of this chapter, that our

research paradigm can in principle be applied with equal ease both

to the modification and to the prophylactic prevention of

undesirable behaviors, it is obvious that attempts to modify drug

behavior present additional obstacles, beoause there is the added

burden of addiction that must be overcome. Such an added burden

seems to be distinctive to the issue of drug abuse. It is not a

problem, when we think of modifying many other socially

undesirable behaviors, such as racist or sexist behavior,

pollution of the environment, or when we think of modifying the

189
behavior of teachers so that they might become better teachers, or

the behavior of drivers so that they might use seat belts.

But if instead we focus upon the prevention of drug abuse, we can

proceed more straightforwardly to ask how the knowledge acquired

from a value-based approach might contribute to prevention. One

suggestion, stimulated especially by Toler’s findings (Table 1) ,

may seem unconventional to specialists in the field of drug abuse

who are committed to the advocacy of more and better drug

education directed to adolescents. While I see nothing wrong with

such an approach, Toler’s findings suggest that it can be

accompanied by, or supplemented with, a more generic value

education approach. Not only the school, but also parents and

religious institutions, can all participate in a consciousnessraising value education program that invites adolescents to

examine their own values and compare them with those that are

characteristic of other groups and subgroups. Such a program

would, one, draw attention to the fact that humans differ in the

priorities they place on personal and social values; two, draw

attention to the fact that drug abusers typically place higher

priorities on personal values at the expense of social values; and

three, point out that such a drug abuser value pattern can at best

only maintain, but not enhance, self-esteem. It is reasonable to

suggest that a generic value education program that unabashedly

stresses the greater importance of social over personal values

will, first, lead to long-term increases in the importance that

adolescents will place on social values, and to concomitant

decreases in personal values. Second, it should culminate in

related behavioral changes that will be manifestations of the

greater priority placed on social values. Such behavioral

manifestations are anticipated to include a generally greater

likelihood to engage in all sorts of pro-social behavior and a

generally lesser likelihood to engage in anti-social behavior,

which would include, but would not be restricted to, a lesser

likelihood of drug abuse.

while the value differences between cigarette smokers, nonsmokers,

and exsmokers are not nearly as marked as those between hard drug

users and non-users, we must, nonetheless, pay attention to the

cross-cultural uniformity of findings regarding value differences

among them. Such findings further suggest a value education

program that focuses upon discouraging hedonic values, upon

fostering competence values and the value of self-discipline, and

upon fostering religious values, as generic ways to prevent

smoking.

A second question that, I believe, merits further research is

whether values are antecedents or consequences of drug abuse. Not

all people who drink alcohol become alcoholics, and not all people

who shoot heroin become heroin addicts. This would suggest that

people differ in such predispositions and it can thus be

conjectured that value priorities, however arrived at, may

190
predispose one to employ or not employ drugs, or to employ drugs

abusively or non-abusively.

Yet, there are reasonable grounds also to conjecture that drug

abuse will lead to changes in value priorities, to an increasing

preoccupation with the gratification of personal values, and to an

increasing indifference about social values. More research is

thus needed to inform us about the conditions under which values

are the antecedents and oonsequents of drug abuse.

A third line of research is the extent to which the priority given

to health5

 over other values is a determinant of drug abuse. Are

adolescents more prone than older persons to abuse drugs because

they care less than older persons about health as a value? Is

this because they see themselves as more indestructible or

invulnerable and thus less motivated than older groups to avoid

drug abuse? If so, research directed toward a better

understanding of the relative importance of health as a value

among persons of varying age might be informative, as would be a

better understanding of the role played by perceived

indestructability, or perceived invulnerability as mediating

variables.

A fourth line of research derives from our successful use of at

least one television program to influence target values,

attitudes, and behavior. It is time now, I believe, to move away

from expensively produced television programs (say, 30 minutes

long) to explore the effects of more economical “spot

announcements." What could we say, for instance, within a 30-

second Public Service, value-based announcement that could

possibly make a difference, that could possibly have a

demonstrable effect on preventing drug abuse among adolescents?

CONCLUSION

Given the enormous problems posed by drug addiction, it seems

obvious that there should be a generally greater payoff from

research efforts aimed at prevention rather than the elimination

of drug abuse. I am therefore altogether comfortable with the

decision of the organizers of this NIDA conference to invite

contributions focusing on prevention.

I believe that the experimental evidence reviewed in this chapter

overwhelmingly demonstrates the validity of our socialpsychological belief system-value-self-confrontation approach to

influencing stability and change in important values, attitudes,

and behaviors. But now, the question that challenges us most is

what leads to the long-term persistence of stable or changed

values, attitudes, and behavior? This is an issue that requires

us to call upon the analytic and theoretical skills of

sociologists as well as psychologists. As I have already

indicated, I believe that the basic sociological variable that

maintains or freezes stable or changed values, attitudes, and

behaviors, which can be initiated by the psychological arousal of

191
feelings of self-satisfaction or self-dissatisfaction, is social

control, which either takes the form of social support or social

pressure. Here the evidence is far from complete and I hope that

future research will focus attention in more detail upon how our

values, attitudes, and behaviors, once initiated by psychological

forces, are then perpetuated or controlled by sociological forces.

FOOTNOTES

1

After having studied the value patterns of literally hundreds

of adult groups over the past decade and a half, it appears to me

that the personal-social "value split" that Toler reports is most

unusual, yet understandable.

2

The research group was headed by Dr. Elemir Hankiss of the

Hungarian Academy of Science. I am extremely grateful to him for

making these data available to me. They are, of course,

summarized here with his permission.

3

For additional evidence bearing on the effects of selfdissatisfaction obtained by others using other theoretical

approaches see Ball-Rokeach et al. in press.

4

While these “batting averages” are impressive, readers may

nonetheless wonder why the percentage of significant effects

decreases from values to attitudes to behavior. I believe the

reasons are mainly methodological. For instance, in one study

(Sherrid and Beech 1976), wherein New York policemen were the

subjects, the behavioral test was whether or not they showed up on

their day off to attend a race relations lecture. Virtually no

one of the experimental or control subjects did, thus leading to

no significant differences.

5

Form G of the Rokeach Value Survey, which is the most recent

version (1982), includes "Health (physical and mental well-being)"

as one of 18 terminal values that is to be ranked in order of

importance.

REFERENCES

Aronson, E. Dissonance theory: Progress and problems. In:

. Abelson, R.P. et 1., eds. Theories of Cognitive Consistency.

A Sourcebook. Chicago: Rand McNally, 1968. pp. 5-27.

192
Ball-Rokeach, S.J.; Rokeach, M.; and Grube, J. The Great American

Values Test: Influencing Behavior and Belief Through

Television. New York: The Free Press, in press. 244 pp.

Bandura, A. Self-efficacy: Toward a unifying theory of

behavioral change. Psychological Review, 84:191-215, 1977.

Conroy, W.J. A multi-variate analysis of the psychological and

associated characteristics of former cigarette smokers.

Unpublished Ph.D. dissertation, State University of New York,

1975.

Conroy, W.J. Human values, smoking behavior, and public health

programs. In Rokeach, M., ed. Understanding Human Values:

Individual and Societal . New York: The Free Press, 1979.

pp. 199-209.

Cook, T.D., and Flay, B.R. The persistence of experimentally

induced attitude change. In: Berkowitz, L., ed. Advances in

Experimental Social Psychology. Vol. 2. New York: Academic

Press, 1978. pp. 2-57.

DeSeve, K.L. An examination of the relationship between Values

and smoking behavior. Unpublished Ph.D. dissertation,

Washington State University, 1975.

Festinger, L. A theory of social comparison processes. Human

Relations, 7:117-140, 1954.

Freese, L., and Rokeach, M. On the use of alternative

interpretations in contemporary social psychology. Social

Psychology, Quarterly, 42(3):195-201, 1979.

Gecas, V. The self concept. In: Turner, R. and Short, J., eds.

Annual Review of Sociology, Vol. 8. Palo Alto, CA, Annual

Reviews, 1982. pp. 1-33.

Gibbs, J.P., ed. Social Control: Views from the Social Sciences.

Beverly Hills, Sage Publications, 1982. 320 pp.

Goldstein, K. The Organism, A Holistic Approach to Biology

Derived From Pathological Data in Man . Boston, Beacon Press,

1963. 533 pp.

Greenwald, A.G., and Ronis, D.L. Twenty years of cognitive

dissonance: Case study of the evolution of a theory.

Psychological Review, 85:53-57, 1978.

Maslow, A.H. Motivation and Personality. New York, Harper and

Row, 1970. 369 pp.

Newcomb, T.M.; Koenig, K.E.; Flacks, R.; and Warwick, D.P.

.

Persistence and. Change: Bennington College and its Students

after 25 years. New York, Wiley, 1967. 292 pp.

Nisbett, R.E., and Ross, L. Human Inference: Strategies and .

Shortcomings of Social Judgment . New Jersey, Prentice-Hall,

1980. 333 pp.

Rogers, C.R. On Becoming a Person. A Therapist's View of

Psychotherapy. Boston, Houghton Mifflin Company, 1961. 420

pp.

Rokeach, M. Value Survey. Sunnyvale, CA, Halgren Tests, 1967,

1982.

Rokeach, M. A theory of organization and change within valueattitude systems. Journal of Social Issues, 24:13-33, 1968a.

Rokeach, M. Beliefs, Attitudes, and Values. San Francisco,

Jossey-Bass, 1968b. 214 pp.

193
Rokeach, M. The Nature of Human Values . New York, The Free

Press, 1973. 438 pp.

Rokeach. M. Change and stability of American value systems, 1968-

1971. Public Opinions Quarterly, 38:222-228, 1974.

Rokeach,M. Value theory and communication researoh: Review and

commentary. In Nimmo, D. ed. Communications Yearbook 3. New

Brunswick: Transaction Books, 1979a. pp. 7-28.

Rokeaoh, M., ed. Understanding Human Values: Individual and

Societal. New York, The Free Press, 1979b. 322 pp.

Rokeach, M. Some unresolved issues in theories of beliefs,

attitudes, and values. In Howe, H.E. Jr., and Page, M.H.,

ads. 1979 Nebraska Symposium on Motivation . Lincoln,

Nebraska: University of Nebraska Press, 1980. pp. 261-304.

Rosenberg, M. Conceiving the Self. New York, Basic Books, 1979.

319 PP.

Scheerer, M. Cognitive theory. In Lindsey, G., ed. Handbook

Social Psychology. Vol. 1. Cambridge: Addison-Wesley, 1954.

pp. 91-142.

Sherrid, S.D., and Beech, R.P. Self-dissatisfaction as a

determinant of change in police values. Jouranl of Applied

Psychology, 61:273-278, 1976.

Toler, C. The personal values of alcoholics and addicts. Journal

of Clinical Psychology, 31:554-557, 1975.

Tolman, B.C. Cognitive maps in rats and men. Psychological

Review, 55:189-208, 1948.

ACKNOWLEDGEMENT

Preparation of this paper was supported by Grant 5 R01 DA02556-03

from the National Institute on Drug Abuse.

AUTHOR

Hilton Rokeach, Ph.D., Washington State University, Social

Research Center, Pullman, Washington 99164-4014

194
Prevention of Adolescent

Substance Abuse Through Social

Skill Development

Mary Ann Pentz, Ph.D.

ABSTRACT

The purpose of this chapter is to evaluate the capability of

social skills training approaches for preventing adolescent substance abuse and to suggest directions for future research in this

area. Social skills and training are defined from the perspective

of social learning theory. Training approaches are then reviewed

for their effect on drug use and drug use-related behaviors. The

results indicate that social skills training reduces substance use

and related behaviors such as aggression, withdrawal, truancy, and

stealing in adolescents. Outcome was enhanced by the inclusion of

modeling in a training program and the use of normal (versus

problem or disordered) adolescents. In addition, discriminant

analyses indicated that the more positive outcomes were discriminable by a focus on prevention, experimental rigor, and training

comprehensiveness, that is, inclusion of multiple techniques and

skills. Follow-up results showed that training effects were

maintained, and that they could be generalized to several areas of

everyday adolescent functioning. The findings suggest that social

skills training is an effective means for substance abuse prevention in adolescents, and that it may have an advantage over more

direct prevention methods in terms of long-term generalization

capabilities. Finally, several issues are raised for their potential impact on social skills training as a strategy for substance

abuse prevention in adolescents. These issues encompass conceptual, methodological, and evaluative domains: development of a

taxonomy of person-situation specificity characteristics to

increase the validity and reliability of assessment and training

procedures; assessment of the relative contribution of individual

differences in adolescents to training outcome; identification of

qualitative developmental shifts in social skills as adolescents

progress through grade, school, and family transitions; and comparison of the maintenance and generalization effects, over time,

of social skills training with more direct abuse prevention

methods. Guidelines are offered for addressing these issues, as

well as directions for the role of social skills training research

in future drug abuse prevention efforts.

195
DEFINING SOCIAL SKILLS

Social skills, sometimes collectively referred to as social competence, are generally defined as the "ability to cope effectively

with interpersonal relationships" (Argyris 1968, p. 148). A more

specific definition alludes to the mutual cost-benefit aspects of

social skills as the "overt and covert learned behaviors that

maximize chances for obtaining positive reinforcement from social

interactions while minimizing cost to self and others" (Gilchrist

1981, p. 63). The mutuality aspect distinguishes social skills

from the constructs of sociability and extroversion, the latter of

which represent more self-centered aspects of behavior and have

been correlated positively with drug use. The notion of including

both overt and covert behaviors under the aegis of social skills

is explained by social learning theory (Bandura 1977; Rosenthal

and Bandura 1978). According to this perspective, the concept of

"social skills" is represented as a dynamic sequence of cognitions

and behaviors that are reciprocally determined over time. The

cognitions represent self-efficacy, i.e., "the conviction that one

can successfully execute the [social skill] behavior to produce

the desired outcomes" (Bandura 1977, p. 193); the behaviors represent the actual overt performance of social skills.

Social skills are differentiated from personal, extra-personal,

and health problem skills in that their primary function is communication with others (Swisher 1976). Particular communicative

function is typically used as a basis for classifying individual

social skills, e.g., praise, disagreement, assertive expression of

rights (see for example, Goldstein et al. 1979).

SOCIAL SKILLS, DRUG USE, AND ADOLESCENTS

Two seemingly disparate bodies of reasearch suggest that social

skills and drug use may be negatively related in adolescence.

Developmental research has indicated that adolescents are concerned with and intellectually ready for development of social

skills that carry them through transitional school, family, and

peer relationships and ultimately assist them in establishing

responsibility in long-term relationships (Douvan and Adelson

1966; Ford 1982; Hops and Cobb 1973; Piaget and Inhelder 1969).

Some of the more notable social skills required in adolescence

appear to be assertiveness, expression of opinion, ability to

disagree and refuse, and ability to make requests and initiate

conversation (Goldstein et al. 1979; Pentz 1980a; 1982a and b;

Schinke 1981). Adolescents who experience delay in learning

social skills or who remain skill deficient are prone to the development of such drug-use-related problems as delinquency, truancy,

aggression, and academic and social withdrawal (Goldstein et al.

1978; Quay and Quay 1965).

At the same time that the need for social skills is increasing in

adolescents, a number of studies have indicated a concomitant

increase in the incidence and prevalence of drug use, particularly

196
cigarettes and alcohol (Pentz 1982a and b; Perry and Murray 1982).

The onset has been related to peer pressure to use drugs, and

exposure to drug-using peers, both of which imply an inability to

exert social skills such as refusal (see Christiansen et al. 1982;

McAlister et al. 1979). Development of drug use in adolescents

has also been correlated with other problematic behavior including

delinquency/aggression and social withdrawal/unassertiveness

(Kellam et al. 1982; Levine and Kotak 1979; Rooney and Wright

1982). This relationship is further substantiated by retroactive,

i.e., remediation-based research on adult drug abusers (e.g.,

Callner and Ross 1976; Chaney et al. 1978; Oei and Jackson 1982);

and on pro-active, preventive-based research on young adolescents

(e.g., Krosnick and Judd 1982; Pentz 1982b). The apparently

negative relationship of social skills to drug use in adolescents

has important implications for the field of drug abuse prevention.

Interest in this relationship has led to investigation of the use

of social skills training for strengthening social skills with the

purpose of reducing or preventing problem behaviors such as drug

use.

SOCIAL SKILLS TRAINING

Social skills are increasingly being regarded as a useful intervention target for ensuring and enhancing mental health

(Masterpasqua 1981). Albee (1981) has recently proposed a prevention equation that includes social skills as a mediator to behaviors such as drug use. Others have expanded this notion to conceptualize social skills not only as a mediator to behavioral responses like drug use, but also as a means for enhancing overall dayto-day functioning (Meichenbaum et al. 1981; Wine 1981). Adolescence is becoming increasingly favored as a critical readiness

period for these enhancement efforts (Hobbs and Robinson 1982).

Interest in the preventive implications of social skills has led

to an upswing in cognitive/behavioral research, most particularly

in the area of social skills training, the primary vehicle for

promotion of social skills.

Social skills training is defined as the collective techniques

used to improve the learning and mastery of social skills (Ladd

and Mize 1983). The emphasis is on mutual benefit and maintenance

of personal integrity in interpersonal situations (Schinke 1981).

It differs from behavior therapy in its emphasis on communicative

rather than specific symptom behaviors, and from psychotherapy in

its greater reliance on direct therapist-initiated procedures such

as instruction versus indirect techniques such as interpretation

(see Trower 1978). Although there is some disagreement over the

categorization of techniques (Ladd and Mize 1983), those most

commonly employed include: modeling (overt or covert, live or

taped, with or without instruction), rehearsal (covert or overt,

with or without interactor), feedback with social reinforcement

(self-or other-initiated), and extended practice (intra- or extratraining, assigned as homework or spontaneous). If used together

in sequence within a single training program, these techniques are

referred to in social learning theory as guided participant modeling (Rosenthal and Bandura 1978). Whether or not these techniques

197
are used, singly or in combination, the theory asserts that training should focus on the cognitive (perception of self-efficacy) as

well as the behavioral (demonstration) aspects of a skill to be

maximally effective.

In the field of drug abuse, there is substantial evidence to show

that social skills training can reduce drug use levels, increase

periods of abstinence, and prevent relapse to problem behavior

such as DWI arrests (e.g., Chaney et al 1978; Foy et al. 1976; Lin

et al. 1982; Oei and Jackson 1982). However, the bulk of this

research has been aimed at adults who have already been labelled

drug abusers. Social skills training with adolescents, on the

other hand, has tended to focus only indirectly on drug abuse as

it relates to problem behaviors including delinquency, aggression,

and withdrawal. It is only very recently that social skills

training has been applied directly to drug abuse prevention in

this age group. The next section of this chapter will review

adolescent social skills training research in three domains: the

author's own work, social skills training that is indirectly

related to drug abuse, and social skills training that is directly

related to drug abuse prevention in adolescents. The latter two

domains are structured to reflect changes in emphasis over the

last decade.

REVIEW OF SOCIAL SKILLS TRAINING WITH ADOLESCENTS

The Author's Research

Pentz's research has followed three trends in the application of

social skills training to adolescents: (1) from secondary to

primary prevention; (2) from indirect to direct evaluation of drug

use; and (3) from single to multiple populations. As part of her

dissertation research, Pentz (1980a) developed a battery of selfreport and behavioral measures for assessing adolescent assertiveness, and a multiple component group training program that

included audiotaped modeling, overt rehearsal, peer feedback with

social reinforcement, and extended practice "homework" in extratraining situations requiring assertive behavior with teachers,

parents, and peers.' The investigation examined person and situation variables by comparing the effects of social skills training

(three sessions with teachers, parents, or peers as trainers

versus instructions versus no-training) and type of adolescent

pre-training behavior (unassertive or aggressive, as identified by

teacher ratings). Results indicated that: (1) three sessions of

training effected significant increases in assertive behavior as

measured by self-report post-test and generalization measures and

by an in vivo behavioral measure of transfer; (2) teacher trainers

produced more increases than parent or student trainers; and (3)

students responded differently to training when grouped homogeneously by unassertive or aggressive behavior, with unassertive

students performing better on self-report and worse on behavioral

measures relative to aggressive students. Both pre- and post-test

unassertive or aggressive responses given by students were highly

congruent with teachers' ratings. The results suggest that social

skills training may have a long-term cost-benefit advantage over

198
more traditional methods of behavioral intervention which have

typically required longer sessions to produce behavioral change

and have been characterized by low rates of behavioral maintenance

and transfer (e.g., behavior modification). Furthermore, the

results suggest that person characteristics (trainer and trainee)

may differentially affect outcome, and that outcome should be

assessed on multiple measures in order to reduce possible biases

or interactive effects associated with method variance (selfreport versus behavioral).

The second study was a follow-up of the first to evaluate the

congruences of students' perceptions of their trainers (Pentz

1980b). Results indicated that relative to students with parents

or peers as trainers, students with teachers as trainers were more

likely to perceive them as fulfilling a trainer role for social

competence training.

A later investigation focused on the validity and reliability of

the social skills construct in 875 sixth through ninth grade

adolescents (Pentz 1981a). Four basic factors were derived. In

addition, social skills correlated with standardized measures of

adolescent pathology (Devereux Adolescent Behavior Rating Scales),

archival measures of school truancy and absence, teacher ratings

of assertiveness, and successfully discriminated unasser ive and

aggressive adolescents. Results suggested that social skills are

a valid construct for study in adolescents, that measures of

adolescent social skills are stable, and that social skills may be

useful for investigations involving drug use-related behavior in

adolescents (i.e., truancy, absence, aggression, and withdrawal/

unassertiveness).

Three other investigations included these social skill measures in

conjunction with measures of self-efficacy. Based on prior

research results, adolescents were again selected on the basis of

unassertive or aggressive behavior displayed with teachers (n=61

ninth grade students), and teachers were used as trainers.

Rehearsal and feedback components were added (Pentz and Kazdin

1982a; Pentz and Kazdin 1982b, respectively). This step-wise

strategy was used to evaluate the costs and benefits associated

with length of training and simplicity of training content.

Social skills training conditions were compared to no-modeling

discussion groups and varied by type of situational stimulus

(single type involving interpersonal situations with teachers

alone versus multiple types involving situations with teachers,

parents, and peers). After three sessions of modeling, results

indicated that overt modeling was superior to both covert modeling

and no-modeling groups, and that the repeated use of a single type

of stimulus (teacher situations) proved more effective on measures

involving school-related social skills. Ater two sessions of

rehearsal and feedback were added, training effects transferred to

spontaneous role-play and to behavior in unobtrusively observed

real-life situations; however, initial modeling and situational

stimulus effects disappeared.

The third study in this group of investigations assessed the

contribution of individual subject differences to outcome in the

199
modeling phase of the previous stepwise investigation (Pentz 1981b).

The purpose was to assess the relative strength of modeling.

Results indicated that individual adolescent differences, particularly in pre-training behavior and anxiety, accounted for more

variance in self-efficacy and behavior than modeling or stimulus

variables. The findings from all three studies in this group

suggest that even a powerful technique such as modeling may be

highly subject to fine-grained person and situation characteristics when it is used singly rather than in combination with other

social skills training techniques.

Most recently, Pentz (1982a and b) has extended the use of social

skills training to whole classrooms of sixth through ninth grade

students on a primary prevention basis. A one-year pilot investigation confirmed the validity and reliability of self-efficacy and

social measures and the positive effects of social skills training

on self-efficacy, social skills, and cigarette and alcohol use.

The purpose of the subsequent two-year longitudinal project was to

evaluate the causal modeling relationship of social skills and

self-efficacy to cigarette and alcohol use and to evaluate the

effects of social skills training conducted by teachers on immediate and long-term outcome. A cohort-sequential design has been

implemented to study the effects of adolescent pre-training behavior (unassertive versus assertive versus aggressive as rated by

teachers) and training (social skills versus instructions versus

no-training) on subsequent self-efficacy, social skills, drug use,

and drug use-related attitudes. The design will allow for crosssectional longitudinal, and cross-cohort comparisons from sixth

through 10th grade. The investigation is currently in its second

year and involves a total of 1472 adolescents in eight suburban

and rural schools.

Several findings have emerged thus far. Based on cigarette and

alcohol use levels, the sample appears to be representative of

other adolescents in the Southeastern United States (Table 1; cf.

Johnston et al. 1980). A four-factor structure of social skills

has been confirmed (Table 2), and initial structural equation

modeling suggests a causal relationship of social skills and

self-efficacy to drug use (Figure 1). Multiple test-retest correlational analyses suggest that, relative to attitudinal and drug

use variables, social skills may provide the most responsive

target for intervention (Table 3). Regression analyses on seventh

and eighth grade subsamples indicated that social skills make

differential contributions to initial drug use and intention to

use drugs depending on the rural or suburban system from which

adolescents are sampled (Table 4). However, additional multivariate analyses have shown that type of system does not affect

training outcome. These results suggest that training trends may

be generalizable across demographic systems, but that achievement

of prescriptive training, i.e., training that maximizes specific

outcomes for specific populations, may depend on the relative

emphasis placed on certain variables (e.g., more emphasis on

teacher-student and parent-child relationships for rural

adolescents).

200
TABLE 1

Respondent's Drug Use in the Last Month

Classified by Substance, Grade, and Sex

Percent of MALES (N=301)* Percent of FEMALES (N=321)*

Substance Once Month- 2 or More Once Month- 2 or Hare

Grade None Twice Week Times Week None Twice Week Times Week

Cigarettes

x Gr. 6

7

8

9

Beer

6

7

8

9

Wine

6

7

8

9

Liquor

6

7

8

9

99.0

98.5

79.4

73.5

1.0

0.0

3.2

7.4

0.0

1.5

17.5

19.1

91.9 7.1 1.0

92.5 7.5 0.0

19.4 11.1 9.5

51.5 26.5 22.0

86.9

87.9

73.0

69.1

13.1

12.1

17.5

19.1

0.0

0.0

9.0

11.8

92.9 7.1 0.0

95.5 4.5 0.0

71.4 14.3 14.3

55.9 26.5 17.6

Cigarettes

6

7

8

9

Beer

6

7

8

9

Wine

6

7

8

9

Liquor

6

7

8

9

97.7

100.0

88.2

77.3

96.6

92.8

94.1

74.7

2.3 0.0

0.0 0.0

10.3 1.5

16.0 6.7

3.4 0.0

7.2 0.0

4.4 1.5

21.3 4.0

96.6 3.4 0.0

94.0 6.0 0.0

86.8 13.2 0.0

70.7 26.6 2.7

97.7 2.3 0.0

96.4 2.4 1.2

91.2 5.9 2.9

70.7 21.3 8.0

201
TABLE 2

Percentage of Common Variance Accounted for by Factors

(Rotated) with Eigenvalues > 1 and Item loadings > .50*

Eiqenvalues % of Variance Cumulative %

Factors Item set: A B C A B C A B C

I. Overall Assertive Behavior 6.48 8.53 9.20 41.0 51.0 58.2 41.0 51.5 58.2

II. Assertive Opinion 3.37 3.49 3.45 21.3 21.0 21.8 62.3 72.5 80.1

III. Assertive Negotiation/Sensitivity 1.91 1.50 1.19 12.1 9.1 7.5 74.4 81.6 87.6

IV. Negative Assertion 1.33 1.33 1.12 8.4 8.0 7.1 82.8 89.6 94.7

*Item Set A generated a fifth factor with an eigenvalue > 1 and item loadings < .40.
FIGURE 1

CAUSAL MODELING OF DRUG USE

x

2

(29)=42.85, p=.O5

Non - significance indicates an acceptable model

NOTE:

FR.USE=Friends' use of drugs

AVAIL.=Availability of drugs

POTINF=Potential influence on drug use

SELFUSE=Self-use of drugs

TPS-LEV and TPS-STR=Level and Strength of self-efficacy in teacher,

parent, and student situations

O-LEV and O-STR=Level and Strength of self-efficacy in novel

situations with others

TPS-TPE and TPS-DEG=Type and Degree of social skill with teachers,

parents, and students

203
TABLE 3

Reliability Coefficients of Variable Clusters

Variable Cluster

Test/Retest

Reliability

(2 Weeks)

Based on N=847

6-9th Grade

Students

Social Attitudes .75

Drug Use .89

Social Competence .74

Note: All correlations were significant at p < .001

Change in

6 Months

Based on

Independent

Sample N=231

6-9th Grade

Students

.71

.67

.36

204
TABLE 4

Actual Drug Use

(F Change Values)

Variable Cig.

Suburban Rural Total

Beer Wine Liquor Cig. Beer Wine Liquor Drug Use

Demographic

Characteristics

Social Competence

Social Attitude

Drug Use Influence

Overall F

Multiple R

Total R2

Cross-sample R

*p < .05

** p ( .01

***p < .001

****p < .0001

Note Based on a matched sub-sample of n=281 7th and 8th grade students

(147 suburban, 134 rural)
TABLE 4 (Cont'd)

Intention to Use Drugs

(F Change Values)

Variable

Demographic

Characteristics

Cig.

Suburban Rural Total

Beer Wine Liquor Cig. Beer Wine Liquor Intention

Social Competence

Social Attitude

Drug Use Influence

Overall F

Multiple R

Total R2

Cross-Sample R

*p < .05

**p < .01

***p < .001

****p < .OOOl

Note Based on a matched sub-sample of n=281 7th and 8th grade students

(147 suburban, 134 rural)
Perhaps even more significant are the training effects associated

with grade and pre-training behavior (unassertive, assertive, and

aggressive as rated by teachers). Although multivariate and univariate analyses indicated increases in social skills and selfefficacy across all grades, there were significant grade x training interactions for drug use and intention. Specifically, social

skills training appears to have the most potential for drug abuse

prevention with sixth and ninth grade students (see Figures 2 &

3). In addition, training appears to be differentially effective

depending on the type of pre-training behavior manifested by

students (Table 5). Assertive and aggressive adolescents in

social skills training groups reported less frequency, amount, and

influence of drug use than other groups. Now in its training

follow-up phase, the project is focusing on the continued causal

effects of social skills on drug use and the maintenance and

generalization of training effects.

Results from this author's research offer evidence for: (1) the

sensitivity of social skills and self-efficacy to developmental

changes; (2) the relationship of social skills and self-efficacy

to drug abuse prevention; (3) system effects on social skills and

drug use development; and (4) person, situation, and grade influences on social skills training for drug abuse prevention. The

findings suggest that social skills training may be generalizable,

as well as individualizable, to different populations of adolescents.

These results are consistent with findings from other social

skills training research as reviewed in a paper by Pentz and Tolan

(1983). It is this review which serves as the basis for the following section.

GENERIC SOCIAL SKILLS TRAINING WITH ADOLESCENTS

Theoretical and policy changes on deficit prevention in the mid

1970's led to a focus on adolescents for social skills training

(Hobbs and Robinson 1982). Early projects tended to include a

variety of interventive procedures in addition to social skills

training, and were originally intended as treatment programs for

rehabilitating delinquent adolescents (for accounts of early programs see for example the PREP program, Filipczak et al. 1979; the

Youth Center Project, Jesness 1976; Achievement Place, Kirigin et

al. 1979; and Patterson's research with conduct problem youth

1974). The review of research in this section includes these

projects as well as 113 other investigations of adolescent social

skills training that were conducted over the past decade (1972-

1982.* The findings are based on a paper by Pentz and Tolan

(1983). Several other reviews of adolescent social skills training are also available. As distinguished from the present review,

they are primarily descriptive rather than empirical in nature

(see Gilchrist 1981; Goldstein et al. 1979; Rotheram 1980; Schinke

1981; and Trower 1978).

Criteria for inclusion in the review were: (1) that a study was

207
FIGURE 2

CHANGE IN TOTAL DRUG USE FROM PRETO POST - TRAINING

(N=692)

208
FIGURE 3

CHANGE IN INTENTION TO USE DRUGS

FROM PRE- TO POST-TRAINING

(N=692)

209
TABLE 5

Training and Pre-Training Behavior Effects on Actual Drug Use

ACTUAL DRUG USE

Source

Mult.

Amount/Day Frequency/Last Month Got Drunk/6 Months

dfa F Cig. Beer Wine Liq. Cig. Beer Wine Liq. Beer Wine Liq.

Between

Training (A)

Pre-Training

Behavior (B)

A X B

Within

Time (T)

AXT

BXT

AXBXT

1.60 .88

***

2.34 2.70

***

3.00 1.57

2.55 3.12

.33 .17

1.15 .33

1.18 .66

3.34 1.27 .06 1.22

3.56

5.18

3.49 .13 2.09

.75 1.38 1.09

1.02 5.84 1.07 1.21

.35 .03 .00

2.03 .09 2.26

3.74*

1.93

1.07

.39 1.51 1.60

3.09 .02

4.11 1.94

***

6.83 1.45

*** .07 10.66

.67 .08

1.16 .65

.49 1.69

2.53 .13 .19 .14

4.15

5.02

1.42 1.06

2.98 1.59

.90

4.02*

.0l 3.94*

3.12 3.38

.02 .00

.34 .70

.82 1.63

.45 .16

2.01 1.65

1.17 2.82

*p < .05

**p < .01

***p < .001

 p < .0001
TABLE 5 (Cont'd)

Training and Pre-Training Effects on Drug Use Intention

Source

Future Intention To Use Drugs

Mult.

dfa

F Cig. Beer Wine tiquor

Between

Training (A) 1 1.14 .94 .18 1.06 2.50

Pre-Training

Behavior (B)

** *

2 2.11 1.48

AXB 2 l.81

**

3.28*4.51

Within

Time (T)

AXT

BXT

AXBXT

***

1 2.51 1.66

1 1.05 4.57*

2 1.25 .45

317 1.30 .82

***

7.46

***

8.15

3.52*

***

7.68

***

6.97

2.15

***

14.67 2.14

.03 .08 .08

.85 .23

.56

.15

.90 1.17

*p < .05 ***p < .001

**p < .01 ****p < .0001
clearly identified as a social skills training study in Psychological Abstracts or ERIC; (2) that the major focus was on adolescents between the ages of 11 and 19; (3) that the study was published in an English-language journal, with a focus on a U.S.

population of subjects; (4) that outcome as well as any follow-up

was reported; and (5) that dimensional and individual study

characteristics were identifiable from the published report. This

procedure resulted in 117 studies which served as the basis for

macro- and micro-analyses of social skills training characteristics and outcome.

Once identified, studies were classified according to macro-level

dimensions of time of publishing (first versus last half of

decade), approach (competence enhancement versus remediation), and

training focus (single behavioral elements of skills such as eye

contact versus combinational skills oriented toward situations

such as job interviewing). Time trends were examined to determine

the growth rate of adolescent social skills training, since the

deficit prevention policies discussed by Hobbs and Robinson (1981)

have been in effect, and to evaluate developmental changes in

methodology and outcome. The approach dimension was evaluated in

order to determine the actual proportion of studies that were

prevention versus remediation oriented, whether certain patterns

of adolescent or situational characteristics were related to

choice of orientation, and whether orientation affected outcomes

(see Meichenbaum et al. 1981; Wine 1981). The behavior elements/

situation dimension was evaluated in response to other research,

suggesting that an ecological (situational) focus of training may

enhance outcome and generalization of training (see Sarason 1981).

Studies were further classified by micro-level characteristics.

The category of person/situation characteristics settings were

labeled clinical, school, or community; subjects were categorized

as normal, specific or limited problem (e.g., delinquency, unassertiveness, learning disability), or major emotional/behavioral

disorder; and trainers were classified as mental health specialist, teacher, or paraprofessional. In the category of training

characteristics, studies were categorized by type of skill trained

(positive or positive and negative); change focus (behavior or

both cognition and behavior); and training components (modeling or

no-modeling included). Within the category of methodology,

studies were classified by design (experimental, quasi-experimental, or descriptive); and by measures (behavioral, self-report,

or report by others, with the number of measures summed).

Finally, in the category of results, studies were classified by

reported outcome (partial, no effect, or negative), and by followup (yes or no). No study reported negative or null effects; thus

only partial and total effectiveness were analyzed.

Chi-squared and Z score proportional difference analyses were

conducted on dimensions and study characteristics. In addition,

three interval scale scores were generated for discriminant analysis in order to determine the level of conceptual and empirical

sophistication of adolescent social skills training research and

to assess the relationship of these levels to outcome (see Bloom

1968; Cowen 1980; and Lorion 1982). A community prevention score

212
was derived from setting, subject, and trainer characteristics. A

training comprehensiveness score represented the degree to which

training included multiple and wide-ranging aspects of social

skills and training components. A third score, experimental

rigor, represented the level of methodological sophistication of

design, measures, and follow-up.

Results are presented in Tables 6-10. As is clear from Tables 6

and 7, the majority of social skills training studies focused on

changing behaviors that have been generally regarded as related to

drug use (see Jessor and Jessor 1977; Smith and Fogg 1978).3 Consistent with factor analytic findings on the structure of social

skills (Pentz 1981a), the most frequently targeted skills were

general prosocial behavior, assertiveness, and initiating conversation. Table 8 and subsequent tests for proportional difference

indicated more adolescent social skills training research conducted in the second half of the decade and a greater representation of situational (ecological) approaches to training.

Slightly, but non-significantly, more studies were aimed at

deficit remediation rather than competence enhancement. However,

both types of studies were characterized by an emphasis on positive skills (and thus long-term prevention). The majority of

studies was also characterized by a high level of methodological

rigor (experimental or quasi-experimental designs, and multiple

measures)

therapeutic

in contrast to findings from several reviews on psychointerventions. Finally, over 93% of the studies

reported total effectiveness (improvement on all measures or for

all subjects when subjects rather than measures were reported).

Furthermore, almost half of the studies conducted follow-up assessments of training effects. Follow-up ranged from under six

weeks to almost five years, and all reported maintenance and/or

generalization effects.

Tables 9 and 10 show the results of chi-square and discriminant

analyses respectively. Results indicated increases over time in

prevention, methodological rigor, and training comprehensiveness.

Enhancement studies, particularly, were characterized by high

scores on these variables, as was positive outcome. Finally, in

terms of specific study characteristics, better training outcomes

were associated with the use of school or community settings for

training, normal subjects as trainees, and modeling as a training

component.

SOCIAL SKILLS TRAINING FOCUSED DIRECTLY ON ADOLESCENT DRUG USE

This body of research is new and thus far limited in scope.

Specifically, this research is characterized by training which

included social skills as they were directly applied to drug abuse

prevention (e.g., training refusal skills for the specific purpose

of refusing drugs in an interpersonal situation involving a drug

use opportunity), and/or by the integration of social skills with

other drug abuse prevention methods. For example, Botvin et al.

(1980) have employed life skills training that includes aspects of

both social and health problem skills. This type of training has

213
TABLE 6

Frequency of Adolescent Social Skills Training Studies

by Reason for Referral

Reason for Referral N (%)

Past Correlates of Drug Use

Delinquent Behavior

Aggressive Behavior Problem

Emotional Disturbance

Passivity/Withdrawal

Family Conflict

Achievement Problems

Drug Use

31 (26.65)

16 (13.68)

14 (11.97)

11 ( 9.40)

6 ( 5.13)

4 ( 3.42)

1 ( .85)

Reasons Not Directly Related

to Drug Use

Retardation

Physical Handicap

----------------------------

No Referral - Enhancement Only

16 (13.68)

6 ( 5.13)

12 (10.26)

214
TABLE 7

Frequency of Adolescent Social Skills Training

Studies by Primary Target for Change

Skill Target N (%)

General Prosocial Behavior 26 (22.22)

Assertiveness 20 (17.09)

Initiating/Maintaining Conversation 15 (12.82)

Non-Verbal Expression 13 (11.11)

Expressing Feelings/Empathy 12 (10.26)

Decision-Making 12 (10.26)

Expressing an Opinion or Request 7 ( 5.98)

Self-Control 5 ( 4.27)

Praise 4 ( 3.42)

Responding to Criticism 3 ( 2.56)

215
TABLE 8

Frequency of Adolescent Social Skills Traininq Studies

by Dimensions and Individual Characteristics
TABLE 9

Time Trends, Dimensional Differences, and Outcome

in Adolescent Social Skills Training (x2 Analyses)

Source

Behavior/ Deficit/

Situation Enhancement

df Time Dimension Dimension Outcome

(N=106) (117) (117) (117)

Person/Situation

Characteristics

Setting

Subjects

Trainers

Training

Characteristics

Skill

Focus

Components

Methodology

Design

Measures

Results

Outcome

Follow-up

2

2

2

1

1

1

2

1

1

1

6.92*6.01*

1.59 2.60

3.08 1.30

4.00*3.59 8.52* *

.31

.84 5.65*

5.87

*

2.27

2.18 8.28*3.67 4.50 *

9.28

* *

4.39

*

5.36*6.43*

1.54

1.82

1.97

.00

***

16.59

***

18.24

5.19*

*** 15.03

1.22 2.60

5.37

*

.64

1.44

.54

3.94

2.20

--

.04

*p < .05

**p < .01

***p < .001

****p < .0001

217
TABLE 10

Step-wise Oiscriminant Analysis of Time, Dimensions,

and Outcome by Community Prevention Training,

Comprehensiveness, and Experimental Rigor Scores

(F. Tests)

Source df F to enter Overall

Time

Step 1 Prevention

Step 2 Rigor

Step 3 Comprehensiveness

Deficit/

Enchancement (DE)

Step 1 Prevention

Step 2 Comprehensiveness

Step 3 Rigor

Behavior/

Situation (BS)

Step 1 Rigor

Step 2 Comprehensiveness

Step 3 Prevention

DE X BS

Step 1 Prevention

Step 2 Comprehensiveness

Step 3 Rigor

Outcome

Step 1 Comprehensiveness

Step 2 Rigor

Step 3 Prevention

1,104 5.72*

2,103 6.46

* *

3,102 5.11

* *

1,115

2.114

3,113

1,115 3.02

2,114 2.99

3,113 2.22

3.113 3.60*

6,224 2.43*

9,270 1.92

*

1,115 5.33*

2,114 4.34*

3,113 2.89*

***

10.91

6.51* *

4.32* *

14.36* *

(df=3)

12.32

* *

(df=3)

6.49

(df=3)

16.92*

(df=9)

8.40*

(df=3)

*p < .05

**p < .01

***p < .001

****p < .0001

218
shown prevention of onset of cigarette smoking in early adolescents and reduction of smoking intentions.

Others have incorporated social skills training into peer training, psychological inoculation, and pressure resistance

approaches (e.g., Hawkins 1981; McAlister et al. 1979; Perry and

Murray 1982; Wodarski and Lenhart 1981). These studies have shown

delays in onset of drug use, and reduction of intentions to use

drugs, and reductions in actual use once it has begun.

Finally, a few studies have assessed the effects of social skills

training as a unitary approach to drug abuse prevention (Schinke

and Blythe in press; Schinke and Gilchrist in press; Williams and

Horan 1981). Results of this research have shown that training

for social skills such as assertiveness in a peer pressure situation leads to decreased drug use, decreased intention to use

drugs, and improvement in drug use-related behaviors such as

aggression.

Review of the studies in this section suggests that social skills

training, whether conducted alone or in combination with other

approaches, is a viable means for preventing drug abuse in adolescents. However, little is known about the relative effects of

social skills training that is directly focused on drug use,

training that is combined with other approaches such as drug

education, generic social skills training, and non-skill-oriented

approaches to drug abuse prevention. Future research should focus

on comparing these approaches in order to determine their immediate and long-term benefits.

FUTURE DIRECTIONS FOR RESEARCH

The review of adolescent social skills training research raises

several issues that are pertinent to future research efforts in

the area of drug abuse prevention with youth. These issues encompass conceptual, methodological, and evaluative domains and are

approached from the perspective ofmaximizingtraining effectiveness and improving the benefit-to-cost ratio involved in conducting preventive research.

First of all, there is a question as to the developmental stability of the social skills construct, and whether its salience and

priority in the developmental sequence of drug use behaviors

changes over time. Friedenburg (1980) has cautioned that social

skill training may be regarded during some age or grade periods as

a means to force adolescents to do what is socially sanctioned.

Whether or not the meaning of social skills changes during the

course of youth and whether its effect on subsequent behavior like

drug use changes in immediacy or strength can be examined in

several types of investigations. For example, Cunningham (1982)

has suggested techniques for evaluating factor invariance and its

relationship to behavior change. Epstein (1980) has suggested

summing and weighting techniques to determine both the stability

of developing behaviors such as social skills and drug use, and

219
the effects of intervention on several extra-training domains of

functioning. Curran (Curran et al. 1979) has suggested evaluating

the generalizability of social skills and training effects across

experimental laboratories as well as areas of subject functioning.

This appears to be especially important in the determination of

agreement on what is meant by social skills, replicability of

training effects, and generalization across different geographic

and demographic areas. Others have suggested evaluation of the

social validity of constructs and training, i.e., assessment of

adolescents' parents', and professionals' opinions of the utility

of social skills and training for drug abuse prevention (Minkin et

al. 1976). Finally, Froman and Hubert (1980) have suggested

evaluation of the developmental sequencing of decision-making in

order to determine the strength and immediacy of influences on

behavior change.

Another area that warrants further research is that of training

prescriptiveness (person, situation, environmental, and developmental considerations that affect training outcome). For example,

although generic social skills training research indicated that

normal adolescents and community/school settings yielded the most

positive outcomes on drug use-related behaviors, little is known

of the contribution of type of adolescent to training effects on

drug use (cf. LaGreca and Mesibov 1979). Also in question is

whether different types of trainers (e.g. peer versus teacher

versus parent) or different levels of training involvement (e.g.,

student versus student and one or both parents) affect drug use

differentially (cf. Pentz 1980a; Iverson et al. 1978). The

effects of behavioral style are additional person variables that

have been suggested as having an influence in causal modeling of

drug use (Huba et al. 1980). Finally, demographic variables,

particularly suburban/rural differences in social skills and

training effects, should be researched further. Several investigators have suggested that drug use development in adolescents

from these areas may differ not only in level, but also in conceptualization (cf. Levine and Kozak 1979; Winfree et al. 1981).

Evaluation of whole communities as factors in social skill development and drug abuse prevention is also open to question (Kim

1982).

The final area that is relatively unexplored involves effects of

social skills and other drug abuse prevention programs which are

dove-tailed by age and grade for the purpose of maximizing

training impact in the face of expected developmental changes (see

Zigler and Cascione 1977). Pursuit of this area of research will

require basic assessment of the validity and reliability of interventions at each grade (see for example, Bloom 1968; Cowen 1980;

and Lorion 1982), comparison of different models of helping and

coping (e.g., compensatory and enlightenment, Brickman et al.

1982), and integration of community and developmental concepts in

research as they relate to youth (Grinder 1982; Masterpasqua

1981).

220
FOOTNOTES

1

programmatic techniques were adapted from Goldstein et al.'s

(1979) Structured Learning Training (SLT) methods for behavior

change in adolescents.

2

See Appendix for the 117 studies included in the review.

3

Studies that actually represent a history of multiple investigations of adolescent social skills training as it applies to drug

use-related behaviors include: Filipczak et al. 1979; Goldstein

et al. 1978; Jesness 1976; Kirigin et al. 1979; Pentz 1980; Rotheram 1981; Sarason and Sarason 1981; and Spence and Spence 1980.

REFERENCES

Albee, G. Preventing prevention in the community mental health

centers. In: Reshik, H., Ashton, C., and Palley, C., eds. The

Health Care System and Drug Abuse Prevention: Toward Cooperation and Health Promotion. Washing, D.C.: National Institute on Drug Abuse, 1981.

Argyris, C. Conditions for competence acquisition and theory. J

Appl Behav Sci, 4:147-177, 1968.

Bandura, A. Self-efficacy: Toward a unifying theory of behavior

change. Psychol Rev, 84:191-215, 1977.

Bloom, B.L. The evaluation of primary prevention programs. In:

Roberts, L.M., Greenfield, N.S., and Miller, M.H., eds. Comprehensive Mental Health: The Challenge of Evaluation. Madison:

University of Wisconsin in Press.

Botvin, G.; Eng, A.; and Williams, C. Preventing the onset of

cigarette smoking through life skills training.

9:135-143, 1980.

Prev Med,

Brickman, P.; Rabinowitz, V.C.; Karuza, J.; Coates, D.; Cohn, E.;

and Kidder, L. Models of helping and coping. Am Psychol,

37:368-384. 1982.

Callner, D.A., and Ross, S.M. The reliability and validity of

three measures of assertion in a drug addict population. Behav

Ther, 7:659-667, 1976.

Chaney, E.F.; O'Leary, M.R.; and Marlatt, G.A. Skill training

with alcoholics. J Consult Clin Pschol, 46:1092-1104, 1978.

Christiansen, B.A.; Goldman, M.S.; and Inn, A. Development of

alcohol related expectancies in adolescents: Separating pharmacological from social learning influences. J Consult Clin

Phychol, 50:336-344, 1982.

Cowen, E.L. The wooing of primary prevention. Am J Comm Psychol,

8:258-284, 1980.

Cunningham, W.R. Factorial invariance: A methodological issue in

the study of psychological development. Exp Aging Res, 8:61-65,

1982.

Curran, J.P. Pandora's box reopened? The assessment of social

skills. J Behav Assess 1:55-17, 1979.

Curran, J.P.; Wessberg, H.W.; Farrell, A.D.; Monti, P.M.; Corrivean,

D.P.; and Cogne, N.A. Social skills and social anxiety: Are

different laboratories measuring the same constructs? J Consult

Clin Psychol, 50:296-406, 1982.

Douvan, E., and Adelson, J. The Adolescent Experience. New York,

Wiley, 1966.

Epstein, S. The stability of behavior II: Implications for

psychological research. Am Psychol, 35:790-806, 1980.

221
Filipczak, J.; Friedman, R.M.; and Reese, S.C. PREP: Educational

programming to prevent juvenile problems. In: Stumphauzer,

J.S., ed. Progress in Behavior Therapy With Delinquents.

Springfield, IL: Charles Thomas, 1979.

Ford, M.E. Social cognition and social competence in adolescence.

Dev Psychol, 3:323-340, 1982.

Foy, D.W.; Miller, P.M.; Eisler, R.M.; and O'Toole, D.H. Social

skills training to teach alcoholics to refuse drinks effectively. J Studies Alcohol, 37:1340-1345, 1976.

Friedenburgr, E.Z. The limits to growth. McGill J Educ, 15:131-

138, 1980.

Froman, T., and Hubert, L.J. Application of prediction analysis

to development priority. Psychol Bull, 87:136-146, 1980.

Gilchrist, L.D. Social competence inadolescence. In: Schinke,

S.P., ed. Behavioral Methods in Social Welfare. New York:

Aldine, 1981.

Goldstein, A.P.; Sherman, M.; Gershaw, N.J.; Sprafkin, R.P.; and

Glick, B. Training aggressive adolescents in prosocial behavior. J Youth Adol, 1:73-92, 1978.

Goldstein, A.P.; Sprafkin, R.P.; Gershaw, N.J.; and Klein, P.

Skill-Streaming the Adolescent: A Structured Learning Approach

to Teaching Prosocial Behavior. Champaign, IL: Research Press,

1979.

Grinder, R.E. Isolation in adolescent research. Hum Dev 25:223-

232, 1982.

Hawkins, J.D. Student team learning: Preventing the flocking and

feathering of delinquents. J Primary Prev, 2:50-55, 1981.

Hobbs, N., and Robinson, S. Adolescent development and public

policy. Am Psychol, 37:212-223, 1982.

Hops, H., and Cobb, J.A. Survival behaviors in the educational

setting: Their implications for research and intervention. In:

Hammerlynch, L.A., Hancy, L.C., and Mash, E.J., eds. Behavior

Change. Champaign, IL: Research Press, 1973.

Huba, G.J. ; Wingard, J.A.; and Bentler, P.M. Framework for an

interactive theory of drug use. In Lettieri, D.J., Sayers, M.,

and Pearson, H.S., eds. Theories on Drug Abuse: Selected

Contemporary Perspectives. National Institute on Drug Abuse

Research Monograph 30. DHHS Pub. No. (ADM) 80-967. Washington,

D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1980.

Iverson, D.C.; Jurs, S.; Johnson, L.J.; and Rohen, R. The effects

of an education intervention program for juvenile drug abusers

and their parents. J Drug Educ, 8:101-111, 1978.

Jesness, C. The youth center project: Transactional analyses and

behavior modification programs for delinquents. Behav Disord,

1:27-36, 1976.

Jessor, R., and Jessor, S.L. Problem Behavior and Psychosocial

Development: A Longitudinal Study. New York, Academic Press,

1977.

Johnston, L.D.; Brachman, J.G.; and O'Malley, P.M. Highlights

From Student Drug Use in America: 1975-1980. National

Institute on Drug Abuse. DHHS Pub. No. (ADM) 81-1006.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off.,

1980.

222
Kellam, S.G.; Brown, C.H.; and Fleming, J.P. Social adaptation to

first grade and teenage drug, alcohol, and cigarette use. J Sch

Health, 52:301-306, 1982.

Kim, S. Feeder area approach: An impact evaluation of a prevention project on student abuse. Int J Addict, 17:305-313, 1982.

Kirigin, K.A.; Wolf, M.M.; Braukmann, C.J.; Fixsen, D.L.; and

Phillips, E.L. Achievement place: A preliminary outcome evaluation. In: Stumphauzer, J.S., ed. Progress in Behavior

Therapy y With Delinquents. Springfield, IL: Charles Thomas,

1979.

Krosnick, J.A., and Judd, C.M. Transitions in social influence at

adolescence: Who induces cigarette smoking? Dev Psychol,

18:359-368, 1982.

Ladd, G.W., and Mize, J. A cognitive-social learning model of

social skills training. Psychol Rev, 90:127-157, 1983.

LaGreca, A.M., and Mesibov, G.B. Social skills intervention with

learning disabled children: Selecting skills and implementing

training.

Levine, E.M.

J Clin Child Psychol, 8:234-241, 1979.

and Kozak, C. Drug and alcohol use, delinquency,

and vandalism among upper middle class pre- and post-adolescents. J Youth Adolesc, 8:91-101, 1979.

Lin, T. ; Bon, S. ; Dickinson, J. ; and Blume, C. Systematic development and evaluation of a social skills training program for

chemical abusers. Int J Addict, 17:585-596, 1982.

Lorion, R.P. Evaluating prevention intervention: Guidelines for

the serious social change agent. In: Felner, R.D., Jason, L.,

Moritsugu, J., and Faber, S.S., eds. Preventive Psychology:

Theory, Research and Practice in Community Interventions. New

York: Pergamon Press, 1982.

Masterpasqua, F. Toward a synergism of developmental and community psychology. Am Psychol, 36:782-786, 1981.

McAlister, A.L.; Perry, C.; and Maccoby, N. Adolescent smoking:

Onset and prevention. Pediatr, 63:650-658, 1979.

Meichenbaum, D.H.; Butler, L.; and Gurson, L. Toward a conceptual

model of social competence. In: Wine, J.D., and Smye, M.D.,

eds. Social Competence. New York: Guilford Press, 1981.

Oei, T., and Jackson, P.R. Social skills and cognitive behavioral

approaches to the treatment of problem drinking. J Studies

Alcohol, 43:532-547, 1982.

Patterson, G.R. Interventions for boys with conduct problems:

Multiple settings, treatments, and criteria. J Consult Clin

Psychol, 4:471-481, 1974.

Pentz, M.A. Assertion training and trainer effects on unassertive

and aggressive adolescents.

Pentz, M.A.

J Couns Psychol, 27:76-83, 1980a.

Perceived similarity of trainers to in vivo stimuli:

A follow-up to assertion training. Unpublished report, May

1980b.

Pentz, M.A. Comparative factor structures of test items and

methods for an adolescent assertion measure. Papers presented

at the annual meeting of the Association for Advancement of

Behavior Therapy, Toronto, Ontario, Canada, November 1981a.

Pentz, M.A. The contribution of individual differences to assertion training outcome in adolescents. J Counsel Psychol, 6:529-

532, 1981b.

223
Pentz, M.A. Adolescent drug use prevention training: Hard knocks

and other lessons. Paper presented at the annual meeting of the

American Psychological Association, Washington, D.C., August

1982a.

Pentz, M.A. Social skills training: A preventive intervention

for drug use in adolescents. Paper presented at the annual

meeting of the American Psychological Association, Washington,

D.C., August 1982b.

Pentz, M.A., and Kazdin, A.E. Assertion modeling and stimuli

effects on assertive behavior and self-efficacy in adolescents.

Behav Res Ther, 28:365-371, 1982a.

Pentz, M.A., Kazdin, A.E. Achieving assertive transfer of

training with adolescents. Manuscript submitted for publication,

December 1982b.

Pentz, M.A., and Tolan, P. Social skills training with adolescents: A critical review of time trends, dimensions and outcome, 1972-1982. Manuscript submitted for publication, January

1983.

Perry, C.L. and Murray, D.M. Enhancing the transition years:

The challenge of adolescent health promotion.

52:307-311, 1982.

J Sch Health,

Piaget, J., and Inhelder, B. The Growth of Logical Thinking:

Psychology of the Child New York: Basic Books, 1969.

Quay, H.C., and Quay, L.C. Behavior problems in early adolescence. Child Dev, 36:215-220, 1965.

Rooney, J.F., and Wright, T.L. An extension of Jessor and

Jessor's problem behavior theory from marijuana to cigarette

use. Int J Addict, 17(8), 1273-1288, 1982.

Rosenthal, T., and Bandura, A. Psychological modeling: Theory

and practice. In: Garfield, S.L., and Bergin, A.E., eds.

Handbook of Psychotherapy and Behavior Change.

Wiley, 1978.

New York:

Rotheram, M.J. Social skills training programs in elementary and

high school classrooms. In: Rathjen, O.P., and Foreyt, J.P.,

eds. Social Competence: Interventions for Children and Adults,

1980.

Sarason, B. The dimension of social competence: Contributions

from a variety of research areas. In: Wine, J.D., and Smye,

M.D., eds. Social Competence. New York: Guilford Press, 1981.

Schinke, S.P. Interpersonal skills training with adolescents.

In: Hersen, M., Eisler, R.M., and Miller, P.M., eds. Progress

In Behavior Modification. Vol. II. New York: Academic Press,

1981.

Schinke, S.P., and Blythe, B.J. Cognitive-behavioral prevention

of children's smoking. Child Behav Ther, in press.

Schinke, S.P., and Gilchrist,L.D. Primary prevention of tobacco

Schwartz, R., and Gottman, J.

smoking. J Sch Health, in press.

behavior.

Toward a task analysis of assertive

J Consult Clin Psychol, 44:910-920, 1976.

Smith, G.M., and Fogg, C.P. Psycological predictors of early

use, late use, and nonuse of marijuana among teenage students.

In: Kandel, D.B., ed. Longitudinal Research on Drug Use:

Empirical Findings and Methodological Issues.

Hemisphere, 1978, pp. 101-113.

Washington, D.C.:

Swisher, J.D. Mental health: The core of preventive health

education. J Sch Health, 46(7):386-391, 1976.

224
Trower, P. Skills training for adolescent social problems: A

viable treatment alternative. J Adolesc, 1:319-329, 1978.

Williams, J., and Horan, J. Longitudinal study of assertion

training as a drug abuse prevention strategy. Unpublished

manuscript, 1981.

Wine, J.D. From defect to competence models. In: Wine, J.D.,

and Smye, M.D., eds. Social Competence. New York: Guilford

Press, 1981.

Winfree, L.T. ; Theis, H.E.; and Griffiths, C.T. Drug use in rural

America: A cross-cultural examination of complementary social

deviance theories.

Wodarski, J.D.,

Youth Soc, 12:465-489, 1981.

and Lenhart, J.D. Comprehensive treatment of

adolescents who abuse alcohol. Paper presented at the Conference on Advances in Clinical Behavior Therapy, Banff, Alberta,

Canada, March 1981.

Zialer. E., and Cascione. R. Head Start has little to do with

mental retardation: Reply to Clark and Clark. Am J Ment Defic,

81:246-249, 1977.

225
APPENDIX. INVESTIGATIONS OF ADOLESCENT SOCIAL SKILLS TRAINING,

1972-1982: STUDIES INCLUDED IN THE REVIEW

Apple, M.M. Kinesic training for the blind: A program. Educ

Visually Handicapped, 4:55-60, 1972.

Avery, A.W. .; Rider, K. ; and Haynes-Clements, L.A. Communication

skills training for adolescents: A five-month follow-up.

Adolescence, 16:289-298, 1981.

Bedell J.R., and Weathers, L.R.

skill trailing:

A psycho-educational model for

Therapist-facilitated and game-facilitated

applications. In: Upper, D., and Ross, S.M., eds. Behavioral

Group Therapy, 1979: (An Annual Review). Champaign, IL:

Research Press, 1979.

Bornstein, M.R.; Bellack, A.S.; and Hersen, M. Social skills

training for unassertive children: A multiple baseline analysis. J Appl Behav Anal, 10:183-195, 1977.

Bornstein, M.R.; lack, A.S.; and Hersen, M. Social skills

training for the highly aggressive child. Behav Mod, 4:173-186,

1980.

Bower, S.; Amatea, E.; and Anderson, R. Assertiveness training

with children. Elem Sch Guid Couns, 10:236-246, 1976.

Branningan, G.C., and Young, R.G. Social skills training with the

MBD adolescent: A case study. Acad Ther, 13:401-404, 1978.

Braukmann, C.J.; Fixsen, D.L.; Phillips, E.L.; Wolf, M.M.; and

Maloney, D.M. An analysis of a selection interview training

package for predelinquents at achievement place. Crim Just

Behav, 1:30-42, 1974.

Braukmann, C.M., and Fixsen, D.L. Behavior modification with

delinquents. In: Hersen, M., Eisler, R.M., and Miller, P.M.,

eds. Progress in Behavior Modification. Vol. 1. New York:

Academic Press, 1975.

Bright, P.D. and Robin, A.L. Ameliorating parent-adolescent

conflict with problem-solving communication training. J Behav

Ther Exp Psychiatry, 3:275-280, 1981.

Buck, M.R. Peer counseling in an urban high school. J Sch Psychol, 15:336-365, 1977.

Burchard, J.D., and Bauera, F. An analysis of timeout and

response cost in a programmed environment. J Appl Behav Anal,

5:271-282, 1972.

Chandler, M.J. Egocentricism and antisocial behavior: The

assessment and training of social perspective-taking skills.

Dev Psychol, 9:326-332, 1973.

Chandler, M.J.: Greenspan, S.; dnd Barenboim, C. Assessment and

training of role-takina and referential communication skills in

institutionalized, emotionally disturbed children. Dev Psychol,

10:546-553, 1974.

Chasanoff, E., and Schrader, C.A. Behaviorally-oriented activities therapy program for adolescents. Adolescence, 14:567-577,

1979.

Cipani, E. Modifying food spillage behavior in an institutional,

retarded client. J Behav Ther Exp Psychiatry, 3:261-265, 1981.

Cooker, P.G., and Cherchia, P.T. Effects of communication skills

training in high school students' ability to function as peer

group facilitators. J Couns Psychol, 23:464-467, 1976.

Crenshaw, D. Teaching adaptive interpersonal behavior: Group

techniques in residential treatment. Child Care Q, 5:211-220,

1976.

226
Dozier, J.E.; Lewis, S.; Kersey, A.G.; and Charping, J.W. Sports

group: An alternative treatment modality for emotionally disturbed adolescents. Adolescence, XIII(51):483-488, 1978.

Elder, J. P.; Edelstein, B.A.; and Narick, M.M. Adolescent psychiatric patients: Modifying aggressive behavior with social

skills training.

Edwards, E.S.,

Behav Mod, 3:161-178, 1979.

and Roundtree, G. Assessment of a behavior modification program for modifying disruptive behavior of emotionally

disturbed adolescent males in a residential facility. Corrective Psychiatry J Behav Technol Methods Ther, 4:171-179, 1981.

Emhoff, J.G.; Redd, W.H.; . and Davidson, W.S. Generalization

trailing and the transfer of prosocial behavior in delinquent

adolescents.

Erland, S. J.,

J Behav Ther Exp Psychiatry, 6:141-144, 1976.

and Kavalich,B. A group response-cost system

mediated by free tokens: An alternative to token reinforcement.

Am J Ment Defic, 2:184-187, 1981.

Fiedler, P.D.; Ornstein, H.; Chiles, J.; Fritz, G.; and Brutt, S.

Effects of assertive training on hospitalized adolescents and

young adults. Adolescence, 14:523-538, 1979.

Filipczak, J.; Archer, M.; and Friedman, R.M. School social

skills training: Use with disruptive adolescents.

4:243-263, 1980.

Behav Mod,

Filipczak, J., and Wodarski, J.S. Behavioral intervention in

public schools: Implementing and evaluating a model. Corrective Soc Psychiatry J Behav Technol Methods Ther 25:104-116,

1979.

Fleming, E.R., and Fleming, D.C. Social skill training for educable mentally retarded children. Educ Training Ment Retarded,

1:44-50, 1982.

Fo, S.O., and O'Donnell, C.R. The "buddy system:" Relationship

and contingency conditions in a community intervention program

for youth and nonprofessionals as behavior change events. J

Consult Clin Psychol, 42:163-169, 1974.

Freedman, B.J.; Rosenthal, R.; Donahoe, C.P.; Schbundy, D.G.; and

McFall, R.M. A social behavioral analysis of skill deficits in

delinquent and non-delinquent adolescent boys. J Consult Clin

Pschol 46:1448-1462, 1978.

Gallagher, P.A., and Heim, R.E. The classroom application of

behavior modification principles for multiply handicapped blind

students. New Outlook for the Blind, 68:447-453, 1974.

Garrigan, J.J. Family therapy for disturbed children: Some

experimental results in special education. J Marriage Fam

Couns, 3:83-93, 1977.

Geller, M.D.; Wildman, H.E.; Kelly, J.A.; and Laughlin, C.S.

Teaching assertive and commendatory social skills to an interpersonally-deficient retarded adolescent. J Clin Child Psychol,

9:17-21, 1980.

Gold, J.A.; and Kelodny, R.L. Group treatment of socially disposed youth: An activity/discussion approach. Soc Work With

Groups, 1: 145-149, 1978.

Grando, R., and Ginberg, B. Communication in the father-son

relationship: Parent-adolescent relationship development program. Fam Coordinator, 25:467-473, 1976.

Gross, A.M.; Brigham, T.A.; Hopper, C.; and Gologna, N.C. Selfmanagement and social skills training. Crim Just Behav,

7:161-184, 1980.

227
Hamre-Nietupski, S., and Williams, W. Implementation of selected

sex education and social skills to severely handicapped students. Educ Training Ment Retarded, 12:364-372, 1977.

Hartman, L.N. The preventive reduction of psychological risk in

asymptomatic adolescence. Am J Orthopsychiatry, 49:121-135,

1979.

Hauserman, N.; Zweback, S.; and Poltkin, A. Use of concrete

reinforcement to facilitate verbal initiations in adolescent

group therapy. J Consult Clin Psychol, 38:90-96, 1972.

Haynes, L.A., and Avery, A.A. Training adolescents in selfdisclosure and empathy skills. J Couns Psychol, 26:526-530,

1979.

Heimberg, R.G.; Cunningham, J.; Heimberg, J.S.; and Blankenberg,

R. Social skills training to prepare disadvantaged youth for

the job interview: A controlled evaluation (cited by R.W.

Gillen and R.G. Heimberg, Social skills for the job interview.)

In: Hersen, M., Eisler, R.M., and Miller, P.M., eds. Progress

In Behavior Modification. Vol. 10. New York: Academic Press,

1980.

Henderson, J.O. A behavioral approach to stealing: A proposal

for treatment based on ten cases. J Behav Ther Exp Psychiatry,

3:231-236.

Hobbs, T.R., and Holt, M.M. The effects of token reinforcement on

the delinquents in cottage settings. J Appl Behav Anal,

9:189-198, 1976.

Hoch, R.A.; Rodger, C.H.; Roddi, C.; and Kennard, D.W. Medicopsychological change. Psychosomatic Medicine, 40:210-215, 1978.

Hynes, J. Adolescent group for mentally retarded adolescents.

Educ Training Ment Retarded, 1:226-231, 1976.

Iverson, D.C.; Juas, S.; Johnson, L.J.; and Rohen, R. The effects

of an education intervention program for juvenile drug abusers

and their parents. J Drug Educ, 8:101-111, 1978.

Jackson, D.A., and Wallace, R.F. The modification and generalization of voice loudness in a 15-year-old girl. J Appl Behav

Anal, 7:461-471, 1974.

Jennings, R.L., and Davis, C.S. Attraction-enhancing client

behaviors: A structured learning approach for "Non-Yavis, Jr."

J Consult Clin Psychol, 45:135-144, 1977.

Jesness, C. The youth center project: Transactional analyses

and behavior modification programs for delinquents. Behav

Disorders, 1:27-36, 1976.

Jesness. O. F. Comoarative effectiveness of behavior modification

and transactional analysis programs for delinquents. J Consult

Clin Psychol, 6:758-779, 1975.

Jones, V.F. Employing behavioral counseling with adolescents. In:

Jones, V. F. , ed. Adolescents With Behavior Problems: Strategies for Teaching, Counseling, and Parent Involvement. Boston:

Allyn and Bacon, 1980.

Kaufman, L.N., and Wagner, B.R. BARB: A systematic treatment

technology for temper control disorders. Behav Ther, 3:84-90,

1972.

Kelly, J.A. ; Furman, W. ; Phillips, J.; Hathoun, S.; and Wilson, T.

Teaching conversational skills to retarded adolescents. Child

Behav Ther, 1:85-97, 1979.

228
Kelly, J.A.; Wildman, B.G.; and Berler, E.S. Small group behavioral training to improve the job interview skills repertoire of

mildly retarded adolescents.

Kelly, J.A.;

J Behav Anal, 13:461-471, 1980.

Wildman, B.G.; Urey, J.R.; and Thurman, C. Group

skills training to increase the conversational repertoire of

retarded adolescents. Child Behav Ther, 1:323-336, 1979.

Kifer, R.E.; Lewis, M.A.; Green, D.R.; and Phillips, E.L. Training pre-delinquent youths and their parents to negotiate conflict situations. J Appl Behav Anal, 7:357-364, 1974.

Kirigin, K.A.; Wolf, M.M.; Braukmann, C.J.; Fixsen, D.L.; and

Phillips, E.L. Achievement Place: A preliminary outcome evaluation. In: Stumphauzer, J.S., ed. Progress in Behavior Therapy

With Delinquents. Springfield, IL: Charles Thomas, 1979.

LaGreca. A.M., and Mesibov. G.B. Facilitating interoersonal

functions with peers in learning-disabled children: J Learning

Disabilities, 14:197-199, 1982.

LaGreca, A.M.. and Mesibov. G.B. Social skills intervention with

learning disabled children: Selecting skills and implementing

training.

LaVirna, G.V.

J Clin Child Psychol, 8:234-241, 1979.

Communication training in mute autistic adolescents

using the written word. J Autism Childhood Schizophrenia,

7:135-159, 1977.

Lebsock, M.S., and Salzberg, C.L. The use of role play and reinforcement procedures in the development of generalized interpersonal behavior with emotionally disturbed. behavior disordered

adolescents in a special education classroom. Behav Disorder,

6:150-163. 1981.

Lee, D.Y.; Hollberry, E.T .; and Hussard, H. Effects of assertion

training on aggressive behavior in adolescents. J Couns

Psychol, 26:459-461, 1979.

Leone, S., and Gumaer, J. Group assertiveness training of shy

children. Sch Couns; 27:134-141, 1979.

LeVine, E.; Rittenhouse, J.; Smith, G. ; and Thompson, T. A conjoint, operant model for assisting profoundly behaviorally

disordered adolescents. Adolescence, XVI(62), 299-307, 1981.

Lindsay, W.R.: Symons, R.S.: and Sweet, T. A programme for

teaching social skills to-socially inept adolescents: Description and evaluation. J Adolesc, 2:215-228, 1979.

Loiselle, J. K., and Greenidge, Behavioral treatment of highrate aggression in a rubella child. J Behav Ther Exp Psychiatry, 2:153-157, 1982.

Long, J.O., and Williams, R.L. The utility of self management

procedures in modifying the classroom behaviors of mentally

retarded adolescents. Adolescence, 11:29-37, 1976.

Maglis, C.L., and McLaughlin, T.F. Effects of a token reinforcement system and teacher attention in reducing inappropriate

verbalizations with a junior high school student- Corrective

Soc Psychiatry J Behav Technol Methods Ther, 3:140-144, 1981.

Maloney, D.N.; Harper, T.N.; Braukmann, C.J.; Fixsen, D.L.;

Phillips, E.L.; and Wolf, M.M. Teaching conversation-related

skills to pre-delinquent girls. J Appl Behav Anal, 9:371, 1976.

Marholin, D.; Plienis, A.J.; Harris, S.D.; and Marholin, B.L.

Mobilization of the community through a behavioral approach: A

school program for adjudicated females. Crim Just Behav

2:130-145, 1975.

229
Matson, J.L.; Esueldt-Dawson, K.; Andrasik, F.; Ollendick, T.H.;

Petti, T.; and Hersen, M. Direct, observational, and generalization effects of social skills training with emotionally disturbed children. Behav Ther, 11:522-531, 1980.

Mayhew, G.L.; Enyart, P.; and Anderson, J. Social reinforcement

and the naturally occurring social responses of severely and

profoundly retarded adolescents. Am J Ment Defic, 83:164-170,

1978.

McCombs, D.; Filipczak, J.; Friedman, R.M.; and Wodarski, J.S.

Long term follow-up of behavior modification with high risk

adolescents. Crim Just Behav, 5:21-34, 1978.

McKinley, T.; Kelly, J.A.; and Patterson, J. Teaching assertive

skills to a passive homosexual adolescent: An illustrative case

study. J Homosexuality 3: 163-169, 1977.

Meichenbaum, D.H.; Bowers: I.S.; and Ross, R.R. Modification of

classroom behavior of institutionalized female adolescent

offenders. In: Stumphauzer, J.S., ed.

Delinquents. Chicago: Charles Thomas 1973.

Mendell, S.; Tyler, F.B.; and Freeman R'W

Behavior Therapy With

Evaluating a psychotherapeutic day Lamp with psychosocial competence and goal

attainment measures.

Mills, C.M., and Walter, T.L. Reducing Juvenile delinquency: A

J Clin Child Psychol, 3:180-183, 1981.

behavioral-employment intervention program. In: Stumphauzer,

J.S. , ed. Progress In Behavior Therapy With Delinquents.

Chicago: Charles Thomas, 1979.

Ollendick, T.H., and Hersen, M. Social skills training for juvenile delinquents. Behav Res Ther, 17:547-555, 1979.

Panzer, B.M.; Wiesner, L.D.; and Dickson, W.D. Program for developmentally disabled children.

Patterson, G.R.

Soc Work, 23:406-411, 1978.

Interventions for boys with conduct problems:

Multiple settings, treatments, and criteria. J Consult Clin

Psychol, 4:471-481, 1974.

Pease, J.J. A social skills training group for early adolescents.

J Adolesc, 2:229-238, 1979.

Pentz, M.A. Assertion training and trainer effects on unassertive

and aggressive adolescents. J Couns Psychol, 27:76-83, 1980.

Pentz, M.A. The contribution of individual differences to assertion training outcome in adolescents. J Couns Psychol,

6: 529- 532, 1981.

Pentz, M.A., and Kazdin, A.E. Assertion modeling and stimuli

effects on assertive behavior and self-efficacy in adolescents.

Behav Res Ther, 28:365-371, 1982.

Peterson, G.A.; Austin, G.J.; and Lang, R.P. Use of teacher

prompts to increase social behavior: Generalization effects

with severely and profoundly retarded adolescents. Am J Ment

Defic, 84:81-86, 1979.

Rhodes, W.A.; Redd, W.H.; and Bergren, L. Social skills training

for an unassertive adolescent. J Clin Child Psychol, 8:18-21,

1979.

Rashbaum-Selig, M. Assertive training for young people. Sch

Couns, 24:115-122, 1976.

Robin, A.L. A controlled evaluation of problem-solving communication training with parent-adolescent conflict.

12:593-609, 1981.

Behav Ther,

230
Robin, A.L.; Kent, R.; O'Leary, K.D.; Foster, S.; and Prinz, R.

An approach to teaching parents and adolescents problem-solving

communication skills: A preliminary report. Behav Ther,

8:639-643, 1977.

Rosenberg, P.P., and Rosenberg, L.M. Sex education for adolescents and their families. J Sex Marital Ther, 2:53-67, 1976.

Rotheram, M.J., and Armstrong, M. Assertiveness training with

high school students. Adolescence, 15:267-276, 1980.

Sanchez-Craig, B.M. Cognitive and behavioral coping strategies in

the reappraisal of stressful social functions. J Couns Psychol,

23:7-12, 1976.

Sarason, I.G. Using modeling to strengthen the behavioral repertory of the juvenile delinquent. In: Krumboltz, J.D., and

Thorensen, C.E., eds. Counseling Methods. New York: Holt,

Rhinehart & Winston, 1976.

Sarason, I.G., and Ganzer, V.J. Modeling and group discussion in

the rehabilitation of juvenile delinquents. J Couns Psychol,

20:442-449, 1973.

Sarason. I.G., and Sarason, B.R. Teaching cognitive and social

skills to high school students. J Consult Clin Psychol,

6:908-918, 1981.

Schinke, S.P., and Gilchrist. L.D. Adolescent pregnancy: An

interpersonal skill training approach to intervention: Soc Work

Health Care, 3:159-167, 1977.

Seligman, L. Multimodal behavior therapy: Case study of a high

school student.

Shoemaker, M.E.

Sch Couns, 4:249-256, 1981.

Group assertion training for institutionalized

male delinquents. In: Stumphauzer, J.S., ed. Progress In

Behavior Therapy With Delinquents. Chicago: Charles Thomas.

1979.

Siejko, M. Education of socially oriented behavior. In:

Olechnowicz, H., ed. Studies In the Socialization of the

Severely and Profoundly Retarded. Warsaw, Poland: Nasza

Ksiegarnia, 1973.

Stilbergeld, S. Thune, E.S. Manderscheid, R.W. The group therapist leadership role: Assessment in adolescent coping courses.

Small Group Behav, 10: 176-199, 1979.

Sloane, H.N., and Ralph, J.L. A behavior modification program in

Nevada. Int J Offender Ther Camp Criminol, 17:290-296, 1973.

Spence, A. J., and Spence, S.H. Cognitive changes associated with

social skills training. Behav Res Ther, 18:265-272, 1980.

Spence, S.H., and Marzillier, J.S. Social skills training with

adolescent male offenders: Short-term effects. Behav Res Ther

17:7-16, 1979.

Spence, S.H., and Marzillier, J.S. Social skills training with

adolescent male offenders-II: Short-term, long-term and generalized effects. Behav Res Ther, 19:349-368, 1981.

Stanlev. S.F. A curriculum to affect the moral atmosphere of te

family and the moral development of adolescents. Dissertation

Abstracts Int, 36:7221-7222, 1976.

Stichart, S.S. Effects of competence and nurturance on imitation

of non-retarded peers by retarded adolescents. Am J Ment Defic,

78:665-673, 1974.

231
Tafte-Tripps, S. Hendonca, P. and Peach, R.V. Training and

generalization of social skill: A study with two developmentally handicapped, socially isolated children. Behav Mod,

6:45-69, 1981.

Terkefson, C. Making contact: A parent-child communication skill

training program. Elem Sch Guid Couns, 11:89-99, 1976.

Thelen, M.A.; Fry, R.A.; Dollinger, S.L.; and Paul, S.C. Use of

videotaped models to improve the interpersonal adjustment of

delinquents. J Consult Clin Psychol, 44:491, 1976.

Thompson, D.G., and Hudson,G.R Values clarification and behavioral group counseling with ninth-grade boys in a residential

school. J Couns Psychol 4:394-399 1982.

Vogelsong, E.L.; Most, R.K.; and Yewchko, A. Relationship

enhancement training for pre-adolescenis in public schools. J

Clin Child Psychol, 8:97-99, 1979.

Warrenfeltz R.B.; Kelly, W. J.; Salzberg, C.L.; Beagle, C.P.;

Levy, S.M.; Adams, T.A.; and Crouse, T.R. Social skills training of behavior disordered adolescents with self-monitoring to

promote generalization to a vocational setting. Behav

Disorders, 7:18-27, 1981.

Weathers, L., and Liberman, R.P. Contingency contracting with

families of delinquent adolescents. Behav Ther, 6:356-366,

1975.

Weinberger, G., and Reuter, M. The "Life-Discussion" group as a

means of facilitating personal growth and development in late

adolescence.

Welch, G.J.

J Clin Child Psychol, 9:6-12, 1980.

Verbal communication training: A procedure to augment contingency contracting. J Behav Ther Exp Psychiatry,

7:301-303, 1976.

Whitman, T.L.; Burish, T.; and Collins, C. Development of interpersonal language responses to moderately retarded children.

Ment Retardation, 10:40-45, 1972.

Williams, W., and Hamre-Nietupski, S. Teaching selected

social skills to severely handicapped students. SALT: School

Application of Learning Theory, 8:1-19, 1976

Wodarski, J.S.; Filipczak, J.; McCombs, D.; Koustenes, G.; and

Rusilko, S. Follow-up on behavioral'intervention with troublesome adolescents. Behav Ther Exp Pshchiatry, 10:181-188, 1979.

AUTHOR

Mary Ann Pentz, Ph.D.

Department of Psychology

University of Tennessee

Knoxville, Tennessee 37996

232
Preventing Adolescent Substance

Abuse Through Drug Education

Joel M. Moskowitz, Ph.D.

The belief that education can solve social problems has been longstanding despite a lack of supportive evidence (Goodstadt 1981;

Noble 1978; Woodcock 1973). This belief is based on the assmptions that social problems are caused by the maladaptive behavior

of individuals,and thatsuchbhaviorcanbe influenced by education. The public schools are considered a logical setting for

primry prevention because their major goal is education,andthey

service a young population that is relatively problem-free. The

present peper examines the efficacy of drug education as preventive solution to the problem of substance abuse. The substances

of interest include alcohol and cigarettes well as psychoactive

drugs taken for non-medical reascns.

Drug education,whichfirstappeazd in the public school curriculum in the 1880's, has largely consisted of didactic instruction

about psychoactive drugs and their use (Globatti 1974). The

information taught has been relatively accurate given available

knowledge during all but two decades. Inthesedecades, the

1890's and 1960's, drug education could best be characterized as

"scare tactics" because much misinfomtion was conveyed in an

attemp to prevent substance abuse through fear arousal (Bukoski

1979; Wepner 1979). Neither approach, however, has been successful in preventing a general increase in the incidence of substance

abuse (Kinder et al. 1980; Plant 1980).

By the mid-1970's, in response to better knowledge about the

correlates of substance abuse, drug education was re-canceptualized

as "a well-defined and structured learning process that assists

individuals to develop affective skills they need to help themselves" (Bukoski 1979). Information about drugs and their effects

became secondary to the davelopment of psychosocial skills related

to problem solving, decisicn-making, values awareness, stress

reduction, and interpersonal communications.

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THEORETICAL APPROACHES

Most drug education programs have been based upon at least one of

three theoretical approaches to behavior change: a knowledge/

attitudes approach, a values/decisicm-making approach, or a social

canpetency approach. The kowledge/attitudes approach has been

used most widely. This approach assumes that increased knowledge

about the consequences of substance use produces more negative

attitudes toward use which, in turn,reduce the likelihood of

use. Recent research has concentrated on two variants of this

approach: Fishbein's behavioral intentions model (Fishbein and

Ajzen 1975) and McGuire's persuasiom-communication model(McGuire

1964, 1974). Fishbein's model assumes that behavior is a volitional act. The model specifies that the intentions to perform a

given behavior are the immmediate determinants of that behavior.

Furthermmore, intentions to engage in an activity are considered to

be a function of attitudes toward the activity and related subjective norms. McGuire's model postulates a sequence of six steps

for beavioral change. The target population must l) be exposed

to a persuasive communication; 2) attend to the material; 3) conprehend its comtents; 4) agree with its conclusions; 5) retain the

induced agreement; and 6) act accordingly. The model addresses

the factors that facilitate this process, including the objectives,

source, and content of a communication. It specifies important

characteristics of the audience and of the mode through which the

communication is presented (such as face-to -faoe or mass media).

For example, if one's goal is to produce sustained attitude change,

then presenting both sides of an argument (cognitive inoculation)

may be more effective than presenting one side. Also, a cammuication may be more effective if the communicator is perceived to

be credible, attractive, and powerful (McGuire 1974).

With regard to substance use, there is little empirical Support

for the causal links Implied by the knowledge/attitudes approach

(Godstadt 1981; Hansom 1980; Kinder et al. 1980). Schlegal and

Norris (1980) subjected adolescents to persuasive communications

regardirg their beliefs about marijuana use. They found that

only same beliefs were amenable to change and that where attitude

change was successful, intentions and behavior changedidnot

follow. Longitudinal research indicates that this approach fails

to account adequately for the influence of prior substance usecn

subsequent use Bentler and Speckart 1979). Furthermore, drugrelated behavior is fairly stable over time (Huba et al. 1980,

1981). Intentions explain little of the variance in subsequent

use after controlling for prior use (Bentler and Speckart 1979;

Huba et al. 1981; Schlegel et al. 1977), suggesting that adolescent

substanceuseis not necessarily a conscicusly planned behavior.

Discussing the potential effects of drug education on drug use,

McGuire has concluded that:

Attitudes are perhaps a partial determinant of action...

However,drug use in young people is probably notthe

most rational area of human behavior. An individual's

decision to use drugs in a given situation derives fran

many factcrs, not justhisgeneralbelief system regarding drug usage. (McGuire 1974, pp. 23-24)

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In contrast to the knowledge/attitudes approach, which focuses on

the activity (i.e., drug use), the values/decision-making approach

focuses on the individual. This model promotes self-examination

of one's needs or values and of the roles that subetance use serves

in fulfilling these values. The objective is to decrease the likelihood of substance use through promotion of self-understanding

and responsible decision-making. Research-adolescents provides

limited support for this approuch inasmuch as logical introspection

regarding the costs and benefits of substance use has not been

found to be highly predictive of subsequent use (Huba et al. 1980).

Moreover, there is little empirical evidence to support the

efficacy of this approach with regard to drug educaticn (Goodstadt

1981), health educatiom (Governail and Sechriest 1980), moral education (Leming 1980; Lockwood 1978), or interpersonal problen-solving

(Urbain and Kendall 1980). Evaluation studies have found this

approach to be ineffective in influencing values organization,

self-esteen, or behaviaral adjustment.

The most recent approach to drug education, social competency,

assumes that individual abuse substances because they lack appropriate psychosocial skills. This approuch recognizes that individuals create theire environment by choosing social situations and

partners, by processing social information in these situations, and

by their interpersonal behavior (Meichenbaum al. in press).

Bandura's theories (1977a, 1977b, 1978, in press) regarding social

learning, reciprocal determinisn,ard self-efficacy, have heavily

influenced conceptualizations about social carpetency. However,

little research has been conducted in this area; thus, knowledge

about the relationships between social cognition and social

behavior is limited (Ford 1982). Research has been hampered by

an inability to develop reliable and valid measurement procedures

(Bellack 1979; urbain and Kendall 1980).

Applications of the social competency approach to drug education

have featured two techniques: modeling health-promting behaviors

and teaching skills to resist social influences (e.g., peers and

family) that promote drug use. Although a substantial body of

research suggests that these influences are major determinants of

drug use (Botvin and McAlister 1982; Braucht 1980; Glynn 1981;

Gorsuch and Butler 1976; Kandel 1980; Radosevitch et al. 1980),

little research indicates how these influences actually operate

(Botvin in press; Braucht and Braucht 1982; Huba et al. 1980;

Jessor 1982). This latter knowledge is necessary to develop

effective program. For example, programs that teach students to

be assertive assume that students are pressured by their friends

to use drugs. In what is likey the best study to have examined

this issue, the investigator concluded that an adolescent's selection of friendsplaysas important a role as conformity pressure

(Kandel 1978). Inspection of the data reported in this study

reveals that most friendship pairs (85%) were initially congruent

with reqard to marijuana use. In most of the initially incongruent pairs, where one member initially used marijuana and the

other did not, marijuana use did not change at posttest (44%) or

both menbers became nonusers(34%); in only 17% of these pairs

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did both members become users. Thus, there is much more evidence

for selection and positive peer influence in this study than there

is for negative peer influence. This evidence calls into question

theutilityofassertiveness training for preventing marijuana use.

In sum, the theoretical approaches to drug education have little

empirical basis. Whereas the knowledge/attitudes models have

been researched considerably, the evidence for the causal links in

these models is inconsistent. Furthermore,there is little support

for the validity of these models as applied to adolescentdruguse.

The values/decision-making and social competency models have not

generated much research. Thus, the assmption that adolescents

abuse drugs because of their deficient values, their inept

decision-making, or their inadequate social shills is unfounded.

There is also little evidence that such deficiencies can be

remedied through education.

EVALUATION RESEARCH

The drug education evaluation literature has been reviewed extensively (Evans et al. 1979; Goodstadt 1980; Hanson 1980; Kinder et

al. 1980; Mackintosh et al. 1981; Rothman and Byrne 1981; Schaps

et al. 1981; Staulcup et al. 1979; Thompson 1978). Based upon

these reviews several corclusions are warranted. First, drug

education programs have been largely ineffective in preventing

substance use or abuse. Whereas many programs are effective in

increasing drug knowledge,very few programs influence drug attitudes, and even fewer influence drug use. Second, most studies

suffer from serious methodological weaknesses which undermine

internal validity, or the ability to make inferences about program

effectiveness. These shortcomings include inappropriate control

groups ard statistical analyses, small sample sizes, sizable

attrition rates, and inadequate measurement procedures. Third,

most evaluation reports neither specify the proqram's goals and

objectives nor describe the target population. Furthermore,the

reports provide only superficial program descriptions, and the

studies do not evaluate program implementation. These shortcomings make it difficult to interpret the meaning of results or

to determine their generalizability.

Our own research on drug education overcomes many of the methodological problems that have plagued prior studies. In two experimental studies evaluating different drug education courses, classes

were matched on the basis of pretest druq use and attitudes and

then randomly assigned to cordition. Pretests and multiple posttests were administered to collect self-report data on a variety

of drug-related variables including knowledge, utilities (i.e.,

perceived positive and negative consequences) , perceptions of peer

attitudes and peer use, attitudes, intentions, and use. Survey

administration procedures that maintained subject identifiability

without introducing response bias were utilized (Malvin and Moskowitz, in press). These procedures enabled sensitive covariance

analyses to be corducted as Well as analyses of the effects of

attrition. Data were analyzed at the class level and/or student

level with class as a random factor. This contrasts with prior

236
studies that have conducted student-level analyses assuming that

students are statistically independent, an assumption that is

rarely warranted (Hopkins 1982; Judd and Kenny 1981). Finally,

implemtation of the courses was documented,aud feedback regarding

the caurseswas obtained from students via interviews or questionnaires.

Both couses primarily were based upon a values/decision-making

approach with secondary emphasis on knowledge and attitudes.

The second course also taught relevant social competencies. In

the first course 7th and 8th grade students were taught decisionmaking skills, a framework for uderstanding needs, alternative

methods for dealing with problems and stress, and information

regarding the emotional, social,and physical consequences of substance use (primarily alchohol, cigarettes, and marijuana). In

the second course 7th grade students were taught decision-making

skills, personal goal setting, a model of motivation, peer and

media influnces on behavior, assertiveness training, and information on the consequences of, and alternatives to substance use.

Special instructors taught the causes in 10 or 12 weekly sessions

conducted during social studiesclasses.

The process evaluation revealed that the first course was too conplicated for many students as the curriculm was "abstract,

difficult, and dense" (Schaps et al. 1982). The outcome evaluation

revealed that the first course produced several of the predicted

effects for 7th grade girls but not for the other sub-groups. As

compared to their controls, the 7th grade experimental girls had

greater drug knowledge, perceived more negative peer attitudes

toward alcohol, cigarette, and marijuana use, and were less involved

in use of alcohol and marijuana. However, all of these effects

disappeared at follow-up one year after completion of the course

(Moskowitz et al. in press-c).

The second course was evaluated in two studies. The first evaluation was a guasi-experimetal study in which drug education was

administered in conjunction with other prevention strategies.

Because these other strategies were found to be ineffective,the

results of this study appear to be attributable to drug education

(Moskowitz et al. in press-d). In this skudy all 7th grade

students in one school received drug education, and 7th grade

students from another school served as a conparison group. Student

feedback regarding this course was superior to the first course.

Positive effects were found on girls' drug knowledge,their perceptions of peer attitudes toward and peer use of drugs,and their

cigarette smoking. Experimental boys exhibited greater drug knowledge but no other differences attributable to the course. At

follow-up one year later the knowledge effects were sustained for

both sexes. In addition, the effect on girls' cigarette smoking

was sustained as well as two of the effects on the four perceived

peer attitude and peer use measures.

The final study evaluated the second course with two instructors;

each taught the course to randomly selected classes in two different schools. For males, no effects were obtained at posttest;

237
however, five months later at follow-up, positive effects were

found an three of the four perceived peer attitude and peer use

Treasures. For females,no effects were found at either posttest

or follow-up.

Same general conclusions can be drawn from this research. Drug

education was more effective for girls inasmuch as their substance

use was positively affected by both courses. However, these behavioral effects were sustained at follow-up only for cigarette use. The

behavioral changes were accompanied by increased knowledge and

changes in perceived peer attitudes toward drug use, but not by

attitudinal changes. Finally, the only replicable effects occurred

for girls on drug knowledge and parceived peer attitudes toward drug

use, but even these effects failed to be replicated in the final

study. In sum, the inconsistency of these findings does not provide a clear direction for future research.

CIGARETTE SMOKING PREVENTON

In contrast to the limited evidance for the efficacy of drug education programs on alcohol and drug use, there has been considerable

evidence for the efficacy of cigarette smoking education on cigarette use. Six studies have found positive effects on cigarette

smoking (Arkin et al. 1981; Evans et al. 1981; Flay et al. 1983;

Hurd et al. 1980; McAllister et al. 1980; Perry et al. 1980) with

programs that share a common theoretical basis in social learning

theory (Bandura 1977b) and persuasive-commuication/cognitiveinoculation theory (McGuire 1964). The programs consisted of 5-11

sessions in which 7th grade students learned about the short-term

effects of cigarette smoking and learned to identify and to resist

the social influences that pranate cigarette use.

In these programs positive peer behavior was modeled by trained

peers who led discussions (Arkin et al. 1981; Hurd et al. 1980;

McAlister et al. 1980; Perry et al. 1980) or appeared on film

(Arkin et al. 1981; Evans et al. 1981; Hurd et al. 1980). Programs

without peer models have also been effective in preventing cigarette smoking (Arkin et al. 1981; Flay et al. 1983); thus, peer

models are not necessary to obtain the effect. Perhaps the modeling that naturally occurs when students, particularly early

adolescents, discuss substance use is as important to the efficacy of these programs as the use of trained peer models.

Another common feature of these programs has been assertiveness

training. Students are taught cognitive and verbal strategies

to resist social pressures to use drugs and than rehearse these

strategies. While there is evidence that such programs prevent

cigarette use (Botvin and Eng 1982; Botvin et al. 1980; Hurd et al.

1980; McAlister et al. 1980; Perry et al. 1980), it is unclear

whether this component is responsible. Other programs have obtained

this effect without teaching assertiveness (Arkin et al. 1981;

Evans et al. 1981). Because no study assessed assertiveness, it is

not known whether students even acquired these skills. Same

research also suggests that individuals do not use assertive behaviors that have been taught (Bellack and Hersen 1978; Bellack

et al. 1979) because they expect to be rebuffed (Fielder and

238
Beach 1978; Kelly et al. 1982). Covington (1981) has criticized

useofthis technique in drug education: "The assertive social

skills taught to resist peer pressure appear calculated to alienate children from the very peer groups with which they must ultimately satisfy their needs for affiliation and competency."

Despite the consistent effects obtained in these studies, it is

premature to conclude that these programs are effective in preventing cigarette smoking. No study has demonstrated effects on

habitual cigarette smoking which does notcccuruntilthehigh

school years (Evans et al. 1979). Furthermore, these studies have

utilized weak non-equivalent control group designs in which all

7th graders in one (or several) school(s) received the treatment,

and those in one (or several) other school(s) served as a control

group. Most studies obtained pretest substance use data only on

cigarettes and only for 7th graders. Given the limit&cigarette

involvement of this age group,these data are inadequate to establish the initial equivalence of treatment and control schools.

Without such knowledge, pre-existing school differences are a

plausible alternative explanation for treatment-control differences

at posttest. Had pretest substance use data been collected at all

grade levels theresearchdesigns might have permitted stronger

inferences about treatment effects by combining longitudinal and

cross-sectionalaldesigns (Tuckman 1979, pp. 52-55). Besides employing a week research design, the studies suffered from hogh rates

of attrition and utilized inappropriate statistical analyses.

Thus, from a mothodological standpoint, these studies are typical

of prior research on drug education.

Nevertheless, the consistent results strongly suggest the effectiveness of curricula that focus on psychosocial influences related

to smoking and provide information about the short-term effects of

smoking. However, this is not the only promising approach for

preventing cigarette smoking. One study that conctrasted several

versions of this appraach with a more traditional program that

presented the long-term health consequences of cigarette smoking

found the latter program to be most effective in reducing the onset of experimental smoking k-kin et al. 1981). Evaluations of

a program that presented the short-and long-term effects of smoking

and taught students variouss psychosocial competencies (decisionmaking, relaxation training,social skills training, self-improvement) have also famd positive effects on experimental cigarette

smoking (Botvin and Eng 1982; Botvin et al. 1980). Finally, our

second drug education course obtained positive effects on girls'

cigarette smoking when the course was delivered to all 7th grade

students in a school, but no effects were famd when only half of

the stdents received it (Moskwitz etal. in press-d). In sum,

since the mid-1970's, a variety of program has been evaluated

that appears to be effective in preventing cigarette smoking among

early adolescents.

The current social climate regarding cigarette smoking may be

essential to the success of recent programs inpreventing cigarette

smoking. During the past few decades the climate regarding cigarette smoking has shifted dramtically towards a general belief

239
that people should not smoke (Russell 1978). This normative change

has been attributed to a sustained anti-smoking campaign in which

persistent anti-smoking publicity has been supported by changes in

public policy regarding cigarette legislation (Warner 1977, 1981).

Behavioral manifestations of the present "non-smoking ethos" are

evidenced by a decline in per capita cigarette consumption since

1973 (Warner 1981), and a decreased prevalence of "current" (past

month or 30 days) cigarette smoking among 12-17 year old youth

since 1974' and among high school seniors since 19762.

Successful cigarette smoking programs capitalize on the non-smoking

ethos in one of two ways. Most programs have used cognitive inoculation, a persuasive-communication technique that has only been

effective in reinforcing "cultural truisms," or beliefs that are

generally accepted in the culture (Tedeschi and Lindskold 1976).

In most prgrams the social influences that promote smoking are

discussed. Such discussion may debunk students' exaggerated misconception about the prevalence of smoking and teach them that

most peers and adults (smokers and non-smokers alike) share their

negative attitudes toward smoking.

Two additional factors contribituted to the success of the programs:

the recipients were early adolescents, and all students in a grade

level participated. According to McGuire (1974), early adolescence

is the age of greatest susceptibility to the types of persuasive

comnmunications used in drug education. Because most of this age

group are strongly opposed to smoking and few are habitual smokers,

the information provided on the effects of smoking reinforces preexisting attitudes. Having all students in a grade level participate ensures that most of an individual's peers are affected by

the curriculum. This should alter the peer group norms to coincide

with the individual's anti-smoking attitudes, hence, reducing the

likelihood of smoking. In one study, student interviews revealed

that "the intervention may have influenoed the entire 'social

atmosphere' regarding smoking" (Botvin and McAlister 1982, p. 238).

Ferry et al. (1980) also recognized the program's influence on

peer group norms; "The long term benefits appear to be a community

where smoking is no longer the acceptable norm" (p.5).

FUTURE RESEARCH AND DEVELOPMENT

The potential effectiveness of drug education may be a function of

the substances addressed by the program. Success in preventng

the abuse of substances other than cigarettes may await in

the social climate towards those substances. New prevention

apprcaches are required because other substances fulfill different

psychosocial functions (Braucht 1980). These functions need to be

researced before relevant drug education programs can be designed

(Bernstein et al. 1972; Dembo 1979; Jessor 1982; Newman et al.

1982; Plant 1980).

Program effectiveness may also be a function of student characteristics including age or grade level (Ekaucht and Braucht 1982;

Braucht et al. 1973; DembO 1979), sex (Braucht and Braucht 1982;

240
Moskowitz et al. in press-d; Schaps et al. 1982), psychological

or behavioral development(Braucht and Braucht 1982; Braucht et al.

1973; Goodstadt 1980), prior substance use (Blum et al. 1978;

Braucht and Braucht 1982; Braucht et al. 1973; Dembo 1979;

Johnson in press), and "problem behavior" involvement (Jessor 1982).

Such individual differences create practical problems for program

design and implementation because programs are usually delivered

to intact classes which include a wide variety of students. Cne

solution is to develop conprehensive programs that address the

specific needs of each subgroup (Botvin in press; Huba et al. 1980;

Jessor 1982). However, such programs may require substantial resources, including highly trained instructors or discussion leaders.

Furthermore, this may be a difficult task if requisite program canponents or instructional objectives are incompatible (e.g., teaching abstinence to same students and responsible use to others).

Research and development efforts will have little payoff to society

unless the problems asscciated with program adoption and dissemination are resolved. Our evaluations of various school-based primary

prevention programs conducted by teachers who received inservice

training revealed substantial variation in classroom implementation

(e.g., Moskowitz et al. 1982, in press-a,b,d; Schaps et al. in press).

The Follow Through evaluation, a study of 22 compesatory education

modles conducted in 158 school districts,found that a given program's effects depended more upon local circumstances than upon the

particular model it employed (Patton 1979). Rothman and Byrne

(1981) cited six references to support their concern about the

conpetence of teachers to provide instruction in health education.

Others have expressed concern about the administrator's (Blun

1976) and the teacher's role in inplementing drug education programs (Evans et al. 1979; Goodstadt 1980; Johnson in press).

Whereas there is a burgeoning literature about the obstacles to

educational innovation, there is little consensus as to appropriate

solutions (e.g., Berman and &Laughlin 1974-1978; Papagiannis et

al. 1982). Prior research has failed to evaluate program implementation adequately; thus, recommendations about procedures to

facilitate program adoption and implementation have little empirical basis (Scheirer and Rezmovic 1982). Demonstration research in

drug education could contribute to the solution of this problem by

evaluating program implementation in addition to program outcomes.

Such research could help to determine how much and in what manner

aprcgrancandeviate from its ideal plan and still manage to meet

its basic objectives (Patton 1979).

A QUESTION OF GOALS

Drug education may embrace a variety of goals such as promoting

abstinence, delaying onset of use, teaching "responsible use" or

informed decision-making, insulating use franitsnegative consequences (e.g., eliminating drinking-related traffic accidents),

and substituting health-promoting behaviors for health-compromising

behaviors (Jessor 1982; Jessor in press). Fran a cognitive standpoints same goals may be easier to achieve than others. For example,

abstinence, the primary goal of anti-smoking programs, is a simpler

241
message to cannmicate than "responsible use," the goal of many

alcohol education programs. Also, abstinence may require fewer

and less sophisticated psychosocial skills to achieve. Although

there are relevant educational, psychological, and health considerations, the choice of goals is ultimately ideological. Because

of the current capaign against smoking, this has been an easy

decision with regard to cigarettes. In contrast, there has been

little consensus as to which goal is most appropriate regarding

use of the other "gateway,' subtances, alcohol and marijuana

(Braucht and Braucht 1982; Carroll 1981; Chug 1981; Unterberger

and DeCico 1968). As a consequence, most drug education programs neither specify nor operationalize behavioral objectives

regarding use of these substances (Brauchtet al. 1973; Goodstadt

1981; Noble 1978). This shortcoming not only makes it difficult

toevaluate these prcgrans, it may also contribute to the failure of

these programs to influence student drug use.

The source of dissension prevention goals is a social climate

that sustains a variety of inconsistent beliefs, values, and norms

regarding substance use and abuse. This heterogeneous climate

manifests itself politically in a complex body of civil and criminal law pertaining to the use, possession,ard sale of substances.

The assumptions about substance abuse underlying these laws are

contradictory, making it difficult to design drug education programs that communicate a logically consistent message (McGuire

1974).

In providing drug education to youth, it is a assumed that students

will have to make decisions regarding their personal drug use.

This massage is communicated implicitly if not exlicitly. That

it may facilitate student experimentation with drugs is a matter

of practical concern. Goodstadt (1980) identified 15 studies

wherein drug education had a negative attitudinal or behavioral

effect. Positive effects were also obtained in these studies,

leading him to suggest that, "It is possible that some 'negative'

impact of drug education programs has to be tolerated as the price

for programs which are more broadly beneficial (e.g., decision

making programs) " (p.96) . However, if this is take the cost of

drug education, the public may be unwilling to pay for it. For

exmple, the National Federation of Parents for Drug-Free Youth,

a coalitian of over 3000 parent groups, recently ratified a series

of resolutions "that reject any education, prevention or treatment

program that advocates condones responsible use of illicit drugs,

including the use of alcohol by minors" (Vejnoska 1983). Professionals also disagree about prevention objectives. A group of

experts on marijuana convened by NIDA concluded that,"Children and

adolescents are sinply not in a position to understand the risks or

deal with the decisions involved in marijuana use" (Carroll 1981).

A consensus regarding prevention goals may help us decide whether

to put our efforts into drug education or other prevention appoaches. Achieving such a consensus

implementation.

shuld expedite program design and

Moreover, it could serve as a first step toward

the creation of a more consistent social climate regarding drug use.

242
FOOTNOTES

1

 National Household

Selected Findings,

Abuse. Rockville,

2

 High School Senior Drug Use: 1975-1982, NIDA Capsules, National

Institute on Drug Abuse. Rockville, MD: Press Office, 1983

REFERENCES

survey on Drug Abuse, 1982: Summary of

NIDA Capsules, National Institute on Drug

MD: Press Office, 1983.

Arkin, R.; Roemhild, H.; Johnson, C.; Luepker, R.; and Murray, D.

The Minnesota Smoking Prevention Program: A seventh-grade health

curriculum supplement. J School Health, 51:611-616, 1981.

Bardura, A. Self-efficacy: Toward a unifying theory of behavioral

change. Psychol Rev, 84:l91-215, l977a.

Bandura, A. Social Learning Theory. Englewocd Cliffs, NJ: Prentice-Hall, l977b.

Bandura, A. The self system in reciprocal determinism. Am Psychol,

33:344-358, 1978.

Bandura, A. Self-referent thoqht: A developmental analysis of

self-efficacy. In: Flavell, J.H. and Ross, L.D., eds.

Social Development: Frontiers and Possible Futures.

Cognitive

cambridge University Press, in press.

Bellack, A. A critical appraisal of strategies for assessing

social skill. Behav Assessment, 1:157-176, 1979.

Bellack, A;, and Hersen, M. Chronic psychiatric patients: Social

skills training. In: Hersen, M. and Bellack, A., eds. Behavior

1978.

Therapy in the Psychiatric Setting. Baltimore: William & Wilkins,

Bellack, A.; Hersen, M.; and Lamparski, D. Roleplay tests for

assessing social skills: Are they useful? J Consult Clin Psychol,

47:335-342, 1979.

Bentler, P., and Speckart, G. models of attitude-behavior relations.

Psycho1 Rev, 86:452-464, 1979.

Berman, P., and McLaughlin, M. Federal Programs Supporting Educational Change (8 vols.). Santa Monica, CA: Rand Corporation, 1974-

1978.

Bernstein, A.; Epstein, L.; Lennard, H.; and Ramson, D. The prevention of drug abuse. In: Golann, S. and Eisdorfer, eds. Handbook of Community Mental Health, Appleton-Century Crofts, 1972.

Blun, R. Drug Education: Results and Recommendations. Lexington,

MA: Lexington Books, 1976.

243
Blun, R.; Garfield, E.; Johnstone, J.; and Magistad, J. Drug education: Further results and recommendations.

426, 1978.

J Drug Issues, 8:379-

Botvin, G. Broadening the focus of smoking prevention strategies.

In: Coates, T., Peterson, A. and Perry,C.,eds. Adolescent

Health: Crossing the Barriers. N.Y.: Academic Press, in press.

Botvin, G., and Eng, A. The efficacy of a multicomponent apprach

to the prevention of cigarette smoking. Prevent Med, 11:199-211,

1982.

Botvin, G.; Eng, A.; and William, C. Preventing the onset of

smoking through life skills training. Prevent Med, 9:135-143, 1980.

Botvin, G., and McAlister, A. Cigarettes smoking amoung children and

adolescents: Causes and prevention. In: Arnold, C.,ed. Annual

Review of Disease Prevention. New York: Springer, 1982.

Braucht, G. Psychosocialresearch on teenage drinking: Past and

future. In: Scarpitti, F. and Datesman, S., eds.

Youth Culture. Beverly Hills: Sage, 1980.

Drugs and the

Braucht, G., and Braucht, B. Prevention of problem drinking among

youth: Evaluation of educational strategies. In: Miller, P. and

Nirenberg, T., eds. Prevention of Alcohol Abuse, Plenun Press, 1982.

Braucht, G.; Follingstad, D.; Brakarsh, D.; and Berry, K. Drug

education: A review of goals, approaches and effectiveness, and a

paradigm for evaluation. Q J Stud Alchohol, 34:1279-1292, 1973.

Bukoski, W. Drug abuse preventiom evaluation: A meta-evaluation

process. Presented at the Annual Meeting of the American Public

Health Association, New York, 1979.

Carroll, J. Perspectives on marijuana use and abuse and recommendations for preventing abuse. Am J Drug Alcohol Abuse, 8:259-282,

1981.

Chng, c. The goal of abstinence: Implications for drug education.

J Drug Educ, 11:l3-18, 1981.

Covington, M. Youth and decision-making delemmas: New approaches

to smoking uptake and prevention. Presented at the International

seminar on School Health Education, Southampton, England, 1981.

Dembo,R. Substance abuse prevention programming and research: A

partnership in need of improvement. J Drug Educ, 9:189-208, 1979.

Evans, R.; Henderson, A.: Hill, P; and Raines, B. Smoking in children and adolescents: Psychosocial deteminants and prevention

strategies. In: Smoking and Health: A Report of the Surgeon

General, Public Health service. DHEW Pub. No. (PHS) 79-5006. Washington, D.C.: Supt. of Docs., U.S. Govt. Printing off., 1979.

244
Evans, R.; Rozelle, R.; Maxwell, S.; Raines, B.; Dill, C.; Guthrie,

T.; Henderson, A.; and Hill, P. Social modeling films to deter

smoking in adolescents: Results of a three-year field investigation. J Applied Psychol, 66:399-414, 1981.

Fielder, D., and Beach, L. Om the decision to be assertive. J

Consult Clin Psychol, 46:537-546, 1978.

Fishbein, M., and Ajzen, I.

ior: An Introduction to Theory and Research. Reding, MA: AddiBelief, Attitude, Intention and Behavson-Wesley, 1975.

Flay, B.; d'Avenas, J.; Best, J.; Kersell, M.; and Ryan, K. Cigarette smoking: Why young people do it and ways of preventing it.

In: McGrath, P. and Firestone, P., eds. Pediatric and Adolescent

Behavioral Medicine. New York: Springer-Verlay, l983.

Fard, M. Social cognition and social copetence in adolescennce.

Develop Psychol, l8:323-340, 1982.

Glcbetti, G. A conceiptual analysis of the effectiveness of alcohol

education programs. In: Goodstadt, M., ed. Research on Methods

and Progrmas of Drug Education. Toronto: Addiction Research

Glynn, T. From family to peer: Transitions of influence among

drug-using youth. In: lettieri, D. and Ludford, J., eds. Drug

Abuse and the American Adolescent. National Institute on Drug

Abuse Research Monograph, 38, DHHS Pub. No. (ACM) 81-1166. Washington, D.C.: Supt. of Docs., U.S. Govt. printing Off., 1981.

Goodstadt, M. Drug education: A turn on or a turn off. J Drug

Educ, 10:89-99, 1980.

Goodstadt, M. Planning and evaluation of alchol education programmes. J Alcohol Drug Educ, 26:1-10, 1981.

Gorsuch, R., and Butler, M. Initial drug abuse: A review of predisposing social psychological factors. Psychol Bull, 83:120-137,

1976.

Governali, J., and Sechrist, W. Clarifyingvalues in a health education setting: An experimental analysis. J School Health, 151-

154, 1980.

Hanson, D. Drug educatim: Does it work? In: Scarpitti, F. and

Batesman, S., eds. Drugs and the Youth Culture, Beverly Hills, CA:

Sage Publicatiaons, 1980. ,pp. 251-282.

Hopkins, K. The unit of analysis: Group means versus individual

observations. Am Educ Res J, 19:5-18, 1982.

Huba, G.; Wingard, J.; and Bentler, P. Applications of a theory of

drug use to prevention programs. J Drug Educ, 10:25-38, 1980.

245
Huba, G.; Wingard, J.; and Bentler, P. Intentions to use drugs

amoung adolescents: A longitudinal analysis. Int J Addict, 16:331-

339, 1981.

Hurd, P.; Johnson, C.; Pechaek, T.; Bast, C.; Jacob, D.; and

Luepker, R. Prevention of cigarette smoking in seventh grade

students. J Behav Med, 3:l5-28, 1980.

Jessor, R. Problem behavior and developmental transition in adolescence. J School Health, 295-300, 1982.

Jessar, R. Critical issues in research al adolescent health promotion. In: Coates, T., Petersen, A. and Perry, C., eds. Adolescent Helath: Crossing the Barriers. New York: Academic Press, in

press.

Johnson, C. Untested and erroneous assumptions underlying antismoking programs. In: Coates, T.; Peterson, A.; and Perry, C., eds.

Adolescent Health: Crossing the Barriers. New York: Academic

Press, in press.

Judd, C., and Kenny, D. Estimating the Effects of Social Interventions. Cambridge University Press, 1981.

Kandel, D. Homophily, selection and socialization in adolescent

friendships. Am J Social, 84:427-436, 1978.

Kandel, D. Drug and drinking behavior among youth. Ann Rev Social,

6:235-285, 1980.

Kelly, J.; St. Lawrence, J.; Bradlyn, A.; Himadi, W.; Graves, K.;

and Keane, T. Interpersonal reactions to assertive and unassertive

styles when handling social conflict situations. J of Behav Ther

Psychiatry, l3:33-40, 1982.

Kinder, B.; Pape, N.; and Walfish, J. Drug and alcohol education

program: A review of outcome studies. Int J Addict, 15:1035-1054,

1980.

Leming, J. Curricular effectiveness in moral/values education: A

review of research. J of Moral Educ, 10:147-164, 1980.

Lackwood, A. The effects of values clarification and moral development curricula on school-age subjects: Acriticalreviewof recent

research. Rev Educ Res, 48:325-364, 1978.

McAlister, A.; Perry, C.; Killen, J.; Slinkard, L.; and Maccoby, N.

Pilot study of smoking, alcohol and drug abuse prevention. Am J

Public Health, 70:719-721, 1980.

McGuire, W. Inducing resistance to persuasion. In: Berkowitz, L.,

ed. Advances in Experimental Social Psychology, Vol. 1, New York:

Academic Press, l964, pp. 191-229.

246
McGuire, W. Commuinication-persuasion on models for drug education.

In: Goodstadt, M., ed. Research on Methods and Programs of Drug

Education. Toronto: Addiction Research Foundation, 1974.

Mackintosh, D.; Tash, W.; and Mock, H. Review of ADAMHA evaluations

of prevention program effectiveness: Final report. Washington,

D.C.: National Institute for Advanced Studies, 1981.

Malvin, J., and Moskowitz, J. Anonymous versus identifiable selfreports of adolescent drug attitudes, intentions and use. Public

Opinion Q, in press.

Meichenbaum, D.; Butler,L.; and Joseph, L. Toward a conceptual

model of social competence. In: Wine, J., and Smye, M., eds.

The Identification and Enhancemment of Social Competence, Washington,

D.C.: Hemisphere Press, in press.

Moskovitz, J.; Malvin, J.; Schaeffer, G.; and Schaps, E. Evaluation

of an affective development teacher training program. J Prevent,

in press-a.

Moskwitz, J.; Malvin, J.; Schaeffer, G.; and Schaps, E. Process

and outcome evaluation of a cooperative learning strategy. Am Educ

Res J, in press-b.

Moskowitz, J.; Schaps, E.; and Malvin, J. Process and outcome evaluation in primary prevention: The Magic Circle program. Evaluat

Rev, 6:775-788, 1982.

Moskowitz, J.; Schaps, E.; Malvin, J.; and Schaeffer, G. The effects

of drug education at follw-up. J Alcohol Drug Educ, in press-c.

Moskowitz, J.; Schaps, E.; Schaeffer, G.; and Malvin, J. Evaluation

of a substance abuse prevention program for junior high school

students. Int J Addict, in press-d.

Newman, I.; Martin, G.; and Weppner, R. A conceptual model for

developing prevention programs. Int J Addict, 17:493-504, 1982.

Noble, E.,

and Health from the Secretary of Hew National Institute on Alcohol

ed. Third Special Report to the U.S.Congress on Alcohol

Abuse and Alcoholism. Washington, D.C.: Supt. of Docs., U.S. Govt.

Printing Off., 1978.

Papagiannis, G.; Klees, S.; and Bickel, R. Toward a political

economy of educational innovation. Rev Educ Res, 52:245-290, 1982.

Patton, M. Evaluation of program implementation. In: Sechrest,

L.; West, S.; Phillips, M.; Redner, R.; and Yeaton, W. Evaluation

Studies Review Annual, Vol. 4. Beverly Hills: Sage Publications,

1979.

Perry, C.; Killen, J.; Slinkard, L.; and mister, A. Peer teaching

and smoking prevention among junior high school students. Adolescence, l5:277-281, 1980.

247
Plant, M. Drugtaking and prevention: The implications of research

for social policy. Br J Addict, 75:245-254, 1980.

Radosevich, M.; Lanza-Kaduce, L; Akers,R.; and Krohn, M. The

sociology of adolescent drug and drinking-behavior: A review of

the state of the field: Part II. Deviant Behav, 1:145-169, 1980.

Rothman, A., and Byme, N. Health education for children and adolescents. Rev Educ Res, 51:85-100, 1981.

Russell, M. Smoking problem: An overview. In: Jarvik, M.,

Cullen, J., Gritz, E., Vogt, T. and West, L., eds. Research on

Smoking Behavior,NaticnalInstitute on Drug Abuse. DHEW Pub. No.

(ADM) 79-581. Washington, D.C.: Supt. of Docs. U.S. Govt, Printing

Off., 1978.

Schaps, E.; DiBartolo, R.; Moskwitz, J.; Palley, C.; and Churgin,

S. Primary prevention evaluation research: A review of 127 impact

studies. J Drug Issues, 11:17-43, 1981.

Schaps, E.; Moskowitz, J.; Condon, J.; and Malvin, J. A process and

outcome evaluation of an affective teacher training primary prevention program. J Alcogol Drug Educ, in press.

Schaps, E.; Moskowitz, J.; Condon, J.; and Malvin, J. Process and

outcome evaluation of a drug education course. J Drug Educ, 12:

353-364, 1982.

Scheirer, M., and Rezmovic, M. Measuring the Implementation of

Innovations. Final Report, Grant No. PRA-8022612, Natural Science

Foundation, 1982.

Schlegal, R.; Crawford, C.; and Sanborn, M. Correspondence and meditational properties of the Fishbein model: An application to

adolescent alcogol use. J Exp Social Psychol, 13:421-430, 1977.

Schlegal, R., and Norris, J. Effects of attitude chanqe on behavior

for highly involving issues: The case of marijuana smoking. Addict

Behav, 5:113-124, 1980.

Staulcup, H.; Kenward, K.; and Frigo, D. A review of federal primary

alcoholism prevention projects. J Studies Alcohol, 40:943-968, 1979.

Tedeschi, J., and Lindskold, S. Social Psychology: Independence,

Interaction and Influence. New York: Wiley, 1975.

Thompson, E. Smoking education programs 1960-1976. Am J Public

Health, 68:250-257, 1978.

Tuckman, B. Evaluating Instructional Program. Boston: Allyn &

Bacon, 1979.

Unterberger, H., and DeCicco, L. Alcohol education re-evaluated.

Bull Nat Assoc: Sec School Principals, 52:l5-29, 1968.

248
Urbain, E., and Kendall, P. Review of social-cognitive problbemsoling interventions with children. Psychol Bull, 88:109-143,

1980.

Vejnoska, J. Parent groups conference addresses youth issues.

NIAAA Information and Feature Service. IFS #1O4, Rockville, MD:

USDHHS, 1983.

Warner, K. The effects of the anti-smoking campaign on cigarette

consumption. Am J Public Health, 67:645-650, 1977.

Warner, K. cigarette smoking in the 1970's: The impact of the

anti-smoking campaign on consumption. Science, 211:729-731, 1981.

Wepner, S. Which way drug education? J Drug Educ, 9:93-103, 1979.

Woodcock, J. Action in the schools. In: Blum, R., ed. Drug

Dealers: Taking Action. San Francisco: Jossey-Bass, 1973. pp.

267-281.

AUTHOR

Joel M. Moskowitz, Ph.D.

Pacific Institute for Research and Evaluation

905 Jefferson Street

Napa, CA 94559

249
Discussion and Recommendations

Carl G. Leukefeld, D.S.W., and Joel M. Moskowitz, Ph.D.

The problem of adolescent drug abuse has received a great deal

of attention during the past decade. Beginning in the late

1960s the prevalence of drug use has increased dramatically.

This steady upward trend which lasted until the late 1970s has

been called "The Drug Epidemic" by the popular press. This

epidemic has spread largely among adolescents (12 to 17 years)

although young adults (18 to 25 years) were also affected.

Despite a decline in adolescent drug use since the late 197Os,

drug abuse among youth remains a problem. For example, the

1982 National Institute on Drug Abuse (NIDA) National High

School Survey, conducted by the University of Michigan,

revealed that 6% of high school seniors reported daily use of

marijuana in 1982, which is down from 11% in 1978 (Johnson

1982).

In an effort to counteract this epidemic, during the 1970s drug

abuse prevention needs were identified, and a variety of

prevention programs were initiated. Many of these programs

were funded at the State level. The early programs included

four types of strategies: information, education,

alternatives, and early intervention. Values clarification and

decisionmaking were popular program components. These two

components were generally utilized in generic primary

prevention programs which made no reference to drugs or drug

use. Due to the urgency of the drug problem, programs were

adopted despite a lack of empirical evidence to support their

efficacy in preventing drug abuse.

A number of demonstration research projects were conducted

during the 1970s to evaluate the effectiveness of substance

abuse prevention programs. However, most of these projects did

not conduct adequate evaluations. Although the programs

generally were not found to be effective, the results can be

attributed to weak methodology (Schaps et al. 1981).

250
In recent years health oromotion and disease orevention have

received considerable attention. The 1979 Surgeon General's

report, Healthy People (USDHEW 1979), attributed as much as 50

percent of mortality to unhealthy lifestyles which include drug

abuse along with other factors. Reducing the misuse of drugs

(and alcohol) has been identified as one of the 15 health

objectives for the nation. In keeping with this objective, the

nation's drug prevention policy is to encourage actions by

every segment of society that will help to avoid starting, or

to stop, the misuse of drugs. Adolescence has been chosen as

one of the four target areas for service and research emphasis.

The present monograph on adolescent prevention research and the

associated 2-day review meeting had several goals: 1) to

evaluate the major modalities/approaches for prevention

interventions in the area of adolescent substance use; 2) to

identify specific approaches or combinations of approaches

which have the greatest potential for effectiveness, taking

into consideration such issues as cost, ease of application,

and size of target audience; and 3) to make suggestions for

program dissemination.

Interventions to prevent adolescent substance abuse can be

categorized in many ways. For this monograph the prevention

approaches have been categorized as follows: Alternative

Activities, Drug Education, Media, Social Skills, Values,

Health Promotion, Life Skills, Community, and Social

Psychological. Each author prepared a paper that evaluated the

research related to one of the above areas. The purpose of

this chapter is to summarize the discussion that occurred at

the review meeting.

RESEARCH METHODS AND RESULTS

The discussion focused on two types of interventions,

alternatives and anti-cigarette smoking education. This focus

did not, however, reflect a lack of interest in other

preventive interventions. In fact, the general sentiment was

that sound research should be encouraged on all theoretically

based interventions, particularly on comprehensive approaches

that address the multiple risk factors associated with drug

abuse.

Few evaluations of alternatives have been conducted, and most

have been methodologically unsound. More importantly,

alternatives have been so loosely conceptualized that this

intervention could entail virtually any licit activity.

Alternatives must be chosen in a manner that reflects the

current state of theoretical knowledge regarding the etiology

of drua abuse. Althouah alternatives directly focused on

preventing drug abuse typically have been introduced during

adolescence, they may be more effective with younger groups

because the predisposition to abuse drugs probably develops

earlier. Alternatives could be utilized to promote a sense of

251
self-efficacy, i.e., to instill the belief that mastering one's

environment can bring satisfaction. Finally, alternatives can

serve an important and unique function in the context of a

comprehensive health promotion program.

Although the research on anti-cigarette smoking education has

not been methodologically strong, recent findings suggest that

several programs have effectively delayed the onset of

cigarette smoking among early adolescents for up to 3 years.

Preliminary evidence indicates that reductions in alcohol and

marijuana use have also been found. The successful programs

provided training in intrapersonal and interpersonal

competencies believed to be related to early cigarette use

(e.g., decisionmaking and assertiveness). In addition, the

programs provided information about the social influences that

promote cigarette smoking and about the immediate physiological

effects and social consequences of smoking.

Future research on anti-cigarette smoking programs should

investigate the efficacy of these programs on minority

populations, as most prior research has been conducted on white

middle-class adolescents. The programs may need to be adapted

for different subcultures. Some concern was expressed that the

curricula are too dependent on verbal skills; however, the use

of peers to model appropriate behaviors could mitigate this

potential problem. Concerns were also raised about the

increased difficulty of conducting research in schools that

service an economically disadvantaged population.

A goal for future research is to determine why these antismoking prevention programs have been effective. The promising

programs are based upon somewhat different models; their

curricula contain many components, and they utilize different

modes of implementation. Few studies, to date, have contrasted

the different models, components, or implementation

approaches. One study suggests that the use of peer leaders is

necessary for a program to yield sustained effects. Prior

research also indicates that program effects are attenuated

when students are exposed to a different social environment;

e.g., when students enter high school. Thus, booster courses

may be required.

In order to revise the underlying models, future evaluations

should assess the hypothesized mediating processes (e.g.,

changes in norms and behavioral competencies). It is unclear

to what extent the effects of a program are attributable to its

influence on peer norms via aggregate attitude change or to its

influence on individuals' knowledge, attitudes, and

competencies. Research on some of the mediating variables will

require development and validation of new assessment techniques.

Future studies should also include process evaluation to

examine program implementation procedures. Such information

will not only be useful in revising programs but also in

252
providing information to tnose who wish to replicate these

programs.

In sum, research on preventive interventions is in its infancy

due to theoretical and methodological inadequacies. Few

interventions are theoretically based. Furthermore, program

evaluations are rarely designed to test theory, as most studies

do not contrast different models of intervention, nor do they

assess program effects on mediating variables. Most

evaluations have suffered from weak research designs. Whereas

most studies evaluate program effects, few studies evaluate

program implementation. The result of these shortcomings is

that there is little knowledge regarding (a) how prevention

proqrams actually operate; (b) which programs have been

effective; (c) why certain programs have been effective; and

(d) whether these programs are likely to be effective in other

settings or with other populations.

DISSEMINATION AND IMPLEMENTATION

The most vigorous discussion addressed dissemination of those

prevention programs for which preliminary research support

exists. Given existing community and State needs for drug

abuse prevention programs, a desire was expressed to develop

program "packages" which would assist agencies in implementing

the most promising programs. The primary programs considered

for dissemination were the cigarette smoking interventions

developed and evaluated by Botvin 1980; Evans 1981;

Johnson 1981; McAlister 1979; Perry 1980; and others.

There was considerable reluctance, however, to endorse or

recommend any prevention approach for dissemination. The

primary concern was that no program has been evaluated in

enough different contexts to warrant ample confidence in its

effectiveness. Furthermore, the implementation of a program

can vary considerably, and some adaptations of a program may

render it ineffective or make it harmful to recipients.

Evaluating different dissemination approaches was suggested to

better understand the potential societal impact of prevention

research. Such research should first examine existing

approaches, including the National Diffusion Network sponsored

by the Department of Education and the National Institute on

Alcohol Abuse and Alcoholism replication models.

RESEARCH RECOMMENDATIONS

The following research recommendations were made during the

course of the discussion. The purpose of this summary is to

suggest some directions in which prevention research

methodology and design can proceed. The following statements

are merely representative of the suggestions made at the review

meeting and do not reflect a consensus.

253
Disseminating promising drug abuse prevention programs

is a complex matter that is not well understood.

Program dissemination should be accompanied by

research that evaluates different dissemination

approaches with regard to process, outcome, and impact.

Promising prevention programs should be evaluated in

minority communities.

Comprehensive community prevention intervention

studies should be developed which "mix and match"

interventions in an effort to test quality, quantity,

and timing of interventions.

Drug-specific variables should be assessed at followup

in ongoing health promotion intervention studies.

Prevention research evaluation strategies, methods,

and designs require further development.

Followup studies of effective interventions should be

continued and expanded in order to understand more

fully the duration and strength of these interventions.

Methodologies from health promotion intervention

studies should be incorporated into drug abuse

community studies.

The use of media techniques in connection with other

interventions should be pursued.

REFERENCES

Botvin, G.J.; Eng A.; and Williams, C.L. Preventing the onset

of cigarette smoking through life skills training.

Preventive Medicine, 9(1):135-143, 1980.

Evans, R.I.; Rozelle, R.M.; Maxwell, S.E.; Raines, B.E.;

Dill, C.A.; Guthrie, T.J.; Henderson, A.H.; and Hill, P.C.

Social modeling films to deter smoking in adolescents:

Results of a three year field investigation. Journal of

Applied Psychology, 66(4):399-414, 1981.

Johnson, C.A. Untested and erroneous assumptions underlying

antismoking programs. In: Coates, T.J.; Petersen, A.C.; and

Perry, C.; eds. Promoting Adolescent Health: A Dialog on

Research and Practice. New York: Academic Press, 198l.

pp. 149-165

Johnston, L.D.; Bachman, J.G.; and O'Malley, P. Student Drug

Use, Attitudes, and Beliefs, National Trends 1975-1982, DHHS

Publication No. (ADM) 83-1260. Washington, D.C.:

Superintendent of Documents, U.S. Government Printing Office,

1983.

Perry, C.L.; Maccoby, N.; and McAlister, A.L. Adolescent

smoking prevention: A third year follow-up. World Smoking

and Health, 5(3):40-45, 1980.

254
Perry, C.: and Maccoby, N. Adolescent smoking: Onset and

prevention. Pediatrics, 63(4):650-658, 1979.

Schaps, E.: DiBartolo, R.; Moskowitz, J.; Palley, C.S. and

Churgin, S. A review of 127 drug abuse prevention program

evaluations. Journal of Drug Issues, 11(1):17-43, 1981.

U.S. Department of Health, Education, and Welfare. Healthy

People, DHEW Pub. No. (PHS) 79-55071. Washington, D.C.:

Superintendent of Documents, U.S. Government Printing Office,

1979.

AUTHORS

Carl G. Leukefeld, D.S.W.

Division of Clinical Research

National Institute on Drug Abuse

5600 Fishers Lane, Room 1OA38

Rockville, Maryland 20857

Joel M. Moskowitz, Ph.D.

Pacific Institute for Research and Evaluation

905 Jefferson Street

Napa, California 94559

255
monograph series

While limited supplies last, single copies of the monographs may be

obtained free of charge from the National Clearinghouse for Drug

Abuse Information (NCDAI). Please contact NCDAI also for information about availability of coming issues and other publications of

the National Institute on Drug Abuse relevant to drug abuse research.

Additional copies may be purchased from the U.S. Government Printing

Office (GPO) and/or the National Technical Information Service

(NTIS) as indicated. NTIS prices are for paper copy. Microfiche

copies, at $5.95, are also available from NTIS. Prices from either

source are subject to change.

Addresses are:

NCDAI

National Clearinghouse for Drug Abuse Information

Room lOA-43

5600 Fishers Lane

Rockville, Maryland 20857

GPO

Superintendent of Documents

U.S. Government Printing Office

Washington, D.C. 20402

NTIS

National Technical Informatlon

Service

U.S. Department of Commerce

Springfield, Virginia 22161

1 FINDINGS OF DRUG ABUSE RESEARCH. NCDAI out of stock

Vol. 1: GPO out of stock NTIS PB #272 867/AS $34.95

Vol. 2: GPO out of stock NTIS PB #272 868/AS $28.95

2 OPERATIONAL DEFINITIONS IN SOCIO-BEHAVIORAL DRUG USE RESEARCH

1975. Jack Elinson, Ph.D., and David Nurco, Ph.D., eds.

NCOAI out of stock

GPO out of stock NTIS PB #246 338/AS $16.95

3 AMINERGIC HYPOTHESES OF BEHAVIOR: REALITY OR CLICHE? Bruce J.

Bernard, Ph.D., ed. NCDAI out of stock

GPO out of stock NTIS PB #246 687/AS $16.95

4 NARCOTIC ANTAGONISTS: THE SEARCH FOR LONG-ACTING PREPARATIONS.

Robert Willette. Ph.D., ed.

GPO out of stock NTIS PB #247 096/AS $9.95

256
5 YOUNG MEN AND DRUGS: A NATIONWIDE SURVEY. John A. O'Donnell,

Ph.D., et al. NCDAI out of stock

GPO out of stock NTIS PB #247 446/AS $16.96

6 EFFECTS OF LABELING THE "DRUG ABUSER": AN INQUIRY. Jay R.

Williams, Ph.D. NCDAI out of stock

GPO out of stock NTIS PB #249 092/AS $9.95

7 CANNABINOID ASSAYS IN HUMANS. Robert Willette, Ph.D., ed.

GPO out of stock NCDAI out of stock

NTIS PB #251 905/AS $16.95

8 Rx: Rx/WEEK LAAM - ALTERNATIVE TO METHADONE. Jack Elaine, M.D.,

and Pierre Renault, M.D., eds. NCDAI out of stock

Not available from GPO NTIS PB #253 763/AS $16.95

9 NARCOTIC ANTAGONISTS: NALTREXONE PROGRESS REPORT. Demetrios

Julius, M.D., and Pierre Renault, M.D., eds.

GPO out of stock NCDAI out of stock

NTIS PB #255 833/AS $16.95

10 EPIDEMIOLOGY OF DRUG ABUSE: CURRENT ISSUES. Louise G. Richards,

Ph.D., and Louise B. Blevens, eds. NCDAI out of stock

GPO out of stock NTIS PB #266 691/AS $22.95

11 DRUGS AND DRIVING. Robert Willette, Ph.D., ed.

NCDAI out of stock

GPO Stock #017-024-00576-2 $5.50 NTIS PB #269 602/AS $16.95

12 PSYCHODYNAMICS OF DRUG DEPENDENCE. Jack D. Blaine, M.D., and

Demetrios A. Julius, M.D., eds. NCDAI out of stock

GPO out of stock NTIS PB #276 084/AS $16.95

13 COCAINE: 1977. Robert C. Petersen, Ph.D., and Richard C.

Stillman, M.D., eds. NCDAI out of stock

GPO Stock #017-024-00592-4 $6 NTIS PB #269 175/AS $22.95

14 MARIHUANA RESEARCH FINDINGS: 1976. Robert C. Petersen, Ph.D.,

ed. NCDAI out of stock

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15 REVIEW OF INHALANTS: EUPHORIA TO DYSFUNCTION. Charles Wm. Sharp,

Ph.D., and Mary Lee Brehm. Ph.D., eds.

GPO out of stock NTIS PB #275 798/AS $28.95

16 THE EPIDEMIOLOGY OF HEROIN AND OTHER NARCOTICS. Joan Dunne

Rittenhouse, Ph.D., ed. NCDAI out of stock

GPO out of stock NTIS PB #276 357/AS $22.95

17 RESEARCH ON SMOKING BEHAVIOR. Murray E. Jarvik, M.D., Ph.D., et

al., eds. NCDAI out of stock

GPO out of stock NTIS PB #276 353/AS $28.95

257
18 BEHAVIORAL TOLERANCE: RESEARCH AND TREATMENT IMPLICATIONS.

Norman A. Krasnegor, Ph.D., ed. NCDAI out of stock

GPO out of stock NTIS PB #276 337/AS $16

19 THE INTERNATIONAL CHALLENGE OF DRUG ABUSE. Robert C. Petersen,

Ph.D., ed. NCDAI out of stock

GPO out of stock NTIS PB #293 807/AS $28.95

20 SELF-ADMINISTRATION OF ABUSED SUBSTANCES: METHODS FOR STUDY.

Norman A. Krasnegor, Ph.D., ed.

GPO out of stock NTIS PB #288 471/AS $22.95

21 PHENCYCLIDINE (PCP) ABUSE: AN APPRAISAL. Robert C. Petersen,

Ph.D., and Richard C. Stillman, M.D., eds.

GPO Stock #017-024-00785-4 $7 NTIS PB #288 472/AS $28.95

22 QUASAR: QUANTITATIVE STRUCTURE ACTIVITY RELATIONSHIPS OF

ANALGESICS, NARCOTIC ANTAGONISTS, AND HALLUCINOGENS. Gene Barnett,

Ph.D.; Milan Trsic, Ph.D.; and Robert Willette, Ph.D.; eds.

GPO out of stock NCDAI out of stock

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23 CIGARETTE SMOKING AS A DEPENDENCE PROCESS. Norman A. Krasnegor,

Ph.D., ed. NCDAI out of stock

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24 SYNTHETIC ESTIMATES FOR SMALL AREAS: STATISTICAL WORKSHOP PAPERS

AND DISCUSSION. Jos. Steinberg, ed. NCDAI out of stock

GPO out of stock NTIS PB #299 009/AS $22.95

25 BEHAVIORAL ANALYSIS AND TREATMENT OF SUBSTANCE ABUSE. Norman A.

Krasnegor, Ph.D., ed.

GPO out of stock NTIS PB #80-112428 $22.95

26 THE BEHAVIORAL ASPECTS OF SMOKING. Norman A. Krasnegor, Ph.D.,

ed. (Reprint from 1979 Surgeon General's Report on Smoking and

Health.)

GPO out of stock NTIS PB #80-118755 $16.95

27 PROBLEMS OF DRUG DEPENDENCE, 1979: PROCEEDINGS OF THE 41ST

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. L.S. Harris, Ph.D., ed. NCDAI out of stock

GPO Stock #017-024-00981-4 $9 NTIS PB #80-175482 $40.95

28 NARCOTIC ANTAGONISTS: NALTREXONE PHARMACOCHEMISTRY AND

SUSTAINED-RELEASE PREPARATIONS. Robert Willette, Ph.D., and

Gene Barnett, Ph.D., eds. NCDAI out of stock

GPO out of stock NTIS PB #81-238875 $22.95

29 DRUG ABUSE DEATHS IN NINE CITIES: A SURVEY REPORT. Louis A.

Gottschalk. M.D., et al. NCDAI out of stock

GPO out of stock NTIS PB #80-178882 $16.95

258
30 THEORIES ON DRUG ABUSE: SELECTED CONTEMPORARY PERSPECTIVES. Dan

J. Lettieri, Ph.D.; Mollie Sayers; and Helen W. Pearson, eds.

NCDAI out of stock

GPO Stock #017-024-00997-1 $10 Not available from NTIS

31 MARIJUANA RESEARCH FINDINGS: 1980. Robert C. Petersen, Ph.D.,

ed.

GPO out of stock NTIS PB #80-215171 $22.95

32 GC/MS ASSAYS FOR ABUSED DRUGS IN BODY FLUIDS. Rodger L. Foltz.

Ph.D.; Allison F. Fentiman, Jr., Ph.D.; and Ruth B. Foltz.

GPO out of stock NTIS PB #81-133746 $22.95

33 BENZODIAZEPINES: A REVIEW OF RESEARCH RESULTS, 1980. Stephen I.

Szara, M.D., D.Sc., and Jacqueline P. Ludford, M.S., eds.

GPO Stock #017-024-01108-8 $5 NTIS PB #82-139106 $16.95

34 PROBLEMS OF DRUG DEPENDENCE, 1980: PROCEEDINGS OF THE 42ND

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. NCDAI out of stock

GPO Stock #017-024-01061-8 $8 NTIS PB #81-194847 $34.95

35 DEMOGRAPHIC TRENDS AND DRUG ABUSE, 1980-1995. Louise G.

Richards, Ph.D., ed.

GPO out of stock NTIS PB #82-103417 $16.95

36 NEW APPROACHES TO TREATMENT OF CHRONIC PAIN: A REVIEW OF

MULTIDISCIPLINARY PAIN CLINICS AND PAIN CENTERS. Lorenz K.Y.

Ng, M.D., ed.

GPO out of stock NTIS PB #81-240913 $22.95

37 BEHAVIORAL PHARMACOLOGY OF HUMAN DRUG DEPENDENCE. Travis

Thompson, Ph.D., and Chris E. Johanson, Ph.D., eds.

NCDAI out of stock

GPO Stock #017-024-01109-6 $7 NTIS PB #82-136961 $28.95

38 DRUG ABUSE AND THE AMERICAN ADOLESCENT. Dan J. Lettieri, Ph.D.,

and Jacqueline P. Ludford, M.S., eds. A RAUS Review Report.

GPO Stock #017-024-01107-O $4.50 NTIS PB #82-148198 $16.95

39 YOUNG MEN AND DRUGS IN MANHATTAN: A CAUSAL ANALYSIS.

Richard R. Clayton, Ph.D., and Harwin L. Voss, Ph.D.

GPO Stock #017-024-01097-9 $5.50 NTIS PB #82-147372 $22.95

40 ADOLESCENT MARIJUANA ABUSERS AND THEIR FAMILIES. Herbert

Hendin, M.D., Ann Pollinger, Ph.D., Richard Ulman, Ph.D., and

Arthur Carr, Ph.D. NCDAI out of stock

GPO out of stock NTIS PB #82-133117 $16.95

41 PROBLEMS OF DRUG DEPENDENCE, 1981: PROCEEDINGS OF THE 43RD

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. NCDAI out of stock

Not available from GPO NTIS PB #82-190760 $40.95

259
42 THE ANALYSIS OF CANNABINOIDS IN BIOLOGICAL FLUIDS. Richard L.

Hawks, Ph.D., ed.

GPO Stock #017-024-01151-7 $5 NTIS PB #83-136044 $16.95

43 PROBLEMS OF DRUG DEPENDENCE, 1982: PROCEEDINGS OF THE 44TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. NCDAI out of stock

GPO out of stock NTIS PB #83-252-692/AS $40.95

44 MARIJUANA EFFECTS ON THE ENDOCRINE AND REPRODUCTIVE SYSTEMS.

Monique C. Braude, Ph.D., and Jacqueline P. Ludford. M.S., eds. A

RAUS Review Report.

GPO Stock #017-024-01202-5 $4 NTIS PB #85-150563/AS $16.95

45 CONTEMPORARY RESEARCH IN PAIN AND ANALGESIA, 1983. Roger M.

Brown, Ph.D.; Theodore M. Pinkert. M.D., J.D.; and Jacqueline P.

Ludford, M.S., eds. A RAUS Review Report.

GPO Stock #017-024-01191-6 $2.75 NTIS PB #84-18467O/AS $11.95

46 BEHAVIORAL INTERVENTION TECHNIQUES IN DRUG ABUSE TREATMENT. John

Grabowski, Ph.D.; Maxine L. Stitzer, Ph.D., and Jack E.

Henningfield, Ph.D., eds.

GPO Stock #017-024-01192-4 $4.25 NTIS PB #84-184688/AS $16.95

47 PREVENTING ADOLESCENT DRUG ABUSE: INTERVENTION STRATEGIES.

Thomas J. Glynn, Ph.D.; Carl G. Leukefeld, D.S.W.; and

Jacqueline P. Ludford, M.S., eds. A RAUS Review Report.

GPO Stock #017-024-01180-1 $5.50 NTIS PB #85-159663/AS $22.95

48 MEASUREMENT IN THE ANALYSIS AND TREATMENT OF SMOKING BEHAVIOR.

John Grabowski, Ph.D., and Catherine S. Bell, M.S., eds.

GPO Stock #017-024-01181-9 $4.50 NTIS PB 84-145-184 $16.95

49 PROBLEMS OF DRUG DEPENDENCE, 1983: PROCEEDINGS OF THE 45TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. NCDAI out of stock

GPO Stock #017-024-01198-3 $12 NTIS PB 85-151553/AS $34.95

50 COCAINE: PHARMACOLOGY, EFFECTS, AND TREATMENT OF ABUSE. John

Grabowski. Ph.D., ed.

GPO Stock #017-020-01214-9 $4.50 NTIS PB 85-150381/AS $16.95

51 DRUG ABUSE TREATMENT EVALUATION: STRATEGIES, PROGRESS, AND

PROSPECTS. Frank M. Tims, Ph.D., ed.

GPO Stock #017-020-01218-1 $4.50 NTIS PB 85-150365/AS $16.95

52 TESTING DRUGS FOR PHYSICAL DEPENDENCE POTENTIAL AND ABUSE

LIABILITY. Joseph V. Brady, Ph.D., and Scott E. Lukas. Ph.D., eds.

GPO Stock #017-024-0204-1 $4.25 NTIS PB 85-150373/AS $16.95

53 PHARMACOLOGICAL ADJUNCTS IN SMOKING CESSATION. John Grabowski.

Ph.D., and Sharon M. Hall, Ph.D., eds.

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260
54 MECHANISMS OF TOLERANCE AND DEPENDENCE. Charles Wm. Sharp,

Ph.D., ed. NCDAI out of stock

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55 PROBLEMS OF DRUG DEPENDENCE, 1984. PROCEEDINGS OF THE 46TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

GPO Stock #017-024-01242-4 $9.50

56 ETIOLOGY OF DRUG ABUSE: IMPLICATIONS FOR PREVENTION. Coryl LaRue

Jones, Ph.D., and Robert J. Battjes, D.S.W., eds.

GPO Stock #017-024-01250-5 $6.50

57 SELF-REPORT METHODS OF ESTIMATING DRUG USE: MEETING CURRENT

CHALLENGES TO VALIDITY. Beatrice A. Rouse, Ph.D., Nicholas J.

Kozel, M.S., and Louise G. Richards, Ph.D., eds.

GPO Stock #017-024-01246-7 $4.25

58 PROGRESS IN THE DEVELOPMENT OF COST-EFFECTIVE TREATMENT FOR DRUG

ABUSERS. Rebecca S. Ashery, D.S.W., ed.

GPO Stock #017-024-01247-5 $4.25

59 CURRENT RESEARCH ON THE

Theodore M. Pinkert, M.D., J.D., ed.

GPO Stock #017-024-01249-1

CONSEQUENCES OF MATERNAL DRUG ABUSE.

$2.50

60 PRENATAL DRUG EXPOSURE:

Ph.D., and Charles C. Lee,

GPO Stock #017-024-01257-2

61 COCAINE USE IN AMERICA:

KINETICS AND DYNAMICS. C. Nora Chiang,

Ph.D., eds.

$3.50

EPIDEMIOLOGIC AND CLINICAL PERSPECTIVES.

Nicholas J. Kozel, M.S., and Edgar H. Adams, M.S., eds.

GPO Stock #017-024-01258-1 $5

62 NEUROSCIENCE METHODS IN DRUG ABUSE RESEARCH. Roger M. Brown,

Ph.D., and David P. Friedman, Ph.D., eds.

GPO Stock #017-024-01260-2 $3.50

63 PREVENTION RESEARCH: DETERRING DRUG ABUSE AMONG CHILDREN AND

ADOLESCENTS. Catherine S. Bell, M.S., and Robert Battjes,

D.S.W., eds.

GPO Stock #017-024-01263-7 $5.50

64 PHENCYCLIDINE: AN UPDATE. Doris H. Clouet, Ph.D., ed.

GPO Stock #017-024-01281-5 $6.50

65 WOMEN AND DRUGS: A NEW ERA FOR RESEARCH. Barbara A. Ray, Ph.D.,

and Monique C. Braude. Ph.D., eds.

GPO Stock #017-024-01283-1 $3.25

261
66 GENETIC AND BIOLOGICAL MARKERS IN DRUG ABUSE AND ALCOHOLISM.

Monique C. Braude, Ph.D., and Helen M. Chao, Ph.D. eds.

GPO Stock #017-024-01291-2 $3.50

67 PROBLEMS OF DRUG DEPENDENCE, 1985. PROCEEDINGS OF THE 47TH ANNUAL

SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG DEPENDENCE,

INC. Louis S. Harris, Ph.D., ed.

GPO Stock #017-024-01292-1 $18.00

IN PRESS OR PREPARATION

68 STRATEGIES FOR RESEARCH ON THE INTERACTIONS OF DRUGS OF ABUSE.

Monique C. Braude, Ph.D., and Harold M. Ginzburg, M.D., J.D., M.P.H.,

eds.

69 OPIOID PEPTIDES: MEDICINAL CHEMISTRY. Rao S. Rapaka, Ph.D.;

Gene Barnett, Ph.D.; and Richard L. Hawks, Ph.D., eds.

70 OPIOID PEPTIDES: MOLECULAR PHARMACOLOGY, BIOSYNTHESIS, AND

ANALYSIS. Rao S. Rapaka, Ph.D., and Richard L. Hawks, Ph.D., eds.

71 OPIATE RECEPTOR SUBTYPES AND BRAIN FUNCTION. Roger M. Brown,

Ph.D.; Doris H. Clouet, Ph.D.; and David P. Friedman, Ph.D., eds.

72 RELAPSE AND RECOVERY IN DRUG ABUSE. Frank M. Tims, Ph.D., and

Carl G. Leukefeld, D.S.W., eds.

73 URINE TESTING FOR DRUGS OF ABUSE. Richard L. Hawks, Ph.D., and

C. Nora Chiang, Ph.D., eds.

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DHHS Publication No. (ADM)86-1280

Printed 1983 Reprinted 1985, 1988