Catalogue of Evidence

Substance use indicators

Background

Substance use is rare among Australian adolescents until the mid-teens, when experimentation and regular use begins to escalate (Table 1; AIHW 2007).  Data from national surveys and a large-scale longitudinal study show that the use of alcohol, tobacco and illicit drugs increases substantially over the adolescent period (Smart et al., 2005; AIHW, 2007).  On average, young Australians are around 14 ½ when they have their first cigarette or full alcoholic drink and around 15 ½ when they first try cannabis.  Among those who experiment with ecstasy or meth/amphetamine, the first experience takes place around 18 years of age on average (AIHW, 2007).

Prevalence of substance use among young people in Australia, 2004

Drug type	Pattern of use	12-15 years (%)	16-19 years (%)	20-24 years (%)
Licit drugs
Tobacco	Current smoker	3	17	27
	Smokes every day	2	14	21
Alcohol	Risk of short-term harm	4	37	45
	Risk of long-term harm	<2	14	17
Illicit drugs
All	In past year	8	26	33
Cannabis	In past year	5	22	27
Meth/amphetamine	In past year	Negligible	6	11
Ecstasy	In past year	Negligible	6	13

Source:  AIHW, 2007

Daily smoking, reported by 14% of those aged 16-19, is believed to be a precursor to nicotine addiction (AIHW, 2007).  Smoking is directly linked to around 19,000 deaths in Australia every year, making it the major single contributor to preventable, premature death and chronic disease (Loxley, Toumbourou and Stockwell, 2004; AIHW, 2007).  Prevention of smoking initiation during adolescence has the potential to prevent adult smoking and long-term adverse health consequences (AIHW, 2007). 

Many young people are drinking alcohol in quantities known to be harmful in the short- and long-term.  For example, 37% of Australians aged 16-19 report ‘binge’ drinking (more than 7 or 5 standard drinks on one day for males or females respectively), compared with the national figure of 21% (AIHW, 2007).  In the short term, alcohol abuse can lead to hospitalisation and death from acute intoxication, road trauma or violence.  Chronic, long-term abuse is associated with liver disease and cancer (Loxley et al., 2004). 

Among adolescents who use alcohol at harmful levels, cannabis use is also common.  These teenagers are at high risk for developing dependence on other illicit drugs, and also for simultaneous polydrug use.  When adolescent alcohol use escalates to the level of dependence or disorder, this affects academic achievement, school adjustment and psychosocial functioning, leads to higher rates of risky sexual behaviour and is a risk factor for suicide (Clark, 2004).

Cannabis is the most common ‘principle drug of concern’ for which Australians aged 10-19 years require treatment (Roxburgh and Burns, 2008).  Regular use is associated with respiratory problems and increased risk of psychosis and depression.  About one in ten daily users become dependent on cannabis.

The  use of psychoactive substances can cause mental health problems in some individuals, and exacerbate existing problems in others (Loxley et al., 2004).  Users are more likely to suffer emotional problems, display antisocial behaviour, and drop out of school.  Their behaviour may result in criminal convictions including possession and property crimes, with long-term social and economic consequences.

Indigenous young people (18-24 years) are twice as likely to be daily smokers than non-Indigenous people of the same age.  According to the ABS 2004-05 National 

Aboriginal and Torres Strait Islander Health Survey, there is little difference in the rates of alcohol consumption between Indigenous and non-Indigenous young people.  There are, however, regional differences as the proportions of young people drinking at risky or high-risk levels increase with remoteness (AIHW, 2007). 

Risk factors

A recent review (Toumbourou, Stockwell, Neighbors, Marlatt, Sturge and Rehm, 2007) outlined four motivational processes that influence adolescent substance use. The first is drug use motivated by the desire to be popular with peers.  Longitudinal data from the Australian Temperament Study confirms that adolescents who use substances and/or engage in antisocial behaviour are likely to have friends who also do these things (Smart et al., 2005). 

The second process is related to youth culture and involves establishing identity (Toumbourou et al., 2007).  Perhaps contrary to expectations, most tobacco smoking and binge drinking tends to occur among young people with average levels of risk factors (Loxley et al., 2004).

The third process, escape from distress, applies particularly to young people who have experienced serious difficulties such as child abuse, neglect or pre-natal exposure to alcohol or drugs (Toumbourou et al., 2007).  There are genetic components to childhood behaviour problems and temperament, both of which predict later substance abuse problems.  An easy temperament promotes positive adjustment and resistance to risk factors, but experiences of neglect and abuse in the early years of life undermine healthy development (Loxley et al., 2004).

In addition, there is evidence that alcohol use disorders may result from a genetic predisposition (Clark, 2004).  Heritability and environmental influences interact, so that children with a genetic liability to develop such disorders may also have parents who have similar problems and therefore have difficulty providing adequate monitoring, consistent discipline and access to health care (Clark, 2004).  Parental supervision, peers and community context determine the availability of alcohol during adolescence, which in turn influences the extent to which the genetic susceptibility is expressed.

The fourth process is self-management, including misuse of drugs to regulate mood (Toumbourou et al., 2007).  Children with conduct disorder and, to a lesser extent, Attention Deficit Hyperactivity Disorder (ADHD), are at increased risk of developing problems with drug use (Clark, 2004; Loxley et al., 2004).  Depression and anxiety have also been identified as risk factors for alcohol abuse (Clark, 2004).  When co-occurring mental disorders are successfully treated, substance abuse tends to decrease (Toumbourou et al., 2007).

Adolescents with low school achievement and poor adjustment, and particularly those who leave school early, are at greater risk.  Other risk factors include criminal activity, positive attitudes to drug use and personality factors such as high sensation seeking (Loxley et al., 2004).

Longitudinal data from the Australian Temperament Study shows that highly antisocial adolescents are more likely to use all types of substances, and to use them at moderate to high levels, than low/non antisocial adolescents. The high levels of co-occurrence indicate that “broad-based intervention programs are needed which can target and ameliorate a range of adolescent problem outcomes…” (Smart et al., 2005, p62)

Protective factors include involvement with adults in sport or community activities and strong family attachment.  Parents who are not in constant conflict with each other, have good communication skills and monitor and supervise their children provide a protective context for healthy development (Loxley et al., 2004).

The evidence base

A recent Australian review (Lubman et al., 2007) concluded that prevention and early intervention programs for substance use should aim to:

• delay the onset of experimentation
• reduce the number of young people who progress to regular or problem use
• encourage current users to minimise or reduce risky patterns of use.

Such an approach is consistent with the harm minimisation focus of Australia’s national drug policy, which involves reducing supply and demand while also implementing strategies to minimise the harmful effects of drug use for individuals and communities (Loxley et al., 2004).

Supply-related policies include law enforcement punishment for possession and distribution.  Demand-reduction strategies for adolescents focus on preventing the initiation of substance use, while harm-reduction strategies acknowledge that experimentation is common and are designed to reduce the potential consequences of use (Toumbourou et al., 2007).

For alcohol and tobacco, tax and other controls on price are among the most effective interventions, particularly when they are based on the strength of the active ingredients (i.e., drinks with higher alcohol content are taxed most heavily, thus encouraging people to choose lower alcohol alternatives) and are linked to consumer pricing movements (Toumbourou et al., 2007).

There is strong support in the literature for family-based interventions, based on the principle that competent parenting provides a protective context for adolescent development (Kumpfer and Alvarado, 2003; Loveland-Cherry, 2005). Such interventions focus on intentions, beliefs, school attachment, family and school problems, self-esteem and self-efficacy, and perceptions of alcohol use by peers and families.  Family protective and risk factors are also targeted.  The effectiveness of community-based or school-based interventions can be enhanced by adding a family-based component, such as homework or assignments requiring the parent to work closely with the child.   (Kumpfer and Alvarado, 2003; Loveland-Cherry, 2005).  Family-based programs tend to be relatively costly to design and deliver (Loveland-Cherry, 2005)

School-based programs can be effective if they are interactive and skills based (Cuijpers, 2003; Faggiano, Vigna-Taglianti, Versino, Zambon, Borraccino and Lemma, 2008) and build social competence (Toumbourou et al., 2007).  However, programs that provide information alone have not produced good outcomes (Loveland-Cherry, 2005; Toumbourou et al., 2007).

Community -based programs with multiple components are not well supported (Gates, McCambridge, Smith and Foxcroft, 2008) but may perform better with media campaign support (Cuijpers, 2003) and booster sessions (Skara and Sussman, 2003).  Preventive screening and targeted brief interventions can be used in primary care or other health settings to encourage more moderate use of alcohol or tobacco (Lubman et al., 2007).

There is general agreement in the literature that it is best to intervene before substance use becomes established, and if possible before initiation of use (Wagner, Tubman and Gil, 2004).  Strong evidence exists for programs delivered to pre-teen and early adolescent children, and the transition from primary to secondary school appears to be a good time to intervene (Petrie, Bunn and Byrne, 2007). Australian reviewers Loxley and colleagues (2004) recommend a protection and risk reduction approach that addresses early childhood development as well as older age groups. 

Effective programs have these key features (Petrie et al., 2007):

1. They develop strategies to involve adolescents in family activities, maintain good relationships, develop social skills, reinforce a sense of personal responsibility and manage conflict.  That is, they have a broad approach, rather than just focusing on substance abuse.
2. Parents are actively engaged as participants.  Such programs tend to be quite demanding on parents’ time, however, and attrition is a problem.

Additional success factors identified by other reviewers (Weissberg, Kumpfer and Seligman, 2003) include:

3. The program is designed around a research-based risk and protective framework and provides continuous, tailored, developmentally and culturally appropriate content.
4. Leaders establish policies, institutional practices and environmental supports around the program to promote optimal child and adolescent development.
5. The program is delivered by well-trained and highly skilled staff.

It is important to note that universal approaches may not address the specific needs of those children most at risk, and may also fail provide a sufficient ‘dose’ to be effective (Weissberg et al., 2003).  For this reason, comprehensive or adaptive programs combining universal, selective and indicated approaches appear promising.  These are long-term programs incorporating several components including community, school and family interventions.

Different program components may be used to target specific risk factors (Montoya et al., 2003).  Thus, adolescents exposed to a chaotic home life and poor parenting may benefit most from a family-based approach.  Those growing up in a toxic social environment in which high levels of crime and poverty are prevalent may require a community-based approach, while a school-based approach may help build resistance to peer influences.

While longer-term outcomes are of most interest in universal or selective prevention, interventions that produce immediate effects have greater potential to benefit adolescents who have undergone outpatient treatment for established substance abuse.  There is an increased risk of relapse in the three months following treatment, and there may be other consequences (e.g., avoiding removal from home into residential care or foster placement) contingent on response to treatment (French, Zavala, McCollister, Waldron, Turner and Ozechowski, 2008). 

Adolescent drug users require ongoing support.  Providing this type of support in a school setting helps overcome many of the barriers to service access for this population, who may not present to a clinic.  It also enables those delivering the intervention to assess and influence the social environment in which the adolescents’ problems are occurring (Wagner et al., 2004).

Selection of interventions: alcohol

Many reviewers have highlighted the potential value of the Strengthening Families Program (SFP) for primary prevention of alcohol abuse in young people (Foxcroft, Ireland, Lowe and Breen, 2002; Physician Leadership on National Drug Policy, 2002; Foxcroft, Ireland, Lister-Sharp, Lowe and Breen, 2003;  Kumpfer and Alvarado, 2003; National Institute on Drug Abuse, 2003; Hayes, Smart, Toumbourou and Sanson, 2004; Loveland-Cherry, 2005; Gates, McCambridge, Smith and Foxcroft, 2006; Petrie, Bunn and Byrne, 2007). 

There are several versions of the SFP and it is not always clear in reviews which version has been the subject of rigorous evaluation.  For example, SFP is acknowledged as a Model Program by the US Substance Abuse and Mental Health Services Administration but the description refers to the original version which consists of 14 two-hour sessions of behavioural skills training (for similar studies, see: National Registry of Evidence-based Programs and Practices).  Developed by Dr Karol Kumpfer in the early 1980s at the University of Utah, SFP was originally was designed for children of drug-addicted parents but has since been widely implemented as a universal and indicated program for three age groups: 3-5, 6-11, and 12-16 years.  Most of the other reviews refer to the ‘Iowa’ version, which was adapted from the original by Dr Virginia Molgaard.  The ‘Iowa’ version or SFP 10-14 is strongly supported by evaluation evidence and has been adapted, to be more culturally appropriate and consistent with a harm minimisation philosophy, for use in the UK and Europe (Allen, Coombes and Foxcroft, 2007).  The authors of a 2002 Cochrane systematic review concluded that the number needed to treat (NNT) was nine for preventing the initiation of problem drinking four years after the SFP 10-14 intervention (Foxcroft et al., 2002).

The SFP 10-14 is a universal prevention program aimed at young adolescents (just before or around the time of transition to high school) and their parents.  It involves seven two-hour sessions which are presented and facilitated by group leaders.  For the first hour, parents and children meet in separate groups.  Youth activities include group discussions, skill practice and social bonding, while parent sessions incorporate presentations, role-plays, group discussions and viewing of DVDs. During the second hour, families get together to practice skills, play games and do family projects.  The UK version has optional booster sessions. Manuals, DVDs and other materials are available commercially.

Several high-quality studies support the SFP 10-14, notably a longitudinal study involving 447 families in Iowa, USA. A total of 33 schools were randomly assigned to each of three groups: SPF, Preparing for the Drug Free Years (see below) and control.  Young people were followed from Grade 6 to Grade 12.  Those in the SPF group had significantly lower rates of alcohol use, drunkenness and tobacco use than controls, and for some outcomes this difference increased over time. Other positive outcomes for youth in the intervention group included fewer conduct problems in school, while their parents had stronger skills in parenting and relationship building and more positive feelings towards their children (Spoth, Redmond and Shin, 2001; Spoth, Randall, Shin and Redmond, 2005).

Outcomes for the other program in this evaluation study, Preparing for the Drug Free Years (PDFY), were also very positive.  Youths in the PDFY group had significantly less growth in alcohol use over time, while their parents had stronger anti-drug attitudes, compared with controls.  Participation in the program was also associated with slower growth in polydrug use, and slower growth in (non-drug) delinquency (Park, Kosterman, Hawkins, Haggerty, Duncan, Duncan and Spoth, 2000).  A further follow up at six years demonstrated that the intervention group had maintained a slower rate of increase of polydrug use over time (Mason, Kosterman, Hawkins, Haggerty and Spoth, 2003). 

PDFY, now known as Guiding Good Choices, is based on the social development model, which predicts that improvements in parental behaviour and family interactions will enhance children's protection against early substance use initiation.  The program is designed for parents of children aged 8 to 14 years and is available commercially (see http://www.channing-bete.com/prevention-programs/guiding-good-choices/).  It involves a weekly, five-session multimedia program led by trainers, that strengthens parents' child-rearing techniques, parent-child bonding and children's peer resistance skills. In the original version, children only attended one session which focused on peer pressure. Guiding Good Choices (aka PDFY) was revised in 2003 and more family-based activities were added; however, the reported evaluation results relate to the original version. The materials would require adaptation to Australian audiences in terms of language and cultural references, and the goal is abstinence rather than harm reduction.

In contrast, the School Health and Alcohol Harm Reduction Project (SHAHRP; McBride, Farringdon, Midford, Meuleners and Phillips, 2004) is an Australian program designed with the explicit goal of harm minimisation.  Classroom-based and implemented universally in the first and second years of high school, SHAHRP was developed at the National Drug Research Institute.  The program has two phases of skills-based activities, a large proportion of which are interactive.  They include skill rehearsal, group discussions and decision making by individuals and groups.

SHAHRP was evaluated in a large-scale randomised controlled trial involving 14 government high schools in Western Australia.  Students were followed for 32 months from baseline, with assessments at 8 and 20 months.  Eight months after the baseline, intervention students were consuming significantly less alcohol than controls, and were less likely to consume at risky levels.  These differences were maintained at 20 months but began to converge (although differences were still significant) at 32 months. Consistent with the goals of the program, intervention students were less likely to drink unsupervised and less likely to experience harm from their own use of alcohol. The authors concluded that harm reduction messages could be effective with students, particularly those who have already used alcohol, as young people with prior experience are less likely to be influenced by programs that advocate total abstinence (McBride et al., 2004; but see also Anderson, 2004; Hamilton, 2004; Hill, 2004 for commentaries on SHAHRP).

Another promising Australian initiative is the Resilient Families Program, which is based on evidence that the engagement of adolescents in risky behaviours, such as alcohol misuse, could be mitigated by positive family and community influences (Shortt et al, 2006). It targets students and their families during the first two years of secondary school (Bond et al, 2000).

A randomised controlled trial comparing the Resilient Families program with regular practice was implemented during 2004 and 2005. Student and parent surveys were conducted in 2004, 2005 and 2006. Parent participation was low, however.  The researchers proposed that paid staff time and financial and other assistance for parents may increase participation, and perseverance may be needed to overcome attitudes and practices that discourage parental involvement (Shortt et al, 2006).  

After one year, the program benefited Year 8 students through higher family attachment, school rewards and school attendance but had no effect on overall alcohol use (Shortt et al, 2007). Nevertheless, there was some indication that attendance at a parent education session and parent involvement in school education were protective factors in relation to alcohol misuse (Shortt et al, 2007).  A second year of follow-up measures with students now in Year 9 is currently being analysed. The authors of the program believe that intervention effects on alcohol misuse may become significant once the full program has been implemented. By early secondary school, some students were already misusing alcohol, suggesting that it may be of benefit to begin the program prior to secondary school (Shortt et al, 2007).

Also considered for the catalogue was Project ALERT, which was developed in the US as a drug prevention curriculum for students in 7^th and 8^th Grades. ALERT Plus is an extension of the original program for 9th grade students with five booster lessons. Project ALERT was recognised as an exemplary program by the US Department of Education and as a model program by the Centre for Substance Abuse Prevention.  Evaluation findings are mixed, however. A controlled trial of the original program found a reduction in the use of cigarettes and marijuana, but not alcohol use, among 8th grade students. A revised version of ALERT was trialled in South Dakota and 18 months after baseline there was a reduction in cigarette and marijuana use initiation, a reduction in current and regular cigarette use, and less alcohol misuse. Evaluation of the ALERT Plus program showed a reduction in the use of alcohol and marijuana among at-risk girls only.

One of the difficulties with universal, school-based interventions is the ‘dose’ delivered may not be sufficient for those most at risk of serious problems.  For this reason, a number of targeted and multilevel programs have been trialled, some with excellent results.  Two promising targeted (selective/indicated) programs are CASASTART and Big Brothers Big Sisters, recommended below for prevention of illicit drug use (Section 4.1.5) but also relevant to alcohol abuse prevention.

The Adolescent Transitions Program combines a universal, school-based intervention with selective and indicated elements targeted to families most at risk.  This adaptive, multilevel approach aims to identify high-risk youths (during the course of the universal intervention) and involve them and their families in further activities specifically targeted at their needs and delivered at effective 'dosages'.  A Family Resource Centre is established in the school and consultants provide services and resources to all parents, as well as a six-lesson curriculum for all Grade 6 students, based on a shortened version of the Life Skills Training program (Botvin et al., 1990). The six sessions focus on: school success; health decisions; building positive peer groups; the cycle of respect; coping with stress and anger; and solving problems peacefully. The Family Check-Up is delivered free of charge to parents who request it, and consists of three sessions: an initial interview, an assessment, and a feedback session.  Families are then linked to further evidence-based services depending on their needs.

A large, randomised controlled trial with longitudinal follow-up found that the Family Check-Up was effective in reaching vulnerable families: engagement was predicted by teacher reports of high risk behaviours at school, youth reports of high family conflict, and absence of the biological father in the home (Dishion, Kavanagh, Schneiger, Nelson and Kaufman, 2002; Dishion, Nelson and Kavanagh, 2003; Connell, Dishion, Yasui and Kavanagh, 2007).  Among those who engaged in the FCU, growth in substance use (alcohol, tobacco and illicit drugs) from ages 12 to 17 was significantly reduced compared with the non-engaged comparison group.  The intervention also reduced growth in antisocial behaviour, and participants were less likely to be arrested during adolescence and less likely to be diagnosed with an alcohol, tobacco or marijuana use disorder by late adolescence.

Selection of interventions: tobacco

Recent reviews of the smoking prevention and reduction literature support comprehensive approaches rather than targeted or single strategies. The evidence shows that programs should be universal in focus, addressing the social influences on young people from school, family and community sources. Interventions can be effectively implemented in school, home and community settings but should be supported with follow-up sessions, brief interventions in a professional setting and restrictions on the sale of tobacco products to young people.

The Gatehouse Project is an Australian evidence-based mental health promotion program that has been rigorously evaluated and shown results in reducing risky behaviours among adolescents, including behaviours relating to substance abuse.  The program is based on attachment theory, which proposes that sound attachments underpin wellbeing throughout life.  The Gatehouse Project aims to promote a sense of connectedness for adolescents by improving security, communication and participation in both school and social contexts (Patton et al, 2003).

The intervention is a multilevel strategy with a ‘whole-school’ focus. Integral to the intervention is the establishment and support of a school-based adolescent health team, identification of school risk and protective factors through student surveys and the implementation of effective strategies that address school environment issues (Bond 2001).

Twenty six rural and metropolitan schools in Victoria participated in the cluster-randomised trial used to evaluate The Gatehouse Project.  Twelve schools were randomly assigned to the intervention and 14 to the control group.  Across three waves of follow up, students in intervention schools were less likely to be regular smokers.  The adjusted odds ratio of the intervention group compared to the control group was 0.66 at the first follow-up and 0.72 and 0.79 for the second and third follow-ups respectively (Bond et al, 2004).  Although the reduction in regular tobacco use was the most notable outcome, the program also appears useful in preventing other substance abuse.

The SFP 10-14 and, to a lesser extent, the Adolescent Transitions Program/Family Check-Up have also demonstrated reductions in tobacco use and are therefore worth considering as general substance use prevention programs.  These two programs are reviewed above (Section 4.1.3).

Another promising Australian program based on harm minimisation principles is Smoking Cessation for Youth Project (SCYP).  This intervention took strategies that have been proved successful with adults and translated them into a program for adolescents.  Program development began in 1997 with a formative and efficacy phase.  From 1999 through to 2002 the effectiveness of the SCYP was compared to traditional abstinence-based approaches.  The third phase ran until 2003 and tested whether smoking-related outcomes could be maintained (Cross, 2008).

Research by Hamilton and colleagues (2000) found that adolescents reacted more positively to a harm reduction message (don’t smoke, but if you do, smoke less) compared a traditional abstinence (don’t smoke) message.  The SCYP program tested the harm reduction approach in a cluster-randomised intervention study involving 4636 students from 30 randomly selected secondary schools in Perth, Western Australia (Hamilton, 2005).  Students who participated in SCYP were less likely to smoke regularly (OR=0.51) and less likely to have smoked in the past 30 days (OR=0.69) when compared to standard abstinence programs and policies (Hamilton, 2005).

The SCYP intervention uses skills-based activities to encourage students not start smoking, to quit or cut down smoking, to assist others in quitting smoking and to reduce exposure to environmental tobacco smoke. In addition a resource for school nurses, Keep Left, was developed to support a harm minimisation approach to student smoking.

Seven Steps to a Smoke Free School is provided by the Victorian Quit program and has easily accessible resources and support from the Quit program. The program provides resources for schools to help them in developing policies around smoking, curriculum content and structure, professional development, parental involvement, support for students and conducting a review of current strategies.

This program was developed to address passive and active smoking among high school students and staff.  It is based on a social influences model which recognises that social factors arising from the media, peers and family play a major role in the initiation and early stages of drug use.  This model is supported by findings from a Canadian survey (Brown & Manske, 1996) which showed that smoking habits of youth were related to the number of their peers who smoked, the smoking habits of their parents and teachers and whether school rules on smoking were violated.  The reviewers were unable to find any evaluation evidence for Seven Steps to a Smoke Free School.

Selection of interventions: illicit drugs

A Victorian study reviewed by Loxley and colleagues (2004) found that most tobacco smoking and binge drinking occurred among students with average levels of risk factors, rather than those ostensibly ‘high risk’.  In contrast, students with high levels of risk factors were more likely to be having problems with illicit drug use.  This suggests a need to direct prevention strategies for legal drugs at all young people, while interventions to prevent illicit drug use may need to be more targeted.  The interventions described below include both universal (Resilient Families Program) and selective/indicated approaches (Big Brothers Big Sisters; Project Towards No Drug Abuse; CASASTART).

The Resilient Families Program is a universally applied, evidence-based Australian program that may have general effects on risky behaviour and substance abuse.  Evaluation of this program is preliminary to date and has focused on outcomes in alcohol use (Shortt et al, 2007).  Nevertheless, parenting and family components have been identified as a key success factor in effective programs for substance abuse (Petrie et al., 2007).

Project Towards No Drug Abuse (Project TND) is also delivered in schools but differs from Resilient Families in that it was developed specifically for youth at high risk for drug abuse and other problems.  The original target group was young people who were no longer integrated into mainstream schools but had been enrolled in ‘alternative’ high schools in California.  Project TND uses a motivation-skills-decision-making model that has proved more effective for high risk/older adolescents than more traditional social influences programming (Sun et al, 2006). The program has been effectively implemented and evaluated in both alternative high schools and general high schools (Sussman et al, 2003; Dent et al, 2001)

Evaluation of the program was conducted between 1994 and 1999 using a cluster-randomised controlled design in which eighteen schools were assigned to an educator-led classroom program and a self-instruction classroom program or a control group (Sussman et al, 2003).  Follow-up of students five years after baseline found significant long-term effects on hard drug use among both intervention groups. Another evaluation in a general high school population also found significantly reduced hard drug use at first year follow-up (Dent et al, 2001).

A schools-as-communities component was incorporated in the original development and evaluation phase of the project, but this component did not add any significant benefit to student outcomes.  Project TND proved effective for both general and high risk student populations, and the classroom component can be delivered by an educator or used in a self-instruction format.

There is no structured curriculum for the Big Brothers Big Sisters mentoring program.  Instead, this program works on the principle that a genuine relationship with a positive role model represents a protective factor against poor outcomes for adolescents who may otherwise lack this caring guidance.  Dating back to 1904, the program is now established in 12 countries, including Australia.  BBBS of America is listed as a 'proven' program for the indicator "Youths not using alcohol, tobacco or illegal drugs" by the Promising Practices Network (Rand Corporation; www.promisingpractices.net/program.asp?programid=125).  It is listed as 'promising' for the indicators "Students performing at grade level or meeting state curriculum standards" and "Children and youth not engaging in violent behaviour or displaying serious conduct problems".

Adult volunteers are linked with vulnerable young people (aged 7-17), and commit to spending at least an hour a week for 12 months engaged in activities together.  The emphasis is on building the relationship between the mentor and young person.  There is a rigorous process of checking potential volunteers to ensure the children's safety.

Big Brothers Big Sisters of America was evaluated in one experimental study in which 1138 young people from eight BBBS agencies were randomly assigned to control or treatment conditions (Ierney, Grossman and Resch, 1995).  Both groups were followed over 18 months, with a very high retention rate of 84.3%.  Young people involved in BBBS were 46% less likely to initiate illegal drug use and 32% less likely to hit someone (difference significant only for girls and white boys).  They were 27% less likely to initiate alcohol use (this was marginally significant), suggesting the program has more general application for preventing all types of substance abuse.  In addition, participating youth attained better grades on average and were less likely to skip school.  Evaluations of the school-based version are under way in America and Canada.

Even more intensive, one-to-one support is provided through the CASASTART program of case management and tailored, integrated services.  The name of this program stands for the US National Center on Addiction and Substance Abuse (CASA) "Striving together to achieve rewarding tomorrows" (START). The program has eight core elements, which are adapted to meet the needs of individual project sites.  Like BBBS, it has no set curriculum.  The eight core components are: enhanced policing and enforcement (including police presence in schools and communities and direct contact with youths and case workers); case management (each looking after 13-18 families); targeted family services; links with the criminal justice system; after-school and holiday activities for youth; access to tutoring and homework assistance; group mentoring; and financial incentives. It can be implemented by youth agencies, social services, schools, police or community-based organisations.

Severely disadvantaged neighbourhoods in six US cities were targeted for the intervention.  Five of these sites were evaluated, using a randomised controlled design (Harrell, Cavanagh and Sridharan, 1999).  One year after the intervention, young people who had been randomly assigned to the treatment group were significantly less likely than controls  to have used drugs in the past month, to have used 'hard' drugs such as cocaine or heroin, or to have used 'gateway' drugs such as alcohol, marijuana, inhalants or cigarettes.  Intervention group youths were also less likely to report selling drugs or committing a violent crime.  Young people in the program reported more positive peer group support, felt less peer pressure and were less likely to associate with delinquent peers. There were no differences on a number of other outcomes, including antisocial risk-taking behaviours, self esteem, family conflict, teen pregnancy, school achievement or attachment, property crimes or gang membership.

Discussion

Adolescent drug abuse prevention programs work best when they are implemented over several years and incorporate several strategies.  Given that the harms relating to substance use may be long-term rather than immediate, developmental strategies need to be supplemented by regulatory approaches and harm-reduction strategies (Toumbourou et al., 2007).

The literature highlights some areas in which those wishing to implement evidence-based prevention programs may need to exercise caution.  The United States has been a source of numerous potentially valuable programs, but writers of a recent Cochrane review noted that the explicit goal of these interventions is often abstinence, rather than harm minimisation (Foxcroft, Ireland, Lowe and Breen, 2002).  Australian reviewers have expressed concern about the cultural appropriateness of this goal (Toumbourou et al 2007, p. 1393):

Among adolescents, zero-tolerance approaches to drug and alcohol prevention are ineffective and in some cases contraindicated.

Loxley and colleagues (2004) strongly recommend further evaluation of successful, ‘transplanted’ programs in the Australian context to ensure they continue to achieve good outcomes.

A cost-effectiveness analysis of four treatment approaches for adolescents with established substance-use disorders found that the more expensive interventions, delivered to individuals, were no more effective than cheaper group-based approaches (French et al., 2008).  Nevertheless, several studies and reviews have highlighted the potential risks of bringing together young people who are all experiencing similar problems as interaction within the group may inadvertantly ‘normalise’ antisocial behaviours (Cho et al., 2004; Loxley et al., 2004; Smart et al., 2005; Toumbourou et al., 2007; Valente et al., 2007).

Further, it is not always true to say that doing something is better than doing nothing.  Reviewing alcohol-use prevention studies, Loveland-Cherry (2005) noted that some of the older, universal programs delivered in schools were unscientific.  Often these knowledge or affect-based programs focused on providing information about the risks of drug use on the assumption that this would frighten teenagers away from using it.  This approach has been shown to be largely unsuccessful, and may be counterproductive, leading to higher rates of substance use (Loveland-Cherry, 2005; Lubman et al., 2007).

Finally, Weissberg and colleagues (2003) have listed five essential steps to implementation of comprehensive prevention strategies:

1. Assess needs and resources;
2. Select appropriate evidence-based interventions;
3. Co-ordinate new initiatives with those under way;
4. Establish resources and supports for quality implementation;
5. Conduct ongoing process and outcome evaluations.

References

Alcohol Education and Research Council (undated) Implementation of the Strengthening Families Program (SFP) 10-14 in Barnsley: the perspectives of facilitators and families. Alcohol Insight. No. 39.

Alcohol Education and Research Council (undated) Preventing alcohol and drug misuse in young people: adaptation and testing of the Strengthening Families Program (SFP) 10-14 for use in the United Kingdom. Alcohol Insight. No. 53.

Allen D, Coombes L and Foxcroft D (2007) Cultural accommodation of the Strengthening Families Programme 10-14: UK Phase 1 study. Health Education Research. Vol. 22, No. 4, pp. 547-560.

Anderson P (2004) Barking up the wrong tree: a comment on McBride et al. 2004. Addiction. Vol. 99, pp. 295-296.

Australian Institute of Health and Welfare (2007) Young Australians: Their health and wellbeing 2007. Canberra: AIHW.

Beckett M, 2008. Current-generation youth programs: What works, what doesn’t and at what cost. Rand Education, Rand Corporation.

Bond L, Butler H, Thomas L, Carlin J, Glover S, Bowes G, Patton G (2007) Social and school connectedness in early secondary school as predictors of late teenage substance use, mental health and academic outcomes. Journal of Adolescent Health; 40:357.e9-357.e18

Bond L, Glover S, Godfrey C, Butler H, Patton GC, 2001. Building capacity for system-level change in schools: lessons from the Gatehouse Project. Health Education & Behaviour: 28(3): 368-383.

Bond L, Patton G, Glover S, Carlin JB, Butler H, Thomas L, Bowes G (2004). The Gatehouse Project: can a multilevel school intervention affect emotional wellbeing and health risk behaviours? Journal of Epidemiology and Community Health; 58: 997-1003

Bond L, Thomas L, Toumbourou J, Patton GC, Catalano R, 2000. Improving the lives of young Victorians in our community: A survey of risk and protective factors, 

Centre for Adolescent Health  Report prepared for Community Care Division, Department of Human Services, Melbourne.

Botvin G, Baker E, Dusenbury L, Tortu S and Botvin E (1990). Preventing adolescent drug abuse through a multimodal cognitive-behavioral approach: results of a 3-year study.  Journal of Consulting and Clinical Psychology; 58: 437-446.

Brown KS, Manske S, 1996. Social Influences in Stephens T, Morin M, editors (Health Canada). Youth Smoking Survey, 1994: Technical Report. Ottawa: Minister of Supply and Services Canada, 1996: Chapter 5: pp. 75-92.

Cho H, Hallfors DD, Sanchez V (2004) Evaluation of a High School Peer Group Intervention for At-Risk Youth. Journal of Abnormal Child Psychology; 33(3): 363-374

Clark D (2004) The natural history of adolescent alcohol use disorders. Addiction. Vol. 99, Suppl. 2, pp. 5-22.

Connell AM, Dishion TJ, Yasui M and Kavanagh K (2007) An adaptive approach to family intervention: linking engagement in family-centred intervention to reductions in adolescent problem behaviour. Journal of Consulting and Clinical Psychology; 75(4): 568-579.

Cuijpers, P. (2003) Three decades of drug prevention research. Drugs: Education, Prevention & Policy; 10(1): 7-20.

Dent CW, Sussman S, Stacy AW, 2001. Project Towards No Drug Abuse: Generalizability to a general high school sample. Preventive Medicine; 32:514-520.

Dishion TJ, Kavanagh K, Schneiger A, Nelson S and Kaufman NK (2002) Preventing early adolescent substance use: a family-centered strategy for the public middle school. Prevention Science. Vol. 3, No. 3, pp. 191-201.

Dishion TJ, Nelson SE and Kavanagh K (2003) The Family Check-Up with high-risk young adolescents: preventing early-onset substance use by parent monitoring. Behavior Therapy. Vol. 34, pp. 553-571.

Faggiano F, Vigna-Taglianti FD, Versino E, Zambon A, Borraccino A, Lemma, P (2008) School-based prevention for illicit drugs' use. Cochrane Database of Systematic Reviews 2008;(2) CD003020

Flynn BS, Worden JK, Secker-Walker RH, Pirie PL, Badger GJ, Carpenter JH and Geller BM (1994) Mass media and school interventions for cigarette smoking prevention: effects 2 years after completion. American Journal of Public Health. Vol. 84, No. 7, pp.1148-1150.

Foxcroft DR, Ireland D, Lister-Sharp DJ, Lowe G and Breen R (2003) Longer-term primary prevention for alcohol misuse in young people: a systematic review. Addiction. Vol. 98, pp. 397-411.

Foxcroft DR, Ireland D, Lowe G and Breen R (2002) Primary prevention for alcohol misuse in young people (Review). Cochrane Database of Systematic Reviews. Issue 3, Art. No. CD003024. DOI: 10.1002/14651858.CD003024.

French MT, Zavala SK, McCollister KE, Waldron HB, Turner CW and Ozechowski TJ (2008) Cost-effectiveness analysis of four interventions for adolescents with a substance use disorder. Journal of Substance Abuse Treatment. Vol. 34, pp. 272-281.

Gates S, McCambridge J, Smith LA, Foxcroft DR (2008) Interventions for prevention of drug use by young people delivered in non-school settings. Cochrane Database of Systematic Reviews 2008;(2) CD005030

Hamilton G (2004) Harm minimization in school drug education: a commentary on McBride et al. 2004. Addiction. Vol. 99, pp. 293.

Hamilton G, Cross D, Resnicow K, (2000) Occasional cigarette smokers: Cue for harm reduction smoking education. Addiction Research & Theory. Vol. 8, No. 5, pp. 419-437.

Hamilton G, Cross D, Resnicow K, Hall M (2005) A school-based harm minimization smoking intervention trial: outcomes results. Addiction. Vol. 100, No. 5, pp. 689-700.

Harrell A, Cavanagh S and Sridharan S (1999) Evaluation of the Children at Risk Program: results 1 year after the end of the program. Research in Brief. Washington DC: US Department of Justice.

Hayes L, Smart D, Toumbourou JW and Sanson A (2004) Parenting influences on adolescent alcohol use. Melbourne: Australian Institute of Family Studies.

Hill L (2004) A well-conducted study, but some caveats: comments on McBride et al. 2004. Addiction. Vol. 99, pp. 292.

Kumpfer KL and Alvarado R (2003) Family strengthening approaches for the prevention of youth problem behaviors. American Psychologist. Vol. 58, No. 6/7, pp. 457-465.

Kumpfer KL, Alvarado R, Tait C and Turner C (2002) Effectiveness of school-based family and children’s skills training for substance abuse prevention among 6-8 year-old rural children. Psychology of Addictive Behaviors. Vol. 16, No. 4S, pp. S65-S71.

Loveland-Cherry C (2005) Chapter 5: Alcohol, children and adolescents. Annual Review of Nursing Research. Vol. 23, pp. 135-178.

Loxley W, Toumbourou JW and Stockwell T (2004) The prevention of substance use, risk and harm in Australia: a review of the evidence. Canberra: Department of Health and Ageing.

Lubman DI, Hides L, Yücel M and Toumbourou JW (2007) Intervening early to reduce developmentally harmful substance use among youth populations. Medical Journal of Australia. Vol. 187, pp. S22-S25.

McBride N, Farringdon F, Midford R, Meuleners L and Phillips M (2004) Harm minimization in school drug education: final results of the School Health and Alcohol Harm Reduction Project (SHAHRP). Addiction. Vol. 99, pp. 278-291.

Montoya ID, Atkinson J, McFaden W (2003) Best Characteristics of Adolescent Gateway Drug Prevention Programs. Journal of Addictions Nursing; 14(2): 75-83

National Institute on Drug Abuse (2003) Preventing drug use among children and adolescents: a research-based guide for parents, educators and community leaders. Bethesda, Maryland: US Department of Health and Human Services.

Patton G, Bond L, Butler H, Glover S, 2003. Changing schools, changing health? Design and implementation of the Gatehouse Project. Journal of Adolescent Health; 33: 231-239.

Petrie J, Bunn F and Byrne G (2007) Parenting programmes for preventing tobacco, alcohol or drugs misuse in children <18: a systematic review. Health Education Research. Vol. 22, No. 2, pp. 177-191.

Physician Leadership on National Drug Policy (2002) Adolescent substance abuse: a public health priority. An evidence-based, comprehensive and integrative approach. Providence, Rhode Island: Brown University.

Roxburgh A and Burns L (2008) Cannabis use among sentinel groups of drug users in Australia: Findings from the Illicit Drug Reporting System (IDRS) and the Ecstasy and Related Drugs Reporting System (EDRS). Drug Trends Bulletin, June 2008. Sydney: National Drug and Alcohol Research Centre, University of New South Wales.

Shanahan P, Elliott B and Dahlgren N (2000) Review of public information campaigns addressing youth risk-taking. A report to the National Youth Affairs Research Scheme. Hobart: National Clearinghouse for Youth Studies.

Shortt A, Hutchinson DM, Chapman R, Toumbourou JW (2007) Family, school, peer and individual influences on early adolescent alcohol use: first-year impact of the Resilient Families Programme. Drug and Alcohol Review. Vol. 26, No. 6, pp. 625-634.

Shortt A, Toumbourou J, Chapman R, Power E (2006) The Resilient Families Program: Promoting health and wellbeing in adolescents and their parents during the transition to secondary school. Youth Studies Australia. Vol. 25, No. 2, pp. 33-40.

Skara S and Sussman S (2003) A review of 25 long-term adolescent tobacco and other drug use prevention program evaluations. Preventive Medicine. Vol. 37, No. 5, pp. 451-474.

Smart D, Richardson N, Sanson A, Dussuyer I, Marshall B, Toumbourou JW, Prior M and Oberklaid F (2005) Patterns and precursors of adolescent antisocial behaviour. Outcomes and connections.  The third report. Melbourne: Australian Institute of Family Studies.

Spoth RL, Guyll M and Day SX (2001) Universal family-focused interventions in alcohol-use disorder prevention: cost-effectiveness and cost-benefit analyses of two interventions. Journal of Studies on Alcohol. Vol. 63, pp. 219-228.

Spoth R, Randall GK, Shin C and Redmond C (2005) Randomized study of combined universal family and school preventive interventions: patterns of long-term effects on initiation, regular use and weekly drunkenness. Psychology of Addictive Behaviors. Vol. 19, No. 4, pp. 372-381.

Spoth RL, Redmond C, Trudeau L and Shin C (2002) Longitudinal substance initiation outcomes for a universal preventive intervention combining family and school programs. Psychology of Addictive Behaviors. Vol. 16, No. 2, pp. 129-134.

Spoth RL, Redmond C and Shin C (2001) Randomized trial of brief family intervention for general populations: adolescent substance use outcomes 4 years following baseline. Journal of Consulting and Clinical Psychology. Vol. 69, No. 4, pp. 627-642.

Sun W, Skara S, Sun P, Dent CW, Sussman S (2006) Project Towards No Drug Abuse: Longe-term substance use outcomes evaluation. Preventive Medicine. Vol. 42, pp.188-192.

Sussman S, Sun P, McCuller WJ, Dent CW (2003) Project Towards No Drug Abuse: two-year outcomes of a trial that compares health educator delivery to self-instruction. Preventive Medicine. Vol. 37, pp. 155-162.

Tierney JP, Grossman JB and Resch NL (1995) Making a difference: an impact study of Big Brothers Big Sisters. Philadelphia, Pa: Public/Private Ventures. Cited by Promising Practices Network at www.promisingpractices.net/program.asp?programid=125.

Toumbourou JW, Stockwell T, Neighbors C, Marlatt GA, Sturge J and Rehm J (2007) Adolescent Health 4: Interventions to reduce harm associated with adolescent substance use. The Lancet. Vol. 369, No. 9570, pp.1391-1401.

Trudeau L, Spoth R, Randall GK and Azevedo K (2007) Longitudinal effects of a universal family-focused intervention on growth patterns of adolescent internalizing symptoms and polysubstance use: gender comparisons. Journal of Youth and Adolescence. Vol. 36, pp. 725-740.

Valente TW, Ritt-Olson A, Stacy A, Unger JB, Okamoto J and Sussman S (2007) Peer acceleration: effects of a social network tailored substance abuse prevention program among high-risk adolescents. Addiction. Vol. 102, pp. 1804-1815.

Wagner EF, Tubman JG and Gil AG (2004) Implementing school-based substance-abuse interventions: methodological dilemmas and recommended solutions. Addiction. Vol. 99, Suppl. 2, pp. 106-119.

Weissberg RP, Kumpfer KL and Seligman MEP (2003) Prevention that works for children and youth: an introduction. American Psychologist. Vol. 58, No. 6/7, pp. 425-432.

2 Proportion of young people using/age of initiating use of: alcohol – recommended strategies

	Supporting evidence	Replication	Documentation	Theoretical basis	Cultural reach
(16.1) Adolescent Transitions Program and Family Check Up	1	Y	Y	Y	LOW SES CALD
(16.2) Strengthening Families Program 10-14	1	Y	Y	Y	LOW SES
(16.3) School Health and Alcohol Harm Reduction Project (SHAHRP)	1	N	Y	Y	UNIVERSAL
(16.4) Resilient Families Program	5	Y	Y	Y	LOW SES CALD

Proportion of young people using/age of initiating use of: alcohol

See Recommended strategy - proportion of young people using/age of initiating use of: alcohol

Proportion of young people using/age of initiating use of: tobacco

See Recommended strategy - proportion of young people using/age of initiating use of: tobacco

Proportion of young people using/age of initiating use of: illicit drugs

See Recommended strategy - proportion of young people using/age of initiating use of: illicit drugs