IV. A Comprehensive Approach
2. Preventing Drug Abuse
Preventing or delaying use of psychoactive drugs, alcohol, and tobacco among adolescents is a critical, national public health goal. The simplest and most cost-effective way to lower the human and societal costs of drug abuse is to prevent it in the first place. More than 255 million Americans do not use illegal drugs. Some sixty-one million Americans who once used illegal drugs have now rejected them; many suffered as a result of drug abuse. Accidents, addiction, criminal involvement, damaged relationships, impaired judgement, and lost educational or employment opportunities were common. Of the fourteen million Americans who currently use illegal drugs, some four million are chronic abusers. Preventing America's sixty-eight million children from using drugs, alcohol, and tobacco will help safeguard our society. Preventing drug abuse is one of the best investments we can make in our country's future. Doing so is preferable to dealing with the consequences of drug abuse through law enforcement or drug treatment.
Prevention is most promising when it is directed at impressionable youngsters. Adolescents are most susceptible to the allure of illicit drugs. Delaying or preventing the first use of illegal drugs, alcohol, and tobacco is essential. Not only does hazardous drug use put young people at risk of negative short-term experiences, but those who do not use illegal drugs, alcohol, or tobacco during adolescence are less likely to develop a chemical-dependency problem. Like education in general, drug prevention is demonstrably most effective among the young. In addition to deterring some initiations completely, drug prevention programs help people who use drugs to use smaller quantities. Successful substance-abuse prevention leads to reductions in traffic fatalities, violence, unwanted pregnancy, child abuse, sexually transmitted diseases, HIV/AIDS, injuries, cancer, heart disease, and lost productivity.
Evidence from controlled studies, national cross-site evaluations, and CSAP grantee evaluations demonstrates that prevention programs work. Good junior high school interventions affect knowledge and attitudes about drugs, use of cigarettes and marijuana, and persist into the twelfth grade.9 Examples of CSAP prevention successes are encouraging. A Cornell University study of six thousand students in New York state found that the odds of drinking, smoking, and using marijuana were 40 percent lower among students who participated in a school-based substance-abuse program in grades seven through nine than among their counterparts who did not. Similarly, an assessment of Project STAR found that forty-two participating schools in Kansas City, Missouri reported less student use of alcohol, tobacco, and marijuana than control sites.10
Prevention programs are not vaccinations that inoculate children against substance abuse. Sadly, significant numbers of young people who participate in the best programs will go on to use drugs. The "no-use" message must be reinforced consistently by parents, teachers, clergy, coaches, mentors, and other care givers. The effectiveness of prevention is difficult to measure given the lag time from when a young person goes through a program and when he or she starts using drugs. MTF historical data, for example, demonstrates that marijuana use among adolescents tends to change in inverse proportion to the percentage of youths who disapprove of marijuana use or perceive such use to be risky. According to MTF data, drug-usage rates change two years after attitudes. Prevention affects the number of new and light users much more than it does the number or consumption patterns of heavy users. Finally, since rates of drug use seem to spread in a manner similar to an epidemic, prevention will be more effective when undertaken early in the cycle when use is proliferating with existing users introducing others to drugs. At this time, enabling one person to abstain can prevent other initiations. Rather than be reactive, prevention programs should be proactive and reach each rising cohort.11
The Central Role of Parents
While all parents are critical influencers of children, parents of children aged eight to twelve are especially influential. Children in this age group normally condemn drug use. Such attitudes and attendant behavior are easily reinforced by involved parents. Parents who wait to guide their children away from drugs until older ages when youngsters are more readily influenced by peers or may have started using alcohol, tobacco, and other drugs, decrease their ability to positively influence children.
Parental example is a determinant of adolescent drug use. Children whose parents abuse alcohol or other drugs face heightened risks of developing substance-abuse problems themselves. There are an estimated eleven million such children under age eighteen in the United States. Every day, these youngsters receive conflicting and confusing messages about substance abuse. Nevertheless, specially crafted prevention messages can break through the levels of denial inherent in these families. SAMHSA's Children of Substance Abusing Parents program is developing community-based interventions services to reduce those risks.
Teachers, coaches, youth workers in all areas of life from faith communities to scouts, and extended family members also provide youth with important protection from drug abuse and support for positive parental training by modeling, teaching, and reinforcing positive behavior. Such "occasional preventionists" are vital in touching the lives of children from chemically dependent families. Adult addiction can have a devastating impact on children. By taking small steps, adult mentors can make a permanent difference in the course of a child's life.
National Youth Anti-Drug Media Campaign
The goal of this bipartisan five-year campaign is to use the full power of the media to educate and enable America's youth to reject illegal drugs. This goal includes preventing drug abuse and encouraging current users to quit. For three reasons, the campaign focuses on primary prevention, which means preventing drug use before it starts. First, primary prevention targets the underlying causes of drug use and therefore has the greatest potential to reduce the scope of the problem. Second, over time a primary prevention campaign will lessen the need for drug treatment, which is in short supply. Third, a media campaign has greater potential to affirm the anti-drug attitudes of youth who are not involved with drugs than to persuade experienced drug users to change their behavior.
The media have come to play an increasingly important role in public health campaigns due to their wide reach and ability to influence behavior. There is significant evidence that carefully planned mass media campaigns can reduce substance abuse by countering false perceptions that drug use is normative and influencing personal beliefs that motivate drug use. Media campaigns have been used to prevent or reduce consumption of illegal drugs and smoking along with risky behavior like driving under the influence of alcohol or without seat belts. For all their power to inform and persuade, the media alone are unlikely to bring about large, sustained changes in drug use. The anti-drug campaign will be truly successful only if media efforts are coordinated with initiatives that reinforce one another in homes, schools, and communities.
The anti-drug media campaign began in January 1998 in twelve test sites and was expanded nationwide in July. Once ads began to run in the twelve test sites, anti-drug awareness increased and requests for anti-drug publications increased by more than 300 percent. The campaign harnesses a diverse mix of television, video, radio, Internet, and other forms of new media to deliver anti-drug messages. Its objectives are "universal," aiming at all adolescents, parents, and primary care-givers. Messages and channels through which they are being delivered are tailored for specific regional, ethnic, cultural, gender, and age differences among members of the target audiences. Paid and public-service advertising, news, public-affairs programming, and entertainment venues are being used in the media campaign. So far, media outlets are matching paid advertisements with public-service time for advertisements and pro-bono programming content. Public-service advertising space generated by the paid campaign is being dedicated to messages that target underage drinking and smoking, as well as other messages related to the campaign's communications objectives. We have also developed partnerships with a broad range of community and civic groups, professional associations, government agencies, and corporations.
In 1998, thirty television programs focused on themes and messages supportive of the campaign. While the campaign's goal was to reach 90 percent of the target audience with four messages a week, by January 1999, 95 percent of the target audience was receiving seven anti-drug messages a week.
Safe and Drug-Free Schools and Communities
The Department of Education's Safe and Drug-Free Schools and Communities Program (SDFSP) provides funds for virtually every school district to support drug and violence prevention programs and to assist in creating and maintaining safe learning environments. The President has announced his intention to overhaul the program to improve its effectiveness. The proposal will require schools to adopt effective drug and violence policies and programs, annual safety and drug use report cards, links to after school programs, and efforts to involve parents. The Department has already implemented principles of effectiveness which require that all SDFSP-funded programs be research-based. The program is moving in a direction designed to ensure that SDFSP fund recipients, including governors, state education agencies, local education agencies, institutions of higher education, and community organizations, adopt programs, policies and practices that are based on research and evaluation. To assist in the identification and adoption ofeffective approaches, an expert review panel will identify promising or exemplary drug and violence prevention programs. The new Drug Prevention and School Safety Program Coordinators initiative will help school districts recruit, hire, and train drug and violence prevention coordinators in middle schools. Coordinators will be responsible for identifying promising drug and violence prevention programs and strategies; assisting schools in adopting the most successful strategies; developing, conducting and analyzing assessments of school drug and crime problems; working with community resources to ensure collaboration; and providing feedback to state educational agencies on programs and activities that have proven to be successful in reducing drug use and violent behavior.
This CSAP initiative will implement a national mentoring program to focus on some of the problems young people face, including alcohol and drug abuse. Adult mentors will be recruited and trained to reach at-risk youth in at least four states through demonstration programs. If evaluations prove positive, the program will be expanded to more states by FY 2004. The National Family Strengthening Initiative will help communities adopt effective, science-based programs to strengthen tutoring and mentoring, both of which enhance youth resiliency and reduce psychosocial factors that put families at risk.
Child Welfare and Welfare Reform
The safety of children and well-being of families are jeopardized by the strong correlation between chemical dependency and child abuse. Several studies have recently found that approximately two-thirds of the over 500,000 children in foster care have parents with substance-abuse problems.12 Yet, according to the Child Welfare League of America, last year only 10 percent of child welfare agencies were able to locate treatment within a month for clients who needed it.13 According to SAMHSA, 37 percent of substance-abusing mothers of minors received treatment in the past year.14 A new federal law regarding adoption and child welfare, the Adoption and Safe Families Act (P.L. 105-89), makes it essential that substance-abuse services for parents be provided promptly if parents are to be afforded realistic opportunities for recovery before children in foster care are placed for adoption.
In addition to compromising parents' ability to care for their children, substance abuse may also interfere with parents' capacity to acquire or maintain employment. An estimated 15 to 20 percent of adults receiving welfare have substance-abuse problems that interfere with employment.15 Yet our welfare systems do not adequately address substance abuse and its familial consequences. If prevention and treatment are not provided to this high-risk population, the same families will remain extensively involved in the welfare and criminal-justice systems at great cost to society and with devastating emotional consequences for affected children. Welfare agencies are generally inexperienced in dealing with substance-abuse issues and may need technical assistance to identify addiction and make appropriate referrals.
Youth Substance Abuse Prevention Initiative
SAMHSA/CSAP coordinates this HHS-wide initiative that is designed to reduce marijuana use by twelve to seventeen year-olds. Major components of the initiative are regional Centers for the Application of Prevention Technologies (CAPTs) and State Incentive Grants (SIGs). CAPTs provide states and communities technical assistance and information about research-based prevention. SIGs encourage collaboration with private and community-based organizations. Nineteen grants have already been awarded to states.
Youth Tobacco Initiative
The Youth Tobacco Initiative is a multifaceted HHS campaign, coordinated by the Centers for Disease Control and Prevention (CDC). Its purpose is to reduce availability of and access to tobacco and the appeal of tobacco products to youth. The campaign includes funding for tobacco prevention and cessation programs, research, legislative initiatives, regulation, and enforcement. It is supported by the FDA, NIH, and SAMHSA. The FDA, under the Food, Drug and Cosmetics Act, regulates and enforces federal age and identification requirements regarding the sale of tobacco products. The FDA also conducts an extensive advertising campaign to deter retailers from selling tobacco products to minors. The NIH, through the National Cancer Institute, NIDA, and others supports biomedical and clinical research on tobacco. SAMHSA, through its Substance Abuse Prevention and Treatment (SAPT) Block Grant, administers the SYNAR Amendment which requires state legislative and enforcement efforts to reduce the sale of tobacco products to minors. Since the enactment of SYNAR in 1994, states have increased their retailer compliance rates from approximately 30 percent to 74 percent in 1998.
States are at the forefront of efforts to prevent tobacco use by youth. Arizona, California, Florida, and Massachusetts are conducting paid anti-tobacco media campaigns, restricting minors' access to tobacco, limiting smoking in public places, and supporting school-based prevention. CDC provides funding for state health departments and national organizations to conduct tobacco use prevention and reductionprograms including media and educational campaigns, training, and surveys. CDC's Office on Smoking and Health has developed a four- point prevention and control strategy to support state campaigns and provides. CDC's Media Campaign Resource Center provides states television and radio advertisements as well as printed material. A critical federal responsibility is the diffusion of science-based models and strategies in support of state and community efforts. Accordingly, CDC funds evaluations of specific programs and disseminates information to the public. CDC's Guidelines for School Health Programs to Prevent Tobacco Use and Addiction, for example, includes recommendations on school tobacco-use policies, tobacco prevention education, teacher training, family involvement, tobacco-use cessation programs, and evaluation.
Youth Alcohol Use Prevention
Alcohol is by far the drug of choice among American youth. Although the legal drinking age in all states is twenty-one, preliminary data from the 1997 NHSDA indicates that more than 50 percent of young adults age eighteen to twenty are consuming alcohol and more than 25 percent report binge drinking (five or more drinks on the same occasion) in the past month. Of those reporting binge drinking, close to half are considered heavy drinkers.16 Rates of alcohol use, binge drinking, and heavy alcohol use increase dramatically in early teen years rising from 6.7 percent among twelve and thirteen year-olds, to 21.1 percent among fourteen and fifteen year-olds, to 33.4 among sixteen and seventeen year olds. Data from NIAAA's National Longitudinal Alcohol Epidemiologic Survey provides convincing evidence that the younger an individual is when drinking begins, the greater the chances are of developing substance-abuse problems in the future.17 The risk for many alcohol-related illnesses rises with the quantity and frequency of alcohol consumption. Other adverse consequences include motor vehicle crashes, injuries, high-risk activities, unprotected sex, violence, crime, and costs to society for police, courts, and jails.
NIAAA has a number of specific initiatives underway to address youth alcohol use including: Alcohol Screening Day, NIAAA National Advisory Council's Subcommittee on College Drinking, Kettering Foundation National Issue Forums on alcohol, and the Surgeon General's Initiative on Underage Drinking. SAMHSA/CSAP, in collaboration with NIAAA, is supporting a five-year research grant program entitled Effects of Alcohol Advertising on Underage Drinking which explores short- and long-term relationships among youth of exposure to alcohol advertising, alcohol expectancies and other mediating variables, and actual consumption of alcohol by youth. CSAP, NIAAA, and the Department of Education are supporting another five-year grant program entitled Prevention of Alcohol-Related Problems among College Students which will identify, test, and/or develop interventions which are effective in the prevention and reduction of alcohol-related problems among college students. SAMHSA supports activities to reduce underage alcohol consumption through its substance abuse prevention grants.