Drug prevention: an overview
What is drug prevention?
‘Prevention has more to do with positive child and adolescent development rather than with talking adolescents out of drugs’
Prevention is evidence-based socialisation, that is, a process of transferring culturally acceptable attitudes, norms, beliefs and behaviours so that young people are enabled to respond to cues in an appropriate manner with adequate impulse control. The aim is not solely to prevent substance use, but also to delay its onset, reduce its intensification or prevent its escalation into problem use. By also designing environments in a way that the physiological risk-taking behaviour of young people does not harm them, it conceptually shares many of the objectives of harm reduction and is not its opposite.
The common view of drug prevention, particularly among lay audiences, is that it consists of informing (generally warning) young people about the effects (most commonly the dangers) of drug use. Prevention is then often equated with (mass media) warning campaigns. However, there is no evidence to suggest that the sole provision of information on drug effects has an impact on drug use behaviour, or that mass media warning campaigns are beneficial for all.
In reality, the challenge of drug prevention lies in helping young people to adjust their behaviour, capacities, and well-being in fields of multiple influences such as environmental stimuli, social norms, interaction with peers, living conditions, and their own personality traits. This view is also reflected in modern prevention approaches which aim to reduce risk behaviours related to substances.
How are prevention strategies classified?
The classification officially used by the EMCDDA is comprised of the following types of prevention, which are complementary to one another. What is important for distinguishing them is the known level of vulnerability for developing substance use problems, not how much or whether people are actually using substances.
Here is a simplified overview of the classification:
- universal prevention addresses a population at large and targets the development of skills and values, norm perception and interaction with peers and social life;
- selective prevention addresses vulnerable groups where substance use is often concentrated and focuses on improving their opportunities and resilience in difficult living and social conditions;
- indicated prevention addresses vulnerable individuals and helps them in dealing and coping with the personality traits that make them more vulnerable for escalating drug use.
This classification of prevention strategies (see Reducing Risks for Mental Disorders, Mrazek and Haggerty, 1994), which is based on the overall vulnerability of the people addressed, has superseded the previously used medical paradigm of primary, secondary and tertiary prevention. While this earlier classification is useful to describe interventions for different stages of diseases as they progress, the medical paradigm is regarded as less suitable for describing complex human behaviour, particularly that which is not dysfunctional. Only a relatively small proportion of individuals that experiment with drugs such as cannabis and cocaine progress to more frequent use patterns.
The ‘ingredients’ of most prevention strategies are mostly informational (from scaring/warning to promoting ‘informed choices’), or developmental, that is, helping children and young people in achieving the behavioural goals in each phase of their social and cognitive development. Typical examples of the latter, more effective, elements are life-skills training, social-emotional learning and self-control training.
These two prevention functions have in common that they address individuals (e.g. adolescents, parents), social groups (e.g. school classes, families, peer groups) or entire populations with the aim to induce mostly deliberate, intentional and motivated changes in behaviour. Environmental prevention approaches complement these by changing the context (physical, economic, social, regulatory etc.) of behaviour instead of primarily targeting behavioural control. Its aim is to make healthy behaviours easier or more attractive than harmful behaviour. Environmental interventions often lead to changes in social norms, values and attitudes. Smoking bans, for example, have profoundly changed the social acceptance of smoking in general, even among people who originally opposed them.
What are typical prevention interventions?
The most frequent, but not necessarily most effective, interventions are:
- School-based prevention programmes. Many of these programmes focus on social skills (empathy, communication), personal skills (decision making, coping, self-control) and information about drugs.
- Programmes for parents. Most of these programmes consist of some information sessions. A few programmes consist of intensive training sessions involving the parent and child.
- Peer-to-peer interventions train young people to convey interventions to their peers.
- Alternative leisure time interventions, such as sports, cultural or outdoor activities, sometimes as a pre-determined intervention and sometimes in the form of a 'voucher' which the young person may exchange for an activity of their choice. In some instances these interventions are aimed specifically at vulnerable young people only.
- Mass media campaigns that inform about the risks and dangers of drugs or aim at promoting effective interventions or positive social norms.
- Counselling and information approaches in nightlife settings, or – more effective – improvements in nightlife environments, e.g. free water, chill-out rooms, staff training.
- Motivational interviewing and brief interventions for young people with heavy alcohol or drug use.
- Counselling interventions for young offenders.
- Regulating the tobacco or alcohol industries with advertisement bans, taxation and sales restrictions.
- Providing a safe and positive learning environment in schools.
Do we know what works and what doesn't?
There is a growing evidence base for what works and what doesn't in the field of drug prevention. See the Best practice portal, Xchange and the UNODC/WHO prevention standards.
In general, the more effective interventions seem to be those that target the social and emotional determinants of substance use and risk behaviour, such as impulsiveness or disinhibition, conformity to perceived norms, automatic reactions to environmental cues or problems with adapting to school and family life. To date, appealing to the minds of young people by informing them about the risks and effects of drug use has not proved to be successful.
What are environmental strategies?
Environmental prevention aims at altering the regulatory, physical and economic environments in which people make their choices about drug use. This perspective takes into account that individuals do not become involved with substances solely on the basis of personal characteristics. Rather, they are influenced by a complex set of factors in the environment, such as what is considered normal or accepted in the communities in which they live, the regulations in their country, the climate and learning atmosphere of their schools, the social media messages, to which they are exposed, and the availability of alcohol, tobacco and illicit drugs as well as how much this consumption is visible.
Environmental strategies often include unfashionable components, like the control of markets or regulatory measures (age controls, tobacco smoking bans). They have therefore an important potential for social debate as they challenge culture-bound understandings of society and public health. For example, in the eyes of many people, behavioural epidemics (obesity, tobacco and alcohol use) are a matter of private concern and personal choice, where the state must not intervene. For public health advocates, they are ‘industrial epidemics’ (i.e. where the interests of powerful industries are at stake), and public health policies are called upon to act in the protection of the vulnerable, especially young people.
What is universal prevention?
Universal prevention addresses the population at large regardless of differing vulnerabilities, predominantly at school and community levels. It aims to reduce substance-related risk behaviour by providing young people with the necessary competences to avoid or delay initiation into substance use, like a 'behavioural vaccine'. Universal prevention is the most common and best-known form of prevention. In universal prevention, it is assumed that all members of the population share the same general risk for substance abuse, although the risk may vary greatly among individuals.
What is selective prevention?
Selective prevention intervenes with specific groups, families or communities which, due to their scarce social ties and resources, may be more likely to develop drug use or progress into dependency. Often this higher vulnerability to problem drug use stems from adverse childhood experiences and social exclusion; this may be the case, for example, for young offenders, school drop-outs or students who are failing academically. Vulnerable groups may be identified on the basis of social, demographic or environmental risk factors known to be associated with substance abuse, and targeted subgroups may be defined by family status or place of residence such as deprived neighbourhoods or those with high drug use or trafficking. Because of the difficulty of implementing experimental evaluation designs, the evidence of the effectiveness of selective prevention is limited.
What is indicated prevention?
Indicated prevention aims to identify individuals with behavioural or psychological problems that may be predictive for developing problem substance use later in life, and to target them individually with special interventions. Its ‘early intervention’ subcategory, however, focuses solely and specifically on identifying individuals who use substances in order to prevent them from progressing into problem drug use. Identifiers for increased individual risk can be impulsive behaviour and early aggression, and alienation from parents, school and peer groups. The aim of indicated prevention is not necessarily to prevent the use of substances, but to prevent the (fast) development of a dependence, to diminish the frequency and to prevent ‘dangerous’ substance use (e.g. moderate instead of binge-drinking).