What are prevention methods for addiction? What does research tell us?

Prevention Program Efficacy

Of the three levels of prevention, primary prevention receives most of the funding and attention, as it is often more effective and less costly than secondary or tertiary prevention. However, the effectiveness of a prevention program is difficult to determine without expensive, long-term studies. As a consequence, a large number of programs are in use in the United States that may not be effective. For example, an estimated 80 percent of youths age twelve to seventeen years were exposed to some form of education about drugs or alcohol in 2004, but only 20 percent were exposed to effective prevention programs.

Research on prevention methods may take the form of a randomized-controlled trial (RCT) or observational study or may use more informal evaluation methods. The most rigorous design tests the program’s effects on a group that receives the intervention and compares results with a second group that did not receive the intervention (a control group).

One of the drawbacks of most of the studies conducted to evaluate prevention programs is that substance abuse is usually self-reported, and so studies may overestimate the benefits of the intervention because of underreporting by participants. In addition, short-term follow-up, lack of randomization, lack of blinding, and failure to control for confounders are all common in the research literature in this area and may cause results to appear more or less significant than if higher-quality research methods had been used.

Another method that is sometimes used to assess interventions is cost-effectiveness research, which includes an assessment of the cost of providing the program and the costs or losses prevented by the program. Taking both costs and benefits into account enables policymakers and communities to choose programs that not only are effective but also are efficient in the use of resources. However, cost-effectiveness is not often evaluated, and there are no requirements that a program be cost-effective for it to be used.

One notable feature of most of the research on substance abuse prevention is that the effect sizes are generally quite small. Therefore, to prevent substance abuse and its adverse consequences, a comprehensive program of intervention strategies is required. No single intervention can reduce the problem enough on its own.

Alcohol Abuse

Prevention of alcohol abuse is a major public health goal, as alcohol abuse is the most costly substance abuse disorder and the consequences are severe. A number of laws and policies have proven effective in preventing alcohol-related problems.

Well supported in the research literature as both effective and cost-effective are alcohol excise taxes of up to 20 percent of the pretax selling price, a minimum legal drinking age of twenty-one years, and a curfew for novice drivers. Laws against serving patrons who are intoxicated and ensuring that servers are trained to recognize impairment are more costly to implement and enforce, and so may not be as cost-effective in the long run. Implementation of stringent drunk driving laws (such as lower blood-alcohol concentration laws, minimum legal drinking-age laws, and sobriety checkpoints) has been credited with reducing the number of alcohol-attributable traffic deaths in the United States since about 1970.

A number of programs aimed at young people have been identified as effective in reducing alcohol abuse in the long term. These programs include Botvin’s LifeSkills Training (LST) and the family-based Strengthening Families Program (SFP). The LST program was designed to be delivered to students in seventh through ninth grades by trained teachers. It has two main goals: developing personal decision-making skills (competence-enhancement) and developing social skills to help students resist peer pressure to smoke, drink, and use drugs. In one RCT, students who attended more than 60 percent of the studied LST training sessions reported significantly lower prevalence rates for weekly drinking, heavy drinking, and problem drinking six years after the initial intervention.

Some LST programs have been specially designed for high-risk youth. In one such study, drinking frequency and drinking amount were significantly lower in students who received LST or a culturally focused intervention compared with students who received information only. In another study, students who received LST reported significantly fewer occasions of binge drinking compared with students who did not. Another variation of the LST program, which incorporated American Indian values, legends, and stories and was delivered to American Indian students in grades three through five, also reported positive long-term effects.

SFP, developed in the early 1980s, is a fourteen-session skills-training program aimed at preventing alcohol, tobacco, and drug abuse among high-risk families. More than fifteen independent studies have found similar positive results with families.

Secondary and tertiary alcohol-abuse prevention programs include screening and brief counseling interventions in primary care settings, employee assistance and skills-training programs in the workplace, and peer interventions and support groups. Brief interventions by clinicians have been shown to reduce alcohol consumption in men, but the evidence is less clear for women. However, heavy drinkers who received a brief (fifteen-to-twenty-minute) intervention have been shown to be twice as likely to decrease their alcohol consumption in the medium term (six to twelve months after an intervention) compared with drinkers receiving no intervention.

Minimal research exists on the effectiveness of workplace prevention programs. The effectiveness of skills training to reduce consumption among college students also has not been proven, although there is weak evidence of some effects. Also, peer-led programs may be more effective than teacher-led programs among young people.

Tobacco Use

As with alcohol, a number of laws and policies have been used to prevent underage smoking and to encourage smokers to quit. Indoor and workplace smoking bans, enforcement of prohibitions on underage purchase, and increased taxes on tobacco products have all been shown to be effective in preventing smoking.

A strong relationship exists between increased taxes on tobacco products and rates of smoking among people of all ages. For example, after an increase of $1.25 in New York State’s excise tax on cigarettes in 2008, the adult smoking rate dropped by 12 percent. Every 10 percent increase in the price of cigarettes reduces youth smoking by about 7 percent.

Going beyond smoke-free workplace policies, some employers have even instituted policies against hiring smokers, although the evidence base is limited in terms of the effectiveness of such policies in preventing smoking; about twenty-nine states have passed laws protecting smokers who smoke on their own time as of 2015.

The We Card Program, established by the Coalition for Responsible Retailing in 1995, “is a youth-smoking prevention” program in the United States. The program primarily involves tobacco sales training and education, which includes the display of graphical materials in retail locations that sell tobacco products. The program’s effectiveness has been questioned in terms of preventing sales of tobacco products to minors. Some critics have argued that the program was intended to enhance positive perceptions of tobacco companies and to reduce law enforcement “stings” of retail establishments. The campaign may even be perceived by some high-risk youths as encouragement to smoke upon turning eighteen.

School-based programs for primary prevention of smoking include information campaigns, skills-training programs, and community interventions. School-based programs that simply provide information have not proven effective in preventing smoking. Although studies of programs that used a skills-training approach have found short-term effects in preventing youth smoking, the highest quality and longest trial (the Hutchinson Smoking Prevention Project, a fifteen-year randomized trial) found no long-term effects. Programs that teach social resistance skills (the ability to resist peer pressure) can reduce the proportion of youth who initiate smoking by about one-third relative to controls, although the effects of the intervention dissipate by about three years after the program ends.

Groups that have been the targets of a number of secondary interventions aimed at preventing smoking in users include pregnant women, persons with heart disease, and persons who have had surgery. The most effective programs for these adults appear to be brief interventions delivered by clinicians. Brief smoking-cessation counseling offered at the first prenatal visit results in more women quitting than no intervention or in an education-only intervention. Full insurance coverage (removing copayments or coinsurance) for smoking cessation therapy, including nicotine replacement (such as nicotine gum or patches) or pharmaceutical products such as Zyban and Chantix, also is effective and cost-effective in reducing tobacco use in current smokers.

Illicit and Nonmedical Pharmaceutical Drugs

Laws and policies designed to prevent drug use are often more severe than those aimed at alcohol and tobacco. In an era of mandatory minimum sentencing and zero tolerance laws, about one-half of all prisoners in US prisons were incarcerated for nonviolent drug offenses in 2015, and the United States has the highest per-capita prison population in the world. Although the Office of National Drug Control Policy (ONDCP) has asserted that prevention is the most cost-effective approach to the drug problem, funding for prevention programs makes up only a small portion of the ONDCP budget; the majority of spending is on law enforcement and interdiction activities.

Many employers require drug testing of employees, particularly those in transportation and security services. Research on the effectiveness of drug testing policies on preventing drug abuse is scarce, but some evidence suggests that productivity is actually lower in firms that have drug testing policies.

Another policy that has recently become more common is mandatory and random student drug testing (MRSDT), often required for student athletes and others who wish to participate in afterschool or other extracurricular activities. The effectiveness of such policies, in terms of their ability to prevent drug abuse, is not clear. A large study funded by the National Institute on Drug Abuse, called Monitoring the Future, has found that schools with MRSDT had virtually identical drug use rates as schools without drug testing.

Many of the same approaches that are used in primary prevention programs for alcohol are also used in programs that aim to prevent drug use. Also, many programs aimed at youths are intended to prevent substance abuse of all types. However, since the 1980s, the emphasis of these programs, including the “Just Say No” national campaign, has typically been on illicit drugs such as marijuana, cocaine, and heroin. More recently, the nonmedical use of pharmaceutical drugs, such as painkillers and stimulants (such as Ritalin), has become a focus of concern.

One of the most commonly used educational programs has long been Drug Abuse Resistance Education (D.A.R.E.)
. In a comparison study in the mid-1990s and in a follow-up study about five years later, schools that used the D.A.R.E. program had no significant reductions in drug use relative to control schools. More broadly, much research has shown that education-only programs are not sufficient to change behavior, although they may be effective in changing knowledge or attitudes.

Programs that can be effective in changing behaviors are usually derived from psychosocial theories and focus on minimizing the risk factors for, and on enhancing the protective factors against, substance abuse initiation. Multiple evaluations since the early 1990s have found that a combination of social resistance skills-training and competence enhancement are among the most effective approaches. Programs that use these approaches and that have shown positive results in RCTs include LST and SFP and the programs Lions Quest Skills for Adolescence, Project ALERT, CASASTART, and Project STAR.

Mass media campaigns appear to have little effect on drug use rates. Billions of dollars have been appropriated by the US Congress since 1998 for the National Youth Anti-Drug Media Campaign, yet evaluations have found no evidence that the campaign had a positive effect on teen drug use and some indications of a negative effect. Although the program was retooled and refocused specifically to address marijuana use in the early 2000s, further evaluations found that the campaign has had no effect on youth marijuana-use rates.

Bibliography

McGrath, Yuko, et al. Drug Use Prevention among Young People: A Review of Reviews. London: Natl. Inst. for Health and Clinical Excellence, 2006. PDF file.

Miller, Ted R., and Delia Hendrie. Substance Abuse Prevention Dollars and Cents: A Cost-Benefit Analysis. Rockville: Center for Substance Abuse Prevention, 2008. PDF file.

National Institute on Drug Abuse. Preventing Drug Use among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders. 2nd ed. Bethesda: NIDA, 2003. PDF file.

O’Connell, Mary Ellen, Thomas Boat, and Kenneth E. Warner. Preventing Mental, Emotional, and Behavioral Disorders among Young People: Progress and Possibilities. Washington, DC: Natl. Academies, 2009. PDF file.

Robinson, Matthew B., and Renee G. Scherlen. Lies, Damned Lies, and Drug War Statistics: A Critical Analysis of Claims Made by the Office of National Drug Control Policy. Albany: State U of New York P, 2007. Print.