Continuation high schools: youth at risk for drug abuse

Acceptance of Drug Use Mediates Future Hard Drug Use Among At-Risk Adolescent Marijuana, Tobacco, and Alcohol Users

Alternative high school (AHS) students typically report higher levels of alcohol and other drug use compared to students attending traditional high schools. Greater use of such drugs as heroin, methamphetamines, and cocaine in this at-risk population may be driven, in part, by a greater latitude of acceptance toward substance use in general, which may accelerate the transition from gateway drugs to hard drugs. Seven hundred seventy-seven adolescents (mean age 16.6; 56% female) were recruited from alternative high schools throughout Southern California. To understand the factors that may lead AHS students to use hard drugs, a model was tested in order to determine if AHS students' latitude of acceptance toward substance use was a mediator between the relationship of past use of gateway drugs and future use of hard drugs. Latitude of acceptance was found to be a statistically significant mediator of future hard drug use (b = 0.03, 95% confidence intervals = 0.01 to 0.05) among gateway drug users. An individual's latitude of acceptance to various drug use behaviors may be consistent with societal norms. However, after exposure to, or use of, gateway drugs, attitudes that are more permissive toward hard drug use may be encountered, the acceptance of hard drugs may expand, and the use of hard drugs may escalate. Interventions designed to reduce the use of hard drugs among at-risk youth may be more persuasive by crafting messages that are within the latitude of acceptance of the target population and prevent the acceptance of hard drug use.

Study protocol for a group-based motivational interviewing brief intervention to reduce substance use and sexual risk behavior among young adults experiencing homelessness

BACKGROUND

Young people experiencing homelessness have alarmingly high rates of alcohol and other drug (AOD) use, which is associated with sexual risk behaviors such as unprotected sex, trading sex, and sex with multiple casual partners. Few risk reduction programs for this population have been developed and rigorously evaluated, particularly those that address both of these interrelated behaviors, use a collaborative and non-judgmental approach, and are feasible to deliver in settings where homeless young people seek services. This paper describes the protocol of a study evaluating a four-session Motivational Interviewing (MI)-based group risk reduction intervention for this population. The protocol has been shown to be efficacious in pilot work over 3 months with 200 homeless young adults [1]. The current study seeks to refine the intervention protocol and evaluate the program on a larger scale.

METHODS/DESIGN

In a cluster-cross-over randomized controlled trial, 18-25 year olds will receive the AWARE risk reduction program (n = 200) or standard care (n = 200) at one of three drop-in centers serving homeless youth in the Los Angeles area. We will evaluate intervention effects on primary outcomes of AOD use and sexual risk behavior, as well as secondary outcomes of health-related quality of life and social stability, over a 12-month period.

DISCUSSION

This project has the potential to fill a significant gap in prevention services by demonstrating that a brief intervention, feasible to deliver within settings where young people experiencing homelessness typically seeks services, can significantly reduce the interrelated problems of AOD use and sexual risk behavior. Trial registration ClinicalTrials.gov Identifier: NCT03735784. Registered November 18, 2018, https://clinicaltrials.gov/ct2/show/record/NCT03735784 (retrospectively registered).

Age-varying associations between e-cigarette use and peer use, household use, and exposure to e-cigarette commercials among alternative high school students in Southern California

INTRODUCTION

Electronic cigarettes (e-cigarettes) have rapidly become the most commonly used tobacco product among youth in the United States. Exposure to advertising, peer use, and household use, increases the risk of current e-cigarette use; however, the influence of these factors may be dynamic across adolescence. The aim of this study is to examine the age-varying associations between e-cigarette use and peer use, household use, and exposure to e-cigarette commercials among alternative high school students in Southern California.

METHODS

Using data previously collected for a tobacco marketing study, we examine the age-varying associations of current e-cigarette use and three risk factors (peer use, exposure to commercials, and household use) across ages 15 to 20 years using time-varying effect modeling (TVEM). Analyses include three waves of data from alternative high school students (N=1060 students; 2036 observations).

RESULTS

The probability of e-cigarette use gradually increased over the age of 15 years and then decreased by the age of 17 years for females and after the age of 18 years for males. Significant gender differences were observed between the ages of 17 and 19.5 years. Peer e-cigarette use was associated with higher odds of current e-cigarette use across all ages for females and after the age of 16 years for males. Exposure to e-cigarette commercials increased current use significantly for males between the ages of 16 and 18 years. Household use increased the odds of current use of e-cigarettes between the ages of 17 and 19 years for males and under 16.5 and over 18 years for females.

CONCLUSIONS

The findings highlight the utility of TVEM in understanding the risk factors of e-cigarette use and suggest that these factors are dynamic across adolescence.

The Rutgers Alcohol Problem Index for Adolescent Alcohol and Drug Problems: A Comprehensive Modern Psychometric Study

OBJECTIVE

The Rutgers Alcohol Problem Index (RAPI) has been used extensively as a measure of alcohol-related problems experienced by adolescents and young adults. The present study aimed to comprehensively examine the psychometric profile and criterion-related validity of an 18-item RAPI adapted to measure negative consequences resulting from alcohol and other drug use in an at-risk adolescent population.

METHOD

Categorical confirmatory factor analysis and the graded response model were used for evaluations of the latent factor structure, item properties, test information, and item invariance across gender, age groups (middle vs. late adolescence), and drug use profiles (readily available drugs vs. other illicit drugs), as well as computation of the item response theory scale scores for each of 617 alternative high school students (44% female).

RESULTS

A reduced set of 16 RAPI items provided plausible evidence of unidimensionality and good measurement precision at a relatively wide range of the latent trait continuum. All but two items were invariant across the drug use profiles. The other illicit drug group had higher levels of the latent substance-related problems than the readily available drug group. Criterion-related validity was supported using a measure of past-year polysubstance use.

CONCLUSIONS

The RAPI can be effectively modified to measure negative consequences resulting from alcohol and other drug use and reflects a sufficiently wide range of the latent continuum of problem use.

Negative Substance Use Consequences Associated With Noncondom Use Among Male, but Not Female, Alternative High School Students

BACKGROUND

Alternative (or continuation) high schools are institutions designed for students at risk for not graduating due to behavioral, educational, or medical problems. The present study explored the relationship between negative substance use consequences (eg, having trouble at school or work) and noncondom use in this at-risk population and whether these associations varied by sex.

METHODS

Participants (N = 1101; 62.9% Hispanic; M_age = 16.85) were sampled from 24 alternative high schools in California, and data were analyzed using cross-sectional multivariate logistic regression models.

RESULTS

We observed a relationship between the number of negative substance use consequences and probability of noncondom use at the last sexual encounter for boys (p < .001) but not girls (p > .05). There were significant associations between specific social consequences (missing school/work) and dependence symptoms (selling personal items to get alcohol or drugs) with noncondom use for boys only. There was a similar association between substance use frequency and noncondom use for boys.

CONCLUSIONS

These findings suggest that substance use consequences may be a useful and advantageous indicator of risky sexual behaviors such as noncondom use for boys, but not girls, in alternative high school settings. Future research and intervention programming recommendations are discussed.

Tobacco, Alcohol, and other Drug use among High-Risk Young People: A Five-Year Longitudinal Study from Adolescence to Emerging Adulthood

The present study described the prevalence of adult role taking and substance use among individuals attending alternative high schools, who were followed for five years to early emerging adulthood (n = 848). Psychosocial factors at baseline and adult role taking at the follow-up were examined as correlates of substance use during emerging adulthood. At this stage of life, 74% of subjects were employed, 30% were married or engaged, and 43% had at least one child. One third of subjects were daily cigarette smokers, and 24% had used marijuana in the past 30 days. Forty-seven percent had experienced negative consequences of alcohol or drug use in the last year. The most consistent positive predictors of substance use in emerging adulthood were male gender and previous drug use. Addiction concern was a consistent negative predictor. After controlling for baseline psychosocial variables, attending school and being married at the five-year follow-up were negative correlates of both personal consequences and problems related to alcohol or drug use.

Alcohol, tobacco, and other drug misuse prevention and cessation programming for alternative high school youth: a review

BACKGROUND

Relative to youth in regular high schools, alternative high school (AHS) youth are at high risk for alcohol, tobacco, and other drug (ATOD) misuse. Prevention and cessation efforts are needed for this population.

METHODS

A systematic, exhaustive literature search was completed to identify ATOD misuse prevention and cessation research studies with AHS youth.

RESULTS

For the AHS population, 23 ATOD misuse prevention or cessation program evaluations were located. This review indicated that successful efforts have focused on instruction in motivation enhancement, life coping skills, and decision making.

CONCLUSIONS

Alcohol, tobacco, and other drug misuse prevention and cessation programming for AHSs is effective, delivered in the classroom or as a school-based clinic. There is little evidence, though, that this programming is effective when delivered through other modalities such as via computer or bridging beyond the school setting. More research and application of evidence-based programming are recommended for youth in AHS settings.

School-based programmes for preventing smoking

BACKGROUND

Helping young people to avoid starting smoking is a widely endorsed public health goal, and schools provide a route to communicate with nearly all young people. School-based interventions have been delivered for close to 40 years.

OBJECTIVES

The primary aim of this review was to determine whether school smoking interventions prevent youth from starting smoking. Our secondary objective was to determine which interventions were most effective. This included evaluating the effects of theoretical approaches; additional booster sessions; programme deliverers; gender effects; and multifocal interventions versus those focused solely on smoking.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Tobacco Addiction Group's Specialised Register, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, Health Star, and Dissertation Abstracts for terms relating to school-based smoking cessation programmes. In addition, we screened the bibliographies of articles and ran individual MEDLINE searches for 133 authors who had undertaken randomised controlled trials in this area. The most recent searches were conducted in October 2012.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) where students, classes, schools, or school districts were randomised to intervention arm(s) versus a control group, and followed for at least six months. Participants had to be youth (aged 5 to 18). Interventions could be any curricula used in a school setting to deter tobacco use, and outcome measures could be never smoking, frequency of smoking, number of cigarettes smoked, or smoking indices.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion, extracted data and assessed risk of bias. Based on the type of outcome, we placed studies into three groups for analysis: Pure Prevention cohorts (Group 1), Change in Smoking Behaviour over time (Group 2) and Point Prevalence of Smoking (Group 3).

MAIN RESULTS

One hundred and thirty-four studies involving 428,293 participants met the inclusion criteria. Some studies provided data for more than one group.Pure Prevention cohorts (Group 1) included 49 studies (N = 142,447). Pooled results at follow-up at one year or less found no overall effect of intervention curricula versus control (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.85 to 1.05). In a subgroup analysis, the combined social competence and social influences curricula (six RCTs) showed a statistically significant effect in preventing the onset of smoking (OR 0.49, 95% CI 0.28 to 0.87; seven arms); whereas significant effects were not detected in programmes involving information only (OR 0.12, 95% CI 0.00 to 14.87; one study), social influences only (OR 1.00, 95% CI 0.88 to 1.13; 25 studies), or multimodal interventions (OR 0.89, 95% CI 0.73 to 1.08; five studies). In contrast, pooled results at longest follow-up showed an overall significant effect favouring the intervention (OR 0.88, 95% CI 0.82 to 0.96). Subgroup analyses detected significant effects in programmes with social competence curricula (OR 0.52, 95% CI 0.30 to 0.88), and the combined social competence and social influences curricula (OR 0.50, 95% CI 0.28 to 0.87), but not in those programmes with information only, social influence only, and multimodal programmes.Change in Smoking Behaviour over time (Group 2) included 15 studies (N = 45,555). At one year or less there was a small but statistically significant effect favouring controls (standardised mean difference (SMD) 0.04, 95% CI 0.02 to 0.06). For follow-up longer than one year there was a statistically nonsignificant effect (SMD 0.02, 95% CI -0.00 to 0.02).Twenty-five studies reported data on the Point Prevalence of Smoking (Group 3), though heterogeneity in this group was too high for data to be pooled.We were unable to analyse data for 49 studies (N = 152,544).Subgroup analyses (Pure Prevention cohorts only) demonstrated that at longest follow-up for all curricula combined, there was a significant effect favouring adult presenters (OR 0.88, 95% CI 0.81 to 0.96). There were no differences between tobacco-only and multifocal interventions. For curricula with booster sessions there was a significant effect only for combined social competence and social influences interventions with follow-up of one year or less (OR 0.50, 95% CI 0.26 to 0.96) and at longest follow-up (OR 0.51, 95% CI 0.27 to 0.96). Limited data on gender differences suggested no overall effect, although one study found an effect of multimodal intervention at one year for male students. Sensitivity analyses for Pure Prevention cohorts and Change in Smoking Behaviour over time outcomes suggested that neither selection nor attrition bias affected the results.

AUTHORS' CONCLUSIONS

Pure Prevention cohorts showed a significant effect at longest follow-up, with an average 12% reduction in starting smoking compared to the control groups. However, no overall effect was detected at one year or less. The combined social competence and social influences interventions showed a significant effect at one year and at longest follow-up. Studies that deployed a social influences programme showed no overall effect at any time point; multimodal interventions and those with an information-only approach were similarly ineffective.Studies reporting Change in Smoking Behaviour over time did not show an overall effect, but at an intervention level there were positive findings for social competence and combined social competence and social influences interventions.

Network interventions

The term "network interventions" describes the process of using social network data to accelerate behavior change or improve organizational performance. In this Review, four strategies for network interventions are described, each of which has multiple tactical alternatives. Many of these tactics can incorporate different mathematical algorithms. Consequently, researchers have many intervention choices at their disposal. Selecting the appropriate network intervention depends on the availability and character of network data, perceived characteristics of the behavior, its existing prevalence, and the social context of the program.

Social network influences on adolescent substance use: disentangling structural equivalence from cohesion

This study investigates two contagion mechanisms of peer influence based on direct communication (cohesion) versus comparison through peers who occupy similar network positions (structural equivalence) in the context of adolescents' drinking alcohol and smoking. To date, the two contagion mechanisms have been considered observationally inseparable, but this study attempts to disentangle structural equivalence from cohesion as a contagion mechanism by examining the extent to which the transmission of drinking and smoking behaviors attenuates as a function of social distance (i.e., from immediate friends to indirectly connected peers). Using the U.S. Add Health data consisting of a nationally representative sample of American adolescents (Grades 7-12), this study measured peer risk-taking up to four steps away from the adolescent (friends of friends of friends of friends) using a network exposure model. Peer influence was tested using a logistic regression model of alcohol drinking and cigarette smoking. Results indicate that influence based on structural equivalence tended to be stronger than influence based on cohesion in general, and that the magnitude of the effect decreased up to three steps away from the adolescent (friends of friends of friends). Further analysis indicated that structural equivalence acted as a mechanism of contagion for drinking and cohesion acted as one for smoking. These results indicate that the two transmission mechanisms with differing network proximities can differentially affect drinking and smoking behaviors in American adolescents.

Prevention education effects on fundamental memory processes

This study evaluated effects of a key session from a nationally recognized drug abuse prevention program on basic memory processes in 211 high-risk youth in Southern California. In a randomized, between-subject design, the authors manipulated assignment to a Myth and Denial program session and the time of assessment (immediate vs. 1-week delay). The authors examined program decay effects on memory accessibility and judgment errors. Those participants exposed to the program session generated more myths and facts from the program than those in the control group, suggesting that even a single program session influenced students' memory for program information and this was retained at least 1 week and detectable with indirect tests of memory accessibility. However, consistent with basic research perspectives, participants in the program-delayed assessment group erroneously generated more fact-related information from the session to the prompt "It is a myth that_____" than the participants in the program immediate assessment group; that is, they retained more facts as myths. These types of program effects, anticipated by basic memory theory, were not detected with a traditional judgment task in the present sample. The results suggest that basic science approaches offer a novel way of conceptually recasting prevention effects to more completely understand how these effects may operate. Implications for program evaluation and conceptualization are discussed.

Dissonance-Based Interventions for Substance Using Alternative High-School Youth

This article describes an innovative new intervention tailored to older youth who are already abusing drugs, but who are not diagnostically ready for treatment. The basic tenet of this intervention is to utilize adolescents engaged in drug use as "experts" in the prevention curriculum adaptation activity. This activity then serves as a mechanism for their dissonance-based change. This process is designed to intervene with drug abusing youth prior to their development of substance dependence. The community-based design grew from a United States federally funded NIDA project (National Institute of Drug Abuse Mentored Research Scientist Award) which found that the youth who conduct program adaptations were effectively engaged, animatedly discussing the payoffs and downsides of drug and alcohol abuse. It is maintained through this research that dissonance between their role of "Preventionist" and their own substance abuse behaviors lead to shifts in attitudes and behaviors. Dissonance-based interventions (DBIs) have been successfully utilized for positive behavioral change with a variety of disorders, but have not yet been implemented with substance abusing youth. Findings of pilot research are shared along with implications for future research and interventions.

One-year follow-up evaluation of the Project Towards No Drug Abuse (TND) dissemination trial

OBJECTIVE

The aims of this trial, conducted 2004-2008, were to examine (1) the effectiveness of Project Towards No Drug Abuse (TND) at the one-year follow-up when implemented on a large scale; and (2) the relative effectiveness of two training approaches for program implementers.

METHOD

A total of 65 high schools from 14 school districts across the United States were randomized to one of three conditions: regular workshop training, comprehensive implementation support, or standard care control. Physical education and health teachers delivered the program to students (n=2538). Program effectiveness was assessed with dichotomous measures of 30-day substance use at baseline and one-year follow-up.

RESULTS

When the program conditions were considered in aggregate and compared to controls, the program showed a marginally significant effect in lowering marijuana use from baseline to the one-year follow-up. Significant program effects on hard drug use were achieved for baseline non-users only. There were no differences in the effects of the two program conditions.

CONCLUSION

Positive outcomes may be achieved by trained teachers when they implement Project TND in real-world high school environments; however, program effects are likely to be weaker than those achieved in efficacy trials. Training workshops may be adequate to build capacity for successful program implementation.

Associations between family structure, family functioning, and substance use among Hispanic/Latino adolescents

This study examined the role of family structure and functioning in predicting substance use among Hispanic/Latino adolescents, surveyed in 9th and 10th grade. The sample (N = 1433) was half female, mostly of Mexican descent, and the majority was born in the United States. Living with a single father was associated with less parental monitoring and less family cohesion (gamma = -0.07, -0.06, respectively). Living with a single mother was associated with less parental monitoring (gamma = -0.10). Living with neither parent was associated with less communication (gamma = -0.08), less parental monitoring (gamma = -0.09), more family conflict (gamma = 0.06), and less family cohesion (gamma = -0.06). Less monitoring was associated with substance use at follow-up (beta = -0.17). Low rates of parental monitoring appear to mediate the association between parental family structure and substance use. Results suggest that improving basic parenting skills and offering additional social support and resources to assist parents in monitoring adolescents may help prevent substance use. These interventions may be particularly beneficial for single parents.

Acculturation and substance use: social influence as a mediator among Hispanic alternative high school youth

Research suggests that acculturation increases the risk of substance use among Hispanic youth. However, this process is not well understood. This study examined associations between acculturation and several substance use indicators among a sample of 714 Hispanic youth attending alternative high schools in southern California. Peer social influence was assessed as a potential mediator. Acculturation, measured by language use, was associated with increased risk of lifetime alcohol, marijuana, and current alcohol, cigarettes, marijuana, and hard drug use, controlling for age, socioeconomic status, and gender. Results of mediation analyses indicate that peer social influence mediated the relationship between acculturation and lifetime alcohol and current alcohol, cigarettes, and hard drug use. Evidence for partial mediation was observed with lifetime and current marijuana use. These results provide evidence that peer social influence is an important mediating variable that should be considered when examining the relationship between acculturation and substance use.

Concurrent predictors of cigarette and alcohol use among U.S. and Russian adolescents

In the present study, we describe correlates of 30-day cigarette and alcohol use among two samples of high school students, one in the Russian Federation (n = 365), and one in the United States (n = 965). The correlates used in the analyses are based on the theory of triadic influence, which organizes predictors of adolescent substance use into three distinct types of influence. Overall, correlates from each of the types of influence were significant predictors of substance use in both samples. The most consistent positive predictors of cigarette and alcohol use across countries were friends' substance use and sensation seeking behavior. Perceived harmfulness of drug use was negatively associated with cigarette and alcohol use in both samples. Having a substance abuser in one's family was negatively associated with alcohol use in the Russian sample, but positively associated with alcohol use in the U.S. sample. In general, similar patterns of relationships between predictors and substance use were seen across both countries.

Working memory capacity moderates the predictive effects of drug-related associations on substance use

Some theories suggest that spontaneously activated, drug-related associations in memory may have a "freer reign" in predicting drug use among individuals with lower working memory capacity. This study evaluated this hypothesis among 145 at-risk youth attending continuation high schools (CHS). This is the 1st study to evaluate this type of dual-process interaction in the prediction of drug use among a sample of at-risk adolescents. The CHS students completed assessments of drug-related memory associations, working memory capacity, and drug use. Control variables included age, gender, ethnicity, and acculturation. Robust multiple regression using least trimmed squares estimation indicated that there was a significant linear by linear interaction between working memory capacity (assessed with the self-ordered pointing task) and drug-related associations (assessed with verb generation and cue-behavior association tasks) in the prediction of alcohol and cigarette use. Consistent with dual-process cognitive theories, drug-related associations in memory predicted drug use more strongly in students with lower levels of working memory capacity. These findings add to the literature implicating the influence of dual cognitive processes in adolescent risk behaviors.

Comparison of indirect assessments of association as predictors of marijuana use among at-risk adolescents

In this study, the authors compared indirect measures that attempt to quantify the level of marijuana associations among adolescents. They also evaluated whether these various methods overlap or tap different aspects of associative processes that may act in concert to influence marijuana use. Automatic drug-relevant associations were assessed in 121 at-risk youth in continuation high schools in California with the use of a word association index and computer-based, reaction time measures (i.e., Implicit Association Test [IAT] and Extrinsic Affective Simon Task [EAST]). Measures of working memory capacity, sensation seeking, and explicit cognitions also were included in analyses as potential confounders. The word association index and the marijuana IAT excited D measure were significant predictors of marijuana use. The word association index accounted for more variance in marijuana use than did the IAT or EAST measures. Further, confirmatory factor analytic models of the indirect measures of marijuana use revealed a significant moderate correlation between the EAST Excitement and Word Association factors but no significant correlations between the Word Association and IAT factors. These findings suggest that there is some convergence among the different indirect measures, but these assessments also appear to tap different aspects of associative processes. The types of indirect measures evaluated in this work provide information about spontaneous cognitions related to substance use, capturing influences on behavior that are not evaluated with traditional explicit assessments of behavior. Findings from this work add to a growing body of research that implicates the importance of implicit associative processes in risk and health behaviors.

Brief intervention for substance use among at-risk adolescents: a pilot study

This pilot study demonstrates that it is feasible to administer brief individualized interventions on alternative high school campuses to students who are at risk of substance abuse. Students actively participated in brief motivational interviews and showed some improvement in five of nine outcomes at three-month follow-ups.

School-based programmes for preventing smoking

BACKGROUND

Smoking rates in adolescents are rising in some countries. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated.

OBJECTIVES

To review all randomized controlled trials of behavioural interventions in schools to prevent children (aged 5 to12) and adolescents (aged 13 to18) starting smoking.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Tobacco Addiction Group's Specialized Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, Health Star, Dissertation Abstracts and studies identified in the bibliographies of articles. Individual MEDLINE searches were made for 133 authors who had undertaken randomized controlled trials in this area.

SELECTION CRITERIA

Types of studies: those in which individual students, classes, schools, or school districts were randomized to the intervention or control groups and followed for at least six months.

TYPES OF PARTICIPANTS

Children (aged 5 to12) or adolescents (aged 13 to18) in school settings. Types of interventions: Classroom programmes or curricula, including those with associated family and community interventions, intended to deter use of tobacco. We included programmes or curricula that provided information, those that used social influences approaches, those that taught generic social competence, and those that included interventions beyond the school into the community. We included programmes with a drug or alcohol focus if outcomes for tobacco use were reported. Types of outcome measures: Prevalence of non-smoking at follow up among those not smoking at baseline. We did not require biochemical validation of self-reported tobacco use for study inclusion.

DATA COLLECTION AND ANALYSIS

We assessed whether identified citations were randomized controlled trials. We assessed the quality of design and execution, and abstracted outcome data. Because of the marked heterogeneity of design and outcomes, we computed pooled estimates only for those trials that could be analyzed together and for which statistical data were available. We predominantly synthesized the data using narrative systematic review. We grouped studies by intervention method (information; social competence; social influences; combined social influences/social competence; multi-modal programmes). Within each group, we placed them into three categories (low, medium and high risk of bias) according to validity using quality criteria for reported study design.

MAIN RESULTS

Of the 94 randomized controlled trials identified, we classified 23 as category one (most valid). There was one category one study of information-giving and two of teaching social comeptence. There were thirteen category one studies of social influences interventions. Of these, nine found some positive effect of intervention on smoking prevalence, and four failed to detect an effect on smoking prevalence. The largest and most rigorous study, the Hutchinson Smoking Prevention Project, found no long-term effect of an intensive eight-year programme on smoking behaviour. There were three category one RCTs of combined social influences and social competence interventions: one provided significant results and one only for instruction by health educators compared to self-instruction. There was a lack of high quality evidence about the effectiveness of combinations of social influences and social competence approaches. There was one category one study providing data on social influences compared with information giving. There were four category one studies of multi-modal approaches but they provided limited evidence about the effectiveness of multi-modal approaches including community initiatives.

AUTHORS' CONCLUSIONS

There is one rigorous test of the effects of information-giving about smoking. There are well-conducted randomized controlled trials to test the effects of social influences interventions: in half of the group of best quality studies those in the intervention group smoke less than those in the control, but many studies failed to detect an effect of the intervention. There are only three high quality RCTs which test the effectiveness of combinations of social influences and social competence interventions, and four which test multi-modal interventions; half showed significant positive results.

A Web-based program for coding open-ended response protocols

A Web-based coding application was designed to improve coding efficiency and to provide a systematic means of evaluating responses to open-ended assessments. The system was developed for use by multiple raters to assign open-ended responses to predetermined categories. The application provides a software environment for efficiently supervising the work of coders and evaluating the quality of the coding by (1) systematically presenting open-ended responses to coders, (2) tracking each coder's categorized responses, and (3) assessing interrater consistency at any time in order to identify coders in need of further training. In addition, the application can be set to automatically assign repeated responses to categories previously identified as appropriate for those responses. To evaluate the efficacy of the coding application and to determine the statistical reliability of coding open-ended data within this application, we examined data from two empirical studies. The results demonstrated substantial interrater agreement on items assigned to various categories across free and controlled association tasks. Overall, this new coding application provides a feasible method of reliably coding open-ended data and makes the task of coding these data more manageable.

Drug abuse prevention program development. Results among Latino and non-Latino white adolescents

Five program development studies from Project Towards No Drug Abuse (TND) were re-analyzed to discern Latino versus non-Latino Whites similarities and differences in receptivity to a wide variety of high school-based drug abuse prevention activities. In most of the program development studies, these youth attended alternative (continuation) high schools in Southern California. Although there were a total of 46% Latino students in these schools, 99% of the students indicated English as the main language spoken at school and home. Thus, taken together, almost all Latino youth in the various studies analyzed preferred to respond to survey questions in English. Latinos were relatively low in socioeconomic status (SES) and used drugs less frequently. Still, this group of highly acculturated Latinos and non-Latino Whites (37% of the school population) perceived that they were attending alternative schools for the same reasons (e.g., lack of credits, truancy). Very few differences in receptivity ratings of proposed TND activities were found as a function of ethnicity. In other words, the data suggest that the same types of lessons are applicable to older teens in both ethnic groups.

Using social networks to understand and prevent substance use: a transdisciplinary perspective

We review findings from research on smoking, alcohol, and other drug use, which show that the network approaCh is instructive for understanding social influences on substance use. A hypothetical network is used throughout to illustrate different network findings and provide a short glossary of terms. We then describe how network analysis can be used to design more effective prevention programs and to monitor and evaluate these programs. The article closes with a discussion of the inherent transdisciplinarity of social network analysis.

Project Towards No Drug Abuse: two-year outcomes of a trial that compares health educator delivery to self-instruction

OBJECTIVES

This paper describes the 2-year follow-up of a 12-session version of an indicated drug abuse prevention program, Project Towards No Drug Abuse (TND). Self-instruction programming often is used to help youth that are at high risk for dropout and drug abuse to complete their high school education. However, a health educator-led program is much more interactive.

METHODS

The effects of self-instruction versus health educator-led versions of this curriculum were examined. Eighteen schools were randomly assigned by block to one of three conditions--standard care (control), health educator-led classroom program, and self-instruction classroom program. Subjects were followed up 1 and 2 years later. Two-year results are reported here.

RESULTS

The self-instruction program produced no behavioral effects relative to the standard care control condition. The 2-year follow-up results indicated maintenance of program effects on cigarette smoking and hard drug use in the health educator-led version.

CONCLUSIONS

Project TND shows maintenance of effects on some drugs 2 years after program implementation, when most youth were young adults. More work is needed to learn how to maintain effects across substances. Continued exploration of modalities of implementation may be helpful.

Interpersonal conflict tactics and substance use among high-risk adolescents

Adolescents who use aggressive tactics to handle interpersonal conflicts may be at high risk for substance use, while adolescents who possess coping strategies to avoid or manage interpersonal conflict may be at lower risk for substance use. This study examined the association between interpersonal conflict tactics and substance use among 631 continuation high school students. Items from a modified Conflict Tactics Scale formed three factors: Physical Aggression, Nonphysical Aggression, and Nonaggression. Logistic regression analyses revealed that adolescents' ways of responding to interpersonal conflicts were associated with their substance use. Use of physical aggression was associated with a higher risk of cigarette, alcohol, marijuana, and other drug use. Use of nonphysical aggression was associated with a higher risk of cigarette and alcohol use. Use of nonaggressive conflict tactics was associated with a lower risk of cigarette use. Adolescents who respond to interpersonal conflicts in an aggressive manner, whether physical or verbal/psychological, may be at increased risk for substance use, while nonaggressive conflict management skills may be protective. Possibly, teaching adolescents nonaggressive techniques for handling interpersonal conflict may be a useful strategy for preventing both interpersonal violence and substance use.

School-based programmes for preventing smoking

BACKGROUND

Smoking rates in adolescents are rising. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated.

OBJECTIVES

To review all randomised controlled trials of behavioural interventions in schools to prevent children (aged 5 to12) and adolescents (aged 13 to18) starting smoking.

SEARCH STRATEGY

We searched The Cochrane Controlled Trials and Tobacco Review group registers, MEDLINE, EMBASE, Psyclnfo, ERIC, CINAHL, Health Star, Dissertation Abstracts and studies identified in the bibliographies of articles. Individual MEDLINE searches were made for 133 authors who had undertaken randomised controlled trials in this area.

SELECTION CRITERIA

Types of studies: those in which individual students, classes, schools, or school districts were randomised to the intervention or control groups and followed for at least six months.

TYPES OF PARTICIPANTS

Children (aged 5 to12) or adolescents (aged 13 to18) in school settings. Types of interventions: Classroom programmes or curricula, including those with associated family and community interventions, intended to deter use of tobacco. We included programmes or curricula that provided information, those that used social influences approaches, those that taught generic social competence, and those that included interventions beyond the school into the community. We included programmes with a drug or alcohol focus if outcomes for tobacco use were reported. Types of outcome measures: Prevalence of non-smoking at follow-up among those not smoking at baseline. We did not require biochemical validation of self-reported tobacco use for study inclusion.

DATA COLLECTION AND ANALYSIS

We assessed whether identified citations were randomised controlled trials. We assessed the quality of design and execution, and abstracted outcome data. Because of the marked heterogeneity of design and outcomes, we did not perform a meta-analysis. We synthesised the data using narrative systematic review. We grouped studies by intervention method (information; social competence; social influences; combined social influences/social competence and multi-modal programmes). Within each category, we placed them into three groups according to validity using quality criteria for reported study design.

MAIN RESULTS

Of the 76 randomised controlled trials identified, we classified 16 as category one (most valid). There were no category one studies of information giving alone. There were fifteen category one studies of social influences interventions. Of these, eight showed some positive effect of intervention on smoking prevalence, and seven failed to detect an effect on smoking prevalence. The largest and most rigorous study, the Hutchinson Smoking Prevention Project, found no long-term effect of an intensive 8-year programme on smoking behaviour. There was a lack of high quality evidence about the effectiveness of combinations of social influences and social competence approaches. There was limited evidence about the effectiveness of multi-modal approaches including community initiatives.

REVIEWER'S CONCLUSIONS

There is no rigorous test of the effects of information giving about smoking. There are well-conducted randomised controlled trials to test the effects of social influences interventions: in half of the group of best quality studies those in the intervention group smoke less than those in the control, but many studies showed no effect of the intervention. There is a lack of high-quality evidence about the effectiveness of combinations of social influences and social competence interventions, and of multi-modal programmes that include community interventions.

Substance use on school property among students attending alternative high schools in the United States

We analyzed nationally representative data from the 1998 National Alternative High School Youth Risk Behavior Survey, conducted by the Centers for Disease Control and Prevention, to determine the prevalence of substance use on school property among alternative high school students in the United States, to describe the characteristics of students who use substances on school property, and to examine the interrelationships of substance-use behaviors. During the 30 days preceding the survey, nearly 48 percent of students used at least one substance on school property and 17 percent used more than one substance on school property. Males were more likely than females and white students were more likely than black or Hispanic students to have used substances on school property. The results of this and other studies suggest that school administrators, public health practitioners, and policy makers should work to improve strategies for reducing substance use in this heterogeneous, hard-to-reach population.

Verifying drug abuse prevention program effects using reciprocal best friend reports

Considerable research suggests that social influences-based drug abuse prevention programming has produced the most consistently successful preventive effects. However, a common criticism of this literature is that most prevention intervention studies rely solely on self-reported substance use. The purpose of this study was to assess the effects of normative education, arguably the most successful component of social influence based prevention programs, on alcohol and cigarette consumption using both self- and reciprocal best friend reports of substance use. Analyses of subsamples of data from 11,995 students participating in the Adolescent Alcohol Prevention Trial revealed that normative education significantly delayed the onset of alcohol use across the eighth, ninth, and tenth grades among public school students. A similar but somewhat less robust pattern was found for cigarette use. These results suggest that self-report bias does not account for previous findings and demonstrate rather convincingly that normative education is an effective drug prevention strategy for public school settings.

One-year prospective prediction of drug use from stress-related variables

Six stress-related variables, gender, age, and ethnicity were investigated as concurrent and prospective predictors of three types of drug use (cigarettes, alcohol, and illicit drug use) among 875 "high risk" adolescents. The stress-related variables were socioeconomic status, "missing" one's parent(s), family conflict, victimization, perceived stress, and stress-drug beliefs. In general, concurrent regression models indicated that those who were lower in socioeconomic status, held stress-drug beliefs favorable toward drug use, and who had been victimized in the last year were more likely to be cigarette, alcohol, or illicit drug users. Prospective regression models indicated that those who had used drugs at baseline and had been victimized in the last year were relatively likely to use drugs the next year. Significant predictors in the multivariable models accounted for between 56 and 85% of those subjects who were above the median on later drug use. Victimization is apparently a relatively important source of stress in the prediction of future drug use. Drug-use intervention implications of these results include the need to provide supportive services to those who have been victims of violent attacks on their person or property.

Predictors of polydrug use among four ethnic groups: a 12-year longitudinal study

We examined adolescent risk and protective constructs associated with adult polydrug use among four ethnic groups. Both mean and relational differences among the constructs were examined by ethnic group. Teenage polydrug use was a significant predictor of adult polydrug use for Caucasians, African-Americans, and Latinos. Although this relationship was not evident for Asians, teenage alcohol use increased adult cigarette use, and early religiosity increased adult alcohol use. Early parental support/bonding predicted less adult Polydrug Use for Caucasians. For Latinos, general social conformity and low liberalism decreased cigarette use as an adult. In general, the implications of the results are that prevention strategies should emphasize the reduction of teenage drug use to decrease adult polydrug use among Caucasians, Latinos, and African-Americans. Future research should examine other possible risk and protective conditions related to adult polydrug use among diverse populations.

Factors in marijuana cessation among high-risk youth

The rise in marijuana use among high school students has generated considerable concern. The apparent failure of current marijuana control efforts may be due in part to ignorance about why students use marijuana and what influences them to consider quitting. This article utilized both open-ended and multiple-choice surveys as well as health educator-led focus groups to assess issues related to marijuana use and cessation among a population of high-risk youth. A total of 842 students participated, assessed as two separate samples from eleven continuation high schools in southern California. Approximately 70 percent of the students are current marijuana users. Interpreting results across both samples, it is apparent that interest in quitting marijuana use among continuation high school students is high. Over half of the marijuana users surveyed have tried to quit and failed. Still, several social images associated with marijuana smokers are positive and subjects express a lack of confidence in the efficacy of marijuana cessation clinic programs. Subjects believe that either self-help or punitive methods are the most effective types of marijuana cessation activities. A reportedly high rate of failed quit attempts suggests that effective marijuana cessation programs are needed in this population. Future programs must address both reasons users resist change, including use of marijuana as a stress reliever, and the particular motivations that subjects report regarding why they desire to quit using marijuana, including legal, vocational, and health consequences.

Self-reported high-risk locations of adolescent drug use

The present study provides a detailed multiple-choice self-report analysis of home, school, and other public locations where youth report using drugs. In addition, these settings were examined as a function of gender, ethnicity, type of drug used, and drug abuse status. The participants for the present study are 413 continuation high school youth, who are at relatively high risk for substance abuse. The single most frequent location of use was the participants' bedroom with a small group of friends. However, heavier users used different drugs across a greater variety of locations. Not surprisingly, drugs were used least at school. Interestingly, the prototypical party drug use situation is not a popular situation for drug use, at least among these high-risk youth.

Influence of alcohol and drug use on AIDS risk behavior among youth in dropout prevention

Youth enrolled in dropout prevention and alternative school programs engage in a number of high risk behaviors in greater numbers than those in traditional school settings [1, 2]. However, data on alcohol and drug use influences and risky sexual behavior are often not collected or reported among these youth due to small enrollments and rapid turnover. In this study alcohol and drug use and sexual behaviors were surveyed among 212 youth in dropout prevention. A risk profile score for HIV/AIDS was developed and the contribution of alcohol and drug use to HIV/AIDS risk was determined. Results showed that use of alcohol and drugs and age of sexual initiation were significantly associated with a high risk profile score. Of sexually active youth, 28 percent reported using alcohol or drugs prior to having sexual intercourse and more than half reported not using condoms during their last sexual experience. Males were more likely than females to use alcohol and drugs before having sex, and were more likely to have had sex with two or more partners. Findings from this study suggest that among youth in dropout prevention, the association of alcohol and drug use to HIV/AIDS risk is significant and that prevention programs need to target alcohol and drug use as important influences on risky sexual behavior.

Implementation and process evaluation of a school-based drug abuse prevention program: Project Towards No Drug Abuse

The present study provides an implementation, process, and immediate outcomes evaluation of the classroom component of Project Towards No Drug Abuse (TND). This project involves development and evaluation of a school-based drug abuse prevention curriculum for continuation high school youth, who are at relatively high risk for drug abuse. Three randomized conditions were evaluated: a standard care, classroom only, and classroom plus school-as-community. The latter condition was an enhanced school-based condition which involved outside-of-classroom meetings and activities. Implementation was high in both program conditions even though this was a higher risk context. Process evaluation data were favorable and did not vary between the two program conditions. Immediate outcomes data (knowledge) was higher in the two program conditions than in the standard care condition. Regarding the classroom program, addition of extra-classroom activities does not appear to alter the quality of delivery of the program.

Immediate impact of thirty-two drug use prevention activities among students at continuation high schools

Those teenagers who are unable to remain in the regular school system for reasons including substance use are transferred to a continuation high school. Generic comprehensive social-influence-drug-use-prevention-activities are less likely to be effective for use with these at risk youth. Thus, both classroom and self-instruction (main mode of instruction at continuation high schools) versions of 16 activities derived from different theoretical sources were tested and ranked on immediate outcome variables. 388 students from six continuation high schools were provided with a pretest-activity-posttest "component study" protocol. The scores on perceived quality ratings were standardized and averaged to permit easy comparisons across lessons. While yielding similar knowledge changes, students who received the health educator led activity consistently reported higher scores on perceived quality. Social influence-oriented lessons, in general, were rated of relatively low perceived quality. The present approach assisted in selection of the lessons with the greatest overall immediate impact.

Implementation and process evaluation of a student "school-as-community" group. A component of a school-based drug abuse prevention program

Little documentation exists regarding the functioning of formalized adolescent groups as drug abuse prevention agents. Two studies are described that were conducted at high schools whose students are at high risk for drug abuse. Twenty-one schools were randomly assigned to one of three conditions: (a) standard care, (b) classroom drug abuse education only, or (c) classroom plus school-as-community. Results of the first study indicated that the school-as-community component--which involved weekly meetings and periodic events at seven schools--was implemented as planned, drug abused focused, and perceived as productive in discouraging drug abuse. In the second study, staff in the classroom plus school-as-community condition self-reported involvement in the greatest number of community activities across the school year, compared with staff from the other two conditions. These two studies support the feasibility of formalized groups of high-risk youth to promote drug-free events.

School-as-community activity selection at continuation high schools

This paper describes two studies which together provide an example of an empirically based "school-as-community" development process used in a large-scale school-based drug prevention trial among youth at continuation high schools in California. First, we generated a list of schools' current community involvement from 96 school personnel and 144 students from 20 continuation high schools. Second, we reduced the number of activities indicated, with some discussion, to a list of 12 populars. Then, we administered this list to a total of 388 students from six continuation high schools who provided perceived quality ratings. We generated six categories of activities from the results of these two studies. These studies reveal a means to determine activities likely to be completed by this school system and a means to limit the variability of activities which could be manipulated in an experimental trial involving a school-as-community component.

Marijuana Use: Current Issues and New Research Directions

Due to recent evidence of the increasing frequency of marijuana use among adolescents and young adults, and due to the many remaining research issues regarding this drug, it is appropriate to summarize some of the important data about marijuana and to suggest some directions for research and service. This article first provides a review of the history, botany, active ingredients, effects, and negative consequences of marijuana use. Next, prevention and cessation of marijuana use are discussed. Finally, this paper provides a selective examination of current issues in marijuana research. Several salient issues are highlighted including its preference among certain subgroups (high risk youth and ethnic differences), its relations with illegal behavior (marijuana use and driving, current marijuana-related legislation, and marijuana use and violence), and its recent portrayal in the media.

Development of a school-based drug abuse prevention curriculum for high-risk youths

This paper presents the rationale for and description of the empirical curriculum development process in Project Towards No Drug Abuse (Project TND), which is a five-year grant funded by the National Institute on Drug Abuse. First, the target population is described, continuation high-school youths who are at high risk for drug abuse. The rationale for developing a classroom-based curriculum tailored for them is also provided. Second, a brief description is provided of state-of-the-art generic social influences drug abuse prevention programming, which has been found to be the most effective among young adolescents. There is a the need to consider other prevention activities, particularly those that include motivational variables, to maximize prevention efforts among higher-risk youths. Third, five types of curriculum development studies are discussed that led to a curriculum that is being implemented with continuation high-school students at schools in five counties in southern California. Finally, the contents of the final curriculum product is provided, which consists of motivation, skills-training, and decision-making components.

Use of the "theme study" as means of curriculum development in continuation high schools

This article presents the evaluation of written paragraphs which described twenty-one drug abuse prevention "themes" contained in thirty-five separate activities, as part of the process of curriculum development targeting Continuation High School students. The goal was to determine which activities were most preferred by these youth. The paragraphs consisted of descriptions of traditional drug abuse prevention program activities, alternative activities using the themes underlying traditional activities, and novel activities generated from newly developed themes. The study was conducted with seven Continuation High Schools. Three hundred and fifteen students participated in this study. Each student rated detailed written descriptions of five activities. Classrooms were randomly assigned to different combinations of paragraphs. An analysis of variance indicated that there were significant differences in preferences among activities, with a marked preference for the alternative and novel activity presentations. Females, Latinos, older students, and non-marijuana users rated the activities higher overall. There were no significant interactions between demographic variables and order of activity preference. If there is a limit in amount of allotted time and resources, the theme study is an appropriate and cost-effective tool for gaining important information for health curricula development.