'What works' in drug education

and prevention?

HEALTH AND SOCIAL CARE

social
research
‘What works’ in drug education and prevention?

December 2016

Fran Warren

Health and Social Care Analysis

Scottish Government

1
Contents
Acknowledgements ................................................................ 4
Executive Summary ................................................................ 5
1. Background ......................................................................... 7
Introduction..................................................................................................... 7
Approach ........................................................................................................ 8
Defining drug prevention and education ........................................................ 9
The evidence base ....................................................................................... 11
Structure of the report .................................................................................. 12
2. Schools-Based Drug Prevention and Education ........... 14
Outcomes from drug education and prevention in schools .......................... 14
Models of drug prevention in schools ........................................................... 14
Findings on universal school-based prevention for illicit drug use ............... 16
Components of effective schools based drug education and prevention ..... 17
3. Effectiveness of Drug Prevention Beyond Schools ...... 20
Broader findings on the effectiveness of education and prevention of drug
use ................................................................................................................ 20
Peer-led interventions .................................................................................. 22
Interventions for high risk/vulnerable young people ..................................... 23
4. Manualised and Licensed Evidence Based Prevention
Programmes .......................................................................... 25
Challenges in successfully implementing evidence based programmes ..... 26
5. Ineffective Approaches ..................................................... 28
What doesn‟t „work‟? .................................................................................... 28
6. Considerations .................................................................. 31
Considerations for policy makers ................................................................. 31
Implications for prevention activity in Scotland ............................................ 33
References ............................................................................. 35
Appendices ............................................................................ 39
A. Problem Drug Use Outcomes Framework – Prevention Logic Model ..... 39

2
B. Abbreviations ........................................................................................... 40
C. Types of Prevention and Education Programmes and Approaches ........ 41

3
Acknowledgements
Thanks are due to several people for their input and advice. In particular:
Harry Sumnall, Professor of Substance Use, Centre for Public Health,
Liverpool John Moores University, Elinor Dickie, Public Health Adviser, NHS
Health Scotland, John Davies, Emeritus Professor, University of Strathclyde
and Ben Thurman of Mentor UK, for their help reviewing the report.

For enquiries about this publication, please contact: Fran Warren, Health and
Social Care Analysis, Scottish Government. Telephone: 0131 244 2541;
email: [email protected]

4
 Executive Summary
 The Cochrane Review of universal schools-based prevention for illicit drug
use shows that a combination of social competence and social influence1
approaches are most likely to be effective in preventing drug use. However,
the evidence is not strong, effect sizes are small, and so the authors conclude
that schools-based programmes should form part of more comprehensive
strategies for drug use prevention to achieve population level impact.

 There are difficulties in disentangling which are the key elements of an

effective approach, especially in hybrid programmes, and whether the
programme components or the delivery aspects and timing account for the
effectiveness.

 Nevertheless, and despite some study quality limitations, there is highly

processed and review-level evidence that school-based interventions which
focus on psychosocial and developmental skills can be effective in reducing
drug use (Dickie, 2014). Prevention programmes for young people are more
likely to be effective if they combine social and personal development,
resistance skills and normative education techniques.

 There are named „manualised'2 and licensed interventions for which there is
evidence of success in reducing drug use among young people. Faggiano et.
al. (2014) state that what may be of greatest relevance is the programme
itself. However, accurate implementation, methods of programme delivery,
age appropriate programmes etc. are all instrumental in delivering success. In
addition, the importance of a country's social context, drug policies and
supporting structures required for delivery all influence the effectiveness of a
programme.

 While the evidence does not show clear findings about how long or
concentrated a programme should be, there is agreement that programmes
need to be of sufficient intensity and duration to influence change and no
reviews suggest the use of a one off single session.

 Evidence suggests that wider programmes that are delivered in schools,

which target multiple risk behaviours, help build self-esteem and life skills are
more likely to be effective in preventing drug use. This suggests a departure
from drug specific education. Generic programmes, such as the Good
Behaviour Game, which do not focus on drug/substance use, can be effective
in reducing substance use and other problematic behaviours in the long term.

1
See Annex C
2
See Chapter 4.

5
 There is considerably more, and more robust, evidence that shows what is
ineffective in preventing drug use amongst young people. These include
knowledge-focussed/information provision (standalone and without reference
to the wider context), fear arousal approaches and stand-alone mass media
campaigns. Using ex-drug users as testimonials in the classroom – an
approach anecdotally considered to be popular in secondary schools in the
UK – is also associated with no or negative prevention outcomes.

 Despite the clear evidence of ineffectiveness of these approaches,

interventions based on these principles continue to operate and be funded,
both in Scotland, the UK and internationally. Given that there is strong
evidence that these approaches are ineffective or potentially harmful, the
Advisory Council on the Misuse of Drugs (ACMD) (2015) suggest that for
ethical reasons, local commissioners should carefully consider their
investment in such approaches, and whether such interventions and
approaches should be discontinued. The European Drug Prevention Quality
Standards (EDPQS) (2015) simply state that such programmes should not be
funded, even if popular.

 Whilst the evidence suggests that drug prevention is better embedded in more
holistic strategies that promote healthy development and wellbeing, drug-
specific prevention interventions for those young people most at risk of harm,
or already misusing drugs should be maintained. However, the evidence also
suggests that young people at greater risk will also benefit from universal
approaches.

 Policy makers/commissioners should consider a range of factors before

commissioning any new intervention, including; ethical principles, quality
standards, avoiding ineffective or potentially harmful programmes/those with
unintended consequences, cost effectiveness, the use of a common language
when discussing prevention principles and high quality evaluation.

 Evaluation is highlighted in the literature as an important part of any

prevention project, especially as the evidence shows that many popular types
of prevention activity are ineffective at changing behaviour, and some may
even cause harm. The ACMD, amongst others, recommend research funders
and charities to support high-quality evaluation research, including economic
evaluation.

 On the basis of these findings, it is argued that new work is needed to

understand what is currently being delivered in schools and the third sector in
Scotland. Such a comprehensive overview of prevention activity in Scotland
would allow an assessment of whether approaches have shifted towards
social competence and social influence approaches and more generic
resilience building approaches in line with the evidence, and whether what is
being delivered in Scotland is cost effective.

6
1. Background

Introduction
At the time of writing, trends in adolescent substance use in Scotland show a
general decline over time. The recently published Scottish Schools
Adolescent Lifestyle and Substance Use Survey (SALSUS) showed that the
proportion of pupils who reported that they had used drugs in the last month
has been gradually decreasing since 2002, with the exception of 15 year old
boys, for whom there has been a small increase between 2013 and 20153.
The focus of this literature review is on drugs, but tobacco and alcohol are
also considered – across all 3 substances prevalence has remained largely
stable since 2013, against a backdrop of considerable decline over the last
two decades4. While this general downward trend in reported substance use
is welcome, there is little understanding currently as to why this is the case,
why reported use of certain substances may be on the rise for particular
groups and what role drug prevention delivered in Scotland has played in this.

The aim of this review is to explore the evidence of effectiveness of different

types of drug prevention and education for children and young people,
principally that which is delivered in schools. There is a need for clarity
around „what works‟ and what does not, to inform approaches taken towards
drug prevention and education for young people in Scotland. This is
particularly important because currently there is a poor understanding of what
prevention activity is being delivered in Scotland, both in schools and more
widely. The lack of a national picture of prevention activity in Scotland was
identified as a gap and highlighted as a priority for research on prevention in
Scotland in both the Report of the Special Working Group on Prevention
(2012) and in the Scottish National Research Framework for Problem Drug
Use and Recovery (2015).
It is recognised that drug education and prevention for children and young
people in schools constitutes only one small aspect of drug prevention.
Dickie‟s extensive logic model on Prevention in her Outcomes Framework for
Problem Drug Use (2014) exemplifies the vast scope of prevention activities
beyond schools-based prevention that feed into achieving prevention
outcomes (attached at Annex A). For the purposes of this paper the evidence
on the effectiveness of school-based prevention programmes is prioritised.
However, the importance of prevention systems has also been emphasised,
and ideally schools-based prevention should be considered as part of a bigger
prevention system which encompasses relevant policy, supporting structures,
organisations, workforce, prevention ethos and culture etc. (Sumnall, 2016).

3
http://www.gov.scot/Resource/0050/00508357.pdf
4
http://www.gov.scot/Resource/0050/00508306.pdf

7
There are already several summaries of the evidence of effectiveness of drug
prevention activities. This review of the evidence was completed in a short
timescale, and is not intended as an exhaustive critical appraisal of the
literature. The paper has sought not to repeat previous work but instead to
draw together the evidence and findings, to help inform responses to
prevention and education in Scotland.

Approach
The literature search was conducted by the Scottish Government Library and
covered a wide range of resources, including: IDOX, EBSCOHOST
(Academic Search, SocIndex), PROQUEST (Applied Social Sciences Index
and Abstracts (ASSIA), ERIC, PAIS International, International Bibliography of
the Social Sciences (IBSS), ProQuest Sociology, Social Services Abstracts,
Sociological Abstracts) and Web of Science. The majority of the literature was
published within the last five years, although some sources are older,
including the evaluation of the effectiveness of drug prevention and education
in Scotland (Stead et al., 2007) and the accompanying literature review (Stead
and Angus, 2004), which were included because of their relevance to
Scotland. The library search included the international literature, but because
of the volume of published material, the Americas and Africa were excluded.

However, given the vast quantity of relevant literature on this topic and the
time constraints that this literature review was conducted in, the focus has
been on the most robust and current systematic reviews on drug prevention
and education, and many of the articles on smaller studies have not been
cited here. Cochrane Reviews are systematic reviews of primary research in
human health care and health policy, and investigate the effects of
interventions for prevention, treatment, and rehabilitation. The Cochrane
Drugs and Alcohol review group have published several systematic reviews
on specific substance use prevention. These are internationally recognized as
the highest standard in evidence-based health care resources and provide the
most robust evidence available regarding the effectiveness of school-based
drug education. For this reason, “Universal school-based prevention for illicit
drug use” (Faggiano, Minozzi, Versino and Buscemi, 2014) is key to
understanding „what works‟ in drug prevention in schools, and is considered
with reference to the companion reviews on alcohol and tobacco.

Robust reviews of systematic reviews, from United Nations Office of Drug

Control (UNODC) (2015) and Brotherhood, Atkinson, Bates and Sumnall
(2013) are other key sources used in this literature review. The UNODC
„International Standards on Drug Use Prevention‟ (2015) summarises the
scientific evidence on effective drug prevention interventions, through a review
of systematic reviews and meta-analysis and assessment of primary studies.
The research by Brotherhood et. al. (2013) was commissioned as part of the
ALICE RAP, EC funded project, and reviewed high quality systematic reviews

8
of primary studies which evaluated the effectiveness of policies and
interventions which target substance use (alongside other addictive
behaviours). Lastly, Stead and Angus (2004) is drawn on to provide findings
on the effectiveness of drug prevention and education in schools. While this
review is not systematic, it is comprehensive and complements the other
systematic reviews cited in this document.

Defining drug prevention and education

There is no commonly accepted definition of „drug prevention‟ in Europe. The
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) define
this as: any policy, programme, or activity that is (at least partially) directly or
indirectly aimed at preventing, delaying or reducing drug use, and/or its
negative consequences such as health and social harm, or the development
of problematic drug use (EMCDDA, 2011). This applies to all psychoactive
substances, both legal and illegal. Drug prevention activities can target whole
populations, subpopulations, or individuals and may also address common
factors that reduce vulnerability to drug use or which promote healthy
development in general.

Drug prevention and education are often discussed interchangeably but there
is a difference between the two. While drug education aims to provide
information, facts, consequences and advice about drugs, upon which
individuals can base decisions and make informed choices, its primary
objective is not to change behaviour, as is the aim of prevention. However,
prevention activities may include "prominent educational components"
(ACMD, 2015). Likewise, while the outcomes of drug education are more
limited than some of the more comprehensive prevention programmes, drug
education can also contribute to preventive outcomes (Thurman and
Boughelaf, 2015). Lastly, what is delivered and termed as „prevention‟ in
schools may in reality be more akin to education.
Prevention science is a relatively new, multi-disciplinary field which has
developed rapidly over the last forty years5. Its main aim is “to improve public
health by identifying malleable risk and protective factors, assessing the
efficacy and effectiveness of preventive interventions and identifying optimal
means for dissemination and diffusion” (Society for Prevention Research,
2011). There is now a much better understanding of 'risk factors', those which
put individuals at a greater risk of initiating drug use, and 'protective factors',
those which contribute to making individuals less vulnerable to this occurring.
Amongst the many factors associated with developing drug use (alongside
other risky behaviours) are: biological processes, personality traits, mental
health disorders, family neglect and abuse, poor attachment to school and the
5
http://www.preventionaction.org/archive/prevention-science-all-is-revealed

9
community, favourable social norms and conducive environments, and
growing up in marginalised and deprived communities (UNODC, 2015).
Known protective factors to drug use and other negative behaviours include:
psychological and emotional well-being, personal and social competence, a
strong attachment to caring and effective parents and to school and
communities that are well resourced and organised (UNODC, 2015). Drug
prevention can tackle the risk factors that increase a person‟s vulnerability to
developing drug use, and build protective factors, building resilience, offering
opportunities for alternative and healthier life choices and developing better
skills and decision making abilities (Public Health England, 2015).
The EMCDDA classifies prevention types according to a scheme developed
by Mrazek and Haggerty (1994). The categories are complementary to one
another and replace the previously used categorisation of primary, secondary,
and tertiary prevention (although this latter categorisation is still used in public
health and is still relevant). This categorisation is based on the overall
vulnerability of the people addressed - the known level of vulnerability for
developing substance use problems distinguishes between the categories,
rather than how much or whether people are actually using substances:
 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
in difficult living and social conditions;
 indicated prevention addresses vulnerable individuals and helps them
in dealing and coping with the individual personality traits which make
them more vulnerable to escalating drug use.
There is also interest more recently in environmental prevention, interventions
that do not use persuasion to change people's attitudes and behaviour, but
instead use interventions that try to limit the availability of opportunities to use
drugs, through national policies, restrictions and actions that affect social and
cultural norms, e.g. drug driving policies (EMCDDA, 2011; ACMD, 2015).
 environmental prevention addresses societies or social environments
and targets social norms including market regulations.

There is support for the use of the US Institute of Medicine (IoM) prevention
classification system as a means of describing the form of prevention
available, from EDPQS (2015) and the ACMD (2015). This classification
system illustrates the continuum of services/interventions and provides a
common language to describe prevention and assists in the planning, delivery
and evaluation of activities. It contains the Universal, Selective and Indicated
categories used by the EMCDDA above.

10
Figure 1. The Institute of Medicine model of prevention (1994; 2009)

Drug prevention is relevant across the lifespan, despite often being

considered as most relevant to young people. As stated in the introduction,
the main focus of this literature review is on universal approaches to drug
education and prevention amongst young people, delivered through school
curricula, although approaches beyond schools are also considered. Schools
represent the most efficient way of reaching large numbers of young people,
so represent the best setting for universal preventive interventions (Faggiano
et. al., 2014).

The evidence base

The EDPQS (2015) state that whilst few people would argue with the view that
prevention is better (and cheaper) than cure, much of what is done in the
name of drug prevention is still not based on what „works‟ or on what
constitutes „quality‟, and scarce resources are still being spent on ineffective
approaches.

There is little clear evidence of „what works‟ in drug prevention and the UK
prevention evidence base is particularly poor (ACMD, 2015). Evaluating
prevention is difficult, in particular, measuring something that has not yet
happened, and unpicking which intervention made the difference in the long
term (Evaluation Support Scotland, 2016). Sumnall points out that evidence
on what „works‟ will be contingent upon; how prevention is defined,
geography, the type of activities included, the outcomes specified etc.
(Sumnall, 2016). In terms of geography, the international nature of most of
the evidence (particularly from the USA), raises questions around the
transferability and adaptability of programmes to the British context. The
advantages and barriers to introducing North American prevention

11
programmes to Europe is explored in depth in the EMCDDA‟s paper „North
American drug prevention programmes: are they feasible in European cultures
and contexts?‟ (EMCDDA, 2013). Long term behaviour change is difficult and
expensive to measure, and so very few evaluations track participants for long
follow up times. This report concludes that it is possible to transfer
programmes but careful adaptation and evaluation is required, and success is
not guaranteed. Scarce resources and opportunities mean that rigorous
evaluations are often not conducted, especially in low to middle income
countries (UNODC, 2015). Many evaluations therefore focus on 'surrogate'
indicators of substance use - short term outcomes, and intermediate
measures such as knowledge and attitudes (see page 14).
Midford and Munro (eds., 2006) write that much of the robust evidence on
„what works‟ in drug education from the USA comes from studies that have
evaluated the rather narrow goals of abstinence and delayed onset of drug
use. For this reason, any reported drug use equates to programme failure,
even though programmes may have had an influence on patterns of use or
associated harm. They write “Most contemporary drug education research is
simply not designed to explore if broader prevention benefits can be achieved”
(Midford and Munro eds., 2006, p215). This is a sentiment echoed by Strang
et. al. (2012) in their review of the evidence for effective interventions for a
Lancet Addiction Series.
The quality of prevention studies and whether they contain biases is also
important when considering the evidence of „what works‟. In certain studies
that have shown statistically significant findings, often the effect is
meaningless, e.g. a reduction of drug use frequency of 0.5 episodes in a
month (Sumnall, 2016). The UNODC also highlight publication bias as an
issue, whereby publications reporting positive results are more likely to be
published than those reporting negative findings, which risks an
overestimation of the effectiveness of drug prevention programmes and
policies (UNODC, 2015).
In contrast to the weak (although improving) evidence base on „what works‟ in
drug prevention, there is much stronger evidence on which prevention
approaches are ineffective in improving drug use outcomes (ACMD, 2015).

Structure of the report

Chapter 2 of this review focusses on schools-based drug prevention and
education, how success is measured, the evidence of effectiveness for
different approaches used in schools and other components necessary for
effective drug prevention and education in schools. Chapter 3 explores
effectiveness of drug education and prevention beyond the school setting, and
considers the evidence to support peer led interventions and specific
programmes for vulnerable young people. Chapter 4 discusses specific
manualised and licensed prevention programmes and considers some of the
issues and challenges involved in implementing these programmes in different

12
contexts. Chapter 5 highlights the evidence for ineffective approaches to drug
prevention and chapter 6 draws on recommendations from the literature for
policy makers. Lastly, thoughts are presented on the implications of this
review for drug education and prevention in Scotland, in particular the need to
map prevention activity for young people being delivered in Scotland. This
mapping can then inform an assessment of whether prevention and education
being delivered to children and young people in Scotland resonates with the
evidence on what is most likely to be effective, highlighted in this review.

13
2. Schools-Based Drug Prevention and
Education

Outcomes from drug education and prevention in schools

In order to determine „what works‟ in drug prevention and education, an
understanding is needed of what outcomes are being sought from drug
education and prevention in schools. The main aim of prevention
interventions delivered to children and young people in schools is not simply
to increase knowledge and understanding of the issue, but also to deter or to
delay the onset of substance use by providing all individuals with the
information and skills necessary to prevent the problem6. The EMCDDA
states the primary outcomes are: Reduction of substance use (in both the
short term and long term), reduction of risky behaviour and reduction of
intention to use. The EMCDDA do not include outcomes related to knowledge
and/or awareness of drugs risks, despite often being included in studies, as
these are „surrogate‟ ones, i.e. there is no evidence that awareness or
knowledge has an impact on drug use. Other outcomes used include delayed
initiation of drug use and prevention of the transition from experimental use to
addiction (Strang et. al., 2012).

Models of drug prevention in schools

There has been considerable change in the approach taken towards drug
education and prevention since the 1960s, both in Scotland and abroad. The
fear based and consequences approaches were discredited in the 1970s and
generally replaced by the provision of factual information (De Haes and
Schuurman, 1975). More recently, evidence has shown the importance and
promise of programmes that combine life skills, resistance skills and
normative education approaches.

There are numerous models for approaches to universal schools-based drug

prevention, based on different theories about the most significant factors
determining drug use. The most recent classification used in the Cochrane
review by Faggiano et. al. (2014) was developed by Thomas (2013) and is
based on the categories used in the companion Cochrane review of smoking.
This is not the only categorisation – there is no universally agreed
categorisation of programmes, by theory, content or process (James, 2011).
In reality programmes often do not fit neatly into one category or another
(particularly when implemented by those who did not design the programme),
often conflating with other approaches, which makes it difficult to unpack the
key elements of an effective approach (Stead and Angus, 2004). However,
6
EMCDDA Best Practice Portal - Prevention interventions for school students:
http://www.emcdda.europa.eu/best-practice/prevention/school-children

14
this categorisation does provide a framework to understand which
programmes show more or less evidence of effectiveness. The descriptions
are verbatim from Faggiano et. al. (2014):
1. Knowledge-focussed curricula (courses of study) give information
about drugs, assuming that information alone will lead to changes in
behaviour. Knowledge-focussed interventions are based on the assumption
that a deficiency of knowledge regarding the risk and the danger of substance
use is the cause of use and abuse, and that increasing knowledge should
influence and lead to a change in attitudes toward drugs (from positive to
negative) and consequently influence behaviour.
2. Social Competence curricula are based on the belief that children
learn drug use by modelling, imitation and reinforcement, influenced by the
child's pro-drug cognitions (perceptions), attitudes and skills. These
programmes use instruction, demonstration, rehearsal, feedback and
reinforcement, etc. They teach generic self-management personal and social
skills, such as goal-setting, problem-solving and decision-making, as well as
cognitive skills to resist media and interpersonal influences, to enhance self-
esteem, to cope with stress and anxiety, to increase assertiveness and to
interact with others. Social competence approaches are based on the
assumption that youth with poor personal and social skills (poor self-esteem,
low assertiveness, poor behavioural self-control, difficulties in coping with
anxiety and stress) are more susceptible to influences that promote drugs
(Griffin 2010). These interventions teach general problem-solving and
decision-making skills, skills for increasing self-control and self-esteem,
adaptive coping strategies for relieving stress and anxiety, and general social,
communication and assertive skills.
3. Social Norms approaches use normative education methods and anti-
drugs resistance skills training. These include correcting adolescents'
overestimates of the drug use rates of adults and adolescents, recognising
high-risk situations, increasing awareness of media, peer and family
influences, and teaching and practising refusal skills. Social norms
approaches are based on the assumption that substance use is a
consequence of an inaccurate perception and overestimate of substance use
among peers. This overestimate can lead to the perception that substance
use is a normative behaviour, which could increase social acceptability among
peers. This kind of intervention also teach strategies to recognise and resist
peer and media pressures, for example resistance skills training and 'say no'
techniques (Griffin 2010).
4. Combined methods draw on knowledge-focused, social competence
and social influence7 approaches together.

7
Faggiano et al. (2014) use 'social norms' and 'social influence' interchangeably.

15
Findings on universal school-based prevention for illicit drug
use
The aim of the Cochrane review by Faggiano et al. (2014) was to evaluate the
effectiveness of universal school-based interventions in reducing drug use
compared to usual curricula activities or no intervention. The review found
that programmes based on a combination of social competence (which aim
to improve personal and interpersonal skills) and social influence
approaches (focussed on reducing the influence of society in general on the
onset and use of substances, by normative education for example) had better
results than the other categories and showed, on average, small but
consistent protective effects in preventing drug use. Information provision
alone, or knowledge based interventions were not found to be an
effective strategy and showed no differences in outcomes, apart from
knowledge, which was improved amongst participants in the programme.

Most of the programmes included in the studies evaluated were based on a

social competence approach. These programmes showed a similar tendency
to reduce the use of substances and the intention to use, and to improve
knowledge about drugs, compared to the usual curricula, but the effects were
rarely statistically significant. Programmes based on social influence
approaches were assessed in eight studies and showed weak effects that
were rarely significant. With regards to 'hard drugs' (heroin, cocaine and
psychedelics), only 2 of the 51 studies analysed in the review found that
universal school based programmes had significantly slowed the frequency of
use of hard drugs and these were variations in the same US programme. It
was unclear whether this effect was due to the programme itself or the quality
of delivery /specialists compared to normal teachers delivering comparison
cases8.
Some programmes also showed counterproductive effects, for example the
programmes „CLIMATE‟, which demonstrated a significant increase in the use
of marijuana, and „ALERT‟ which demonstrated an increase in the use of other
drugs.
These findings are consistent with those in the alcohol and tobacco Cochrane
reviews, and while useful in demonstrating what type of approach is likely to
be more effective, the effects of school based programmes are small. The
authors state that these findings cannot be used to conclude that all
programmes using the combined social competence and social influence
approach will be effective, as they observed considerable variability in the
results within the same approach (possibly because of the variability in
outcomes and scales across the studies). Since the effects of schools based
programmes are small, Faggiano et. al. conclude that these should form part
of more comprehensive strategies for drug use prevention, in order to achieve

8
http://findings.org.uk/PHP/dl.php?file=drug_ed.hot&s=dy

16
population level impact. The authors also suggest that what really matters is
the programme itself, and named some programmes as showing consistent
patterns of positive results that can be recognised as effective, such as „Life
Skills Training‟ and „Unplugged‟. See section on manualised and licensed
evidence based prevention programmes (page 25) for more detail.

Components of effective schools based drug education and

prevention
Besides getting the right theoretical model of drug education and prevention
delivered in schools, other components determining effectiveness also need to
be considered, such as how, by whom and to whom the programme is
delivered. It is difficult to unpick the key components of effective programmes
but the following are considered central. Firstly, the delivery process and
methods of programme delivery are integral to the success of education and
prevention interventions. Interactive programmes are those with a higher
amount of participation by students, through discussion, brainstorming or skills
practice (Stead and Angus, 2004). The most interactive programmes include
all participants and include participation between peers, while the least
interactive comprised of teachers presenting information or leading
discussions (see page 22 for discussion of peer-led interventions). There is
strong evidence to show that programmes which include student to student
interaction and active learning are more effective at influencing drug use
behaviour than non-interactive (passive and didactic) programmes (Stead and
Angus, 2004).

Secondly, Stead and Angus (2004) find from their review of the literature that
there is modest evidence to show that multi-component drug education
programmes (those that include a school curriculum as well as other
components, e.g. a media campaign, parent programme or policy activity) or
those which target a young person‟s environment (school, family or
community) are more likely to be effective than single component programmes
that target just the individual. There is also evidence that environmental
interventions - those which target the school teaching environment rather than
the individual - can be effective in reducing other risk taking behaviours in
young people (Stead and Angus, 2004).
Thirdly, the timing of interventions is important and need to be age
appropriate, as the age at which the intervention is delivered can have an
impact on the programme‟s effectiveness. Chowdry, Kelly and Rasul (2013)
write that timing is important in any intervention to reduce risky behaviour, and
it needs to be early enough to be preventative (before young people begin to
experiment and engage in the risky behaviour) but also timed to be relevant,
as intervention too early can be a wasted effort. McBride (2002) echoes this
but also stresses the importance of drug education continuing as young
people mature, so they have the knowledge and skills to deal with risky

17
scenarios as they present more regularly as they grow older (McBride, 2002 in
Midford and Munro eds., 2006). Stead and Angus (2004) reviewed the
evidence on effectiveness of drug education at specific ages and found that it
does not appear to be more or less effective at particular ages. However,
Midford and Munro (eds., 2006) state that the research evidence shows the
transition from primary to secondary school is the best time to start drug
education (Midford and Munro eds., 2006, p220). They also argue that timing
of drug education should be influenced by drug use prevalence data for the
target student population, as these can indicate „critical change points‟. While
most drug education programmes are targeted in the early years of high
school (12-13 years old typically), often no rationale for this choice of age
group is given (Midford and Munro eds., 2006, p220).
Fourthly, in terms of who delivers the intervention, there is evidence that
peers should be involved in (although not necessarily lead in) programmes,
and also that trained teachers and health professionals can be effective
(Stead and Angus, 2004; UNODC, 2015). It is likely that the success of the
„delivery agent‟ will be closely bound up with the type of programme being
delivered, the amount and quality of training they receive, how credible the
person delivering the programme is considered to be by those receiving the
programme, and importantly, how well the programme is implemented.
Faggiano et. al. (2014) assert above that what really matters is the
programme itself. The point about how well the programme is implemented is
therefore instrumental. Chapter 4 goes on to look at manualised and licensed
prevention programmes and considers „implementation fidelity‟ - whether
interventions are delivered as intended, which is critical to the successful
translation of evidence-based interventions into practice.
Finally, while the evidence does not show clear findings about how long or
concentrated a programme show be, there is agreement that programmes
need to be of sufficient intensity and duration to influence change and no
reviews suggest the use of a one off single session9 (Stead and Angus,
2004). See below the summary by UNODC on characteristics associated with
positive prevention outcomes:

9
This is in contrast to brief interventions, which can have a preventative effect.

18
UNODC, International Standards on Drug Use Prevention (2015), page 21.

19
3. Effectiveness of Drug Prevention
Beyond Schools

Broader findings on the effectiveness of education and

prevention of drug use
Below is a table drawn from the ACMD report (2015) which summarises the
findings from one piece of research on the evidence of effectiveness for a
wide range of policies and interventions designed to address young people‟s
addictive behaviours (Brotherhood et. al, 2013). This is included here
because it contains further evidence beyond that on schools-based prevention
on „what works‟ in substance use prevention (including alcohol and tobacco).
The findings on schools are consistent with those in Chapter 2. Pre-school
family programmes, multi-sector programmes with multiple components
(including school and the community) and some skills development
based programmes (similar to the social competence and social influence
approach described above) are promising and likely to be beneficial, if
implemented correctly. The evidence is summarised in the table below, and
the approaches in bold are those that deal specifically with illicit drug use (it
should be noted that the table may not be comprehensive) (ACMD, 2015).

Table 1 - ‘What works’ in substance use prevention for young people – a

summary of Brotherhood et al., 2013
Beneficial
Interventions and  No evidence identified
approaches which
showed robust evidence
for positive effects on
addictive behaviours.
Research evidence for
the intervention or
approach is likely to be
transferable to young
people in other
geographies.
Likely to be beneficial  Universal programmes such as the Good
Interventions and Behavior Game; Life Skills Training; and
approaches for which Unplugged in reducing alcohol misuse
there was some, but  Universal family-based programmes in
limited, evidence for producing small/medium to long-term
positive effects on reductions in alcohol misuse
addictive behaviours.  Web-based and individual face-to-face
Research evidence for feedback in reducing alcohol misuse up to
the intervention or three months after intervention

20
approach was likely to  Brief motivational interviewing in producing
be transferable to young short- and medium-term reductions in
people in other tobacco use
geographies but caution  Multisectoral (including the school) and
is warranted and community-based interventions at
adaptation studies are preventing tobacco use, particularly when
recommended. delivered with high intensity and based on
theory
 Addition of media-based components
(supporting the core curriculum) to school-
based education at preventing tobacco use
 Pre-school, family-based programmes in
producing long-term reductions in the
prevalence of lifetime or current tobacco
use, and lifetime cannabis use
 Multisectoral programmes with multiple
components (including the school and
community) in reducing illegal drug use
 Motivational interviewing in producing
short-term reductions in multiple
substance use
 Some skills-development-based school
programmes in preventing early stage
illegal drug use.

Mixed evidence  Whole school approaches that aim to

Interventions and change the school environment on use of
approaches for which multiple substances
there was some  Pre-school, family-based programmes
evidence of positive showed mixed effects on alcohol use in later
effects in favour of the adult life
intervention, but which  Manualised universal community-based
also showed some multi-component programme targeting
limitations or unintended alcohol misuse
effects that would need  Universal school-based tobacco prevention
to be assessed before programmes
implementing them  Community-based tobacco prevention
further. programmes when delivered in combination
with a school-based programme
 Mass media approaches to tobacco
prevention, or the addition of mass media
components to community activities
 Some social influence programmes can
produce short-term reductions in
cannabis use, particularly in low-risk

21
 populations
 Parental programmes for parents
designed to reduce use of multiple
substances by young people. Where
effective, programmes included active
parental involvement, or aimed to
develop skills in social competence, self-
regulation, and parenting skills.

Interventions that do not have substance use outcomes and may not focus on
drugs at all, but rather on children and young people‟s attachment to and
behaviour at school, can be effective at reducing substance use, e.g. The
Good Behaviour Game (see page 25). Similarly, there may be interventions
whose focus is on drug use/misuse but which may also help reduce other,
different risk taking behaviours. The EDPQS, former UKDPC and ACMD
(amongst others) promote a more generic approach, which target multiple risk
behaviours, of which drug use is only one (see Chapter 6).

Peer-led interventions
Peer-led interventions do not appear in the table by Brotherhood et. al. (2013)
above, but the EMCDDA lists these in a section headed „likely to work‟ 10, and
so are included here. Peer education can be described as „the teaching or
sharing of health information, values and behaviours between individuals with
shared characteristics‟ (MacArthur et al., 2015). This can involve all or part of
the delivery of an intervention by peers the same age or older in formal or
informal settings, and have been used to target substance use, sexual risk
behaviour, HIV prevention and psychosocial wellbeing among young people
(MacArthur et al., 2015). The rationale for this approach is that young people
learn from each other and have greater credibility, sensitivity and
understanding than adults when discussing health behaviour, and can act as
positive role models to reinforce these messages.

A review of 29 reviews found evidence in favour of the effectiveness of peer

educators in school-based drug prevention programmes in reducing all
substances use at post-test, but this relative effectiveness did not extend to 1
or 2 year follow-ups (McGrath et al., 2006). More recently, MacArthur et. al.
(2015) conducted a systematic review to investigate and quantify the effect of
peer-led interventions that sought to reduce tobacco, alcohol and/or drug use
among people aged 11-21 years. Most of the studies reviewed were on
tobacco and alcohol use, and only 3 of the studies (all from the US) focussed
on cannabis use (no studies were found that examined other drug use), but
the findings tentatively suggest that peer-led interventions may possibly be

10
http://www.emcdda.europa.eu/best-practice/prevention/school-children#Faggiano2014

22
effective in preventing cannabis use among young people (MacArthur et al.,
2015).
ASSIST (A Stop Smoking In Schools Trial) is a peer-led, licensed programme,
developed in Wales and England, which has shown reductions in adolescent
smoking prevalence (Campbell et. al., 2008 in MacArthur et. al., 2015).
ASSIST is different to other peer-led prevention interventions in that the peers
are selected by the pupils, rather than the teachers and so a different type of
peer is selected from the „usual suspects‟. ASSIST programme is currently
being trialled in Scotland by the Scottish Government11, and an approach
which combines ASSIST and FRANK12 is being tested in England13 which will
produce findings for drug and tobacco prevention. The results of the trial in
England, which include drugs, will be of interest.

Interventions for high risk/vulnerable young people

As well as understanding „what works‟ and does not in universal prevention, it
is also important to consider the differential effects of programmes in
population subgroups – „what works‟ for whom (ACMD, 2015). Of particular
importance are high-risk groups, those young people who are at an increased
risk of involvement in drug/substance misuse, or who are already using
substances.

The National Institute for Health and Care Excellence (NICE) Public health
guideline [PH4] on Substance misuse interventions for vulnerable under 25s
(2007)14, states that vulnerable and disadvantaged children and young people
aged under 25 who are at particular risk of misusing substances include:
“those who are – or who have been – looked after by local authorities,
fostered or homeless, or who move frequently, those whose parents or other
family members misuse substances, those from marginalised and
disadvantaged communities, including some black and minority ethnic groups,
those with behavioural conduct disorders and/or mental health problems,
those excluded from school and truants, young offenders (including those who
are incarcerated), those involved in commercial sex work, those with other
health, education or social problems at home, school and elsewhere and
those who are already misusing substances”.

Understanding the „differential prevention impact‟ of programmes on

vulnerable young people/high risk groups is important, as it allows for better
targeting and refinement of programmes and importantly may reduce the
possibility of interventions reinforcing health and social inequalities (ACMD,
2015). The evidence is mixed, and while some studies show that there is no

11
A process evaluation is underway which will report in 2017.
12
http://www.talktofrank.com/
13
http://medicine.cardiff.ac.uk/clinical-study/assist-frank/
14
This guideline is currently being updated and is due to be published in 2017.

23
difference in intervention effectiveness across sub-groups, others show
prevention programmes to be effective only in the higher risk groups, while
others show the opposite, with stronger effects in the lower-risk groups
(ACMD, 2015).
While the evidence suggests that drug prevention is better embedded in more
holistic strategies that promote healthy development and wellbeing, there is a
case for maintaining drug-specific prevention interventions for those young
people most at risk of harm, or already misusing drugs. NICE, as highlighted
above, provide guidance on substance misuse interventions for under 25s15
and has recently consulted on draft guidelines for this group for 201716.
However, the evidence also suggests that young people considered at greater
risk will also benefit from universal approaches, and so tailored approaches
may not always be required (Spoth et al., 2006, in ACMD, 2015).
One universal programme with benefits for higher risk young people is the
School Health and Alcohol Harm Reduction Project (SHAHRP). SHAHRP is
an interactive universal school based programme with a psychosocial and
developmental approach, focussing on harm reduction philosophy with skills
training, education and activities with the aim of bringing about behaviour
change. Although focussed on alcohol, the findings from Australia, and from
the adapted SHAHRP programme in Northern Ireland are worth highlighting.
In both evaluations, the results demonstrate that this approach shows
evidence of effectiveness amongst the higher risk young people, who some
may argue are the group where risk reduction is most important17. Findings
from the Northern Ireland evaluation showed that SHAHRP was viewed
positively, seen as enjoyable and worthwhile by the recipients and engaging
and relevant to the young people‟s experiences of alcohol use (Harvey et al.,
2016). This compared to "alcohol education as usual", which was viewed
negatively as unstructured, boring, repetitive and unrealistic. The authors
conclude that one reason alcohol education is not generally effective may be
due to the failure to engage young people (Harvey et al., 2016).

15
https://pathways.nice.org.uk/pathways/substance-misuse-interventions-for-vulnerable-under-25s
16
https://www.nice.org.uk/guidance/indevelopment/GID-PHG90/consultation/html-content
17
http://findings.org.uk/PHP/dl.php?file=drug_ed.hot&s=dy

24
4. Manualised and Licensed Evidence
Based Prevention Programmes
Research has shown that a number of named prevention programmes are
likely to be beneficial and cost effective (ACMD, 2015). These have been
subject to high quality research and are known as 'manualised‟ interventions,
and have been standardised through the creation of manuals and protocols for
those who implement them (ACMD, 2015). Manualised programmes are
often highly structured (e.g. school based prevention programmes), and are
often accompanied by training and implementation guidelines. Whilst many
are available free of charge, particularly those programmes developed in the
UK, the EU, and Australia, some well-known manualised interventions have
licensing requirements, providing organisational rights to deliver the
programme. Programme developers may sometimes also charge annual fees,
with additional costs for official intervention materials, training, and analysis of
screening questionnaires etc. (Sumnall, 2016). Other programmes that are
available free of charge may have some conditions on their use; for example,
deliverers must undergo training or implementation and cannot be funded by
the alcohol and tobacco industries.

One example of a manualised prevention programme that has shown positive

results is the Good Behaviour Game (GBG)18. This is an evidence based early
intervention programme delivered in primary schools which seeks to improve
socialisation skills and behaviour in the classroom. Unlike many school based
prevention approaches, the GBG is not a curriculum but it is based on a social
influence approach. The Game is played in the classroom several times a
week and teams are rewarded for adhering to classroom rules such as
working quietly, being polite to others, not leaving their seats without
permission, and following directions. Teachers monitor teams for rule-
breaking, and good behaviour and team co-operation is rewarded with praise
and small prizes such as stickers and badges. At the end of the Game the
winning team are praised, and sometime prizes are offered.

Although the programme does not directly mention drugs or substance

misuse, its intended outcomes are to prevent: substance misuse, risky sexual
behaviour and violent and anti-social behaviour. Evaluations of the GBG have
shown significant benefits in the short term (reductions in aggressive
behaviour and ability to focus and work independently) as well as notable long
term effects in males. In one long-term trial in the USA, participation in this
programme in primary school was associated at age 19-21 with significantly
lower rates of drug and alcohol use disorders, delinquency and imprisonment
for violent crimes, suicide ideation and use of school based services (ACMD,
2015).
18
http://goodbehaviorgame.org/

25
Alongside the GBG, the ACMD paper also highlights 'PreVenture‟19 and the
'Strengthening Families'20 programmes, as of interest to the UK, having been
trialled, piloted or implemented in the UK. The Cochrane Drugs and Alcohol
reviews highlighted „Unplugged‟ and „Life Skills Training‟ as showing positive
effects and recommended these programmes for implementation. Some of
these programmes aim to reduce all types of substance use, rather than
focussing just on illegal drugs, and some also target other high risk behaviours
(e.g. sexual health). Rather than exploring each of these programmes in turn,
there are a range of databases online that list details of programmes in the
field of drug prevention that demonstrate effective practice (with varying
degrees of evidence to prove their effectiveness). For example, the UK
Centre for Analysis of Youth Transitions (CAYT) repository of evidence based
services and programmes for young people21, US National Registry of
Evidence-Based Programmes and Practices22, the EMCDDA Exchange on
Drug Demand Reduction Action (EDDRA) examples of evaluated practices 23,
and the National Institute of Drug Abuse (NIDA)24 all list examples of
evidence-based drug prevention programmes.

Despite showing evidence of success, programmes such as these cannot be

guaranteed to be effective, and can often fail to replicate initial successful
results. One notable example is the seven nation European trial of the
Unplugged programmes, the largest European drug education trial ever
conducted. At the follow up at 15 months after the lessons ended, the results
were disappointing, showing that Unplugged probably had some of the
intended effects, but the results were “patchy, modest and usually statistically
insignificant”25. Some of the reasons why interventions that show evidence of
effectiveness then go on to fail in other contexts are explored below.

Challenges in successfully implementing evidence based

programmes
Prevention programmes which show initial successful results may not be
replicated when implemented more widely, particularly if they are not led by
the programmes developers and not implemented as the designers intended.

The importance of a nation‟s social context, drug policies and a need for high
quality supporting structures has been emphasised by many commentators as

19
„PreVenture‟ is different to other programmes mentioned here in that it is an Indicated rather than
Universal prevention programme, targeted at young people at greater risk of co-occurring substance
use and other emotional or behavioural disorders.
20
http://www.strengtheningfamiliesprogram.org/
21
http://mentor-adepis.org/cayt/
22
http://nrepp.samhsa.gov
23
http://www.emcdda.europa.eu/themes/best-practice/examples#
24
https://www.drugabuse.gov/publications/preventing-drug-abuse-among-children-adolescents-in-
brief/chapter-4-examples-research-based-drug-abuse-prevention-programs
25
Drug and Alcohol Findings, Hot topic -Drug education yet to match great (preventive) expectations

26
having a significant influence on the effectiveness of programmes. An
evidence based programme is necessary but not sufficient – also required are
the structures in place to support the delivery and implementation (training of
teachers, funding, support at national and local level etc.).

'Implementation fidelity' is the degree to which an intervention is delivered as

intended and is critical to successful translation of evidence-based
interventions into practice (Breitenstein et al., 2010). Manualised and highly
structured programmes do not always transfer from one geographic or cultural
setting to another and the structures for delivering prevention programmes
might not always be in place (Public Health England, 2015).

Diminished fidelity may be why interventions that show evidence of efficacy in

highly controlled trials may not deliver evidence of effectiveness when
implemented in real life contexts/routine practice. For example, the
mechanisms for delivery might differ and the EDPQS stress that poorly trained
staff members cannot deliver high quality prevention (EDPQS, 2015).
Transferring programmes to substantially different contexts may require
adaptation and re-evaluation (Faggiano et. al, 2014). The ACMD briefing
paper on prevention of drug and alcohol dependence emphasises that the
difficulties and challenges in implementing manualised interventions in routine
practice, with fidelity, and on a large scale are exacerbated because we do not
have well established and robust national and local prevention systems in
place (ACMD, 2015). In most cases, more research needs to be done to
determine whether the success of these interventions can be replicated in
real-world settings in routine practice, and how programmes and policies can
be effectively implemented and disseminated (ACMD, 2015).

There are some steps that can be taken to maintain important elements of
programmes which are rolled out in the UK (James, 2011). For example, the
content of the programme needs to be realistic for the time available in
schools, as in the past teachers have found the volume and content to be
overambitious and unrealistic. Flexibility and adaptability of the programme is
also instrumental, and while this can be positive in meeting the needs of
different groups, programme developers should provide sufficient training and
guidance to teachers on which parts of the programme can be adapted
without compromising the core components (James, 2011).

The UNODC (2015) stress that when adapting evidence based programmes
to different contexts several steps are taken: (i) “A careful and systematic
process of adaptation that does not touch the core components of the
programme, while making it more acceptable to the new socio-economic/
cultural context: this would take place with the support of the developers of
the programme...” and (ii) “A scientific monitoring and evaluation component
in order to assess whether the programme is actually effective in the new
socio-economic/cultural context”.

27
5. Ineffective Approaches

What doesn’t ‘work’?

There is much stronger evidence of prevention approaches that have
consistently been shown to be ineffective at improving drug use outcomes,
than approaches that have shown to be effective. The table below
summarises evidence on approaches shown to be ineffective from a much
larger review of effectiveness of policies and interventions to address young
people‟s addictive behaviours (Brotherhood et. al, 2013 in ACMD, 2015). As
above, the approaches in bold are those that deal specifically with illicit drug
use.

Table 2 – Ineffective interventions and approaches in substance use

prevention for young people – a summary of Brotherhood et al., 2013
Ineffective
Interventions and  Mailed, group feedback, and social-marketing-
approaches which based approaches to reduce alcohol misuse
produced negative  Web and computer-based interventions to
effects on substance prevent tobacco use
use behaviours when  Universal family-based programmes to prevent
compared to a tobacco use
standard intervention  Use of competition incentives to prevent
or no intervention. tobacco use in school children
 Standalone school-based curricula
designed only to increase knowledge about
illegal drugs
 Recreational/diversionary activities, and
theatre/drama based education to prevent
illegal drug use
 Individual programmes that have combined
school and community-based interventions
to prevent illegal drug use
 Mentoring programmes have no short- or
long-term preventative effects on illegal
drug use
 Mass media programmes targeting illegal
drug use.

The ACMD (2015) summarise these and other findings on approaches for
which there is evidence of ineffectiveness, as including: information
provision (standalone school-based curricula designed only to increase
knowledge about illegal drugs), fear arousal approaches (including „scared
straight‟ approaches), and stand-alone mass media campaigns.

28
The information provision model assumes a „rational consumer‟ or „information
deficit‟ approach to drug use in young people, put simply, the idea that young
people do not have a clear understanding of the potential consequences of
participating in risky behaviour, and giving them this information would make
such behaviour less appealing. This hypotheses is not supported by the
evidence (ACMD, 2015). As highlighted above in the Cochrane Review, at
best, information provision improves drug-related knowledge, but there is no
evidence that information provision alone changes behaviour and reduces
drug use (Stead and Angus, 2004). Chowdry et. al. (2013) point out that there
is limited information as to why this approach is not successful at reducing
risky behaviour. For example, whether the lack of success is due to the
approach itself, the behaviour it tries to deter, or because of the method of
delivery. Whatever the answers to these questions, information provision
approaches continue to operate both in Scotland and internationally, despite
the lack of evidence to show that they reduce drug use. If the stated aim
(usually of schools based drug education) is to improve drug related
knowledge rather than to change behaviour then this is perhaps less
problematic, provided that the limitations of the information provision approach
are made transparent.

Public Health England write that it is vital that accurate and relevant
information is made available to people about health harm, and that while
there is no evidence to support information provision as effective in changing
behaviour on its own, it can nonetheless reduce harm and inform choice
(Public Health England, 2015). Midford and Munro (eds., 2006) also write that
while the information only approach is now well understood to be a „failure‟, a
study by Tobler et. al (1999) found that effective drug education programmes
must provide relevant knowledge, and even the best delivery method is not
sufficient for an effective programme (Tobler et. al, 1999 in Midford and Munro
eds., 2006). Midford and Munro also write that further research is needed to
delineate what constitutes essential content knowledge (Midford and Munro
(eds.), 2006, 225).

Stand-alone mass media campaigns for illegal drug use are at best
ineffective, and at worst associated with harmful effects (also known as
„iatrogenic effects‟ - i.e. they increase a behaviour that is trying to be
prevented). The ACMD recommend that mass media campaigns are
therefore only delivered as part of multiple component programmes to support
school-based prevention (ACMD, 2015).
Below is a table from the UNODC review which adds some further points on
the components of programmes likely to be ineffective. As stated earlier, in
Scotland there is little knowledge about what types of prevention activity are
being delivered in schools and in the third sector. Anecdotally however, it
would seem that the last two on the list below – the ex-addict „in the
classroom‟ approach and using police officers to deliver the programme or
session – are reasonably common, despite being classed by the UNODC as
„programmes with no or negative prevention outcomes‟.

29
UNODC, International Standards on Drug Use Prevention (2015), page 21.

Given that there is strong evidence that these approaches are ineffective or
iatrogenic, the ACMD (2015) suggest that for ethical reasons, local
commissioners should carefully consider their investment in such approaches,
and whether such interventions and approaches should be discontinued. The
EDPQS (2015) are less equivocal and argue that such programmes should
not be funded, even if popular. However, Foxcroft (2005 in ACMD, 2015)
suggest a „precautionary pragmatism‟ when there is uncertainty about the
effectiveness of an approach. Considerations to be weighed up include:
whether the prevention activity is likely to be associated with harm, the
potential costs and harms of withdrawing this activity/not delivering any
prevention activity, and potential benefits to other health and wellbeing
outcomes, even if these are not apparent for drug use. The section below on
considerations for policy makers includes the recommendation for
commissioners to use quality standards and guidelines on intervention
development and delivery to guide these decisions (ACMD, 2015).

30
6. Considerations

Considerations for policy makers

Before commissioning any prevention activity, there are important
considerations for policy makers. Firstly, the EDPQS (2015) have proposed
certain principles that should underpin all prevention activities and which
should be considered at the outset. According to these, prevention should:

 Respect participants‟ rights and autonomy

 Provide real benefits for participants (i.e. ensuring that the programme
is relevant and useful for participants)
 Cause no harm or substantial disadvantages for participants
 Obtain participants‟ consent before participation
 Ensure that participation is voluntary
 Tailor the intervention to participants‟ needs
 Involve participants as partners in the development, implementation,
and evaluation of the programme.
Commissioners of prevention activities should be mindful before
commissioning a prevention programme that drug and substance use
prevention is likely to have only limited effects as a standalone activity.
Prevention activities should be embedded in general strategies that support
development across multiple life domains (ACMD, 2015). The ACMD (2015)
recommends that authorities commissioning prevention programmes should
consider drug and substance use prevention as part of a more general
strategy supporting all aspects of users‟ lives.

Prevention should adhere to quality standards – The EDPQS, UNODC and

Mentor-ADEPIS are amongst those who provide quality standards. These
should be used when developing or introducing new interventions and/or
improving existing interventions. The EDPQS focus on structural aspects in
their quality standards, so that these are relevant in different contexts and in
relation to different types of interventions (EDPQS, 2015).
Prevention projects should incorporate high quality evaluation, and be
developed from the findings of evaluation (ideally with economic evaluation).
The UNODC advise that a scientific monitoring and evaluation component is
required to assess the effectiveness or otherwise of an intervention, and
recommend collaborations with academic and research institutions to achieve
this, alongside the use of an experimental or quasi experimental design. They
write, “In the field of medicine, no intervention would be used unless scientific
research had found it to be effective and safe. The same should go for drug
prevention interventions and policies” (UNODC, 2015).

31
Randomised Control Trials (RCTs) clearly play a key role in providing
evidence of effectiveness, particularly in the field of healthcare. However,
given the importance of context and geography in influencing drug education
and prevention programmes, there is also a case for theory-driven
evaluations, which seek to unpack why an evaluation or programme works,
giving a contextualised understanding of effectiveness and which elements
are effective and ineffective in improving the chances of programmes
exporting successfully to other contexts (Davies et. al., 2000). A mixture of
randomised and theory driven approaches to assessing „what works‟ is likely
to be advisable (Davies et. al., 2000).

Those working in the prevention field should be encouraged to use a

common language (both in the UK and internationally) to help make
prevention strategies more coherent (ACMD, 2015). The IoM Prevention
taxonomy is proposed as a first step towards a common prevention language.
Ineffective or iatrogenic programmes - when considering commissioning
prevention programmes, caution is urged as without clear evidence of
effectiveness, some programmes may be associated with unanticipated
harmful outcomes. Programmes without clear evidence of effectiveness
should only be delivered as part of a research programme, where there is
well-developed programme logic, and where costs and harms associated with
a lack of action are considered to be high (ACMD, 2015). The EDPQS go
further and argue that ineffective or iatrogenic programmes and approaches
should not be funded, even if they are considered popular (The EDPQS,
2015). As above, quality standards and guidelines on intervention
development and delivery are recommended to guide such actions. The
EDPQS for example, provide guidance and toolkits for „developing, organising
and delivering prevention activities‟26. Where commissioners are uncertain,
NICE and Public Health England (PHE) provide resources to help easily
understand the evidence. PHE have provided a summary of the UNODC
prevention standards and provide examples of relevant and UK guidelines,
programmes and interventions available in England27.

Faggiano et. al (2014) present an ambitious proposition for a European

central, transparent, and evidence-based process for behavioural prevention
interventions (Faggiano et. al, 2014). They state that currently across Europe
no prior evaluation is required before implementing a prevention intervention,
and this can lead to widespread dissemination of „potentially ineffective or
harmful interventions‟. Such a standardised approval process, they argue,
would lead to positive outcomes for practice, the dissemination of effective
interventions in Europe and more impactful prevention at a time of scare
economic resource (Faggiano et. al, 2014).

26
http://prevention-standards.eu/standards/
27
http://ranzetta.typepad.com/files/the-international-evidence-on-the-prevention-of-drug-and-alcohol-
use-summary-and-examples-of-implementation-in-england.pdf

32
Economic analysis can provide important information on the cost
effectiveness of interventions, and whether prevention programmes
represent good value for money compared to other approaches, or to doing
nothing at all (ACMD, 2015). There is a lack of data on the cost effectiveness
of drug prevention programmes in the UK, and economic evaluations in
prevention is difficult, but economic analysis has been conducted in the US,
including one of the GBG, where the programme shows a cost benefit ratio of
1:26 (Mentor-ADEPIS, 2014a). What evidence there is on cost effectiveness
suggests that programmes do not have to show considerable impacts to be
cost effective (James, 2011). The ACDM stress that there is a need for
economic analysis from the UK, where prevention programmes have been
rolled out, but foresee barriers to achieving this given the long periods
required to demonstrate positive benefits.
The ACMD also recommend viewing prevention approaches as inter-related
and emphasise the need to consider context and to take a wider view of the
prevention system. The ACMD write “Commissioners and prevention
providers should be aware that although not understood well, actions in one
part of the overall prevention „system‟ may have beneficial or untoward effects
in another. To understand the likely effects of a prevention initiative, the
action must be located in an overall framework which includes (but is not
limited to) such factors as the influence of national policy (which may be
positive or negative in effect), national and local delivery systems, professional
competencies, available resources and services, competing and compatible
actions, and public acceptability of the action” (ACMD, 2015).

The review has shown that the evidence supports embedding universal drug
prevention actions in wider strategies that aim to support healthy development
and wellbeing in general (ACMD, 2015). The ACMD propose that prevention
is part of a „complex system‟ of policies, interventions and activities and
suggests that “the greatest preventative benefits may be obtained through
policies and actions that target multiple risk behaviours, of which
substance use is just one”. The ACMD report also notes the UK Drug Policy
Commission‟s statement regarding prevention in their final report (UKDPC,
2012), which advised against „drug-specific education‟ and highlighted the
importance of supporting schools to implement broader programmes that
aimed to build self-efficacy, help with impulse control and teach life skills,
preferably as part of the national curriculum.

Implications for prevention activity in Scotland

There is a lack of knowledge around what prevention and educational
interventions are currently being carried out in schools in Scotland, and how
this compares with the findings above on „what works‟ and what is ineffective.
However, there are findings from a large scale evaluation of the effectiveness
of drug education in Scottish schools, carried out on behalf of the Scottish

33
Executive and published in 2007 (Stead, et al., 2007). The focus was on
(illegal) drug education, and not inclusive of smoking and drinking, or New
Psychoactive Substances, which were not an issue at the time the research
was conducted. The evaluation compared findings from a literature review of
what is likely to be effective in drug education (Stead and Angus, 2004) with
what was being delivered in Scottish schools in 2004 and 2005 (through a
survey of teachers and observations). In line with the findings above, the
study found that drug education using highly interactive and social influences
approaches, specifically including resistance skills and normative education
elements are consistently found to be more effective than other approaches
(Stead et al., 2007). The research found that while the vast majority of schools
in Scotland were providing drug education, information provision
predominated and that drug education lessons were not as interactive as they
could be. Only a minority of lessons used social influence approaches and
virtually none used normative education approaches. Substantial use was
also made of external visitors (police, drug enforcement agency, nurses,
theatre groups), which raises questions as to whether these included „fear
appeals‟ and ex-addicts, also shown to be ineffective or to have
counterproductive effects.
New work is needed to understand what is currently being delivered in schools
and the third sector in Scotland, and whether approaches have shifted
towards social influence and social competence approaches and more generic
resilience building approaches in line with the evidence. It is also important to
know whether current approaches maximise scarce resources and are cost
effective. A mapping exercise of what is being delivered in Scotland will show
whether school-based drug education in Scotland still comprises mainly of
information provision alone – a possibility given that many schools may have
traditionally viewed their role as purely educational. Guidance and support for
schools to incorporate more components associated with preventive outcomes
discussed above may be required.

Stead et. al.‟s recommendations from 2007 regarding schools-based drug

education are likely to still be relevant, including: “more can be done to
enhance its effectiveness, particularly through clearer guidance on evidence-
based methods and approaches, and on continuity and progression; further
training and support to boost teachers‟ knowledge, skills and confidence; and
more attention to resources”. On the first point mentioned, Stead et. al. make
a more specific recommendation to “Give consideration to providing schools
with an annotated list of recommended drug education programmes which are
based on effective approaches and have been evaluated.” These are useful
considerations and other more strategic approaches such as targeting
decision-makers at the council level, as well as schools, also merit
consideration.

34
References

ACMD (2015). Prevention of drug and alcohol dependence. Recovery

committee prevention briefing 25/02/15, available at:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/
406926/ACMD_RC_Prevention_briefing_250215.pdf (accessed January
2016)

Bandura, A. (1977). Social Learning Theory. Englewood Cliffs, NJ: Prentice

Hall, 1977.

Brotherhood A. B., Atkinson A., Bates G., Sumnall H. R. (2013). Adolescents

as customers of addiction. ALICE RAP Deliverable 16.1, Work Package 16.
Background report 2: Review of reviews. Liverpool: Centre for Public Health

Chowdry, H., Kelly, E. and Rasul, I. (2013). Reducing risky behaviour through
the provision of information. Research report for the Department for
Education, by the Institute for Fiscal Studies and UCL.

Davies, T., O., Nutley, M. and Smith, P. C (eds.) (2000) What Works?
Evidence-based policy and practice in public services. The Policy Press.

De Haes W. and Schuurman J. (1975). "Results of an evaluation study of

three drug education methods." International Journal of Health Education:
1975, 28(4), suppl., p 1-16.

Dickie, E. (2014). Outcomes Framework for Problem Drug Use, available at:
http://www.healthscotland.com/uploads/documents/24442-
Outcomes%20Framework%20for%20Problem%20Drug%20Use..pdf

Edmonds, K., Sumnall, H., McVeigh, J., Bellis, M. (2005). Drug Prevention
among vulnerable young people. National Collaborating Centre for Drug
prevention, available at: http://www.cph.org.uk/wp-
content/uploads/2012/08/drug-prevention-among-vulnerable-young-people.pdf

European Monitoring Centre for Drugs and Drug Addiction (2011) European
drug prevention quality standards. A manual for prevention professionals.
Luxembourg: Publications Office of the European Union, 2011, available at:
http://www.emcdda.europa.eu/system/files/publications/646/TD3111250ENC_
318193.pdf

European Monitoring Centre for Drugs and Drug Addiction (2013) North
American drug prevention programmes: are they feasible in European cultures

35
and contexts. Luxembourg: Publications Office of the European Union, 2011,
available at:
http://www.emcdda.europa.eu/system/files/publications/729/TDAX13002ENN_
final_442518.pdf

European Monitoring Centre for Drugs and Drug Addiction (2015) Prevention
of addictive behaviours. Updated and expanded edition of Prevention of
substance abuse. Luxembourg: Publications Office of the European Union,
2015, available at:
http://www.emcdda.europa.eu/attachements.cfm/att_242416_EN_TDXD1501
8ENN.pdf

Evaluation Support Scotland (2016) 'What does the Scottish Approach mean
for evaluation? Learning from the third sector'. Powerpoint presentation.

Faggiano F., Allara E., Giannotta F., Molinar R., Sumnall, H., Wiers, R.,
Michie, S., Collins, L., Conrod, P (2014). Europe Needs a Central,
Transparent, and Evidence-Based Approval Process for Behavioural
Prevention Interventions.

Faggiano F., Minozzi S., Versino E., Buscemi D. (2014). Universal school-
based prevention for illicit drug use. Cochrane Database of Systematic
Reviews 2014, available at:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003020.pub3/pdf

Griffin, K. W., Botvin, G. J. (2010). Evidence based interventions for

preventing substance use disorders in adolescents. Child and Adolescent
Psychiatric Clinics of North America 2010;19:505-26.

Harvey, S. A., McKay, M. T., Sumnall, H. R., (2016). Adolescents‟ reflections

on school-based alcohol education in the United Kingdom: education as usual
compared with a structured harm reduction intervention. Journal of Substance
Use, 2016,00(00):1-6.

James, C. (2011). Drug Prevention Programmes in Schools: What is the

Evidence? Mentor, London, available at:
http://mentoruk.org.uk/media/filer_public/97/ee/97ee0bbd-9a50-4418-a49a-
3fa1a93b4b49/drug-prevention-final.pdf (accessed 4 July 2016)

MacArthur G., Harrison S., Caldwell D. M., Hickman M., Campbell, R. (2015).
Peer-led interventions to prevent tobacco, alcohol and/or drug use among
young people aged 11-21 years: a systematic review and meta-analysis.
Addiction, 111, 391-407.

36
McGrath Y., Sumnall H., McVeigh J. and Bellis M. (2006). „Drug use
prevention among young people: a review of reviews‟, National Institute for
Health and Clinical Excellence, January 2006. ISBN: 1-84629-147-X

Mrazek, P. J., & Haggerty, R. J. (Eds.). (1994). Reducing risks for mental
disorders: Frontiers for preventive intervention research. National Academies
Press.

Mentor Adepis (2014a). Early Intervention and Prevention. Alcohol and Drug
Prevention Briefing Paper, available at: http://mentor-adepis.org/wp-
content/uploads/2014/09/Early-Intervention-and-Prevention-briefing-paper.pdf

Mentor Adepis (2014b). Efficient needs assessment in schools, available at:

http://mentor-adepis.org/wp-content/uploads/2014/04/Efficient-needs-
assessment-in-schools11.pdf

Mentor Adepis (2015). Building resilience and character in young people,

available at: http://mentor-adepis.org/wp-content/uploads/2015/12/Building-
resilience-and-character-in-young-people-ADEPIS-updated.pdf

Midford, R. and Munro, G. (eds.) (2006). Drug education in schools: Searching

for the silver bullet. IP communications, Melbourne.

National Institute for Health and Clinical Excellence (2007). Substance misuse
interventions for vulnerable under 25s. Public health guideline, available at:
https://www.nice.org.uk/guidance/ph4/resources/substance-misuse-
interventions-for-vulnerable-under-25s-55454156485

Public Health England (2015). The international evidence on the prevention of

drug and alcohol use. Summary and examples of implementation in England,
available at: http://ranzetta.typepad.com/files/the-international-evidence-on-
the-prevention-of-drug-and-alcohol-use-summary-and-examples-of-
implementation-in-england.pdf

The Scottish Government (2015). Scottish National Research Framework for

Problem Drug Use and Recovery, available at:
http://www.gov.scot/Resource/0048/00487035.pdf

Society for Prevention Research. (2011). Standards of Knowledge for the

Science of Prevention. Fairfax, VA: Society for Prevention Research.

Stead M and Angus, K. (2004). Literature Review into the effectiveness of

school drug education. Scottish Executive, available at:
http://www.gov.scot/Resource/Doc/96342/0023318.pdf

37
Stead M., MacKintosh A. M., McDermott, L., Eadie D., Macneil M., Stradling
R., Minty S. (2007). Evaluation of the Effectiveness of Drug Education in
Scottish Schools. Scottish Executive, available at:
http://www.gov.scot/Publications/2006/03/14135923/0

Strang J., Babor T., Caulkins J., Fischer D., Humphreys K. (2012). Drug policy
and the public good: evidence for effective interventions. Addiction 2 Series.
The Lancet. 2012; 379.

Sumnall, H. (2016). Guiding effective and cost effective prevention in practice,

PowerPoint presentation, Public Health Institute, Liverpool John Moores
University, Liverpool.

The European Prevention Standards Partnership (2015). EDPQS Prevention

Position Paper: Defining “drug prevention” and “quality”. Liverpool: Centre for
Public Health.

Thomas, R. E., McLellan, J. and Perera, R. (2013). School-based

programmes for preventing smoking. Cochrane Database of Systematic
Reviews, available at:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001293.pub3/epdf

Thurman, B., & Boughelaf, J. (2015). “We don‟t get taught enough”: an
assessment of drug education provision in schools in England. Drugs and
Alcohol Today, 15(3), 127-140.

UK Drug Policy Commission (2012). A Fresh Approach To Drugs. The final

report of the UK Drug Policy Commission, available at:
http://esmeefairbairn.org.uk/news-and-learning/publications/uk-drug-policy-
commission-a-fresh-approach-to-drugs

United Nations Office of Drug Control (2015). International Standards on Drug

Use Prevention, available at:
https://www.unodc.org/documents/prevention/UNODC_2013_2015_internatio
nal_standards_on_drug_use_prevention_E.pdf

38
Appendices
A. Problem Drug Use Outcomes Framework – Prevention Logic
Model
The „Prevention‟ nested logic model – “The relevant links in the chains have
been lettered (A to E) and reflected in the model for ease of reference. Where
available, evidence has been drawn from key sources...We have called this
information „highly processed evidence‟” (Dickie, 2014).

39
B. Abbreviations

ACMD - Advisory Council on the Misuse of Drugs (UK)

ASSIST - A Stop Smoking In Schools Trial

CAYT - Centre for Analysis of Youth Transitions

EDDRA - EMCDDA Exchange on Drug Demand Reduction Action

EDPQS - The European Drug Prevention Quality Standards

EMCDDA - The European Monitoring Centre for Drugs and Drug Addiction

GBG – The Good Behaviour Game

IoM - (US) Institute of Medicine

NICE - The National Institute for Health and Care Excellence

NIDA - National Institute of Drug Abuse (US)

PHE - Public Health England

SALSUS - Scottish Schools Adolescent Lifestyle and Substance Use Survey

SHAHRP - School Health and Alcohol Harm Reduction Project (Australia and
Northern Ireland)

UKDPC - UK Drug Policy Commission

UNODC - United Nations Office of Drug Control

40
C. Types of Prevention and Education Programmes and
Approaches

Affective Programmes
EMCDDA - affective focused interventions, aimed to modify inner qualities
(personality traits such as self-esteem and self-efficacy, and motivational
aspects such as the intention to use drugs).

Social Competence
Thomas and Perera (2008) - Social competence curricula use enhancement
interventions (also called Affective Education) based on Bandura‟s social
learning theory (Bandura, 1977). This model hypothesizes that children learn
drug use by modelling, imitation, and reinforcement, influenced by the child‟s
pro-drug cognitions, attitudes and skills. Susceptibility is increased by poor
personal and social skills and a poor personal self-concept (Botvin, 2000).
These programmes use cognitive- behavioural skills (instruction,
demonstration, rehearsal, feedback, reinforcement, and out-of-class practice
in homework and assignments). They teach generic self-management
personal and social skills, such as goal-setting, problem-solving, and decision
making, and also teach cognitive skills to resist media and interpersonal
influences, to enhance self-esteem, to cope with stress and anxiety, to
increase assertiveness, and to interact with others of both genders.

Social Influence
Thomas and Perera (2008) - Social influence approaches, based on
McGuire‟s persuasive communications theory (McGuire 1968) and Evans‟s
theory of psychological inoculation (Evans 1976), use normative education
methods and anti-tobacco resistance skills training. These include correcting
adolescents‟ overestimates of the smoking rates of adults and adolescents,
recognising high-risk situations, increasing awareness of media, peer, and
family influences, teaching and practising refusal skills, and making public
commitments not to smoke. They often apply the techniques of generic
competence enhancement to specific anti-tobacco, anti-alcohol, and anti-drug
goals.

Social Norms
Faggiano et. al (2014) – see social influence above.

Fear-based approaches
James (2011) “Research has consistently found that attempting to frighten
young people away from using drugs through fear-based approaches is
ineffective (Prevention First, 2008). In general, people often have a defensive
response to messages arousing fear and unpleasant emotions. Warnings that
do not match young people‟s personal experiences or what they perceive
amongst their friends will not be believed and can undermine the credibility of
the messenger. Cragg (1994) argues that emphasising the dangers of drugs

41
may in fact enhance the status of drug-taking as part of youth culture and a
rite of passage” (James, 2011, 8).
Knowledge based approaches/Factual Information provision
EMCDDA - knowledge focused interventions, aimed to enhance knowledge of
drugs, and drug effects, and consequences. These approaches assume that
information alone will lead to changes in behaviour.

Multi-model approaches
Thomas and Perera (2008) - Multi-modal programmes combine curricular
approaches with wider initiatives within and beyond the school, including
programmes for parents, schools, or communities and initiatives to change
school policies about tobacco, or state policies about the taxation, sale,
availability and use of tobacco.

42
 social
research
© Crown copyright 2016
You may re-use this information (excluding logos and images) free of charge
in any format or medium, under the terms of the Open Government Licence.
To view this licence, visit http://www.nationalarchives.gov.uk/doc/open-
government-licence/or e-mail: [email protected].
Where we have identified any third party copyright information
you will need to obtain permission from the copyright holders concerned.

The views expressed in this report are those of the researcher and
do not necessarily represent those of the Scottish Government or
Scottish Ministers.

This document is also available from our website at www.gov.scot.

ISBN: 978-1-78652-630-4

The Scottish Government

St Andrew’s House
Edinburgh
EH1 3DG

Produced for
the Scottish Government
by APS Group Scotland
PPDAS84274 (11/16)
Published by
the Scottish Government,
November 2016

Social Research series

ISSN 2045 6964
ISBN 978-1-78652-630-4

Web and Print Publication

www.gov.scot/socialresearch

PPDAS84274 (11/16)