ECAD paper creating alternatives

By Peter Stoker, Director, National Drug Prevention Alliance
to the ECAD 10th Anniversary Mayors’ Conference Stockholm
May 15, 2003

‘Creating the Alternatives – Policy and Prevention’

My links with ECAD have been partly with Tomas, but also in my own country with Peter Rigby – so sadly lost to us all last year. In giving this paper I would like to record my personal gratitude to Peter, and all that he did through ECAD in the struggle for sanity, in this sometimes crazy world in which we find ourselves
I have worked in this field for over 15 years; in Counselling, Treatment, Justice, Education and – not least – in Prevention. I have visited or dialogued with drug programmes and agencies in more than 20 countries and NDPA continues to exchange information and good practice with many more, through our membership of organisations like Drug Watch International, the Drug Prevention Network of the Americas, and the Institute for Global Drug Policy. All this has woken me up to the ‘World of Alternatives’, and this morning I hope to bring you some insight into practical, workable Alternatives you could apply in your own city.
Alternatives. Creating the Alternatives. It is said that we live in a sometimes crazy world, and one sign of this occasional craziness is when we give unjustified hearing to people who offer ‘alternatives’ to our present social and legal policies which may suit them very well, but which would be deeply dangerous to our children and to our society. Maybe we should blame ourselves for this; perhaps the Crazy Alternative might not sound so attractive if we became more effective in making people hear the Sane Alternative.
As we are in Scandinavia, let’s consider Hans-Christian Andersen’s story of the Emperor’s New Clothes – in which it took the innocence of a child to open the eyes of adults, an internationally-known metaphor describing blindness to the truth. An affliction taken to new heights when it comes to drug abuse.
Society obviously differs between different countries, but in western society we can see some broadly similar patterns. Let me describe what we see in the UK. Our society is one in which behaviour is conditioned by the conspicuous pursuit of consumption, by the demand for rapid gratification (‘Give me pleasure NOW); by an environment in which people march for of their rights but never for their responsibilities, by the idea that we have ‘ a right to be happy’, by the elevation of the Self above the Society (Me first) – and certainly by the elevation of youth, above all. [Ref 1] When you take all this into account, it is easy to see how drugs can have assumed a new prominence.
We also live in a society where ‘Political Correctness’ shackles our thinking, so that, for example, I can no longer call myself ‘able-bodied’ but must instead call myself ‘a person who is non-disabled’. This is just one more example of how clever use of words can confuse the mind, in the same way that the Tailor confused the Emperor – and the way in which the Emperor’s subjects went along with the deception.
This is the fertile ground in which drug-abuse grows, and one of the cleverest tactics of the pro-drug lobby is to convince you that there is no alternative – we must surrender to the inevitable; accept drug use, legalise it, and keep the harm to a minimum – for the users, that is!
We have allowed ourselves to be seduced by clever words and convoluted arguments – and a major part of this process is that the sane counter-argument to this insane dialogue gets only a tiny proportion of the media’s attention. If we were to apply the ‘Emperor’s Clothes’ logic that is advanced for drug abuse to other social behaviours there would be a national, if not international outcry.
Let’s take a fictitious example. Suppose you were designing a new social policy concerning rape. Would you think it enough to just provide services for the victim after the attack? Surely not. How about some Harm Reduction advice for the rapist? They have rights too, you know. After all, maybe it was just ‘recreational rape’ – and the rapist’s lawyer says he is ‘an otherwise law-abiding person’. Maybe if we relaxed the law this would improve things – and look at all the police time we would save! ……It is at times like this that I envy that child who showed us that the Emperor had no clothes. I envy him because his story ended with the community recognising the truth and common sense of what he said.
I have enough faith in human behaviour to believe that we will achieve this condition of sanity with drugs policy in the end – but I am also sure that it will not be achieved through apathy. Ultimately, we get the society we deserve. That is why the commitment all of you are showing through your support of ECAD – and through your actions which flow from that – is so very important. The question then is, how can we create saner alternatives?
My eminent fellow-speakers this morning will be telling you about their successes in treatment and rehabilitation. I have visited several of them in my travels, including Delancy Street – whose speaking slot I have filled today – and I can testify to what marvellous projects they are. They do an enormously valuable job, and deserve more support. But we don’t beat problems only by treating the casualties – and the sheer numbers of those with problems mean we have to do something else as well. Just consider the numbers. If we take the four major projects presenting here, and add in other large projects such as Betel in Spain, Delancy street in America, and Synanon in Germany, their combined throughput is probably something under 10,000 people a year, and yet it is said that in Britain alone we have more than 250,000 addicts. One thing is sure; treatment centres are unlikely to become redundant in our lifetime or our children’s lifetime.
Another concern is that whilst the projects presenting here today are models of good practice, not everybody matches these standards. A survey of British treatment projects on behalf of the Big Issue magazine found that most drugs other than heroin were rarely addressed by treatment centres, and that for heroin there was often only the ‘new solution’ of prescribing methadone. Big Issue found that far from weaning people off drugs, methadone prescriptions were supporting 33% of addicts for 5 years or more and 16% for 10 years or more, with both percentages rising. Moreover, 80% of methadone ‘clients’ were also using street drugs, with 44% of those on prescribed methadone using heroin on a daily basis. – and up to 50% of them still commit crimes.
If treatment and rehabilitation alone cannot turn the tide, what else is there? Let’s go back for a minute to that imaginary social policy we were looking at; the policy for rape. If we agree that rape is a bad thing; bad not just for the victim, but bad for the rapist and bad for society as a whole, our policy would not confine itself to just reacting to it, and treating the casualties. Our core policy would be to prevent it.
Rapes still happen, but we do not take this as evidence that the prevention of rape should be abandoned, anymore than we seek to dissolve driving schools because we still suffer car crashes. We take a rational view that if we were to be fatalistic about rape, there would be a lot more of it around. So, instead of surrendering, we work harder at improving our rape prevention technology.
I want however to qualify one point in my remarks: there is actually a limited scope for Harm Reduction – provided you deliver it to the right people in the right setting. It was properly defined and limited as to its scope in Britain’s first National Drug Strategy in 1995 [Ref2], a definition also enshrined in the 1998 strategy [Ref 3] which Keith Hellawell – whom you heard speaking so eloquently yesterday – designed and introduced. The ‘limit of scope’ is to use it only with people you know are users, on a one-to-one basis, as part of the treatment process; that is, whilst the user is moving towards cessation. Drug workers like myself have always practised this limited scope – indeed one could argue that there is a moral obligation to do so. But this practice only relates to a fraction of our population – it has nothing to do with the hijacked version of Harm Reduction [Ref 4] which is applied to the whole population, and which asserts that:
• You cannot prevent drug use
• You are inhibiting personal rights if you try
• Everyone may use at some time, so
• Guidance for everyone on how to use is the key, and
• Policy should be confined to reducing harm
This is a very cunning alternative – for if you introduce it, and then find that use increases, its proposers will say this proves that Prevention is useless and therefore Harm Reduction is clearly the right path to follow. A self-fulfilling prophecy. (The story of how this came about is too long to repeat here).
The truth is that in the past we have rarely tried to prevent, in the true sense of the word, that is, working ‘pre the event’. This is the Alternative on which I want to focus for the remainder of this paper, and in the process to give you some useful Alternatives to consider, from the examples I’ve seen around the world.
Let’s start with a piece of Prevention history. A common claim by the pro drug lobby is that “the Just Say No approach doesn’t work”. This has been repeated so many times that it has become a mantra – a classic example of the Orwellian principle; that if you repeat a lie often enough it becomes perceived as the truth. Saying that Just Say No “doesn’t work” is simply another way for the pro-drug lobby to claim that “the War on Drugs is failing”. Another cliche. Another lie.
Very few members of the general public know that in the so-called ‘War on Drugs’ a victory was recorded every year for 12 years, and that over those 12 years drug abuse was reduced by over 60 per cent – an astonishing public health success by any standards. [Ref 5] Even if they do know that, they are unlikely to know that one particular prevention programme was pre-eminent throughout the period. The name of the country? America. And the name of the programme? Just say No.
The Just Say No programme was much more than the chanting of slogans. It was a comprehensive personal, social and health education programme, backed up by trained volunteers and professionals. I have copies of their manuals and I can assure you of that. [Ref 6] But we can now see that a major factor in its success at that time – between 1980 and 1992 – indeed perhaps the main factor, was the culture of the society in which it was operating.
Culture is vital as the deciding factor in behaviour. And the key cultural force that swung into action to generate those successful years was not the Ministry of Education, or the Ministry of Health, or the Police and Courts – it was the community. Ordinary communities like yours, in cities across America. Parents were the main activists, acting just as that little boy did when he saw the Emperor – they exposed the truth, which the professionals had been too blinded by dogma to see. The parents shamed the professionals into producing truly preventive programmes – with the splendid results I have just stated. And those proven techniques are still available to you today – if your city only has the political will to use them.
America may have been one of the first to properly tackle prevention, but it was by no means the only one. Let’s take a quick trip around the world and see some of the other things that have happened in this context: Most countries have good and bad aspects, so in the time available this will have to be a simplified review.
Poland: The Warsaw Institute has seeded many good prevention programmes.
Germany: More than 30 of our Teenex camps, plus parent skills trainings.
Portugal: Projecto Vida and others have executed many good projects, including over 35 Teenex camps..
Belarus: Is keen to co-operate with UK on prevention.
Kazan: Has sent young people to UK Teenex prevention camps. Keen to do more.
Bulgaria: Excellent community structures are now addressing drug prevention and other services. Burgas, on the Black Sea coast, is an ECAD member and is one of the cities in which we have just started work.
Italy: Has changed to more preventive policies. Hosts the World Prevention conference 2003 – in Rome.
Belgium: Exemplary work has been initiated in the Eastern cantons, over many years.
Sweden: Has drug use levels far below the rest of Europe, largely from inducing a culture which discourages drug abuse.
Latin America: Countries like Brazil and Peru have vigorous prevention programmes. The next world conference of the International Task Force on Strategic Drug Policy will be in Argentina, next month.
Spain: Have just invited UK to co-operate on a primary school prevention programme.
Australia: Birthplace of two wonderful prevention programmes – Life Education Centres (now operating in several countries) and the Kangaroo Creek Gang.
New Zealand: an oasis of prevention – make sure you get a copy of ‘The Great Brain Robbery’ – one of the best advisory books for non-expert parents and community officials I have ever seen.
America: so much has been and is being done to prevent drug abuse. Check out the websites at NIDA and CSAP, which you can reach via the links on our site. I would also like to say a word at this point about a great programme, which has so many daggers sticking out of its back it looks like a porcupine. That programme is DARE. It is precisely because it has been so successful, so widely adopted, that it has become a constant target for the pro-drug lobby and the professionally jealous. Like everything else, it has had its faults in the past, but it has addressed many of these and is now launching a strengthened curriculum. Its unique involvement of police officers in a sustained relationship with schools – not just a quick visit – has many benefits in and beyond prevention. Already seven police forces in UK are using it, with more coming.
United Nations: Despite all our worries about the money and heavy pressure applied to it, the UN came up with the right result in its recent 46th meeting of its Commission on Narcotic Drugs – ruling out any weakening of drug laws. I am sure that the 1.3 million signatures collected by many groups – including ourselves – under the leadership of Hassela Nordic Network had a big influence, and I would like to add my congratulations to HNN for this tactical masterpiece.
Plenty of good news, then. But before you assume everything’s solved, I must emphasise that the well-financed and highly-resourced machinery of the pro drug lobby is having a significant and growing effect…

Holland: Their story is well documented, liberalization continues, despite polls showing that 70% of Dutch citizens want the lax drug laws rescinded.
Switzerland: We hear glowing reports of their heroin experiments, but this is hardly surprising when we learn that the head of the experiments is also the head of the Swiss branch of the International Anti-prohibition League, a major player in legalisation.
United Kingdom: We have been subjected to enormous pressure, with international backing for the pro-drug lobby, and we are almost certainly about to have cannabis re-classified to a lower class of legal penalty – ridiculously demoted to rank alongside steroids instead of alongside amphetamines. This is despite a wide range of new research against cannabis – and no new science in favour of it. But the good news is that both the Select Committee [Ref 7] and the Advisory Council to the Government have turned their back on all the dishonest argument, and have said they will not recommend legalisation or decriminalization – (and, for good measure, they have said the same thing about ecstasy). They have also exposed the ‘medical cannabis’ argument by inviting scientific trials, but ruling out any use of ‘cannabis as grown’ (because if its extreme variability and pharmacological unreliability as well as undesireable side-effects) and they also rule out any use of smoking as a delivery method. Their stated intention is to test extracts of cannabis, not smoked but ingested by normal medical means, and not to be of psychoactive effect. So, you don’t smoke it and you don’t get high – not at all what the pot lobby had in mind!
East Europe: As I have said already, there are good outcrops of prevention, but this region is held to ransom by pro-drug influences, most notably George Soros, who has put tens of millions of dollars worldwide into weakening drug laws.
Australia: When South Australia first decriminalized cannabis possession there was a significant increase in use by young people, compared to neighbouring states. Sadly, this experience has not deterred the liberalisers, and worse is to come. Western Australia is now considering following suit.
Canada: Policy is deteriorating in the same way as Australia.
From time to time I encounter drug liberals who assert that there is no proof of prevention. I usually refer them to the research work of Nancy Tobler; [Ref 8] she analysed no less than 240 successful prevention programmes. 240. And still they come, with their cries that there is no evidence. And yet if you press them on the subject, the more honest of them will admit that there is little or no evidence of effectiveness of Harm Reduction. Such evidence as there is can often be damning, as is the case with Baltimore in the USA; this city has one of the biggest needle exchange and condom issue schemes in the USA and yet it has ended up with the highest levels of drug abuse, the highest level of HIV infection and is amongst the highest levels of addiction. Harm Reduction may be having an effect in Baltimore, but it is not the effect that the public were promised. Coming back to Nancy Tobler; she looked at the 240 programmes and found 140 that had enough common factors to allow her to conduct what is called a meta-analysis. From this she was able to indicate the components of the more successful programmes. Another advanced researcher, Bonnie Benard, who is now with NIDA – the National Institute on Drug Abuse – has repeated the same kind of comparative exercise over many years, and from this has produced a set of “Criteria for Effective Prevention” which are a classic, timeless in their value. [Ref 9] A summary of Bonnie’s criteria is included in the written paper supporting this talk.
If I had to choose just one key criterion from what I have seen in all these countries, it would be Culture. Localised programmes will be effective locally, and programmes concentrating on one topic – such as self-esteem or drug awareness – may be effective in those areas, but not much elsewhere. If you are intent on generating a healthier environment in your city then you need to look to generating a health-oriented, prevention-oriented culture right across your community – in the home, in the school, in the workplace, in the youth organization, in the leisure areas, in the shops, in the churches and temples – and certainly in the media.
Culture can be artificially distorted, at least in the short term – which is where the media can be particularly effective, or particularly damaging. But cultural changes generally are slower to happen, and require steady application of energy. If that effort is sustained then change will occur, like the dripping of water that wears away the stone. The drug liberals have learnt this truth – we must learn it too, along with another truth.- that we sometimes forget that today has not always been . We did not always have the drug culture and the society culture we have now. It was changed before, by others. It follows that we can change it again.
What can an ordinary city do to produce a more healthy culture? One of the most comprehensive examples I have seen of this is “Project Revitalisation” in Vallejo, California. [Ref 10] The project is designed to tackle drugs, alcohol and crime in the city’s worst areas. The heart of the project is a strong community partnership: – the Vallejo Fighting Back partnership, Vallejo Code Enforcement, Vallejo Chamber of Commerce, Vallejo Police Department, Vallejo Neighbourhood Housing, California Employment Department, the Private Industry Council, and many neighbourhood associations. It works to integrate neighbourhood revitalisation, alcohol and other drug policy, neighbourhood safety, job-training, and co-ordination of human services into a comprehensive effort. The project’s goals are to sort out and regularize the jumble of disorganized buildings and facilities, regenerating the neighbourhood; to reduce crime, and foster safety and quality of life for the residents of these deteriorating, crime-ridden neighbourhoods.
Project Revitalisation is based on four principles:
• The physical make-up of a community has an important influence on its vulnerability to crime. This is equivalent to the very successful “Broken Windows” project run in New York [Ref 11]
• Neighbourhoods where residents have commitment and interest in improving their area can influence the level of crime
• Everybody, individuals and families, must personally gain from the project. You cannot expect people drowning in problems such as unemployment, addiction, lack of child care and other human service shortages to be interested in improving their neighbourhoods
• problems with alcohol and other drugs contribute to neighbourhood deterioration and must be specifically addressed.
In a five phase process, Project Revitalisation moves from initial assessment to detailed assessment, then to initial ‘pilot’ interventions before full implementation. The final phase is to reinforce the new stability of the neighbourhood by establishing permanent neighbourhood groups.
First reports of results from the project show encouraging improvements; there has been a reduction in police call-outs and an improvement in the perception of safety by residents – this is a very important feature in my own country, where fear of crime is often as crippling as crime itself.
The efforts to reduce illegal drugs are probably well understood already; particular alcohol policies that Vallejo introduced included:
• ‘Conditional use’ (trial) permits for regulation of new alcohol outlets.
• Improved ordinances to regulate existing outlets.
• An ordinance for youth parties, to reduce non-commercial access of alcohol by young people
• A social nuisance ordinance to hold property owners accountable for standards of building maintenance and for the conduct of their residents
• A rental property inspection ordinance
Vallejo is a very comprehensive scheme but I’m sure you will agree that there is no ‘rocket science’ in what they are doing. Their deliberately steady progress, involving all the elements of the community at each stage, is reminiscent of the excellent work done by Dr Ernst Servais [Ref 12] in the Eastern cantons of Belgium. Both projects recognised that unless you carry the community with you at each stage, the effect of your labours is likely to be short-lived.
In summary, then, what Alternative do we have? What tools do we have in our toolbox? We could list these under three simple headings;
• Before drug use
• Early stages of drug use, and
• Problematic stages of drug use
Culture. Prevention. Education. Parenting. Big Brothers and Sisters. Peer-group prevention. Policing for prevention. Media. Spiritual aspects. Workplaces. Sports (including FIT technology). Arts. Music.
Early stages:
Intervention. Counselling. Befriending. Harm reduction. Policing. Diversion (Alternatives). Containment.
Problematic stages:
Primary care. Treatment. Harm reduction. Justice. Drug courts. Restorative justice. Probation. Prison-based rehab treatment. Halfway houses. After-care. Relapse prevention.
Encompassing many of these initiatives, one brand new and usefully comprehensive addition to NDPA’s library has been the publication ‘Blueprint for a Drug-Free Future’ [Ref 13] by the Hudson Institute, USA.
Money – as always – comes into it. And because treatment is easier for accountants to count, it has traditionally tended to get much more of the available funding than other services. In economic terms, however, prevention gives a better return; even using conservative figures, prevention can be seen to give a payback of $6 for every dollar spent, [Ref 14] compared to only $3 for every dollar spent on treatment.
How might we inter-relate these services? Here is my model for doing that:
With the overall aim of a healthy society, the strategy relevant to the majority of the population has to be prevention. This does not mean that you have to accept anything in the name of prevention, or preventive education. You have every right to ask questions as to what a project is specifically aiming to achieve – and demand evaluations to make sure you get what you were promised.
For those who start to get involved – and they are still a minority – it is probably enough to expose them to prevention processes which they may well not have experienced before. Those who continue to stay involved will need more intervention effort, maybe even some form of treatment, but the outcome should still be that when they cease using this is affirmed by prevention processes. The problematic users are the ones we hear about most, but they are almost certainly only a few percent of your population. This whole structure needs to be buttressed by firm but fair legal and justice systems which firstly deter, then intervene, and – above all – correct aberrant behaviour. A justice system does not have to be confined to punishment, indeed I would argue that such a system is likely to be counter-productive; it should be a sensitive mix of punishment, retribution, restoration and rehabilitation.
• There is no one programme around that does it all.
• What works for one person very well will not work at all for another .
• We need to see all of our services – prevention, education, intervention, treatment and so on as part of a continuous whole – and apply them holistically.
• We should not be afraid of having a variety of initiatives, but we should make sure that they are all inter-related.
• Don’t rush it, and don’t tamper with bits of the problem. This is like playing with the ecology – and will probably be equally disastrous.
• Always monitor and evaluate for process and outcome.
• Don’t be afraid to trust your gut feeling. If you have clear goals, then something which feels bad probably is bad.
• Don’t try to be an expert, but know where the ‘experts’ live – and in choosing them, be careful to check their background and agenda .
There is a great deal that you can do in managing a team of experts by asking some simple questions, such as: What are we trying to achieve? How are we trying to achieve it? What is it for? Is everything we are doing pointing in the same direction – if not, why not?
And remember – if one of these ‘experts’ offers you a wonderful new set of clothes, fit for an Emperor – get rid of him!
[up] 1. Stoker, P: Moralising, demoralizing .. the fight for Personal and Social Education. 2000. NDPA.
[up] 2. UK Government: Tackling Drugs Together. UK Drug Strategy 1995. HMSO.
[up] 3. UK Government: Tackling Drugs to Build a Better Britain. 1998. HMSO.
[up] 4. Stoker, P: The History of Harm Reduction. 2001 NDPA.
[up] 5. US Biennial National Household Surveys, correlated with Michigan Schools System. (Ongoing).
[up] 6. Just Say No International. Just Say No Club Book/Teen Leader Guide.1989. Walnut Creek, CA USA.
[up] 7. UK Home Affairs Select Committee. The Government’s Drug Policy – Is it working?. 2002. HMSO.
[up] 8. Tobler, N. Meta-analysis of 143 adolescent drug prevention programs. 1986. Journal of Drug Issues.
[up] 9. Benard, B. Characteristics of Effective Prevention Programs. 1987 acquisition. (Contact NIDA, USA).
[up] 10. Sparks, M. Project Revitalisation – Vallejo, California. 1998. Prevention Pipeline (NIDA).
[up] 11. Kelling, G. L., Coles C. M. Fixing Broken Windows. 1997. pub Touchstone, NY USA.
[up] 12. Servais, E. Before it’s too late. 1991. SPZ-ASL, Schnellewindgasse 2, B-4700, Eupen, Belgium.
[up] 13. McGarrell, E. F., Hutchens, J.D. Blueprint for a Drug-Free Future. 2003. Hudson Institute, Indianna.
[up] 14. Masi, D. A. Designing Employee Assistance Programs. 1984. Published by Amacom.
NDPA, P O Box 594, Slough, SL1 1AA, UK. Tel/Fax: +44 (1753) 677917.
Attachment to Peter Stoker paper to ECAD Conference, May 03,Stockholm
By Bonnie Benard (With annotations by Peter Stoker to relate to the UK scene)
A. Multiplicity: the causes of drug/alcohol abuse are multiple: personality, environmental, behavioural (Kandel, Logan, 1984; Hawkins et al, 1951). Programmes tackling only one area usually fail. You should target multiple systems (youth, families, schools, community, workplace, media, etc). Also use multiple strategies (information, lifestyles, positive alternatives, community policies) (Botvin, 1982).
B. Target whole community. School based programmes benefit less than community based approaches.
C. Target all youth. not just “high rise for prevention. Adolescence is seen to be a high risk time (for all youth in terms of health compromising behaviour. Labelling ‘high risk’ youth can provoke stigmatisation and lead to self fulfilling prophecies. There is however an argument for defining ‘high risk’ communities where an additional resource over and above the general prevention effort could be justified.
D. Build drug prevention into general health promotion. Drug abuse has been found by several (Lofquist, 1993) to be part of a complex pattern of interrelated factors e.g. delinquency, truancy, school failure, precocious sexuality, which share common antecedents.
E. Start early and keep going! Even in infancy there are influences in later behaviour. Developmental difficulties by age 3 are difficult to overcome (Burton White). Here it is of course relevant to mention Trevor Williams, Noreen Wetton and Alysoun Moon of the Southampton University team who have demonstrated so graphically in their “Jugs and Herrings” research paper that primary age children are not blissfully ignorant of drugs and alcohol. Prevention programmes starting from what children actually know are essential. Many secondary schools still seem to regard Years 11 and 12 as the age at which discussion of drugs or indeed sexuality) should be facilitated. Stable doors and horses come to mind!
F. Adequate quantity. ‘One shot prevention efforts do not work (Kumpfer, 1988) There must be a substantial number of interventions, each of a substantial duration Project DARE (Drug Abuse Resistance Education) initiated by Los Angeles Police and now in several other states delivers no less than seventeen onehour lessons to any given year and this is only part of the school programme.
G. Integrate family/classroom/school/community life. This is easier to say than do, but where it has happened results have been enhanced.
H Supportive environment, empowerment. Where young people are encouraged to participate and take responsibility their behavioural outcomes are improved. In Britain now peer education methods proven elsewhere are being piloted.
J. Knowledge/Attitudes/Behaviour. Address these as a set, i.e. each must be directly tackled rather than assuming one will flow from another. The behavioural component is in part addressed by social skills development, but also supported by positive reinforcement activities drug free social/sporting events, commendations (preferably with something for everyone), media coverage, etc. Research suggests that Social Learning Theory (Bandura, 1977) produces some of the most profound improvements.
K. Drug specific curriculum. Affective education programmes that had not specifically covered drugs (including alcohol) were found unsuccessful, even though they addressed knowledge, attitudes and lifeskills.
L. Gateway drugs. So called because people now using heavy end drugs almost always started on these. Gateway drugs can be tobacco, alcohol and cannabis or, these days in Britain, even heroin! Concentration on prevention of these is therefore likely to prevent use of all substances. British research by MORI (Parents against Tobacco, 1990), showed that of youth who smoked tobacco 50% had also tried an illegal drug compared with only 2% of those who did not smoke tobacco. It should be particularly noted that cannabis is far from harmless: physical, mental and social damage is now being increasingly accepted as a reality.
M. Salient material. Whatever is used needs to identify with the audience, including:
• Ethnic/cultural sensitivity
• Appeal to youth interests
• Short term outcomes to be emphasised as important to youth as well as long term
• Appealing graphics and appropriate language, readability
• Appropriate to real age/reading age a key factor:
In a survey of 3,700,000 young American children, 25% of 9 year olds felt ‘some’ to ‘a lot’ of peer pressure to try drugs or alcohol (Weekly Reader, 1987).
N. Alternatives. Activities have to be plausible, be more highly valued than the health-compromising behaviour. Too often these alternatives are poorly thought through.
P. Lifeskills. Development of these will be of wider benefit than drug prevention. Included will be:- Communication, Problem Solving, Decision Making, Critical Thinking, Assertiveness, Peer Pressure Reversal, Peer Selection, Low Risk Choice Making, Self Improvement, Stress Reduction and Consumer Awareness (Botvin, 1985).
Choosing your friends has been found in some research to be more effective than resisting the peer pressure of said friends. Consumer awareness is a ‘companion’ to resisting peer structure, i.e. resisting media pressure.
Q. Training prevention workers. For the school setting the greater emphasis on experiential and interactive work requires teacher training to extend into youth work skills. Community development skills are valuable in taking school initiatives into the community. Imported ‘prestige’ role models are all very well, but good results have been achieved with parents, peers, teachers, or outside agency workers.
R. Community norms. Consistency of policies throughout schools, families and communities can greatly enhance impact.
S. Alcohol norms. Because of its dual status as a beverage and as an culturally accepted drug, alcohol is problematic for prevention. However, heart disease and tobacco prevention programmes have shown that societal norms can be changed.
T. Improve schooling! Listed here as a target because of its important correlation with healthy lifestyle. Within the current British economic and academic climate the most realistic hope may lie with co operative learning, see the TRIBES program for example.
U. Change Society. Don’t just stop with improving schools: add your voices to pressure for improvement in employment. housing, recreation and self development. (See ‘Project Revitalisation’ in Vallejo, California, for example). It is naive to suppose that prevention can take place in a political vacuum. Jessop recognises that failing to acknowledge the need for macro environmental improvement while at the same time placing the responsibility for health solely with the individual is tantamount to ‘blaming the victim’.
V. Design, implementation, evaluation. Evaluations have generally concentrated on outcomes rather than the quality of design. However, implementation is as much dependent on engaging all sectors of the community (be it a school. a workplace, or a town) as it is on quality of design. Evaluation should therefore measure process as well as outcome.
W. Goal setting. Unrealistic or immeasurable goals help no one. It is important to set not only long4erm outcome goals (for prevention is long term) but also “process goals” such as increased involvement of parents and community, academic success, increased student teacher interaction. and so on.
X. Evaluation and amendment. Prevention workers have been criticized for giving too little attention to this area., the crushing shortage of funds has much to do with it (in America the ratio of funding between interdiction policy and prevention is about 200: 1). This lack of emphasis on evaluation has been the Achilles heel which pro drug campaigners have gleefully attacked. Effective evaluations have been those including longitudinal design, multiple measures of process as well as outcome (Tobler, 1986), and cost benefit analysis (CBA). CBA is perhaps the greatest marketing tool prevention has; where CBA has been applied substantial cost effectiveness has been demonstrated.

Bonnie Benard can be contacted at NIDA, the National Institute on Drug Abuse, 6001 Executive Boulevard, Bethesda,MD 20892-9561, or

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