Drug and Alcohol Abuse

SCHOOL
Gilbert J. Botvin
Kenneth W. Griffin

COLLEGE
Leigh Z. Gilchrist

SCHOOL

Drug and alcohol abuse are important problems that affect school-age youth at earlier ages than in the past. Young people frequently begin to experiment with alcohol, tobacco, and other drugs during the middle school years, with a smaller number starting during elementary school. By the time students are in high school, rates of substance use are remarkably high. According to national survey data, about one in three twelfth graders reports being drunk or binge drinking (i.e., five or more drinks in a row) in the past thirty days; furthermore, almost half of high school students report ever using marijuana and more than one-fourth report using marijuana in the past thirty days. Marijuana is the most commonly used illicit drug among high school students. However, use of the drug ecstasy (MDMA) has seen a sharp increase among American teenagers at the end of the twentieth century, from 6 percent in 1996 up to 11 percent reporting having tried ecstasy in 2000. Indeed, at the beginning of the twenty-first century, ecstasy was used by more American teenagers than cocaine.

Many educators recognize that drug and alcohol abuse among students are significant barriers to the achievement of educational objectives. Furthermore, federal and state agencies and local school districts frequently mandate that schools provide health education classes to students, including content on drug and alcohol abuse. The Safe and Drug-Free Schools Program is a comprehensive federal initiative funded by the U.S. Department of Education, which is designed to strengthen programs that prevent the use of alcohol, tobacco, drugs, and violence in and around the nation's schools. In order to receive federal funding under this program, school districts are expected to develop a comprehensive education and prevention plan, which involves students, teachers, parents, and other members of the community. Thus it is clear that schools have become the major focus of drug and alcohol abuse education and prevention activities for youth. This makes sense from a practical standpoint because schools offer efficient access to large numbers of youth during the years that they typically begin to use drugs and alcohol.

Since the 1970s several approaches to drug and alcohol abuse education and prevention have been implemented in school settings. Traditionally, drug and alcohol abuse education has involved the dissemination of information on drug abuse and the negative health, social, and legal consequences of abuse. Contemporary approaches include social resistance and competence-enhancement programs, which focus less on didactic instruction and more on interactive-skills training techniques. The most promising contemporary approaches are conceptualized within a theoretical framework based on the etiology of drug abuse and have been subjected to empirical testing using appropriate research methods. Contemporary programs are typically categorized into one of three types: (1) universal programs focus on the general population, such as all students in a particular school; (2) selective programs target high-risk groups, such as poor school achievers; and (3) indicated programs are designed for youth already experimenting with drugs or engaging in other high-risk behaviors.

Traditional Educational Approach

Information dissemination. The most commonly used approach to drug and alcohol abuse education involves simply providing students with factual information about drugs and alcohol. Some information-dissemination approaches attempt to dramatize the dangers of drug abuse by using fear-arousal techniques designed to attract attention and frighten individuals into not using drugs, accompanied by vivid portrayals of the severe adverse consequences of drug abuse.

Methods. Informational approaches may include classroom lectures about the dangers of abuse, as well as educational pamphlets and other printed materials, and short films that impart information to students about different types of drugs and the negative consequences of use. Some programs have police officers come into the classroom and discuss law-enforcement issues, including drug-related crime and penalties for buying or possessing illegal drugs. Other programs use doctors or other health professionals to talk about the severe, often irreversible, health effects of drug use.

Effectiveness. Evaluation studies of informational approaches to drug and alcohol abuse prevention have shown that in some cases a temporary impact on knowledge and antidrug attitudes can occur. However, 1997 meta-analytic studies by Nancy Tobler and Howard Stratton consistently fail to show any impact on drug use behavior or intentions to use drugs in the future. It has become increasingly clear that the etiology of drug and alcohol abuse is complex, and prevention strategies that rely primarily on information dissemination are not effective in changing behavior.

Contemporary Educational Approaches

Social resistance approach. There has been a growing recognition since the 1970s that social and psychological factors are central in promoting the onset of cigarette smoking and, later, drug and alcohol abuse. Drug abuse education and prevention approaches are increasingly more closely tied to psychological theories of human behavior. The social resistance approach is based on a conceptualization of adolescent drug abuse as resulting from pro-drug social influences from peers, persuasive advertising appeals, and media portrayals encouraging drug use, along with exposure to drug-using role models. Therefore, social influence programs focus extensively on teaching students how to recognize and deal with social influences to use drugs from peers and the media. These resistance-skills programs focus on skills training to increase students' resistance to negative social influences to engage in drug use, particularly peer pressure.

Methods. The goal of resistance-skills training approaches is to have students learn ways to avoid high-risk situations where they are likely to experience peer pressure to smoke, drink, or use drugs, and/or acquire the knowledge, confidence, and skills needed to handle peer pressure in these and other situations. These programs frequently include a component that makes students aware of prosmoking influences from the media, with an emphasis on the techniques used by advertisers to influence consumer behavior. Also, because adolescents tend to overestimate the prevalence of tobacco, alcohol, and drug use, social resistance programs often attempt to correct normative expectations that nearly everybody smokes, drinks alcohol, or uses drugs. In fact, it has been proposed that resistance skills training may be ineffective in the absence of conservative social norms against drug use, since if the norm is to use drugs, adolescents will be less likely to resist offers of drugs.

Effectiveness. Resistance skills programs as a whole have generally been successful. A comprehensive review of resistance skills studies published from 1980 to 1990 reported that the majority of prevention studies (63%) had positive effects on drug use behavior, with fewer studies having neutral (26%) or negative effects on behavior (11%)–with several in the neutral category having inadequate statistical power to detect program effects. Furthermore, several follow-up studies of resistance skills interventions have reported positive behavioral effects lasting for up to three years, although longer term follow-up studies have shown that these effects gradually decay over time, suggesting the need for ongoing intervention or booster sessions.

The most popular school-based drug education program based on the social influence model is Drug Abuse Resistance Education, or Project DARE. The core DARE curriculum is typically provided to children in the fifth or sixth grades and contains elements of information dissemination and social influence approaches to drug abuse prevention. DARE uses trained, uniformed police officers in the classroom to teach the drug prevention curriculum. Despite the popularity of DARE, 1998 evaluation studies of DARE by Dennis Rosenbaum and Gordon Hanson examined the most scientifically rigorous published evaluations of DARE and concluded that DARE has little or no impact on drug use behavior, particularly beyond the initial posttest assessment. Some of the possible reasons why DARE is ineffective may be that the program is targeting the wrong mediating processes, that the instructional methods are less interactive than more successful prevention programs, and that teenagers may simply "tune out" what may be perceived as an expected message from an ultimate authority figure.

Competence enhancement approach. A limitation of the social influence approach is that it assumes that young people do not want to use drugs but lack the skills or confidence to refuse. For some youth, however, using drugs may not be a matter of yielding to peer pressure but may have instrumental value; it may, for example, help them deal with anxiety, low self-esteem, or a lack of comfort in social situations. According to the competence-enhancement approach, drug use behavior is learned through a process of modeling, imitation, and reinforcement and is influenced by an adolescent's pro-drug cognitions, attitudes, and beliefs. These factors, in combination with poor personal and social skills, are believed to increase an adolescent's susceptibility to social influences in favor of drug use.

Methods. Although these approaches have several features that they share with resistance-skills training approaches, a distinctive feature of competence-enhancement approaches is an emphasis on the teaching of generic personal self-management skills and social coping skills. Examples of the kind of generic personal and social skills typically included in this prevention approach are decision-making and problem-solving skills, cognitive skills for resisting interpersonal and media influences, skills for enhancing self-esteem (goal-setting and self-directed behavior change techniques), adaptive coping strategies for dealing with stress and anxiety, general social skills (complimenting, conversational skills, and skills for forming new friendships), and general assertiveness skills. These skills are best taught using proven cognitive-behavioral skills training methods: instruction and demonstration, role playing, group feedback and reinforcement, behavioral rehearsal (in-class practice) and extended (out-of-class) practice through behavioral homework assignments.

Effectiveness. Over the years, a number of evaluation studies have been conducted, testing the efficacy of competence-enhancement approaches to drug abuse prevention. These studies have consistently demonstrated behavioral effects as well as effects on hypothesized mediating variables. More important, the magnitude of reported effects of these approaches has typically been relatively large, with studies reporting reductions in drug use behavior in the range of 40 to 80 percent. Long-term follow-up data indicate that the prevention effects of these approaches can last for up to six years. In summary, drug abuse prevention programs that emphasize resistance skills and general life skills (i.e., competence-enhancement approaches) appear to show the most promise of all school-based prevention approaches.

Challenges for School-Based Drug Abuse Prevention

In the final analysis, research-based prevention programs proven to be successful are unlikely to have any real public health impact unless they are used in a large number of schools. However, programs with proven effectiveness are not widely used. Drug prevention programs most commonly used in real-world settings are those that have not shown evidence of effectiveness or have not been evaluated properly. Thus an important area that deserves further attention is how effective school-based drug abuse prevention programs can be widely disseminated, adopted, and institutionalized. Furthermore, once effective programs are disseminated, steps must be taken to ensure that programs are implemented with sufficient fidelity. Regardless of how effective a prevention program may be, it is not likely to produce the desired results unless it is provided in full and by qualified and motivated staff.

Alcohol, tobacco, and other drugs used in American colleges and universities represents a public health problem of critical proportions. Institutions of higher education are under increased scrutiny due to policy developments from the public health, governmental, and higher education sectors in the 1990s that place revised importance on initiatives addressing student substance use. Despite variation in campus use rates, no institution of higher education is immune to substance use and its related adverse consequences. The negative effects reach beyond the parameters of the campus, catapulting this issue into the forefront of the national agenda. It is in the interest of society to design and implement policies and programs that aim to curb college student substance use and abuse.

Extent of Use

Alcohol, tobacco, and other drug use represents a ubiquitous problem for American colleges. Alcohol and other drug use on college campuses radically increased between 1993 and 1997, then stabilized between 1997 and 1999. This trend produces great concern as college student use rates are expected to climb due to a radical increase in drug use among those aged twelve to seventeen.

Alcohol, tobacco, and marijuana represent the most frequently used drugs on college campuses. Nationwide, 84 percent of college students report having drunk alcohol within the last year, 68 percent within the previous month, and 3.6 percent on a daily basis, according to Henry Wechsler (1996). Tobacco use shares a student use rate similar to alcohol. Schools indicate a significant increase of 28 percent in student smoking during the 1990s, with nearly one-third of college students having smoked within the past year. Drug use rates are rising on campuses; Arthur Levine and Jeanette S. Cureton estimated that 25 percent of students indicated that they had used some form of illegal drug within the past year. The prevalence of marijuana use rose 22 percent between 1993 and 1999–an increase that occurred among most student demographic groups and at almost all kinds of colleges. Marijuana is used by 24 percent of college students, cocaine by 4 percent, and hallucinogens by nearly 5 percent.

Alcohol

Alcohol is the number one drug of choice for college students of both two-year and four-year institutions, and continues to pose tremendous challenges to higher education. On average, college students consume about 4.5 drinks per week and about two in five college students engage in high-risk or binge drinking at least once in an average two-week period. Binge drinking, consuming five or more drinks in succession for men and four for women, is on a substantial increase, affecting about two fifths of the college population. It accounts for the majority of alcohol consumed and is associated with the bulk of problems encountered on campuses, impacting students' social lives, health, and education.

The negative consequences of student alcohol use span well beyond the parameters of the college campus and affect students, the institution, and the community. Alcohol is associated with increased absenteeism from class and poor academic performance, which results in a lower grade point average. The majority of injuries, accidents, vandalism, sexual assaults and rape, fighting, and other crime, on and off college campuses, are linked to alcohol and other drug use. Unplanned and uninhibited sexual behavior may lead to pregnancy and exposure to sexually transmitted diseases and HIV/AIDS. Alcohol use can be associated with injury and death from drinking and driving, alcohol poisoning, and suicide.

Tobacco

Many students perceive the college years as a time of experimentation, although in fact it is a period heavily shaped by environmental factors, social norms, and peer influences. During these years, it is common for intermittent tobacco use to quickly manifest into a life-long habit. For college students, tobacco in the form of cigarettes, smokeless tobacco, and cigars presents a legal and accessible alternative to other drug use. Its use is linked to various cancers, emphysema, heart disease, and other life-threatening illnesses.

Other Drugs

By their nature, illicit drugs do not carry a legal age for purchase, consumption, or distribution. Therefore, colleges must address the problem somewhat differently than they do alcohol and tobacco. Students are entering higher education with increased exposure to drugs, which predisposes them to substance dependency. Variation exists among college and universities as to the rate and type of substances used. Marijuana, amphetamines, hallucinogens, inhalants, cocaine, steroids, and designer drugs represent but a few general forms entering the higher education arena. Marijuana is reported as the illicit drug of choice on campuses. Illicit drug use factors into tragedies that include rape, overdose, vandalism, violence, and death. Memory loss, diminished concentration and attention, increased absenteeism, impaired academic performance, and physical illness are also associated with drug use.

Secondhand Effects

The secondhand effects of substance use on campus are often overlooked and underappreciated for the deleterious effects they may have on students and the quality of their collegiate experience. Students who abstain, use legally, or in moderation often suffer secondhand effects from the behaviors of students that use substances in excess. Nonbinging and abstaining students may become the targets of insults and arguments, physical assaults, unwanted sexual advances, vandalism, and humiliation. Sleep deprivation and study interruption results when these students find themselves caring for intoxicated students. Passive smoke is associated with life-threatening health risks, and smoking within residence halls places people at risk due to fire.

Campus Environment

Perceptions of campus use, campus climate, substance availability, awareness of campus policies and enforcement, and students' family histories of substance abuse impact the extent of substance use on any given campus. The campus and surrounding community exert profound influence on innumerable facets of student life. Establishments encircling college campuses that cater specifically to college students contribute to the substance use climate by selling to underage or intoxicated students. The social, academic, and cocurricular milieux are often shaped by the social norms and perceptions related to campus alcohol, tobacco, and other drug use.

Students typically overestimate the amount and the extent of high-risk drinking, tobacco use, and illicit drug use on their campus and on college campuses in general. These misconceptions lead students to feel pressured and justified in their increased substance use. By exploring how students perceive substance use, policies, and rule enforcement on campus, college administrators are better able to discern and roughly predict how students will react to the perceptions of social norms.

Social fraternities, sororities, and athletics typify student groups at high risk for substance abuse. Fraternities and sororities often find themselves at the center of growing concern as their mere presence on campus is associated with higher campus-wide levels of substance use, particularly alcohol consumption. Leaders of Greek organizations, particularly male members, accounted for the highest alcohol consumption on many college campuses. Due to the integral social role these organizations occupy on most college campuses, the practices they espouse often advocate the use of alcohol, tobacco, and other drugs.

Intercollegiate athletics represents an important aspect of the college experience. However, the college athlete may experience anxiety associated with the dual roles and conflicting expectations of being both an athlete and a student. Attempting to rectify this discourse, college athletes may become increasingly susceptible to substance dependency. Collegiate athletes are more likely to use alcohol and smokeless tobacco, and experience binge drinking more than nonparticipating students. Colleges and universities compound the problem by sending students mixed messages concerning substance use by endorsing alcohol and tobacco industry advertising at collegiate sporting events.

Policies

Affecting the campus environment relies heavily on the pervasive commitment of the college or university. Focused policy, procedures, prevention strategies, data gathering, counseling, and referral approaches enable schools to effectively address this problem. Institutions often find themselves caught in a legal quagmire when they attempt to combat rising substance use and are confronted with issues of legal responsibility and institutional liability while simultaneously acknowledging the behavioral and health implications related to substance abuse.

Local, state, and federal governments play a central role in assisting and bolstering higher education's efforts to reduce substance use and the resulting problems that plague American college campuses. Federal legislative such as the 1986 amendments to the Higher Education Act of 1965, Drug-Free Schools and Communities Act of 1989, and the Crime Awareness and Campus Security Act of 1990 represent such initiatives. The 1998 Parental Notification law permits schools to inform parents if their child violates the rules or laws governing alcohol or controlled substances. The Drug-Free Schools and Campuses regulations mandate that schools prepare a biennial report, which certifies that the school has implemented and assessed prevention policy and programs and documents the consistency of policy enforcement. This report must be made available to anyone who requests it.

With increasing cost pressures on colleges, it is difficult to assure adequate and continuous funding for substance-related programs and policy enforcement. In 1993, the Higher Education Center for Alcohol and Other Drug Prevention was established by the United States Department of Education to assist in developing and carrying out substance prevention policies and programs. The U.S. Department of Education and other granting organizations provide national funding support in an effort to address this issue. Specialized task forces and advocacy groups, such as the National Institute on Alcoholism and Alcohol Abuse task force on college drinking, illustrate the nation's commitment to this problem.

Substance abuse is not a campus-centered problem but one that impacts the entire community. To effect change, institutions of higher education acknowledge the need to form committees and coalitions, comprised of administration, students, parents, faculty, alumni, campus organizations, governmental and law enforcement agencies, and the community. By activating multiple, campus-wide policy levers, campus leaders ensure that initiatives span all facets of the institution.

Schools are tightening regulations, strengthening academic requirements, adjusting course scheduling, and offering extended hours for library and recreational facilities, while providing alternative alcohol-free campus-sponsored activities. Schools are withdrawing endorsement of alcohol and tobacco industry advertising on campus and establishing substance-free residences. By targeting social groups such as fraternities and sororities for programming and monitoring of policy compliance, schools are attempting to further shape the social climate. Novel disciplinary actions exhibit the decisive consequences of such behavior, provide support services, and offer mandatory alcohol or drug assessment with the possible introduction of counseling, Twelve Step, and treatment services.

Programs

Through a paradigm that conceptualizes students' college experience systemically, substance-related strategies strive to alter the social, physical, intellectual, legal, and economic environment on campus and in surrounding communities. Effective initiatives offer diversified programs that account for students' developmental level year in school, age, and level of readiness to change behavior with special attention to the first-year experience.

A variety of creative and versatile approaches are available to institutions of higher education to address issues related to substance use. Education, prevention, counseling, and treatment programs are the most commonly utilized. Approaches that promote increased understanding about substance use and the related effects, provide suggestions for alternative substance-free activities, and attempt to counter misconceptions around social norms comprise the foundation to effective program initiatives.

Standardized programs, developed and distributed by external vendors, offer schools an alternative method for educating students. Many schools find these programs beneficial because of the variety of issues targeted. With the advent of novel technology, innovative and interactive computer programs add to the program arsenal. Often expensive, standardized programming may not to be a viable option for institutions with limited resources.

Campus-initiated programming offers another option for colleges and universities. These efforts may include programming such as alcohol awareness month, safe spring break, and substance-free social activities. The formation of substance use task forces, student organizations, and committees corrals the campus community around efforts to devise strategies and initiate change in campus norms, perceptions, and climate. Typically cheaper than standardized initiatives, these methods are readily utilized.

Higher education must recognize that alcohol and other drug use and the problems that result from substance abuse are never entirely going to go away. Nevertheless, through continued commitment, campus communities significantly impact the problem through policy and program initiatives that are directed at altering social norms, climate, and practices. To initiate and maintain change in higher education with respect to alcohol, tobacco, and other drugs, programs, policies, and partnerships must become permanent and pervasive fixtures on college and university campuses.