Preventing drug misuse by young people: we need to do more than ‘just say no’

Most drug prevention programmes, such as school-based drug education and mass media campaigns, aim to encourage individuals not to use drugs. These strategies have had mixed, often disappointing, results (Paglia & Room 1998). Despite significant expenditure on prevention, youth drug use has increased in most developed countries over the past several decades (Bauman & Phongsavan 1999). This has occurred in tandem with increased rates of other problem behaviours among youth, such as suicide, antisocial behaviour and depression (Rutter & Smith 1995; Keating & Hertzman 1999). Three inter-related areas of research indicate that we need to take a broader view of how to prevent drug problems. The first is research on the aetiology of drug abuse, problem behaviour, crime and psychosocial disorders among young people. The second is research on developmental transitions in child and adolescent development. The third is research on macro-environmental influences—economic, social and physical environmental influences—on health and social outcomes. These three areas are described briefly below. Research on the aetiology of drug use (Hawkins et al. 1995; Spooner 1999) has shown that it is one of a number of types of problem behaviour in adolescence (Jessor 1998) that includes crime (Jessor 1998; National Crime Prevention 1999; Loeber & Farrington 2000) and poor mental health and school dropout, all of which share common antecedents and impair preparation for adulthood. Shared risk factors for drug use and other problem behaviours include: individual characteristics (e.g. a genetic predisposition to poor behavioural self-regulation and difficulties with affect regulation and social skills), family factors (e.g. parental family management techniques, family relationships, role modelling, conflict and stress), peer relationships (e.g. rejection by prosocial peers and association with antisocial peers), local neighbourhood (e.g. neighbourhood poverty) and macro-environmental factors (for example, socioeconomic deprivation). These risk factors often co-occur and may have direct and indirect effects on drug use. For example, the family may directly affect drug use and other problem behaviours by teaching social values and social skills, and indirectly affect other risk factors, e.g. influencing the choice of peers or moderating the impact of local poverty. This research on the aetiology of drug use and other problem behaviours has demonstrated that there are multiple influences on drug use behaviours, and that these influences contribute to a range of other problem behaviours. Drug prevention is ineffective if it does not address the range of contributing risk factors. It is inefficient if it does not draw from, and work collaboratively with, related programmes such as crime prevention. Early childhood is one of the most critical periods for the development of competencies in all domains of life (Keating & Hertzman 1999; National Research Council 2000). Developmental pathways and transitions in early childhood are affected by social circumstances that have been hypothesized to produce biological changes that may affect competency and wellbeing over the life-cycle (Keating & Hertzman 1999). There are two competing explanatory models for this developmental process. The latency model proposes that psychosocial and socio-economic conditions early in life have a marked effect on later life, independently of intervening experience. It assumes that there are critical and sensitive periods in brain development during which failure to receive appropriate stimulation impedes normal development. The pathways model proposes that life events have a cumulative effect and that psychosocial and socio-economic circumstances throughout life reinforce or ameliorate these effects. According to this model, successful interventions must address core developmental processes during important transition points in development ( Keating et al. 1999). The ability to negotiate a transition successfully is important for coping with the next stage of a person’s life. Failure to cope with a transition can create problems that cumulate with subsequent experience. Interventions at transitions points are most effective because at these times individuals are open to advice and to learning how to cope with transitions. From the perspectives of both the latency and pathways models, concentrating drug prevention efforts in adolescents is providing too little, too late. There is growing evidence that early childhood interventions are cost-effective ways to reduce drug abuse, criminal behaviour and employment when they are adequately implemented in high-risk populations (Karoly et al. 1998; Tremblay et al. 1999; National Research Council 2000). Drug prevention efforts have focused typically on changing individuals. There is increasing evidence that the macro-environment, which includes economic, social and physical dimensions, influences drug use and other health-related behaviours. In the economic environment, there has been concern with socio-economic gaps and clusters of economic disadvantage. Over the past several decades the overall wealth of many developing countries has increased, but the disparity in income between rich and poor has also increased (Gregory & Hunter 1995; Smith et al. 1995; Parham et al. 2000). Widening socio-economic gaps have been associated with poorer health (Wilkinson 1997; Acheson 1999; National Centre for Epidemiology and Population Health 1999), and a range of adverse impacts on ‘developmental health’: the physical and mental health, wellbeing, coping and competence of a population (Keating et al. 1999). As argued by Kawachi and others, income inequality contributes to resentment, which in turn disrupts social cohesion (Kawachi et al. 1999; Winter 2000). Societies with lower social cohesion tend to have less trust and poorer social controls, particularly over young people. Areas with higher income disparities have also been found to invest less in human capital, including schools, further contributing to socio-economic problems. Low socio-economic status, which includes unemployment, typically clusters in communities, creating shared environmental risk factors, such as a lack of positive role models, for children growing up in those areas (Kawachi et al. 1999; Vinson 1999). A range of economic policies have been proposed to address socio-economic deprivation. These include taxation, education and labour policies (Turrell et al. 1999). None of these policies are under the control of the health sector but they affect significantly the health and wellbeing of the population. Characteristics of social environments have been found to affect health and wellbeing (Yen & Syme 1999). Modern developed societies are marked by individualism and libertarianism. While these philosophies have brought economic benefits, they have also undermined shared norms, values and feelings of belonging, alienating youth and producing pessimism and a sense of powerlessness (Halpern et al. 1995; Eckersley 1997). Davis has identified the following characteristics of social environments that encourage resilience in children: neighbourhood schools, churches, and youth organizations that provide positive role models for children and infrastructure for youth programmes; strong social networks in which adults are connected with each other; and residents who have a sense of control over key areas of their lives, for example, owning their own homes (Davis 1999). The physical environment within which young people grow up is a third macro-environmental influence on child development. For example, policies that discourage young people from using public spaces, without providing safe spaces in which to socialize, may alienate youth and increase opportunities for drug subcultures to develop (White et al. 1994; Malone & Hasluck 1998; Malone et al. 2000). Building roads that increase reliance on private cars rather than public transport can contribute to a loss of community (Newman & Kenworthy 1999). Some social groups are affected disproportionately by the macro-environmental influences, including the economically disadvantaged. These include sole parents (Hess et al. 1995), rural populations (Higgs 1999; Taylor et al. 1999; Senior et al. 2000) and indigenous peoples (Hunter 2000), all of which have higher rates of youth drug use (Fergusson et al. 1994; Forero et al. 1999; Hall et al. 1999; Bond et al. 2000) in substantial part because of their economic disadvantage. For example, family structure is not related to youth drug use or delinquency when factors such as family adjustment and socioeconomic status are taken into account (Dryfoos 1990; Fergusson et al. 1994; Sokol-Katz et al. 1997). From the above research on aetiological and developmental contributors to drug use and other health and social outcomes, it is apparent that drug prevention programmes need to address multiple risk and protective factors for drug and other problem behaviours, with attention to macro-environmental factors as well as the individual factors and family factors. Macro-environmental factors are influenced by multiple government departments, not just health. Consequently, consideration of the impact of all government policies and programmes on the health and social impacts on the population is required (Keating et al. 1999; Marmot 2000; National Research Council 2000). For example, policies that affect the quality of public school education, urban planning policies, policing of public spaces and decisions about public transport should all be required to demonstrate that they would not have a negative impact on the health and social wellbeing of the population. Further, a shift in public spending to support the crucial period of early childhood has been recommended. Keating examined the costs of failing to provide supportive contexts for developmental health, in terms of reduced school performance, increased antisocial behaviour and reduced work participation. He identified significant cost benefits from investing in child development. These cost benefits were greatest, up to $7 return for every $1 invested, when the investments were made in the most deprived sectors of the population (Keating et al. 1999). This finding is consistent with other reviews of the cost benefits of early childhood interventions (Schorr & Schorr 1989; Karoly et al. 1998; National Research Council 2000). Adoption of these perspectives will broaden our understanding of problem drug use. It will be seen as one of a group of health risk behaviours that share antecedent risk factors. Early childhood will be recognized as a period of critical importance. The influence of macro-environmental factors will be recognized from birth—long before exposure to drug prevention programmes. Such a broader perspective will encourage intersectoral collaboration, the adoption of a long-term perspective and the abandonment of the current system of uncoordinated, short-term, drug-specific prevention programmes. This editorial was based upon a report commissioned by the Australian National Council on Drugs (ANCD). The views expressed in this paper are those of the authors and not the ANCD.