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 Keating 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 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 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 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 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 Malone et al. 2000). Building roads that increase reliance on private cars rather than public transport can contribute to a loss of community (Newman 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 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.