Prevention and Education

"In 2016, about 1 in 9 youths aged 12 to 17 (11.4 percent) reported that they had participated in alcohol, tobacco, or drug use prevention programs outside of school in the past year (Table A.4B in Appendix A). This estimate was similar to the percentages in 2004 to 2015, but it was lower than the percentages in 2002 and 2003. Nevertheless, in any given year since 2002, the majority of youths did not participate in prevention programs outside of school in the past year."

"In 2016, 71.8 percent of youths aged 12 to 17 who were enrolled in school in the past year reported having seen or heard drug or alcohol use prevention messages at school (Figure 10). This percentage was lower than the percentages in 2002 to 2013, but it was similar to the percentages in 2014 and 2015. In 2002, for example, 78.8 percent of adolescents who were enrolled in school reported exposure to substance use prevention messages at school.

"In 2016, 72.7 percent of youths aged 12 to 17 reported having seen or heard drug or alcohol use prevention messages in the past year from sources outside of school, such as posters, pamphlets, the radio, or television (Figure 10). The percentage in 2016 was lower than the percentages in 2002 to 2012, but it was similar to the percentages in 2013 to 2015."

" Substantial differences were found in perceived availability of the various drugs (Tables 9-10 to 9-12). In 2022 the percentage of 12th graders reporting it would be fairly easy or easy to get a drug varied from 12% or less for heroin, crack, and crystal methamphetamines to 69% and above for alcohol, vaping devices, and marijuana.

" In general, the more widely used drugs are reported to be available by higher proportions of the age group, as would be expected. The substances with the highest levels of use in 2022, specifically marijuana, alcohol, and vaping devices, also place in the top three in terms of perceived availability.

" Older adolescents generally perceive drugs to be more available. For example, in 2022, 26% of 8th graders said marijuana would be fairly easy or very easy to get (which we refer to as “readily available”), versus 49% of 10th graders and 70% of 12th graders.

" Higher availability among both the more widely used drugs and also older age groups is consistent with the notion that availability is largely attained through friendship circles. (Friends clearly are the leading source through which 12th graders obtain prescription drugs, as discussed above.) The differences among age groups may also reflect less willingness and/or motivation on the part of those who deal drugs to establish contact with younger adolescents.

" Marijuana appears to be readily available to the great majority of 12th graders; in 2022, 70% reported that they think it would be very easy or fairly easy to get—far higher than the proportion who reported ever having used it (38%).

" There is a considerable drop in availability after marijuana, alcohol, cigarettes, and vaping; the next most readily available class of drugs for 12th graders is amphetamines, with 33% saying these drugs would be very or fairly easy to get, followed by hallucinogens other than LSD (31%).

" Substances with the lowest availability among 12th grade students in 2022 are crystal methamphetamine (8%), crack (11%), heroin (12%), cocaine powder (12%), and steroids (16%).

" In each grade similar percentages of students reported they could fairly or very easily get a vaping device, e-liquids with nicotine, or flavored vaping solutions. In 8th grade the percentage were, respectively, 35%, 33%, and 31%. In 10th grade they were 52%, 51%, and 49%. In 12th grade they were 69%, 67%, and 66%.

" In 2022, 34% of 8th graders, 48% of 10th graders, and 54% of 12th graders thought that cigarettes would be fairly easy or very easy for them to get if they wanted some.

" Alcohol has the highest level of availability in each grade. The percentage saying it would be fairly easy or very easy to get in 8th grade was 42%, in 10th grade was 59%, and in 12th grade was 78%.

" Drug availability levels are lowest in 8th grade. Even so, in 2022 marijuana was reported as readily available by about one in four (26%) 8th grade students.

" Because many inhalants—such as glues, butane, and aerosols—are universally available, we do not ask about their availability. See Table 9-12 for the full list of drugs included in the questions for 12th graders; a few of these drugs were not asked of the younger students (see Tables 9-10 and 9-11)."

"Compared to teens in families with strong Family Ties, teens in families with weak Family Ties are:
"• Four times likelier to have tried tobacco;
"• Four times likelier to have tried marijuana; and
"• Almost three times likelier to have tried alcohol."

"Four studies evaluated the cost-effectiveness of prescription opioid misuse prevention, three of which were conducted in the USA and one in South Korea. The interventions identified for the USA setting were a school-based programme, a family-centred programme and misuse-deterrent opioid formulations; a doctor's database assisting patient risk assessment was evaluated in the South Korean setting. All four studies utilised economic models to evaluate cost and benefit of intervention over 1- to 30-year time horizons.

"Two of the studies evaluated misuse-deterrent opioid formulations against extended-release opioids. White et alReference White, Birnbaum, Rothman and Katz31 conducted a CBA with a third-party payer perspective (i.e. private insurance), using a 1-year time horizon; Kumar et alReference Kumar, Agboola, Synnott, Segel, Webb and Ollendorf27 conducted a CEA considering a health sector perspective with a 5-year time horizon. Both studies included direct costs related to healthcare utilisation.Reference Kumar, Agboola, Synnott, Segel, Webb and Ollendorf27 The White et alReference White, Birnbaum, Rothman and Katz31 budget impact model estimated that there were potential cost-savings ranging from US$0.748 to US$2 billion for the insurance payer; however, the misuse-deterrent opioid prescription cost used in the study was a shadow cost or a similar cost of a branded opioid. In contrast, the misuse-deterrent opioid prescription costs used by Kumar et alReference Kumar, Agboola, Synnott, Segel, Webb and Ollendorf27 were actual drug costs that resulted in significant costs to the healthcare system. Sensitivity analysis indicated that the model was sensitive to misuse-deterrent opioid price, where a 40% reduction in misuse-deterrent opioid prescription cost would result in cost neutrality.

"The study by Crowley et alReference Crowley, Jones, Coffman and Greenberg21 evaluated youth school-based programmes, a family-centred programme or a combination of both, and compared them with having no programme over a 6-year time horizon. Only intervention delivery costs were included in the analysis. A willingness-to-pay (WTP) threshold of US$8667 per case of non-medical opioid misuse prevented was established based on the average societal cost for youth engaged in nonmedical prescription opioid use. Three sets of interventions (Life Skills Training (LST) programme only, Strengthening Families Program 10–14 (SFP:10–14) + All Stars programme and SFP:10–14 + LST) were deemed to be cost-effective, given that the ICER fell below the predetermined WTP threshold of US$8667 to prevent one youth from misusing prescription opioids before the 12th grade.Reference Crowley, Jones, Coffman and Greenberg21

"The South Korean study by Kim et alReference Kim, Kim and Suh25 evaluated an opioid abuse preventive programme, ‘the Network System to Prevent Doctor-Shopping for Narcotics’, which allows doctors access to a database of a patient's previous narcotics use, allowing them to determine if a patient is at risk of misusing narcotics. Over a 30-year time horizon, compared with no programme, implementing the programme was determined to be cost-effective (US$227 per QALY; WTP threshold of US$31 362 per QALY) from a healthcare system perspective. Threshold analysis showed that the programme was 100% cost-effective even when using a WTP threshold of US$900 per QALY. Furthermore, including cost beyond the healthcare system under a societal perspective indicated that the intervention was cost-saving against having no programme.Reference Kim, Kim and Suh25 "

"Three studies evaluated cannabis use prevention interventions. Two studies evaluated school-based interventions and the third study evaluated two family-centred interventions and a web-based intervention.

"A school-based educational programme integrated within different curriculums was evaluated by Mitchel et alReference Mitchel, Hu, Donnell and Swisher28 in the USA. The CEA used a pre–post study design with a 10-month time frame. This study resulted in one of three integrated curriculums being effective. The study did not report an ICER, but instead presented an ‘effective cost’ or a cost-effectiveness ratio by dividing the societal cost of an intervention by the number of students with positive intervention effects. The study showed that the ‘effective cost’ for the religion curriculum with prevention education programme was US$181 per case prevented of cannabis and cigarette consumption.Reference Mitchel, Hu, Donnell and Swisher28 The second school-based intervention, Project ALERT (Adolescent, Learning, Experiences, Resistance and Training), was evaluated with an economic model in the Swedish setting by Deogan et al.Reference Deogan, Zarabi, Stenström, Högberg, Skärstrand and Manrique-Garcia22 Project ALERT aimed to prevent cannabis experimentation and continuation of use compared with a ‘do nothing’ scenario under a societal perspective. In their modelling, they included prevention of regular use of cannabis and transitioning to using other illicit drugs. The study found that the intervention was cost-effective at 20 years, with an ICER of US$2845 per QALY gained. When the time horizon was extended to a lifetime time horizon, the ICER reduced to US$1904 per QALY gained.Reference Deogan, Zarabi, Stenström, Högberg, Skärstrand and Manrique-Garcia22

"The third cannabis prevention study by Pennington et alReference Pennington, Collins, Leigh, Martin, Owen and Fischer30 simulated three different targeted behavioural interventions identified from literature review. Two family-based interventions (Focus on Families and Familias Unidas) were evaluated against active comparators with short time horizons of 1 and 2 years, respectively. The cannabis model generated for the evaluation included intervention, crime and treatment of potential psychotic disorder costs that was described as a partial public sector perspective. Considering the reported WTP threshold of US$31 014, none of the interventions were cost-effective. Reported ICERs were US$153 915 305 per QALY gained (Focus on Families) and US$373 711 per QALY gained (Familias Unidas). The third intervention was modelled over 2 years and was a web-based intervention that resulted in an ICER of US$741 697 per QALY gained, which also exceeded the WTP threshold."

"Five studies were identified that looked at prevention of methamphetamine use, ecstasy use, cocaine use and general drug use. Evaluated preventive interventions were family-centred programmes; school-based interventions; screening, brief intervention and referral to treatment (SBIRT); and motivational interviewing. The first four were evaluated in a universal population whereas motivational interviewing was evaluated in an at-risk or indicated population.

"Hajizadeh et alReference Hajizadeh, Stevens, Applegate, Huang, Kamboukos and Braithwaite24 evaluated a family-centred intervention, ParentCorps, comparing it with a standard pre-kindergarten programme by using a model that simulated pre-kindergarten children over a lifetime. The societal perspective included healthcare (obesity, diabetes and drug use related), judiciary and productivity in addition to intervention costs. ParentCorps was shown to have a savings of US$4703 and an additional 0.27 QALYs.Reference Hajizadeh, Stevens, Applegate, Huang, Kamboukos and Braithwaite24 In the USA setting, an economic evaluation alongside an RCT evaluated the cost-effectiveness of a family-based intervention, Iowa Strengthening Families Program (ISFP), and a school-based intervention, LST, or a combination thereof, in preventing methamphetamine use. Guyll et alReference Guyll, Spoth and Crowley23 undertook economic analyses using both CEA and CBA. The perspective taken was from the employer and included productivity-related costs in addition to employer-funded healthcare costs. The CEA utilised a 5.5- to 6.5-year time horizon, whereas the modelled CBA evaluated a career-duration time horizon (from 18 to 65 years). ISFP, LST and a combination of LST and an adaptation of ISFP (SFP:10–14 + LST) were found to be effective and cost-effective under CBA. ICERs reported for CEA were US$31 664 (ISFP), US$6377 (LST) and US$78 206 (SFP:10–14 + LST) per past-year methamphetamine use case prevented. Modelled CBA results showed positive benefit–cost ratios of 3.84 (ISFP), 19.04 (LST) and 1.56 (SFP:10–14 + LST).Reference Guyll, Spoth and Crowley23 Another school-based intervention, Social and Emotional Training (SET), was evaluated by Klapp et al in seventh to ninth grade students over 5 years. The study reports an intervention cost of US$596 per student and a benefit of US$8292 from avoided social burden of drug use, equivalent to US$13.9 per dollar spent.Reference Klapp, Belfield, Bowden, Levin, Shand and Zander26 The final universal prevention study evaluated SBIRT compared with no SBIRT, under a healthcare perspective CBA for adults. The study reports annual cost-savings equal to a ratio of US$16 per dollars spent.Reference Paltzer, Moberg, Burns and Brown29

"Pennington et alReference Pennington, Collins, Leigh, Martin, Owen and Fischer30 assessed motivational interviewing for at-risk young gay and bisexual men, and a family-based intervention for newly homeless youth for cocaine use prevention. The modelling used a partial public sector perspective by including healthcare and criminal justice sector costs over a 2-year time horizon. Costs in the model included intervention, criminal justice and cocaine dependence treatment costs (including cocaine-specific hospital admission and cocaine-related cardiovascular treatment). Two motivational interviewing interventions were evaluated against educational videos in gay men. ICERs reported for the motivational interviewing interventions were US$698 549 and US$306 455 per QALY gained. The family intervention was evaluated against standard care by modelling a homeless youth population, and reported an ICER of US$1 500 422 per QALY gained.Reference Pennington, Collins, Leigh, Martin, Owen and Fischer30

"In the Pennington et alReference Pennington, Collins, Leigh, Martin, Owen and Fischer30 study, a targeted prevention strategy, motivational and cognitive behavioural intervention, was modelled for prevention of ecstasy use in people who occasionally use illict drugs. The intervention was modelled over a 1-year time horizon and included similar costs as mentioned previously. The intervention resulted in a ICER of US$731 622 per QALY gained.Reference Pennington, Collins, Leigh, Martin, Owen and Fischer30"

"Overall, these data reveal that, while use of individual drugs (other than marijuana) may fluctuate widely, the proportion using any of them is much more stable. In other words, the proportion of students prone to using such drugs and willing to cross the normative barriers to such use changes more gradually. The usage rate for each individual drug, on the other hand, reflects many more rapidly changing determinants specific to that drug: how widely its psychoactive potential is recognized, how favorable the reports of its supposed benefits are, how risky its use is seen to be, how acceptable it is in the peer group, how accessible it is, and so on."

"Compared to teens who have five to seven family dinners per week, those who have fewer than three family dinners per week are twice as likely to say they expect to try drugs (including marijuana and prescription drugs without a prescription to get high) in the future (17 percent vs. 8 percent)."

"The profiles of young cannabis users, at least in the early stages of consumption, do not differ from those of young alcohol or tobacco users. This supports the idea that universal prevention for young people should not focus on cannabis alone, but should be aimed at preventing use of alcohol and tobacco too."

"• Youths aged 12 to 17 were asked several questions related to the extent of support, oversight, and control that they perceived their parents provided or exercised over them in the year prior to the survey interview. In 2012, among youths aged 12 to 17 who were enrolled in school in the past year, 70.3 percent reported that their parents limited the amount of time that they spent out with friends on school nights. This rate in 2012 was similar to the rate reported in 2011 (69.9 percent) and also in 2002 (70.7 percent). In 2012, 81.3 percent reported that in the past year their parents always or sometimes checked on whether or not they had completed their homework, and 80.6 percent reported that their parents always or sometimes provided help with their homework. Both of these rates reported in 2012 were similar to the rates in 2011 (81.1 and 80.4 percent, respectively). The rate in 2012 for parents checking on whether youths had completed their homework was higher than in 2002 (78.4 percent). However, the rate for parents providing help with homework in 2012 was similar to the rate in 2002 (81.4 percent)."

"• Most youths aged 12 to 17 believed their parents would "strongly disapprove" of their using substances. In 2012, 89.3 percent of youths reported that their parents would strongly disapprove of their trying marijuana or hashish once or twice, which also was the rate in 2011 and was similar to the 89.1 percent reported in 2002. Most youths in 2012 (90.5 percent) reported that their parents would strongly disapprove of their having one or two drinks of an alcoholic beverage nearly every day, which also was the rate in 2011, but was higher than the rate in 2002 (89.0 percent). In 2012, 93.1 percent of youths reported that their parents would strongly disapprove of their smoking one or more packs of cigarettes per day, which was similar to the rate reported in 2011 (93.2 percent), but was higher than the 89.5 percent reported in 2002.

"• Youths aged 12 to 17 who believed their parents would strongly disapprove of their using specific substances were less likely to use these substances than were youths who believed their parents would somewhat disapprove or neither approve nor disapprove. For instance, in 2012, past month cigarette use was reported by 4.6 percent of youths who perceived strong parental disapproval if they were to smoke one or more packs of cigarettes per day compared with 31.9 percent of youths who believed their parents would not strongly disapprove. Also, past month marijuana use was much less prevalent among youths who perceived strong parental disapproval for trying marijuana or hashish once or twice than among those who did not perceive this level of disapproval (4.3 vs. 31.0 percent, respectively)."

"• In 2012, past month use of illicit drugs and cigarettes and binge alcohol use were lower among youths aged 12 to 17 who reported that their parents always or sometimes engaged in supportive or monitoring behaviors than among youths whose parents seldom or never engaged in such behaviors. For instance, the rate of past month use of any illicit drug in 2012 was 7.6 percent for youths whose parents always or sometimes helped with homework compared with 18.1 percent among youths who indicated that their parents seldom or never helped. Rates of current cigarette smoking and past month binge alcohol use also were lower among youths whose parents always or sometimes helped with homework (5.1 and 5.9 percent, respectively) than among youths whose parents seldom or never helped (12.8 and 13.4 percent)."

"Unfavorable preliminary findings from the evaluation were reported by Westat in 2002. Beginning in 2002, ONDCP [Office of National Drug Control Policy] took a number of steps that were intended to strengthen the power of the campaign to achieve positive results. These steps included more rigorous ad copy testing and a concentration on anti-marijuana messages. However, the post-2002 results yielded no evidence of positive impacts and some evidence of negative and unintended consequences in relation to marijuana use. Specifically, exposure to advertisements during the redirected campaign was associated with higher rates of marijuana use initiation among youth who were prior nonusers of marijuana."

"Exposure to early life stress, even to more severe forms such as physical and sexual abuse and emotional neglect, is common in the general population. The degree of risk for adult psychopathology tends to be correlated with the severity of childhood maltreatment and the number of childhood SLE [stressful life events]. An important causal pathway that links early life stress to the onset of psychiatric disorders is the altered homeostasis in the HPA [hypothalamicpituitary-adrenal] axis and the altered stress response circuitry that underlies many disorders including anxiety, depression, PTSD, and addiction. There appears to be a direct pathway from chronic stress exposure in prepubertal children via adolescent problem drinking to alcohol and drug dependence in early adulthood that is independent of family history. Of course, this can only occur in individuals exposed to the availability of alcohol or drugs. Early life stress may increase vulnerability to addiction through permanent effects on the expression of genes within the mesolimbic dopamine reward pathway. Early onset of problem drinking in stress-exposed children may exacerbate the deleterious effects on the developing brain. Since a large proportion of stress-exposed children do not go on to develop addiction, clearly resilience factors, including gene–environment interactions, are important. This review of the literature indicates that prevention should focus on early intervention in problem families to forestall maltreatment. Adolescence is a critically vulnerable time for the development of risky drinking habits, and this is an area where prevention, through the development of positive family, peer, and neighborhood-mediating factors, is vital. A holistic approach to the treatment of alcohol and drug dependence is essential since treatment is unlikely to be effective unless underlying impediments such as early life stress are recognized and addressed."

"Youths who used illicit drugs in the past year were significantly less likely than youths who had not used drugs to report that they received prevention messages in a special class about alcohol or other drugs at school or as part of another regular class, such as a health class, although these differences were not large. Nearly half of youths who used illicit drugs in the past year reported that they received education or information about alcohol or other drugs as part of a regular class at school, and nearly 30% of youths who used illicit drugs reported being in a special class about alcohol or other drugs at their schools. Youths who were drunk on 51 or more days in the past year did not differ significantly from their counterparts with regard to receipt of alcohol or other drug education as part of a special class.

"In addition, findings from Table 13.8 suggest that youths’ exposure to prevention messages outside school, such as through the media, was fairly widespread but appeared to be unrelated to illicit drug use or being drunk on 51 or more days in the past year. Nearly 80% of youths who used illicit drugs and more than three-fourths of youths who were drunk on 51 or more days in the past year reported being exposed to prevention messages outside school."

"Prior to 1981, daily use of cigarettes among 12th graders was generally inversely related to SES, with each successively higher SES group smoking less (Figure 5-12f). Between 1981 and 1991, this ordinal relationship diminished substantially because (a) the two highest SES groups showed some gradual increase in use; (b) the next two strata remained unchanged; and (c) the lowest SES group showed a decline in use, which brought it from the highest smoking stratum to the lowest (probably due to its racial composition, as will be discussed in the next section). The net result of this and other trends was a near elimination of the SES differences among 12th-grade students in daily cigarette smoking. From 1992 to 1997, all strata showed an increase in daily smoking.

"From 1997 to 2003, there were sharp declines in smoking in the two highest SES strata— with later and slower downturns in the other strata—once again opening up some differences by SES, though not as large as the differences that existed in the 1970s and 1980s. This time the lowest SES stratum is not at the top but rather down near the bottom of the rankings—again, likely because of its racial composition.

"It is possible that the introduction of the Joe Camel advertising campaign in 1988 helped account for the closing of the socioeconomic gap in the late 1980s, and that its termination in 1997 helped account for the re-emergence of that gap. We know that between 1986 and 1997, the rise in smoking was sharper among 12th-grade boys than 12th-grade girls, and the Camel brand was particularly popular among boys and those whose parents had higher than average education.72 So, the Joe Camel ad campaign appears to have been particularly effective with boys from more educated strata, raising the smoking rate of their SES strata and nearly eliminating the relationship between SES and smoking that existed before and after the years of the campaign for that brand."

"A well-designed and executed multiyear study of the impact of the ONDCP [Office of National Drug Control Policy] anti-drug media campaign on teen initiation of drug use, or cessation of drug use, shows disappointing results for the campaign. The study provides no evidence that the campaign had a positive effect in relation to teen drug use, and shows some indications of a negative impact."

"The extent of exposure to the ONDCP 'Above the Influence' campaign (RQ1) was assessed by cross-tabulating the measures of self-reported exposure to this campaign with each of the four treatment/control cells at the fourth wave of data collection, the point by which such exposure would have taken place for all study participants. Of youth in the control community/control school cell, 73% said they definitely had seen the ONDCP 'Above the Influence' campaign. The self-reported exposure to the ONDCP campaign was similar in the three treatment cells (68–79%).
"We can be confident that this exposure is in large measure due to actual exposure and not false recognition or youth providing what they may have believed to be a socially desirable response, as the percentage reporting they had definitely seen one of the two foils, or fake campaigns, was much less than the percentage reporting exposure to the ONDCP campaign. For example, in the control cell in which 73% of youth said they’d definitely seen the 'Above the Influence' campaign, 14.6% reported definitely seeing one foil and 20.2% claimed they definitely saw the other (false recognition of the two foils was highly correlated — 67% of those claiming recognition of the first foil also claimed recognition of the second). Similar differences were found in the other cells. These levels of false recognition are typical in response to survey questions about self-reported exposure that do not include actual images of an advertisement (see Shapiro (1994) for a discussion of false recognition of messages)."

"The NSPY [National Survey of Parents and Youth] did not find significant reductions in marijuana use either leading up to or after the Marijuana campaign for youth 12 to 18 years old between 2002 and 2003. Indeed there was evidence for an increase in past month and past year use among the target audience of 14- to 16-year-olds, although it appears that the increase was already in place in the last half of 2002, before the launch of the Marijuana Initiative. It will be worthwhile to track whether the nonsignificant decline from the second half of 2002 through the first half of 2003 is the beginning of a true trend. There was a significant decrease in lifetime marijuana use among youth 16 to 18 years of age from 2002 to 2003; however, since this significant decrease was not replicated in either the directly relevant past year or past month time periods, it is difficult to ascribe the change to the campaign."

"In the United States in the 1970s and 1980s, cannabis use appears to have increased the risk of discontinuing a high school education, and of experiencing job instability in young adulthood (Newcombe and Bentler, 1988). The apparent strength of these relationships in cross-sectional studies (e.g. Kandel, 1984) has been exaggerated because those adolescents who are most likely to use cannabis have lower academic aspirations and poorer high school performance prior to using cannabis than their peers who do not (Newcombe and Bentler, 1988). It remains possible that factors other than the marijuana use account for apparent causal relations. To the extent they may exist, these adverse effects of cannabis and other drug use upon development over and above the effect of pre-existing nonconformity may cascade throughout young adult life, affecting choice of occupation, level of income, choice of mate, and the quality of life of the user and his or her children."

Regarding exposure to ONDCP's National Anti-Drug Media Campaign and marijuana use by 12-18 year olds, a report prepared for NIDA by Westat and the Annenberg School of Communication determined: "In sum, the data do not support claims of favorable Campaign influence on any of the four original cognitive outcomes. Moreover, the newly added variable—perceptions of other kids' use of marijuana—shows a significant unfavorable cross-sectional association with both measures of exposure for the Campaign as a whole as well as for the redirected Campaign, and the unfavorable associations extend across most major subgroups of age, sex, race/ethnicity, and risk. It appears possible that perceptions of other kids' use of marijuana may be the mediating mechanism, the 'link' as it were, between Campaign exposure and unfavorable delayed effects on marijuana social norms and initial use." (The four cognitive outcomes are: Intentions to Use Marijuana; Attitude/Belief; Social Norms; and Self-Efficacy to Refuse Marijuana.)

"The community treatment parameter estimate was significant (?=?0.51, p=0.026), indicating that community-level treatment lowered the propensity to use marijuana at the last measurement occasion over and above the effect of the 'Above the Influence' campaign. There was no evidence that school-level treatment affected the marijuana use at the last measurement occasion. Neither the community-level nor the school-level treatment for the 'Be Under Your Own Influence' campaign provided evidence of an effect on the linear rate-of-change for marijuana use. In other words, while there was evidence of a significant effect of the community-based component of the 'Be Under Your Own Influence' campaign on post-test marijuana use, the strong and consistent effects of the prior campaign on both post-tests and reduced linear trajectory of marijuana use were not replicated."

"Westat's analysis of the relationship between exposure to campaign advertisements and youth self-reported drug use in the NSPY [National Survey of Parents and Youth] data for the entire period covered by its evaluation -- assessments that used statistical methods to adjust for individual differences and control for other factors that could explain changes in self-reported drug use -- showed no significant effects of exposure to the campaign on initiation of marijuana by prior nonusing youth. Westat's analysis found significant unfavorable effects -- that is, a relationship between campaign exposure and higher rates of initiation -- during one round of NSPY data and for the whole period of the campaign among certain subgroups of the sample (e.g., 12-1/2- to 13-year-olds and girls). Westat found no effects of campaign exposure on rates of quitting or use by prior users of marijuana."

"The younger and more often teens use marijuana, the more likely they are to engage in other substance use and the higher their risk of developing a substance use disorder. Among high school students, 7.5 percent used marijuana for the first time before the age of 13. CASA’s analysis of national data finds that the average age of initiation of marijuana use among high school students is 14.3 years old. Compared to those who began using marijuana after age 21, those who first used it before age 15 are:
• More likely to have ever smoked a cigarette (93.3 percent vs. 86.4 percent);
• More than twice as likely to have ever misused controlled prescription drugs (56.5 percent vs. 22.9 percent); and
• Two and a half times as likely to have ever used other illicit drugs (70.2 percent vs. 27.8 percent)."

"Annual marijuana prevalence peaked among 12th graders in 1979 at 51%, following a rise that began during the 1960s. Then use declined fairly steadily for 13 years, bottoming at 22% in 1992—a decline of more than half. The 1990s, however, saw a resurgence of use. After a considerable increase (one that actually began among 8th graders a year earlier than among 10th and 12th graders), annual prevalence rates peaked in 1996 at 8th grade and in 1997 at 10th and 12th grades. After these peak years, use declined among all three grades through 2007 or 2008. After these declines, an upturn occurred in use in all three grades, lasting for three years in the lower grades and longer in grade 12. Annual marijuana prevalence among 8th graders increased in use from 2007 to 2010, decreased slightly from 2010 to 2012, and then declined significantly in 2016. Among 10th graders, use increased somewhat from 2008 to 2013 and then declined after that. Among 12th graders, use increased from 2006 to 2011 and then held level through 2016. As shown in Table 8, daily use increased in all three grades after 2007, reaching peaks in 2011 (at 1.3% in 8th), 2013 (at 4.0% in 10th), and 2011 (at 6.6% in 12th), before declining slightly since. Daily prevalence rates in 2016 were 0.7%, 2.5%, and 6.0%, respectively, with one in seventeen 12th graders smoking daily."

"Teens also say they are seeing more peers in school smoking marijuana and more teens (73 percent) report having friends who smoke marijuana regularly (71 percent) – significantly higher than four years ago. Since 2008, there have also been significant declines in teen perceptions that they will lose respect, harm themselves, or mess up their lives if they use marijuana."

"Part 86 of the Drug and Alcohol Abuse Prevention Regulations (Education Department General Administrative Regulations), requires that, as a condition of receiving funds or any other form of financial assistance under a federal program, an institute of higher education (IHE) must 'adopt and implement a drug prevention program as described in § 86.100 to prevent the unlawful possession, use, or distribution of illicit drugs and alcohol by all students and employees on school premises or as part of any of its activities.'
"Changing drug and alcohol policies on campus has never affected federal funding to institutes of higher education. In fact, according to the U.S. Department of Education documentation provided to SSDP on May 2, 2012, no college or university participating in the Federal Student Aid programs has ever lost Title IV eligibility as a result of non-compliance with the DFSCA."

"An SRO [school resource officer] carries out some of the functions of a guidance counselor or social worker, such as mentoring or advising, but with arresting authority and license to carry a weapon in schools. In a national assessment of SRO programs, SROs reported that they spend approximately 20 hours per week on law enforcement activities, 10 hours on advising and mentoring, 5 hours on teaching (e.g. G.R.E.A.T. or D.A.R.E. programming⁹), and another 6 or 7 hours on other activities.¹⁰"

"Overall, these data reveal that, while use of individual drugs (other than marijuana) may fluctuate widely, the proportion using any of them is much more stable. In other words, the proportion of students prone to using such drugs and willing to cross the normative barriers to such use changes more gradually. The usage rate for each individual drug, on the other hand, reflects many more rapidly changing determinants specific to that drug: how widely its psychoactive potential is recognized, how favorable the reports of its supposed benefits are, how risky its use is seen to be, how acceptable it is in the peer group, how accessible it is, and so on."

Drug Abuse Resistance Education (DARE)

A federally funded Research Triangle Institute study of Drug Abuse Resistance Education (DARE) found that "DARE's core curriculum effect on drug use relative to whatever drug education (if any) was offered in the control schools is slight and, except for tobacco use, is not statistically significant."

"Our results are consistent in documenting the absence of beneficial effects associated with the DARE program. This was true whether the outcome consisted of actual drug use or merely attitudes toward drug use. In addition, we examined processes that are the focus of intervention and purportedly mediate the impact of DARE (e.g., self-esteem and peer resistance), and these also failed to differentiate DARE participants from nonparticipants. Thus, consistent with the earlier Clayton et al. (1996) study, there appear to be no reliable short-term, long-term, early adolescent, or young adult positive outcomes associated with receiving the DARE intervention."

Dr. Dennis Rosenbaum, a professor at the University of Illinois at Chicago, completed a six-year study of 1,798 students and found that "DARE had no long-term effects on a wide range of drug use measures"; DARE does not "prevent drug use at the stage in adolescent development when drugs become available and are widely used, namely during the high school years"; and that DARE may actually be counter productive. According to the study, "there is some evidence of a boomerang effect among suburban kids. That is, suburban students who were DARE graduates scored higher than suburban students in the Control group on all four major drug use measures."

"Unfortunately, despite evidence of its effectiveness, Congress appropriated no funding for the Media Campaign in Fiscal Year (FY) 2012, and the campaign is now operating on a minimal budget composed of its unobligated balances as the Youth Drug Prevention Media Program. The Administration has requested $20 million for the Media Program in FY 2013, which will allow the Media Program to implement its two-tiered approach to reach America’s young people with anti-drug messaging both at the national level (tier one) and at the community-specific level (tier two)."

The GAO reported in 2006 that "From fiscal year 1998 through fiscal year 2006, Congress appropriated over $1.4 billion to support the campaign. For fiscal year 2007, the President’s budget requested $120 million for the campaign, an increase over the fiscal year 2006 appropriation, to purchase additional media time and space to increase the reach and frequency of the campaign’s messages, which would restore appropriations to their fiscal year 2005 level."

"Another possibility is that youth who had other protective factors in their lives would be more sympathetic to the aspirational messages, and as a result notice and remember them, producing higher self-reported campaign recognition and spurious positive predictive effects. This explanation, while it cannot be excluded, seems to pose only a modest threat to inference for several reasons. One is that those interested in using a product are more likely to attend to relevant messages, as noted above. Another reason is that evaluation of the prior 'My Anti-drug' campaign found at best neutral and often clear tendencies toward negative associations between earlier self-reported recognition measures of the campaign. It is not clear why spurious positive relationships would be found for the aspirational messages in 'Above the Influence' and not for the negative consequence, refusal skill, and normative messages found in the 'My Anti-drug' effort (Hornik et al. 2008). Even if there was something uniquely protective and compelling about the aspirational theme, this would suggest that the messages were well-targeted, but that the causal process was more complex than captured here, involving reinforcement of existing positive perceptions (Slater 2007). This would qualify but not change the basic findings of these analyses. Finally, the analyses of mediation reported above provide some support for our hypothesized causal processes.
"Therefore, despite the uncertainties associated with use of the self-report measure, ONDCP exposure predicting lower uptake and greater association of non-use with personal aspirations and autonomy seems plausible. At minimum, these results provide reason to believe that the possibly iatrogenic effects of the earlier version of the ONDCP campaign are not evident in response to the rebranded campaign. The negative findings from the evaluation of the 'My Anti-drug' campaign (Hornik et al. 2008) were also based on self-report and associational data in a panel data set."

"GAO's [Government Accountability Office] review of Westat's evaluation reports and associated documentation leads to the conclusion that the evaluation provides credible evidence that the campaign was not effective in reducing youth drug use, either during the entire period of the campaign or during the period from 2002 to 2004 when the campaign was redirected and focused on marijuana use."

"The evaluation of the media campaign reinforces the lack of linkage between the media campaign and teen drug use behavior."

"In the previous reports, based on both favorable trends over time and cross-sectional associations, there was evidence supportive of Campaign effects on talking with children; on beliefs and attitudes regarding monitoring of children; and, in the case of the cross-sectional associations, on doing fun activities with them. These results still hold when Wave 7 parent reports are added, although youth reports of monitoring and talking behaviors are not consistent with parent reports and thus call into question the favorable changes in behavior that may be associated with the Campaign."

"In light of the fact that the phase III evaluation of the media campaign yielded no evidence of a positive outcome in relation to teen drug use and congressional conferees’ indications of their intentions to rely on the Westat study, Congress should consider limiting appropriations for the National Youth Anti-Drug Media Campaign beginning in the fiscal 2007 budget year until ONDCP is able to provide credible evidence of the effectiveness of exposure to the campaign on youth drug use outcomes or provide other credible options for a media campaign approach."

Regarding the federal Anti-Drug Media Campaign, an independent report by Westat and the Annenberg School found that: "Overall, the results are mixed. Some positive trends in youth outcomes occurred over the period covered by NSPY, though evidence linking them to Campaign exposure is weak. In particular, the proportion of nonusing youth saying they would “definitely not” try marijuana over the next 12 months was significantly higher in 2004 than in 2002, the last year prior to the redirected Campaign, which included the Marijuana and Early Intervention Initiatives. On the other hand, the associational analyses provide no evidence to support a claim that the favorable trend in youth intentions was influenced by Campaign exposure."