Bridging the Gap between Substance Use Prevention Theory and Practice

Transcription

1 CHAPTER 14 Bridging the Gap between Substance Use Prevention Theory and Practice BRIAN R. FLAY JOHN PETRAITIS INTRODUCTION In theory, there is nothing so practical as a good theory. When it comes to substance use (su) there is no shortage of theories (Flay, Petraitis, & Miller, 1995). In fact, Lettieri, Sayers, and Pearson (1980) reviewed 43 different theories of su 20 years ago, and the list has grown measurably since then. Unfortunately, there is a gap between su theories and su prevention. Years of work developing and refining theories has rarely resulted in practical changes in how prevention programs are planned, implemented, or evaluated. This chapter examines different forms of su, different causes of su, and different approaches to su prevention. It offers one theory of su prevention as an example of the practical applications of theory and goes on to discuss how theory has gained prominence historically and how theory can become even more important in su prevention. DIFFERENCES IN SU AND SU PREVENTION To have its greatest influence on the design, implementation, and evaluation of su prevention programs, prevention specialists and su theorists must be explicit about what they mean by su. It is not simply a black-and-white, dichotomous construct that has the same meaning for all theorists and prevention planners; it is, of course, a continuous variable that has degrees or varying BRIAN R. FLAY Preventive Research Center, University of Illinois at Chicago, Chicago, Illinois JOHN PETRAITIS Department of Psychology, University of Alaska, Anchorage, Anchorage, Alaska

2 290 Brian R. Flay AND John Petraitis shades of gray and an assortment of meanings. Some of the gray comes from the fact that for any particular substance there are at least four levels of use. It is widely recognized that the use of a substance, such as alcohol, progresses from no use through trial and experimental use, regular use, and, for some people, abuse and dependence (Clayton, 1992; Flay et al., 1983; Leventhal & Cleary, 1980; May hew, Flay, & Mott, 2000). It is also widely recognized that with a variety of substances available, there are at least four different patterns of SU. As Kandel (1989; Kandel & Yamaguchi, 1993) and others (e.g., Graham et al., 1991) note, people typically experiment with alcohol and/or tobacco first, progress to alcohol intoxication, move to marijuana use (if at all), and only advance to other substances, such as cocaine, after gaining experiences with tobacco, alcohol, and marijuana. If the different levels of use are crossed with the different patterns, the term "substance use" potentially has at least 16 different meanings, ranging at the lowest end of trial or experimental use of alcohol or tobacco to the high end of dependence on illicit drugs. Acknowledging the various definitions of su is important because some theories, such as the social development model of Hawkins and Weis (1985), have more obvious implications for the prevention of lower levels and earlier patterns of su. Other theories, such as Sher's (1991) model of vulnerability, have more implications for the prevention of advanced levels and patterns of su. Accordingly, a theory is only capable of improving the design, implementation, and evaluation of a prevention program when the theory and the program focus on the same range of su. Similarly, before theory can contribute to prevention practices, theorists and prevention specialists must be clear about what they mean by "prevention" a term that has different meanings depending on the type of program used to alter behaviors or prevent certain conditions. The Institute of Medicine (IOM, 1994) suggests that programs aimed at reducing the risk of psychological disorders fall into three general categories. Universal prevention uses relatively non-intrusive interventions, delivers the interventions through people who are not necessarily experts in prevention, and aims at either the general public or large subpopulations who, as a group, have "not been identified on the basis of individual risk" (IOM, p. 24). Selective prevention, by contrast, tailors more intensive programs for smaller subpopulations that have above-average risk for developing a particular disorder. It is not assumed that the effects of selective programs will generalize to a broader cross-section of the public. Finally, indicated prevention uses experts to deliver more intensive interventions to individuals (as opposed to subpopulations) who, through individual screening, are found to have a strong pattern of risk factors or who exhibit early symptoms that foreshadow the full development of clinical disorder. At the heart of the IOM typology is the recognition that programs that aim to prevent psychological disorders differ in their breadth (from those that try to affect millions of people at once to those that aim at a few people at a time) and depth (from those that are fairly brief or non-intrusive to those that are longer or more intensive). The same is true of programs that aim to prevent su. The Television, School, and Family Project (TVSFP) was an example of a broad-based program (Flay et al., 1988). The goal of the TVSFP was to reduce or prevent tobacco use in a broad cross-section of adolescents by providing standardized school- and media-based messages that were integrated into usual activities at school, at home, and with parents. Although the project was designed for breadth and involved adolescents in numerous activities for several weeks, it was not designed to provide the depth of other programs, such as the Strengthening the Families Program (SFP, Kumpfer, Molgaard, & Spoth, 1996). The SFP tries to prevent adolescent su with fairly intensive training of parents (through discussion of reinforcement principles, family communication, problem solving, and limit setting), children (through discussion of emotions, social skills, and resistance to peer pressure, among many other things), and entire families (through family therapy and role playing among family members). Although SFP was designed with more

3 Bridging the Gap between Substance Use Prevention Theory and Practice 291 depth than TVSFP, it has less breadth because it was designed specifically for children whose parents were substance abusers (see Chapter 4). It follows from the above discussion that prevention programs can differ in (1) the levels and patterns of su they try to prevent, (2) the degree to which they target the general public or more high-risk individuals, and (3) the intensity of their effort. Considering each of these factors can help prevention planners identify the goals of their programs. However, considering these factors does not identify the means of achieving those goals. That is, the above considerations tell prevention planners where they want to go but not how to get there. Knowing, for example, that they want to prevent alcohol onset with a broad program tells prevention planners nothing about how to design a program that actually reduces alcohol onset in the most efficient manner. For that, prevention planners need a basic understanding of the causes of su. MAJOR INFLUENCES ON SU There have been several reviews of the correlates and predictors of SU, including reviews of research on cigarette smoking (see Conrad, Flay, & Hill, 1992; Mayhew et al., 20(K)), illicit substance use (see Petraitis et al., 1998) and both licit and illicit substance use (see Hawkins et al., 1992). The following are some of the major influences on SU. Substance-Specific Cognitions Expectations although not always accurate abound about the immediate physiological effects of, the social reactions to, the likely legal consequences of, and the less immediate health consequences of su (Stacy et al., 1996). For example, preteens might expect that smoking their first cigarette will make them feel instantly nauseous, will eventually help them look mature, and probably will not give them lung cancer in the long-term future. Numerous longitudinal studies of cigarette smoking and illicit su suggest that substance-related beliefs play an important role in su (for reviews, see Conrad et al., 1992; Petraitis et al., 1998). For instance, Kandel, Kessler, and Margulies (1978) found that 16-year-olds were more likely to use marijuana if, as 15-yearolds, they did not consider its use to be personally harmful, and if they did not fear any negative consequences of its use. Similarly, lessor, Donovan, and Costa (1991) concluded that adolescents who thought the benefits of marijuana use exceeded its costs were more likely to use marijuana as young adults. Prior Experience with su Beliefs about su do not arise from thin air. They can grow from prior experiences with su, and it is widely assumed that one of the best predictors of future behavior is past behavior. This holds true with su (see Petraitis et al., 1998). Several studies have found that past levels of use of a given substance, such as tobacco, can predict future levels of use of that substance. Furthermore, prior use of one substance, such as alcohol, can predict use of other substances, such as marijuana. For instance, we found 14 longitudinal studies in which prior levels of alcohol use significantly predicted subsequent levels of marijuana use, and we found no studies in which alcohol use was not a significant predictor of marijuana use (Petraitis et al., 1998).

4 292 Brian R. Flay AND John Petraitis Substance-Related Attitudes and Behaviors of Other People Beliefs about su no doubt also arise when people listen to others especially peers, parents, and other family members as they voice their endorsement of or opposition to su, and when people watch as others either use or abstain from substances. Although the relationship is less robust than often assumed, studies have shown that adolescent su is more common in families in which the parents have favorable attitudes toward su and engage in some su themselves (see Petraitis et al, 1998). The relationship between peer su and an adolescent's own su is, by contrast, very robust: study after study has fairly consistently found that the substance-related attitudes and behaviors of peers predict an adolescent's use of cigarettes (see Conrad et al., 1992) and illicit substances (see Petraitis et al., 1998). Thus, having friends who have positive attitudes toward su and who use substances might put people at risk for su. We say "might" because there is mounting evidence that the link between peer su and an adolescent's own su might arise, in large part, because adolescents who are inclined toward su select friends who also use or are inclined to use substances (Bauman & Ennett, 1996). Family Environment In our review of longitudinal studies of illicit su (Petraitis et al., 1998) we found that the childhood home environments of people who are more heavily involved in su are different from the home environments of people who are less involved in su. For instance, longitudinal studies generally (although not consistently) suggest that the people who are at greater risk for su are those who come from homes with (1) higher socioeconomic status; (2) divorced or separated parents; (3) parents who were abusive, negligent, or offered little emotional support; and (4) a discrepancy between the quality of parent-child relations that the children wanted and the quality that they obtained. There is also some evidence that children are at risk for su later in life if they come from homes where a parent has a history of a psychiatric disorder or the parents were permissive with the child (see Petraitis et al., 1998). Deviant Behaviors and Unconventional Values For some people, su is not the result of difficult home environments or the substance-related attitudes of other people. Rather, it is the result of a rejection of conventional values and an attraction to unconventional behaviors. Our review of longitudinal studies (Petraitis et al., 1998) found that adolescents were at risk for su if they either (1) rejected traditional values, (2) were critical of mainstream society, (3) were tolerant of deviance, (4) were politically detached or alienated, (5) were not religious, or (6) were not conunitted to education. Moreover, several studies found that adolescents were at risk for su if they had a history of disobedience or deviant behavior, such as vandalism. Personality Traits and Affective States For other people, su might be driven either by basic and stable personality characteristics or by more transient affective states. In line with this, several studies have shown that su is more common among people who characteristically (1) lack persistence or the will to achieve long-term

5 Bridging the Gap between Substance Use Prevention Theory and Practice 293 goals, (2) lack emotional stability or emotional control, (3) are disinhibited and seek thrills, (4) are rebellious, (5) are assertive, or (6) are aggressive or hostile toward others (see Petraitis et al., 1998). Furthermore, there is some evidence that su is more common after periods of anxiety, low self-esteem, and depressed mood. However, the evidence concerning anxiety, self-esteem, and depression generally shows that these affective states are not consistently or strongly related to su (see Petraitis et al., 1998). Biological Influences Not only does su tend to run in families (see Sher, 1991) it is also linked to a variety of biological factors (see Cloninger, 1987; Phil, Peterson, & Finn, 1990; Tarter, Alterman, & Edwards, 1985). For instance, studies have shown that cigarette use among girls (but not boys) is positively related to testosterone levels (Bauman, Foshee, & Haley, 1992); the early onset of puberty predicts the onset of cigarette use (Wilson et al., 1994); and levels of serotonin and dopamine influence cocaine consumption among rats (White, 1997). There are two likely mechanisms by which biological influences contribute to su. First, biological factors, such as genetic differences or interuterine exposure to substances, might affect su indirectly through more direct effects on personality characteristics that increase the risk of su. For example, genetics might contribute to risk-taking characteristics, which in turn might contribute to su. In line with this type of indirect effect, research suggests that substance abuse among adolescents is more common among those with difficult temperaments (particularly high activity levels) than among adolescents with less difficult temperaments (Tarter et al., 1990). Second, biological factors might affect su more directly by making some people either more susceptible to the reinforcing physiological effects, such as relaxation, of various substances or have stronger physiological cravings for specific substances. Certainly, some people are genetically more sensitive to the physiological effects of substances. As examples: dopamine metabolism in adults might be affected by in utero exposure to substances (Middaugh & Zemp, 1985); similarly, maternal smoking during pregnancy seems to increase the risk that children will smoke during adolescence (Kandel, Wu, & Davies, 1994); and Asians who have inherited a genetic mutation of mitochondrial aldehyde dehydrogenase or human alcohol dehydrogenase metabolize alcohol more slowly, have stronger alcohol-flush reactions, and are less susceptible to alcoholism than Asians who do not have these genetic variants (Thomasson et al., 1993). In the case of cigarette use, some research suggests that the strength of physiological reactions ^be they pleasing or aversive to substances is a risk factor for su. In particular, Pomerleau et al. (1993) demonstrated that people who have the strongest physiological reactions (either positive or negative) to nicotine are at greatest risk to escalate from experimental smoking to regular smoking. Comorbidity A startling number of people who have problems with substance abuse or dependence also have other psychological disorders (Mueser, Bennett, & Kushner, 1995). For instance, having a major depressive episode triples the odds that a person will also have an abuse or dependence problem within a year, and having bipolar disorder increases the odds by more than 600% (Kessler et al., 1996; see also Johnson, Posner, & Rolf, 1995.) Moreover, when people have histories of psychological disorders and su problems, the chances are extremely high that the psychological disorder came first. Specifically, Kessler et al. (1996) found that when people had a history of both a

6 294 Brian R. Flay AND John Petraitis psychological disorder and a su problem, only 12.8% reported that the su problem clearly preceded the psychological disorder, whereas 83.5% reported that the psychological problem predated the su problem, suggesting that psychological problems might cause su problems. Self-Medication Some researchers (e.g., Khantzian, 1985) have suggested that su arises when people try to cope with difficult emotional challenges, such as divorce, or, as indicated earlier, when people try to control the symptoms of psychological problems. In line with this, Bibb and Chambless (1986) found that 43% of nonalcoholic patients with agoraphobia reported using alcohol to medicate their anxiety, and 90% of agoraphobics with alcoholism turned to alcohol to reduce their anxiety. Although there is compelling evidence that people with psychological problems have high levels of su, in general, there is far less evidence that people selectively seek out specific substances that effectively counteract the symptoms of their disorders. For instance, people with depression do not seem to seek out stimulants to combat lethargy, and people with anxiety do not seem to seek out the calming influences of marijuana any more than people who do not suffer from anxiety. In fact, Mueser et al. (1995) concluded that clinical diagnoses are not a major determinant of which substance people use and that people with clinical diagnoses are at risk for abusing whichever substances are most available to them. THE THEORY OF TRIADIC INFLUENCE Understanding su is a bit like cooking. Preparing a dish requires two things: a list of ingredients and a recipe that tells how those ingredients get combined. Similarly, understanding su requires a list of factors that contribute to su and an understanding of how those factors work together to influence su. That is, before we can understand su we need to understand what factors are involved, what causal processes link one factor to another, which factors affect su directly and which factors affect su more indirectly, which factors mediate the effects of other factors, and which ones moderate the effects of others. For this, we need theories. This section describes a theory that identifies many of the factors involved in su and examines how those factors might mediate or moderate each other. Specifically, it describes the theory of triadic influence (TTI) and shows how it, as just one example of su theory, can be used to advance su prevention. Three Streams and Multiple Levels of Influence The TTI argues that three basic types or streams of influences contribute to su and its prevention (Flay & Petraitis, 1994). First, there are cultural factors that might contribute primarily to attitudes toward su. An unfavorable (or favorable) media depiction of su is just one example of a cultural/attitudinal influence, and beliefs or expectations about su would be another. Second, there are social or interpersonal factors that might contribute primarily to the social pressures people experience that lead them to believe that su is either acceptable or not. Growing up in a home where alcohol is not (or is) consumed is an example of such an influence. Having negligent parents or bonding with substance-using peers are two more examples of situational or microenvironmental factors that might contribute to social pressures to use substances. Third, there are intrapersonal factors that might affect one's motivation to use or abstain

7 Bridging the Gap between Substance Use Prevention Theory and Practice 295 Culturat/AttitudinalStream Social/Normative Stream Intrapersonal Stream Cultural Environment (e.g., local employment rates, public policies about SU) Interpersonal Environment (e.g., Parental negligence. unconventbnal siblings) Biology/Personality (e.g., poor impulse control genetic sensitivity to SU) r Expected Evaluation 1 consequences of expected L OfSU J jatnsequenes J Perceived norms concerning SU Motivation to] comply with close QthersJ Interpersonal Self, skills determination A (willpower) FIGURE The theory of triadic influence. from substances or might affect one's ability to resist pressures to use substances. Weak impulse control, genetic sensitivity to substances, and self medication are examples of intrapersonal influences. The TTi also argues that within each stream of influence there are several levels or tiers of influence. As shown in Figure 14.1, variables at the top of each stream are the furthest removed from SU (e.g., rigid parenting style, neighborhood unemployment rate, and sociability). As such, the effects of such "ultimate" influences are the most distal, the most mediated, and often the most difficult for anyone or any program to change. Below the ultimate-level influences are distal influences (e.g., bonding to deviant role models and rebelliousness). When compared to ultimate-level influences, distal-level influences are less numerous, less far removed from su, have effects on su that are less mediated, and are usually less difficult to change. Then, near the bottom of Figure 14.1, there is a smaller set of proximal influences (e.g., substance-related attitudes, normative beliefs, resistance skills) that probably have direct effects on intentions to use substances and actual su and might be the easiest for individuals or programs to alter (at least in the short run). Within-Stream Mediating Processes Mediation lies at the core of TTI. The theory does more than just provide a list of variables that contribute to su; it offers suggestions about the numerous mediating processes that link each variable to other variables and su. In another paper (Flay & Petraitis, 1994), we describe in detail the mediating processes by which the effects of ultimate-level influences in the attitudinal stream

8 296 Brian R. Flay AND John Petraitis begin tofilterdown through distal- and proximal-level influences. Some of thatfilteringprocess is depicted in the left side of Figure For example, in the cultural/attitudinal stream, we suggest a process by which ultimate-level attitudinal influences, such as media depictions of su, might contribute to su by contributing to distal-level attitudinal influences, such as subjective beliefs about the general consequences of su. These distal-level attitudinal influences, in turn, probably contribute to the proximal-level and attitudes towards su. Although we are not aware of any studies that assessed the mediating processes involving ultimate-level attitudinal influences, several studies support the mediating processes between distal and proximal attitudinal influences. Stacy, Newcomb, and Bentler (1991) found that adolescents who lack conventional values (a distal variable) have more positive expectations for alcohol use (a proximal variable) and are at greater risk for su. Webb et al. (1993) found that an adolescent's tolerance for deviance contributes to positive expectations for alcohol use which, in turn, contributes to su. A similarfilteringprocess (from ultimate, through distal, to proximal) is probably at work with social influences as well. As depicted in the center of Figure 14.1, inadequate schools, poor home environments, and negative parenting styles might contribute to su by weakening conventional bonds and increasing exposure to role models who use substances. Weakened bonds and exposure to su by role models might, in turn, affect the amount of social pressure people feel to use or avoid substances. In line with the mediating processes among TTI'S social influences, Rodriquez, Adrados, and De La Rosa (1993) found that weak involvement of parents in the lives of their adolescents (an ultimate-level social influence) is replaced by increased involvement with deviant peers (a distal influence); involvement with deviant peers, in turn, contributes to su among the adolescents. Also in line with TTI. Flay et al. (1994) found that smoking by parents and friends (distal influences) contributes to beliefs that smoking is widespread and socially acceptable (proximal influences); and these beliefs, in turn, influence intentions to smoke and subsequent smoking. In addition, the previously citedfilteringprocess probably exists with the intrapersonal influences. Therefore, as depicted on the right side of Figure 14.1, genetic traits and basic personality characteristics (such as behavioral control and emotional control) might contribute to su indirectly by contributing to a person's self-concept and competence in various social roles. Self-concept and competencies then contribute to the strength of someone's determination to use or avoid substances and to his or her skills in situations where su is being considered. Unfortunately, empirical support for the mediating processes among TTI'S intrapersonal influences is weak because few studies have assessed the links among the different levels of intrapersonal influences. However, Dielman et al. (1989) found that having an external health locus of control (an ultimate-level influence) contributes to low self-esteem (a more distal influence) which, in turn, contributes to alcohol use among adolescents. Similarly, Newcomb and Harlow (1986) found that an external locus of control contributes to a sense of meaningless and lack of direction in life which, in turn, contributes to su. Between-Stream Influences Although mediation within streams lies at the core of TTI, some mediating processesflowbetween streams in Figure For instance, Ellickson and Hays (1992) found that weak bonds to school (a distal variable) contribute to positive expectations for su (a proximal variable) which, in turn, contribute to su. Another example is that poor behavioral control (an ultimate-level intrapersonal influence) might contribute to su through its contribution to involvement with substance-using peers (a distal-level social influence). In fact, Wills et al. (1994) found just such an effect. Similarly, social influences might be mediated by attitudinal influences. For instance, Ellickson and Hays

9 Bridging the Gap between Substance Use Prevention Theory and Practice 297 found that weak bonds to school (a distal-level social influence) contribute to positive expectations for su (a proximal-level attitudinal influence) which, in turn, contribute to su. In addition to mediating influences between streams, there are moderating processes, or interactions, between streams. For example, we do not believe that poor behavioral control (an ultimate-level intrapersonal influence) increases or decreases parental su (a distal-level social influence). However, it might alter the effects of parental su so that parental su has a stronger effect on adolescents who lack behavioral control but might have no effect on adolescents who have strong behavioral control. In a similar manner, exposure to a program (an ultimate-level attitudinal influence) that teaches refusal skills might have no effect on adolescents who already have strong social skills (a distal-level intrapersonal influence) but might have its strongest effect on adolescents who have the weakest social skills. Developmental Influences Experimentation with su is largely a phenomenon of adolescence and young adulthood. Although TTi has no developmental stream, it recognizes that three milestones of adolescent development might contribute to the three streams of TTI. First, attitudinal processes might be affected by the development of formal operational thought and the ability to think hypothetically, consider various alternatives, envision possible outcomes, and plan ahead. Until these complex mental skills are fully developed, young adolescents have limited capacities to understand or foresee the longterm consequences of their behavior (Orr & IngersoU, 1991). This, paired with generally good health (Brindis & Lee, 1991), might contribute to an adolescent's cavalier attitudes about health (Leverison, Morrow, & Pfefferbaum, 1984) and tendency to underestimate personal risks from health-compromising behaviors (Millstein, 1991), such as su. Second, intrapersonal processes might be affected by an adolescent's search for self-identity or sense of self a search that might lead to experimentation with different ideas, values, and lifestyles. The search is not easy, and during it adolescents are psychologically vulnerable (Konopka, 1991), self-conscious, concerned about social appearances (Elkind & Bowen, 1979), and highly self-critical (Lowenthal, Thumer, & Chiriboga, 1975; Rosenberg, 1985), possibly because for thefirsttime they can envision discrepancies between who they are and who they want to be or ought to be (Damon, 1991; Higgins, 1987). su might serve as a coping mechanism as adolescents search for an identity and feel vulnerable and self-conscious during this stage of intrapersonal flux (Flammer, 1991). Finally, social processes might be influenced by the independence adolescents seek from parents. Usually beginning at puberty, positive interactions between adolescents and parents diminish (Steinberg, 1991), and adolescents begin seeking independence from their parents (Montemayor & Flannery, 1991). Their independence from parents is replaced by greater dependence on peers, and relations with peers "become more pervasive, more intense, and carry greater psychological importance" (Foster-Clark & Blyth, 1991; p. 786) during adolescence. Not too surprisingly, adolescents are more susceptible to and compliant with social pressures than are children or adults (Bemdt, 1979; Landsbaum & Willis, 1971). This is especially true of pressures to engage in deviant acts (Brown, Clasen, & Eicher, 1986), like su. THE ROLE OF THEORY IN SU PREVENTION Careful attention to theories about the onset of and prevention of su is necessary for the proper development, implementation, and evaluation of su prevention. Following are six specific

10 298 Brian R. Flay AND John Petraitis ways in which theory functions in the advancement of prevention (see also Flay & Petraitis, 1991). 1. Theories can identify risk and protective factors. All prevention programs must provide some intei*vention (such as information about su or access to adult supervision after school) designed to decrease or delay su. However, program developers need to know what to provide. And, this is thefirstfunction of theory; theory guides the development of interventions by helping identify protective factors (knowledge about the dangers of su) and risk factors (lack of adult supervision after school) for su. It is no coincidence that su prevention programs only started teaching refusal skills after Bandura's (1977) theoretical work on self-efficacy. In this and countless other cases, theories have suggested the basic content that has gone into developing new and more effective approaches to prevention. 2. Theories can expand the list of risk and protective factors. Not only must interventions provide something, they probably must provide many things. Like TTI, most theories of su suggest that a great many risk and protective factors influence su. Therefore, theories can remind us that the most effective interventions are probably those that target a wide range of risk and protective factors. Accordingly, theories help us design more effective approaches to prevention. For instance, one glance at Figure 14.1 reminds prevention planners that su has its roots in numerous cultural/attitudinal, social/normative, and intrapersonal influence and reminds planners that simple interventions are likely to have modest effects. Moreover, Figure 14.1 reminds planners that among the three streams of influences, only a few factors probably affect su fairly directly (such as attitudes toward su) and that most factors probably have indirect effects (genetically inherited traits). 3. Theories can point toward intervening variables and modifiableriskand protective factors. Having a thorough list of risk and protective factors is not enough. Program developers also need to focus their intervention on risk and protective factors that are modifiable (such as self-esteem) rather than permanent (such as gender), inflexible, or difficult to modify (poverty). Knowing, for example, that rural males are at high risk for dependence on smokeless tobacco is of little use in developing effective prevention programs for them. Their gender, after all, is not something program providers can change. However, if program developers understand the causal processes and intervening variables that link gender and smokeless tobacco use they are in a better position to develop an effective program. Theories, in conjunction with empirical support, explicitly articulate the intervening causal process that link unmodifiable variables with su. Consequently, theories give program developers more than a list of risk and protective factors: theories also give developers a list of protective factors (knowing that smokeless tobacco can cause cancer) that can be modified and enhanced by a program and a list of risk factors (poor refusal skills) that can be modified and reduced by the program. 4. Theories can point toward the appropriate audience. In addition to telling us what to provide, theories also tell us for whom to provide it. That is, theories can tell us for whom an intervention is likely to be most effective. Not all people have the same level of risk, and, consequently, not all people ought to be targeted for equal levels of su prevention. Furthermore, not all people will have the same reaction to a program. For instance, a program that emphasizes the dangers of su might reduce the su of low risk-takers but might promote su among high risk-takers. Thus, theories especially theories that articulate moderating or interaction effects can suggest populations for which programs ought to be delivered, populations for which the program should not be delivered, and

11 Bridging the Gap between Substance Use Prevention Theory and Practice 299 variables that might moderate a program's effect. Consequently, theories can suggest whether prevention efforts should be universal, selective, or indicated. 5. Theories can help anticipate program power. Theories can also lead to consensus regarding the potential magnitude of program effects. Because theories often include a variety of causes, they can alert us to the fact that prevention programs that target one or two causes of su might have only modest effects because they do not address the other factors that contribute to su. Judging the potential impact of a program against TTI, for example, might help program planners more realistically anticipate the size of their program's impact. No doubt well-intended su prevention efforts have been conducted around the country under the assumption that simply teaching kids about the dangers of su will, by itself, have a meaningful impact on their audience. However, if program providers realized that information about substances and su is only one variable in a more complex web of variables, they would come to expect more modest effects from their programs. In short, theories help us anticipate whether prevention programs will have small, medium, or large effects. 6. Theories point toward likely program effects. Finally, theories can help locate the various effects of an intervention. All programs are probably designed to have an immediate effect on some variables that are expected to have subsequent effects on sv. For instance, prevention programs might try to increase knowledge about the negative consequences of su in the hope that such knowledge will change attitudes toward su and, eventually, reduce su. By spelling out the intervening variables, theories allow us to measure the appropriate variables and help us locate the immediate, intermediate, and long-term effects of a program. Theories, like TTI, suggest exactly which variables are most likely to be affected by a program. Efforts To Incorporate Theory in su Prevention Although a good theory has these and other practical benefits, the use of theories in su prevention has varied over the past decades. Beginning in the 1960s, the use of theory in su prevention progressed throughfivegenerations, relying on increasingly complex theories of su. KNOWLEDGE-BASED TRAINING. Thefirstgeneration of prevention efforts popular during the 1960s followed a universal approach to prevention and attempted to deter su by presenting information about its harmful consequences. This knowledge-based approach relied on the assumption that adolescents would stay away from su if they knew about the risks involved in su, especially the long-term risks to personal health. Although such efforts appealed to common sense, their attention to theory was fairly limited, and the programs were usually unsuccessful for several reasons. First, the novel information they provided about drugs sometimes increased su (Goodstadt, 1978). Second, their effects were limited by an emphasis on the long-term consequences of su consequences that are of little importance or value to youth (Evans, 1976). Third, they focused on only one aspect of su (the consequences of su) while not focusing on other determinants. As noted previously, altering only one determinant of a behavior will not be of much use if the unaltered determinants are important. Fourth, although these programs might have provided information about the negative consequences of su, they only provided one source of information about su, while competing sources of information (such as peers and the media) might have overpowered the effects of knowledge provided by the programs. Fifth, these programs adopted a strategy of universal

12 300 Brian R. Flay AND John Petraitis prevention, providing a relatively modest intervention across the board. As such, they provided unnecessary information to people who were never at risk for su, and they provided too little intervention for those who were at greatest risk for su. VALUES-BASED TRAINING. Thefirstgeneration of prevention attempted to deter su by educating adolescents about the consequences of su. The second generation tried to deter su by changing adolescents' values with regard to su and by teaching students how to make decisions using their knowledge and evaluations of consequences. These affective approaches ^popular during the 1970s relied on the assumption that adolescents need to know more than the risks involved in su; they need to have negative values about su and its consequences and positive values about nonuse and its consequences. For example, student athletes might be deterred from su if they were taught to think about their values and realize that su might interfere with athletic performance. However, like knowledge-based efforts, values-based efforts did not rely heavily on theory and had limited success in pait because they generally focused on only one cause of su (evaluations of the consequences of su), tried to alter values with only one source of information (such as a health educator) that might have been overwhelmed by other sources (peers and the media), and provided universal prevention when more selective or indicated prevention was warranted. The success of values-based efforts hinges on the ability of relatively short-lived and superficial presentations to change relatively long-standing and central values of adolescents something that now seems unrealistic. As a result, values-based efforts might have taught adolescents about values but might not have permanently changed those values or had a lasting effect onsu. RESISTANCE SKILLS TRAINING. Thefirsttwo generations were characterized by getting adolescents to recognize and appreciate the risks involved in su. The third generation focused on teaching adolescents to recognize and say "no" to social pressures to use drugs. During the 1980s, prevention researchers focused on the role of social influences (particularly from peers and the media) as determinants of su and developed approaches to making youth aware of the extent to which their behavior is influenced by peers and the mass media, raising their awareness of the misperceptions of their peers' behavior, and teaching them skills to resist social pressures. Like earlier prevention efforts, resistance skills efforts tended to adopt a strategy of universal prevention, providing the program, for example, to all youth in school without knowing their individual risks for su or whether they came from a subpopulation with elevated risk. These approaches had more success than the previous approaches, but their effects were still small, fragile (Flay, 1985), and short term (Flay, Koepke, et al., 1989; Murray et al., 1989), perhaps because (1) most of them still focused on only some of the major determinants of su and generally did not consider other determinants (such as knowledge and values); (2) the interventions tended to be of short duration; (3) the social influences in adolescents' social environments were not changed by the interventions; and (4) the interventions tended to be more universal than selective or indicated, thereby delivering more program than was necessary for some individuals but far less than was necessary for individuals at greatest risk for su. Interventions developed and tested by Botvin (1996; Botvin et al., 1990) at Cornell University were the exception in that they tended to be more like, and foreshadowed, the fourth-generation approaches. COMPREHENSIVE INTERVENTIONS. Since the mid-1980s, researchers like Botvin (1996), Pentz et al. (1989), Biglan et al. (1995,1996), and Dishion et al. (1996) have emphasized more comprehensive approaches to prevention. First, they focused simultaneously on several

13 Bridging the Gap between Substance Use Prevention Theory and Practice 301 major determinants of su. For example, Botvin's Life Skills Training program tried to prevent su by teaching adolescents (1) better decision-making and problem-solving skills, (2) skills for controlling anxiety and anger, (3) techniques for self reinforcement, (4) social skills and ways to overcome shyness, and (5) about su and pressures toward su (such as direct peer pressure and media influences). Second, they were comprehensive and tried to curb more than just su. For instance, Botvin's program tried to enhance social skills, improve personal decision-making skills, and promote self-control skills. Third, their programs used multiple agents to deliver the intervention. These included health professionals, teachers, older peers, parents, the mass media, schools, and other community organizations (such as the American Lung Association). Such programs not only involved these agents in the educational or change process but also aimed to change the schools and communities in which youth grow up. And finally, the interventions were of longer duration. It is clear that short-term programs will have short-term effects because most of the influences that contribute to su will continue to exist long after a short program has ended. As such, more recent programs have included booster sessions that occur months or years after the initial intervention ended. INTENSIVE SELECTIVE INTERVENTIONS. Despite the improved effects of comprehensive universal interventions, it is clear from the TTI model that for programs to have larger effects that persist over time, they must change the social context or the broader cultural environment in which youth spend most of their time. Accordingly, another trend among more recent programs has been a move toward more selective and/or indicated interventions. For example, both Dishion et al. (1996) and Kumpfer et al. (1996) have developed interventions that not only have strong theoretical foundations but rely on theory to screen for individuals who are at greatest risk for su. These programs are not universally provided to everyone in a geographic area or school. Rather, they are only provided to those individuals who show a strong pattern of risk factors. For example, Dishion et al.'s Adolescent Transitions Program focuses on adolescents who have four or more risk factors. COMPREHENSIVE MULTILEVEL INTERVENTIONS. The emerging generation of preventive interventions will (1) involve universal, selective, and indicated levels of prevention activities; (2) target multiple levels of influence, from ultimate to proximal; and (3) address multiple behaviors or problems in a single, integrated program. The FAST Track project by the Conduct Problems Prevention Research Group (CPPRG: Bierman, Greenberg, & CPPRG, 1996; CPPRG, 1992; McMahon, Slough, & CPPRG, 1996) already provides one example of this approach. In education, some Comprehensive School Reform models also exemplify such a strategy. (Flay, 2002, Ray, Allred, & Ordway, 2001.) CONCLUSION Reducing su has been an elusive goal, and su prevention programs for the past 30 years have had, at best, only modest success. Although programs have relied increasingly on theory and increasingly more comprehensive theory, they still have a long way to go to make full use of su theories. Therefore, it is our belief that su could be reduced further if program planners relied more on theory when designing their programs. A heavy reliance on theory could build programs upon a foundation of (1) less than obvious risk and protective factors, (2) multiple risk and protective factors that are modifiable within the context of the intervention, (3) careful consideration of how audience characteristics might moderate or interact with program effects, and (4) realistic

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