Chapter 48 Prevention of Substance Abuse

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DOI: 10.1176/appi.books.9781585623440.359197

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Chapter 48. Prevention of Substance Abuse

PREVENTION OF SUBSTANCE ABUSE: INTRODUCTION

Prevention is usually thought of as relevant primarily for children and youths, not adults. For every

drug, several potential targets exist in trajectories of drug use for prevention activities. These

include 1) initiation; 2) continuation; 3) progression within a drug class to more extensive,

intensive use patterns; 4) progression across drug classes; 5) progression to dependence; 6)

regression to cessation; and 7) lapse and relapse. The preponderance of research on substance

abuse prevention to date has focused on two targets: 1) attempts to reduce the likelihood of

initiation (or at least delay onset) and prevalence of use among youths and 2) reducing the

likelihood of relapse among adult drug abusers. In this chapter, we concentrate on primarily

youth-focused prevention.

The strategies that have been used to attempt to reduce the likelihood of initiation or delay onset

are based on at least two assumptions: 1) catch youths before they start using drugs and 2) find

youths where they are, and deliver prevention to them. The best place to find youths is in school or

in front of a television set, where they spend a disproportionate amount of time. Therefore, a great

deal of what we know about prevention (its efficacy and effectiveness) comes from school-based,

curriculum-driven programming and from media-based prevention initiatives. Some efforts have

been made to deliver substance abuse prevention to families, workplaces, and communities, but

these efforts have been minimal in comparison to school and the media as vectors for prevention.

Because of the disproportionate focus on youths and initiation among youths, a significant amount

of attention has been devoted to the so-called gateway drugs: tobacco, alcohol, and marijuana. One

aspect of the concept of gateway is the time order, or sequence of occurrence, of initiation. It is

therefore interesting that most efforts to prevent use of gateway drugs do not involve use of

inhalants, steroids, or nonmedical use of prescription medications that are often prescribed for

youths (e.g., medications for treatment of attention-deficit/hyperactivity disorder [ADHD]). Use of

inhalants and ADHD medications often precede use of some or all of the three gateway drugs that

get the most attention. Some drug-specific prevention initiatives have been developed for inhalants

and steroids, but these are usually stand-alone efforts largely independent of prevention efforts

targeting the gateway drugs. Almost no prevention efforts have specifically targeted use of

cocaine, heroin, methamphetamine, lysergic acid diethylamide (LSD),

methylenedioxymethamphetamine (MDMA; “ecstasy”), and prescription drugs in general. Use of

multiple drugs is seldom the focus of substance abuse prevention activities, even though multiple

drug use is the norm rather than the exception.

From an etiological perspective, the dominant approach to substance abuse prevention has been to

identify the predominant risk and protective factors for substance abuse (Clayton 1992; Hawkins et

1. 1992). These risk and protective factors are usually grouped into several domains: genetic,

biological, social, psychological, contextual, economic, and cultural. The first two of these domains

are clearly specific for individuals rather than population groups and cannot be changed. This is

important because the essence of prevention is attempting to modify changeable and malleable risk

and protective factors. If a factor is not amenable to change, then it is not a legitimate target of

preventive intervention efforts. Thus, most substance abuse prevention initiatives are focused

primarily on changing the social, psychological, contextual, economic, and cultural risk and

protective factors that are predictive of drug use.

TAXONOMIES OF PREVENTION

There are three broad-based taxonomies of prevention. The first taxonomy and one that is mostPrint: Chapter 48. Prevention of Substance Abuse http://www.psychiatryonline.com/popup.aspx?aID=359201&print=yes…

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familiar to clinicians is the traditional medical and public health model. Primary prevention is

preemptive in nature and involves reduced incidence of a disorder (i.e., occurrence of new cases).

Secondary prevention is focused on reducing prevalence (i.e., the total number of new and old

cases). Tertiary prevention is focused on reducing the sequelae and complications arising from the

problem or disorder once it is manifest.

The second taxonomy is the one most widely used in the substance abuse prevention arena:

A universal preventive measure is desirable for everybody in the eligible population. A selective

preventive measure is desirable only when the individual is a member of a subgroup of the population

whose risk of becoming ill is above average. An indicated preventive measure applies to persons who, on

examination, are found to manifest a risk factor, condition, or abnormality that identifies them,

individually, as being at high risk for the future development of a disease. (Mrazek and Haggerty 1994,

1. 20–21)

The third taxonomy of prevention is less widely used but clearly anchored in population-based

public health. It involves downstream interventions, in which the focus is on the individual and his

or her lifestyle or behavior; midstream interventions, in which the focus is on the community and

institutions within communities; and upstream interventions, in which policies that support

prevention are made (McKinlay and Marceau 2000).

The field of substance abuse prevention has, for the most part, adopted the universal, selective,

and indicated constructs to guide its work.

SCHOOL-BASED, CURRICULUM-DRIVEN PREVENTION

The scientific roadmap (see Flay et al. 2005) for school-based, curriculum-driven prevention

involves clinical trials testing for efficacy (the beneficial effects of a program or policy under

optimal conditions of delivery), effectiveness (effects of a program or policy under more real-world

conditions), and dissemination (taking a program to scale with widespread reach and penetration).

In this section, we review selected efficacy and effectiveness trials. Clinicians should note that

research on the prevention of substance abuse is subject to the same scientific process and

principles applicable to evaluation of treatment protocols.

We have found an extensive literature on randomized trials of the efficacy of “social influences” or

“social competency” school-based curricula that usually attempt to change the following types of

mediators: 1) normative beliefs among adolescents, 2) perceptions of consequences of substance

use or abuse for adolescents, and 3) social problem-solving skills (e.g., communication skills,

decision-making skills, resistance and assertiveness skills).

Life Skills Training

Perhaps the most widely cited study of a school-based prevention program with efficacy is Life

Skills Training. This social influences and competency program involves 15 sessions during the

sixth grade, 10 booster sessions in the seventh grade, and 5 booster sessions in the eighth grade.

Botvin et al. (1995) randomly assigned 56 schools to a control condition or two experimental

conditions. The first experimental condition involved teachers personally trained by Botvin and his

colleagues who also received technical assistance as needed. In the second condition, teachers

received training from Botvin and his colleagues via videotape but no technical assistance. Botvin

also divided his sample into those students who were exposed to 60% or more of the lessons

(labeled by Botvin as “high fidelity”) and those who received fewer than 60% of the lessons (“low

fidelity”). The emphasis was on gateway drugs (i.e., tobacco, alcohol, marijuana), and youths were

followed up on for 6 years. No statistically significant differences were found between teachers

who were personally trained and those who received training via videotape. Statistically significant

effects on drug use were noted when the control condition was compared with the two

experimental conditions “for students in the high-fidelity condition.” However, note that between 1

in 4 and 1 in 3 students were classified as low fidelity. These low-fidelity students were probably

more likely to be high-risk youths. Separate analyses by these authors determined that noPrint: Chapter 48. Prevention of Substance Abuse http://www.psychiatryonline.com/popup.aspx?aID=359201&print=yes…

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statistically significant effects were seen between low-fidelity students and the students in the

control condition. Simply put, Life Skills Training seems to work for those with good attendance

(present for 60% or more of the lessons), not for those with higher absenteeism.

Hutchinson Smoking Prevention Program

Whereas the Life Skills Training study focused on prevention of use of a few gateway drugs, the

Hutchinson Smoking Prevention Program (HSPP) focused only on smoking. The study was

conducted in 40 school districts, 20 of which received the intervention, and 20 of which served as

the control districts (Peterson et al. 2000). The 40 districts were selected at least partially because

they contained only one high school, so experimental and control participants would never be

mixed. The theory-driven social influences intervention began in the third grade and continued

through the tenth grade, with content developmentally tailored to grade level. The total number of

potential prevention exposure units was 46.75 hours. Implementation fidelity was high, with 80%

of the teachers effectively communicating the key concepts of the lessons. None of the control

districts violated their commitment to remain free of interventions during the 15-year trial. Overall,

the HSPP study retained 93% of the participants at 2 years beyond high school. To lose only 7% of

the sample over this period of time is impressive.

The principal results examined daily smoking among males and females in the twelfth grade. The

results were disappointing. Less than 1 percentage point difference was found between

experimental and control students (males and females were examined separately) in daily smoking

in the twelfth grade. HSPP and the Life Skills Training interventions were driven by a social

influences framework, there were considerably more exposure units in the HSPP than in Life Skills

Training, the focus was on one instead of a few drugs, and the design in the HSPP was rigorous

(Clayton et al. 2000).

Project ALERT

Project ALERT, a universal prevention program, now involves 11 lessons in the seventh grade and 3

booster sessions in the eighth grade, but its initial version included 8 lessons in the seventh grade

and 3 lessons in the eighth grade. The first evaluation occurred between 1984 and 1986 in 30

schools: the lessons were taught by adult health educators in 10 schools, the curriculum was

delivered by adult teachers assisted by teenage peer leaders in 10 schools, and 10 schools served

as controls. The results were promising—those who received the intervention were 30%–50% less

likely to start using or to be currently using marijuana. Among students who were experimenting

with cigarettes at the beginning of the seventh grade, those in the intervention group were

33%–55% less likely to become regular or current smokers. Only modest reductions were found for

alcohol use. There were no significant differences by who delivered the intervention (see Ellickson

and Bell 1990). These youths were followed up on through the ninth, tenth, and twelfth grades (see

Ellickson et al. 1993). As has been true for many such prevention efforts, the significantly different

effects observed earlier had decayed by the last follow-up.

Project ALERT is particularly interesting because the early research was used to change some

aspects of the curriculum (new sessions on inhalants, smoking cessation, and alcohol as well as

home learning activities to get parents involved), new research was conducted to test efficacy and

effectiveness (Ellickson et al. 2003; Ghosh-Dastidar et al. 2004), and an independent evaluation

was conducted (St. Pierre et al. 2005). In the large randomized trial, Ellickson et al. (2003) found

effects for the revised curriculum on initiation of cigarette and marijuana use, current and regular

cigarette use, and alcohol misuse. The reported reductions ranged from 19% to 39%. Effects were

not observed for initial and current drinking or for current and regular marijuana use.

Ghosh-Dastidar et al. (2004) found a moderate effect on targeted risk factor mediators associated

with cigarette and marijuana use and more modest gains with the pro-alcohol risk factors.

St. Pierre et al. (2005) conducted an effectiveness trial that involved agricultural extension agents

to deliver the curriculum. They found no positive effects on substance use or the mediators and risk

factors addressed by the curriculum. In addition, they engaged in a substantial effort to explainPrint: Chapter 48. Prevention of Substance Abuse http://www.psychiatryonline.com/popup.aspx?aID=359201&print=yes…

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why no effects were found and were not able to offer a feasible and defensible explanation for the

differences in their evaluation and those conducted by the individuals who developed and tested

the curriculum for efficacy and early effectiveness.

From our selective review of the vast scientific literature on substance abuse prevention

programming that is school-based and curriculum-driven, several points emerge:

Efficacy designs often do not resemble reality (Hallfors et al. 2006). Most efficacy trials collect baseline

data, and some get the intervention and others do not. A follow-up usually occurs 1 year or more after

the intervention. Drawing a line from baseline to follow-up for experimental and control participants

and asserting that the difference between the lines exists because of exposure to a school-based,

curriculum-driven intervention is audacious and ignores the thousands of experiences individuals have

in the interim that could influence scores at follow-up.

Influences on substance abuse exist at multiple levels. The curricula used in social influences and

competency interventions assume that the most critical predictors of drug use lie “inside” the individual

in his or her ability to make good decisions and use resistance skills. These approaches largely ignore

the fact that every child receiving a prevention lesson has a family, regardless of what that consists of;

lives in a neighborhood and a community; and may be embedded in a variety of peer and social

organizational groups (e.g., boy and girl scouts, soccer teams). These “outside the individual”

environmental influences may have an equal or even stronger effect on substance abuse than do

intraindividual factors.

Substantial differences exist across schools and across classes and cohorts within schools. This

heterogeneity is often missed or ignored in evaluation research. Some schools are at “higher” risk for

having greater incidence and prevalence of drug use than are other schools. Classification of entire

schools according to risk has been largely ignored (Cameron et al. 1999).

Almost all prevention programming has focused on substance abuse patterns as the targeted

outcomes. Considerably less attention has been paid to the outcomes of most importance to school

administrators and teachers: academic performance indicators such as grades, achievement test

scores, and attendance, retention, and school order or disorder.

Teachers delivering the curriculum in a school are critical. Little research has been done on the

differential effectiveness of teachers to deliver these curricula, and almost no attention has been paid

to the conglomeration of ineffective teachers in chaotic schools with students from high-risk familial

and neighborhood environments.

Even with these caveats, prevention science shows that school-based, curriculum-driven prevention

programming has produced statistically significant effects under controlled conditions. Societal,

community, and parental concerns about drug use among children have led to widespread

dissemination in schools of prevention programming that has passed muster on efficacy criteria

(albeit usually not via independent evaluation). In other words, evidence indicates that prevention

in schools works, but the most appropriate questions may be

Whom does prevention work for?

Where does prevention work?

When does prevention work?

Why does prevention work?

How does prevention work?

MEDIA-BASED PREVENTION

A substantial amount of research has been conducted on media as a vector for prevention of

substance abuse. In this section, we selectively review some of the more prominent efforts. When

mass media mechanisms, particularly public service announcements (PSAs), are used as a strategy

to help prevent substance abuse, the goal is to have viewers be aware of the media message,

encode it, decode it, be able to recall the message and where one encountered it, and then apply

the essence of the message to decisions about drug abuse.

Partnership for a Drug-Free AmericaPrint: Chapter 48. Prevention of Substance Abuse http://www.psychiatryonline.com/popup.aspx?aID=359201&print=yes…

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Recall is, of course, one of the most important measures of effectiveness. When this one criterion is

used, the “This is your brain; this is your brain on drugs” PSA created by the Partnership for a

Drug-Free America scores very high. However, the ultimate goal of media campaigns is to raise

awareness and draw attention to an issue and change knowledge, attitudes, and behavior about

that issue or phenomenon. Although the “This is your brain on drugs” campaign is widely

remembered, the actual effects of the campaign were not evaluated.

American Legacy Truth Campaign

The “Truth” tobacco countermarketing campaign has been extensively and rigorously evaluated. It

was initially delivered in Florida with significant positive effects (Niederdeppe et al. 2004; Sly et al.

2001) and later used as part of a national campaign directed by the American Legacy Foundation.

Farrelly et al. (2005) found a dose-response relation between exposure to the Truth antismoking

advertisements and the prevalence of smoking among youths. In fact, they estimated that the

campaign accounted for about 22% of the 18%–25.3% decline in smoking prevalence that

occurred nationally among youths between 1999 and 2002 (Thrasher et al. 2004). Wakefield et al.

(2006) used the Monitoring the Future surveys to examine the effect of the tobacco

industry–sponsored smoking prevention advertising. They found no beneficial effects and the

possibility of some harmful effects on youths in grades 10 and 12.

Office of National Drug Control Policy’s National Youth Antidrug Media

Campaign

The Office of National Drug Control Policy’s National Youth Antidrug media campaign has three

goals: 1) educate and enable America’s youths to reject illegal drugs; 2) prevent youths from

initiating use of drugs, especially marijuana and inhalants; and 3) convince occasional users of

these and other drugs to stop using drugs.

Research evaluating the Office of National Drug Control Policy’s antidrug campaign covering the

period 1999 through June 2004 (Orwin et al. 2006) found that more than 7 of 10 parents and

youths reported exposure to one or more of the media messages weekly. The recall of the

advertisements increased substantially over the years of the campaign. Brand recognition of the

campaign’s theme was high. The campaign had favorable effects on 3 of 4 parent beliefs and

behavior outcome measures (i.e., talking with children about drugs, doing fun activities, beliefs

about monitoring). However, no evidence of effects on parental monitoring behavior was found

until the last data collection of the campaign. Parental monitoring is considered a major protective

factor for prevention of adolescent drug use. Furthermore, no evidence indicated effects on

marijuana, the early interventions, or the campaign as a whole. However, unfavorable effects did

occur. Higher exposure led to weaker antidrug norms, and there may have been a significant

unfavorable effect of exposure to the marijuana initiative on when use of marijuana began.

Health communications researchers at the University of Kentucky have been conducting efficacy

trials on a different approach to constructing PSAs. The traditional approach to targeting or

segmenting audiences for any kind of message, including antidrug messages, is by demographics

(age, gender, race/ethnicity, socioeconomic status, special interests). Some communications

researchers have used so-called psychographic characteristics (in particular, sensation seeking) to

target or segment audiences for antidrug messages. The assumption is that those high in sensation

seeking will pay attention only to messages high in sensation value and will be especially attracted

to messages embedded in high-sensation value programming. Palmgreen et al. (2001) evaluated

three televised antimarijuana campaigns in two matched communities over several months and

found a reversal in the upward developmental trend in 30-day marijuana use among high-sensation

seekers. Low-sensation seekers had low levels of marijuana use, and no campaign effects were

noted for them.

Use of various forms of mass media illustrates the universal, primary, and upstream types of

prevention programming. Some campaigns have been clearly efficacious and effective but others

less so, as described earlier. Substance abuse is a complex phenomenon. Major differences arePrint: Chapter 48. Prevention of Substance Abuse http://www.psychiatryonline.com/popup.aspx?aID=359201&print=yes…

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seen between substances and the etiological factors that account for abuse of the various

substances. Capturing the essence of a message that is persuasive and compelling in 30-second

PSAs is extremely difficult. Confirming that these short bursts of prevention programming have

measurable effects on patterns of substance abuse (e.g., initiation, continuation, progression) is a

formidable task. The success rates with tobacco use in the Truth campaign and in the community

trial that used sensation seeking as a targeting variable are evidence of the value of media-based

prevention and the need for further work on media-based prevention programming.

COMMUNITY-BASED COALITIONS

A huge effort has been expended to prevent substance abuse where the proverbial “rubber meets

the road”—in communities—primarily through the vehicle of community antidrug coalitions and

community mobilization. One of the first broad-based community coalition efforts involved the

so-called Fighting Back initiative in communities. Fourteen middle-sized (population between

100,000 and 250,000) communities participated. Community leaders chose, developed, and

implemented prevention strategies that included, at a minimum, public awareness, prevention

targeted specifically at youths, early identification and intervention, treatment and relapse

prevention, and, later in the program, environmental strategies. The Fighting Back initiative was

essentially about community empowerment and mobilization.

Hallfors et al. (2002) conducted a rigorous evaluation of the effects of 12 of the Fighting Back

community efforts. The results are counterintuitive but instructive:

Strategies aimed at either youth or community prevention outcomes showed no effects, while strategies

to improve adult-focused outcomes showed significant negative effects over time, compared to matched

controls. Coalitions with a more comprehensive array of strategies did not show any superior benefits,

and increasing the number of high-dose strategies showed a significant negative effect on overall

outcomes. (Hallfors et al. 2002, p. 237)

These findings are disappointing because the assumption of community-organized,

community-driven, and community-focused prevention is intuitive and because large amounts of

funding were invested in the Fighting Back initiative. Before the evidence of efficacy was available,

the federal government invested an even larger amount of funding toward antidrug community

coalitions in a much larger number of communities (i.e., effectiveness before evidence of efficacy).

Although the evidence from the initiative described earlier is not compelling, evidence does show

that community coalitions focused on high-risk drinking and alcohol-related injuries have been

effective. Holder et al. (2000) combined several mutually reinforcing strategies (i.e., media

attention to alcohol problems, changes in alcohol serving practices in local bars and restaurants,

reductions in retail sale of alcohol to young people, increased enforcement of drinking and driving

laws, and reductions in the concentration of alcohol retail outlets) to produce significant reductions

in high-risk alcohol behaviors and consequences. Most of the strategies described by Holder and his

colleagues are environmentally and policy oriented rather than attempts to change risk factors

“under the skin.”

Substance abuse is a complex bundle of issues necessarily embedded in communities that are

themselves extremely complex. Given the heterogeneity within and across communities, it is not

surprising that marshalling “research” evidence of the efficacy and effectiveness of community

coalitions to prevent substance abuse would be difficult. From a more clinical perspective, the

efficacy of specific community coalitions may require a “perfect storm” mixture of 1) a problem

that is particularly salient at the time, 2) leadership with the persuasive skills and charisma to

focus the community on the malleable aspects of the problem, 3) a willingness of the existing

organizations and coalitions to put this problem above the problem to which they are devoted, 4)

the readiness of the community at large to tackle this problem, and 5) a willingness to change

leadership in different phases of response to the problem. Some leaders are great at galvanizing

energy around an issue but not good at maintaining and sustaining that energy.

CONCLUSIONPrint: Chapter 48. Prevention of Substance Abuse http://www.psychiatryonline.com/popup.aspx?aID=359201&print=yes…

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Prevention is often offered as the answer to just about everything. Prevention covers the breadth

of public health activity from head lice and dog bites to substance abuse and bioterrorism.

Prevention is relevant across the developmental age range from prenatal through infancy;

childhood; adolescence; young, mid, and older adulthood; to death. Unfortunately, the construct is

used so widely in every arena of public discourse that its essential elements and the evidence base

for preventive interventions are often not clear and sometimes not known. Prevention can take

place at many levels—from the individual to interpersonal to local to state, national, and

international levels. Prevention and treatment are often thought of as ends of a continuum. An

alternative approach is to see treatment as another kind of prevention.

Prevention is often focused on attempting to change specific behavioral patterns but requires that

we start with the consequences of behavior to understand better what must be prevented. For

example, supply reduction efforts (usually law enforcement activities) can be seen as primary

prevention for the consequences of drug abuse (crime, burden on the treatment system, premature

mortality, and excessive morbidity associated with substance abuse). Prevention requires an

understanding of health disparities to determine which strategies will provide the most reach and

penetration to populations most at risk. Efficacious and effective prevention strategies and

programs are necessarily designed to influence known malleable risk and protective factors that, if

changed, may lead to a reduction in the consequences of substance abuse. Prevention is often

thought of as the bailiwick of health behavior specialists, but it cannot succeed without a

comprehensive and integrated understanding of a variety of disciplines that contribute to our

knowledge of the epidemiology, etiology, and treatment of substance abuse.

KEY POINTS

Prevention science is still a relatively new area of scientific investigation. Even so, tremendous progress has

been made in conducting rigorous research on efficacy and effectiveness, and research on dissemination has

ramped up in recent years.

Prevention requires a focus on malleable risk and protective factors that exist at numerous levels. If

something cannot be changed, it is not a legitimate target of prevention. To date, more attention has been

paid to intraindividual factors that may be malleable than to environmental factors that could be changed

and, if changed, could affect many individuals.

Prevention has focused largely on children and youths rather than adults; on initiation of drug use rather

than other transition points (continuation, progression within and across drug classes, regression to

cessation, and relapse); and on school-based prevention that is curriculum-driven, televised media messages,

and the formation and sustenance of community-based coalitions. Little has been done to make prevention

more comprehensive and integrated and to parse out the effects of various prevention strategies considered

together rather than independently.

Substance abuse is complex. Large individual differences in substance abuse patterns exist, but the biggest

return on investment in prevention will focus on covering large segments of the population and accepting a

relatively small percentage change rather than having a large effect on a small number of individuals.

Prevention as it currently exists does not lend itself well to individual tailoring.

Accumulating evidence indicates that school-based, curriculum-driven prevention programming can be

efficacious, but a host of substantive and research issues remain to be solved.

Evidence indicates that media-based prevention strategies can be efficacious, but the knowledge base is

suggesting that there are many issues and problems that need to be examined rigorously.

Evidence suggests that community coalitions can have an efficacious effect on substance abuse at the

community level, but significantly more work is needed to have an algorithm that seems to work across

communities.

Documentation that a prevention effort is efficacious in a controlled setting does not in any way guarantee

that it will be effective when disseminated. Studies of effectiveness and dissemination are needed to show

compellingly how to take a prevention program to scale.Print: Chapter 48. Prevention of Substance Abuse http://www.psychiatryonline.com/popup.aspx?aID=359201&print=yes…

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Those involved in substance abuse prevention are often hard on themselves for not reporting large effects

from interventions. A lesson may be learned from the prevention of cardiovascular disease. As many as 20%

of the people who receive prescriptions do not even get them filled, and about 50% of the people taking

routine medicines take them inconsistently (Miller 1997). After a major national push on hypertension, fewer

than 60% of those receiving treatment had the condition “controlled” (Hajjar and Kotchen 2003).

The question that has driven the substance abuse prevention field to date is “Does prevention work?” In the

coming decades, the question driving the field will be “Prevention works, but for whom, when, where, under

what circumstances, why, and how?”

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smoking: the Florida “truth” campaign. Am J Public Health 91:233–238, 2001 [PubMed]

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delivered in schools by cooperative extension. Prev Sci 6:305–317, 2005

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SUGGESTED READING

Botvin GJ, Baker E, Dusenbury L, et al: Long-term follow-up results of a randomized drug abuse prevention

trial in a white middle-class population. JAMA 273:1106–1112, 1995

Farley T, Cohen DA: Prescription for a Healthy Nation: A New Approach to Improving Our Lives by Fixing Our

Everyday World. Boston, MA, Beacon Press, 2005

Farrelly MC, Davis KC, Haviland ML, et al: Evidence of a dose-response relationship between “truth”

antismoking ads and youth smoking prevalence. Am J Public Health 95:425–431, 2005

Hallfors D, Cho H, Livert D, et al: Fighting back against substance abuse: are community coalitions winning?

Am J Prev Med 23:237–245, 2002

Peterson AV, Kealey KA, Mann SL, et al: Hutchinson Smoking Prevention Project: long-term randomized trial in

school-based tobacco use prevention: results on smoking. J Natl Cancer Inst 92:1979–1991, 2000

Wakefield M, Terry-McElrath Y, Emery S, et al: Effect of televised, tobacco company-funded smoking

prevention advertising on youth smoking-related beliefs, intentions, and behavior. Am J Public Health

96:2154–2160, 2006

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