Scientific Basis for the Strategy

Various theories from the fields of sociology, psychology, and psychopharmacology have been used to explain the causes of drug use initiation and continued use. Although the details of these theories and the differences among them are beyond the scope of this document, their basic point of agreement is worthy of note: Adolescent drug use can be explained, in large part, by a combination of psychological characteristics and factors associated with the social environment.

Factors associated with adolescent drug use.

The causes of adolescent drug use have been studied extensively over the past several decades. Recently, data from 242 recent etiological studies were meta-analyzed to identify the social and psychological variables that consistently relate to drug use (Hansen, 1997). The results of this analysis are summarized in this section (See Table 1).

Social exposure to drug use among peers and siblings (and parents to a lesser extent), and the perception of social pressures to use drugs appear to play a critical role in the initiation and continuation of adolescent drug use. Social exposure to drug use can influence trial and use in many ways, including creating the perception that drug use is normative, enhancing the likelihood of encountering social pressure to use drugs, and increasing access to drugs.

Drug use is also highly related to a constellation of what are referred to as "deviant behaviors," including antisocial behaviors, truancy, cheating, vandalism, hostility, fighting, lying, and being in trouble with the police. In addition to the factors listed in Table 1, poor academic performance, low academic aspiration, and attributes of the home environment have also been shown to be strongly associated with drug use (Newcomb & Felix-Ortiz, 1992).

Another psychological factor, sensation seeking, has also been shown to correlate strongly with drug use. Sensation seeking is a personality trait, possibly with biological origins, that is associated with the need for novel, complex, ambiguous, and emotionally intense stimuli (Zuckerman, 1979). High school students who score above the median on a scale of sensation seeking are 3-4 times more likely than those who score below the median to report using marijuana in the past month, and 5-10 times more likely to report using other drugs such as cocaine, uppers, and downers (Donohew, 1990). High sensation-seeking adolescents also tend to have more positive attitudes towards drug use (Hoyle et al., in press).

Youth vulnerability to drug use initiation is heightened during periods of transition, such as the transition from elementary school to middle school, and the transition from middle school to high school (Sloboda & David, 1997), and in certain situations, such as when large amounts of time are spent in settings unsupervised by a responsible adult. The transitions from elementary to middle school, and from middle to high school, are accompanied by important developmental and environmental changes that challenge an adolescent's intellectual, social, and emotional coping skills. They are times when adolescents' identity and self-esteem are threatened; they are also times when the environments in which adolescents function change dramatically to provide less structure and supervision, and, therefore, more opportunities for risky behaviors. Participation in non-structured activities, such as "latchkey kid" status, going to parties, hanging around in the neighborhood, visiting restaurants, and seeking out entertainment, has been identified as a significant risk factor for substance abuse (Hansen, Rose, & Dreyfoos, 1993). Conversely, participation in structured activities has a protective influence and reduces the likelihood of drug use initiation, especially for youth in high-risk environments (Hansen, Rose, & Dreyfoos, 1993; Parker, 1990; Schaps et al., 1981; Schinkee et al., 1992; Tobler,1986).

Drug use can be prevented by influencing adolescents' beliefs and skills.

The initiation of drug use is largely an outcome of social influences in adolescents' lives. Drug use prevention programs based on social influence approaches (i.e., programs that focus on the social influences that promote drug use) have, in recent years, proven highly successful in preventing substance use among middle school-aged children and beyond (Botvin et al., 1990, 1995a; Ellickson & Bell, 1990; Hansen & Graham, 1991; Hansen, Johnson, Flay, Graham, & Sobel, 1988; Johnson, et al., 1990; Tobler, 1986).

In programs based on social influence models, adolescents are taught how to recognize situations in which they are likely to experience peer pressure to use drugs so that they may avoid them. They are also taught how to resist such peer pressures in a variety of situations, and, ideally, are given opportunities to gain mastery of the resistance skills and build confidence by practicing them in a safe environment. Correcting adolescents' misperceptions that a majority of their peers use drugs is the third important component of these programs. Each of these messages and activities communicates to adolescents that refraining from drug use is an acceptable and desirable behavior (Botvin, 1995).

Project STAR, a substance use program implemented with middle-school students, is an example of a successful program based on a social influence model. Program participants are about 50 percent less likely to use marijuana during middle school (MacKinnon et al., 1991), and remain 30 percent less likely to use the drug at three-year follow up (Sloboda & David, 1997; Johnson et al.,1990).

A basic assumption of social influence approaches is that adolescents are motivated to avoid drug use until such time that they experience social pressures to use drugs. While this assumption is true for a majority of middle school-aged adolescents, it is not true for some adolescents, who seek out drug use as a coping mechanism or for some other reason. The social influence approach can be extended to increase its impact on such children by supplementing resistance skills training with generic self-management and social skills. These skills include decision-making and problem-solving skills, skills for enhancing self-esteem, social and assertiveness skills, and productive coping strategies for dealing with stress and anxiety. Adolescents who possess these self-management and social skills become more achievement oriented and, therefore, less motivated to use drugs. They can also apply these skills to deal successfully with a variety of challenges, including social pressure to use drugs.

The Life Skills Training curriculum is an excellent example of a social influence-based program that has been modified to include generic self-management and social skills. Program participation during middle school has been shown to reduce substance abuse by 59 to 75 percent (Botvin et al., 1995a; Sloboda & David, 1997). Studies also show that booster sessions of the program can help maintain program effects over a longer period of time.

A recent synthesis of etiological studies identified the key psychological variables that have been shown to be associated with drug use (Hansen, 1997). The beliefs, attitudes, and values that are most strongly associated with drug use are listed in Table 2. These include adolescents' personal beliefs about drug use and its consequences, their beliefs about the acceptability and prevalence of drug use, their commitment to staying drug free, their susceptibility to social and environmental pressures, and their ability to set personal goals.

Promoting parenting strategies is another means of reducing adolescent drug use.

Parents (or other primary caregivers) are the most important and long-lasting influence in children's lives. Although adolescence is a time when parental influence appears to be overshadowed by peer influence, parents' actions play a crucial role in protecting adolescents from drug use and a wide variety of other risky behaviors (Baumrind, Moselle, & Martin, 1985; Bry, 1988; Carnegie Council on Adolescent Development, 1995; Newcomb and Felix-Ortiz, 1992; Resnick et al., 1997; Spoth, Yoo, Kahn, & Redmond, 1996).

One parenting strategy that is particularly critical in preventing substance use and other problem behaviors is parental monitoring. Broadly defined, parental monitoring includes a series of behaviors that are designed to facilitate parents' awareness of the child's activities, while communicating to the child that the parent is concerned about and aware of his or her activities and friends. Active parental monitoring directly contributes to reduced risk of drug use. It also decreases the child's involvement with deviant peers who might encourage involvement in a variety of problem behaviors (Biglan, et al., 1995; Dishion and McMahon, under review).

Many types of parenting interventions have been developed to teach parents general child management strategies and a variety of task-specific parenting behaviors. Interventions of this type have been shown to enhance the quality of parent-child relationships, and to reduce adolescent drug use and other problem behaviors (Bank, Marlowe, Reid, & Patterson, 1991; Dishion & Andrews, 1995; Kazdin, 1995; Spoth, Redmond, & Shin, in press; Spoth, Redmond, & Lepper, in press; Szapocznik & Kurtines, 1989; Taylor & Biglan, in press).

Mentors and other youth-influential adults can also play an important role in preventing drug use.

Besides their parents, adolescents come into daily contact with a host of others who can potentially reinforce, disrupt, or compensate for any lacking protective parental influences. These include educators, mentors, coaches, grandparents and other family members, and youth workers and volunteers in programs like the Boys and Girls Clubs and Scouting. Others who impact youth positively -- although on a less frequent basis -- can include athletes and entertainers, DARE officers, and even individuals in the community without a formal connection to adolescents. Through their actions and words, these people can help to inspire and guide adolescents in a number of important ways. For example, enrollment in a Big Brothers/Big Sisters program has been shown to reduce the likelihood of drug use by nearly 50 percent (Tiernay, Grossman, & Resch, 1995). Moreover, this type of mentoring relationship also benefits participants in other ways by reducing their involvement in violence, and by improving their attitudes toward school work, their school attendance, and their relationships with their family and peers.

Situational Basis for the Strategy

Popular culture portrays drug use as a normal behavior.

Adolescents are deeply immersed in popular culture as it is conveyed through various forms of media. On average, American children are exposed to at least 8 hours of media per day including television, radio, movies, recorded music, comics, and video games (Williams and Frith, 1993). Both media programming and advertising content tend to portray drug use as common and normal. For example, by his or her 18th birthday, an average adolescent will have seen 100,000 television commercials for beer (Monroe, 1994), and will have watched 65,000 scenes on television depicting beer drinking (Coombs, Paulson, & Palley, 1988). Anecdotal evidence suggests that many media messages tend to normalize drug use by portraying it as common, something to be expected, or even humorous.

In view of the myriad media messages that normalize drug use, The National Youth Anti-Drug Media Campaign must be distinctive. One way to enhance its visibility and identity is to integrate different components of the campaign under certain unifying features to build an image akin to "brand identity." A strong brand identity amplifies the impact of a campaign in a number of ways. First, it helps people to remember the key campaign messages because they can connect discrete messages with each other and with the "bigger picture" of the campaign. Second, it stimulates more conversation and comment, an outcome that is particularly important for behavior change campaigns. Third, in time, the unifying features themselves could come to represent the messages and the image of the campaign, leading people to immediately recall the key campaign messages every time the symbol is presented.

Many consumer advertising campaigns (e.g., Budweiser beer, Coca Cola, Toyota) capitalize on the fact that a series of advertisements with a unifying theme, tone, or feature attract more attention and comment than the same number of unrelated advertisements. Perhaps the best example of this strategy is the Nike campaign, which has elevated a simple graphic with no inherent meaning (the Nike Swoosh) to a universally recognized symbol of the Nike brand and a gutsy, sporty lifestyle.

Adolescents believe that drug use is common and normal.*

Given the media environment, it is perhaps not surprising that most adolescents have an exaggerated perception of the prevalence of drug use among their peers, and of the degree to which their peers approve of drug use (PATS, 1997). Early adolescents (9-11 years) know of relatively few users among their own friends and classmates, but are confident that drug use is very prevalent among older children. Most adolescents of middle school age say that drug use is very prevalent in their communities and schools, and regard it as socially accepted behavior. High school age adolescents are even more likely to express this view. The perceived social acceptability of marijuana among young people and their exposure to its use have been rising steadily since 1992, and there has been a decrease in the proportion of adolescents who personally disapprove of marijuana use (MTFS, 1997; PATS, 1997).

The perceived reasons for using marijuana differ by age of the adolescent.

Early adolescents (9-11 years) have very strong anti-drug attitudes. They are aware of very little drug use in their own age group, but are aware of use among older adolescents and adults in their communities. Adolescents of this age group can think of few compelling reasons why someone would want to use drugs, but they realize that some people think it is cool, and that older youth feel "peer pressure" to use drugs.

Middle school-aged adolescents (typically ages 12 and 13) tend to think that kids their age often use marijuana because they have seen their peers and older teenagers using it and, therefore, feel a pressure to use it themselves. This peer pressure is often subtle and covert, and may consist of unspoken expectations rather than overt offers. Many adolescents in this age group believe that shared use of marijuana is a good way to make and keep friends, and some believe that refusing drugs can do serious damage to their social lives. Adolescents of this age also feel that drugs can relieve social and other stresses and help a person feel good about him- or herself.

Relaxation and coping with stress appear to be even more important reasons to use marijuana among the adolescents of high school age. Marijuana use is seen by many in this age group as a way to "chill out with friends" and forget one's problems. It is also perceived to lower social inhibitions and to help one to fit in and be accepted by other young people. Overt peer pressure to use drugs may also play an important role in this age group, particularly among boys.

The perceived negative consequences of marijuana use also vary by age.

Early adolescents (9-11 years) have an exaggerated perception of the physical consequences of marijuana use. Many believe that, like other illicit drugs, marijuana has severe physical consequences such as death from overdose, addiction, and brain damage. Children of this age group think that marijuana is much more dangerous than alcohol and cigarettes. Although they primarily focus on the physical consequences of marijuana use, this age group also exaggerates the negative psychological consequences of marijuana. They believe that marijuana can make one "lose one's mind," alter one's personality, and generally mess up one's life. Few children in this age group know the specific effects of using marijuana, and how these are different from the effects of using other drugs.

Older adolescents tend not to believe that marijuana causes much physical harm, unless it is laced with stronger substances. They also tend to rate marijuana use as less harmful than alcohol and tobacco. Their concerns about marijuana are centered on the impact it can have on a person's judgment and on their ability to think clearly and function normally. Using marijuana is perceived to be harmful, mostly because it can lead to a variety of large and small problems in their day-to-day lives, problems such as crashing a car, being taken advantage of by other people, being sexually promiscuous, and generally "losing control."

High school-age adolescents also recognize the negative consequences of being caught using marijuana. These include angering or disappointing one's parents, getting thrown off a sports team, going to jail, or losing one's job. The monetary cost of marijuana is also seen as a drawback. Many acknowledge that using marijuana has both short-term physical consequences (such as putting on weight, getting stained lips and teeth, and having red, bleary eyes), and long-term physical consequences (such as blackened lungs, difficulty in breathing, and cancer), but these consequences are not very salient for this age group.

Middle school-aged adolescents have attitudes that reflect a transition from the vague "dire consequences" beliefs of the younger children to the more practical and specific consequences cited by high school-aged adolescents. All in all, this group is concerned about a wide range of negative consequences. They tend to believe that marijuana is physically harmful (although not fatal), and can cause a host of physical problems, including cancer, heart problems, lung problems, and general ill health. In addition, many are aware of, and concerned about, the short-term physical symptoms of marijuana use, such as red eyes, slowed movements, slurred speech, headache, and feeling tired and hungry. Social consequences of marijuana use, such as losing one's friends or family and incurring social disapproval, are also of concern. Many also focus on the harm that marijuana may do in the long run, either by leading to addiction and "messing up" their lives, or less extremely, by compromising their academic and extra-curricular performance and aspirations.

Adolescents' perceptions about inhalants.

Older adolescents report that inhalants are used only when other substances are not available. They recognize several negative physical consequences of using inhalants, including brain damage, inability to breathe, damage to the nose and lungs, heart problems, and death.

Younger adolescents also list a litany of physical consequences, but many early adolescents classify all drugs that are snorted or sniffed as inhalants. The negative consequences that they mention may primarily apply to drugs such as cocaine and speed, which can also be inhaled.

According to data collected by the Partnership For A Drug-Free America, adolescents do not completely understand the dangers of using inhalants. Less than half of adolescents ages 9-15 think that sniffing can cause brain damage and death. More often, adolescents cite less serious consequences, such as getting dizzy, getting a headache, and passing out. Early adolescents (9-12 year-olds) in particular do not appreciate the real risks of inhalant use. They see inhalant trial as less risky than marijuana trial, and tend to think that getting dizzy or getting a headache are the most probable consequences of using inhalants (PATS Youth, 1997; PDFA, 1994a).Adolescents believe parents are critical role models.

Adolescents of all ages assert that parents cannot tell their children not to use drugs if they are using drugs themselves. Adolescents feel that the primary role for parents with regard to curbing drug use is to be good role models. Younger children also believe that harsh disciplinary tactics work well, but many older adolescents do not believe that parents' admonitions are effective.
Whereas younger adolescents see their parents as sources of information and warnings about the dangers of drugs, older adolescents tend not to discuss drugs with their parents. Adolescents of all ages, however, are concerned that their parents will be enraged or disappointed if they discover that their child uses drugs.

Parents have mixed feelings and incomplete knowledge.

Although most parents are quick to admit that illegal substance use is a big problem among teenagers today, relatively few acknowledge that their own child is at risk. For example, while self-reported drug use among teenagers is approximately at 44 percent, only 21 percent of parents think that their teenager has tried marijuana (PATS, 1997). Similarly, three percent of parents think their child has abused an inhalant, whereas 23 percent of teens say they have done so (PATS, 1997). This tendency of parents to underestimate their own children's vulnerability to drug use makes them less likely to take action to protect their children from drugs.

Most parents also feel helpless and don't know how they can protect their children from drugs. A large proportion (40 percent) think they have little or no influence over their teenager's decision to use (or not use) drugs. They tend to avoid personal responsibility and cast the blame for teenage drug use on a variety of socio-cultural factors, such as drug use by their children's friends, the media, the neighborhood environment, and popular music (National Survey of American Attitudes on Substance Abuse II, 1996).

Parents tend to underestimate the negative consequences of marijuana. Nearly a quarter of parents surveyed by the National Survey of American Attitudes on Substance Abuse II (1996) said that they would regard marijuana use by their child as a normal part of growing up. Many baby-boomer parents also feel uncomfortable about disclosing their own past marijuana use to their children while exhorting their children to stay away from drugs.

Many parents are also unaware of the more serious physical risks of inhalant use. Getting dizzy is the most commonly acknowledged risk of inhalant use (81 percent), followed by getting a headache (79 percent), and getting brain damage (74 percent). About a third of parents do not know that inhalants can cause death, and even fewer understand how and in what circumstances this may happen (PDFA, 1994a).

Youth-influential adults may also have mixed feelings.

Relatively little is known about the relevant perceptions of youth-influential adults. According to a recent survey of teachers and principals, 96 percent of school principals and 81 percent of the teachers believe that teachers are responsible for advising, counseling, or informing students about the dangers of alcohol, tobacco, and illegal drugs. Despite this assumption of responsibility, less than half of the teachers (46 percent) feel that they have adequate training in how to deal with substance abuse and teach their students about its dangers (National Survey of American Attitudes on Substance Abuse III, 1997).

Moreover, this study also found that teachers and principals do not regard drug use as a problem to the extent that parents and students do. Only about 15 percent of teachers and principals regard drug use as the primary problem faced by teenagers today, compared to about 35 percent of teenagers and 26 percent of parents. About half of teachers and principals feel that a student who uses marijuana every weekend can continue to do well at school, and about a third say that illegal drugs have not been very harmful (or have not been harmful at all) to the quality of their students' education.

A critical asset -- effective school-based programs -- has not been widely adopted.

Despite teachers' and principals' feelings of responsibility regarding the need to educate their students about the consequences of drug use, and despite the existence of proven school-based intervention programs, anecdotal evidence indicates that relatively few schools and communities have actually implemented drug prevention programs that are proven to be effective. Encouraging widespread adoption of effective school-based drug prevention programs has great potential to reduce national rates of adolescent drug use, and therefore must be an objective of the National Youth Anti-Drug Media Campaign.

* Unless otherwise noted, the generalization made in this and subsequent sections on adolescent's perceptions are based on focus groups conducted by the ONYX Group for ONDCP in late 1997. A total of 30 focus groups were conducted in and around Los Angeles, Dallas, Philadelphia, and Chicago. Twenty-four of the groups were single-gender, mixed-race groups stratified by age (9-11 year olds, 12-13 year olds, and 14-16 year olds) and population density (large city and small city/rural area); 3 were mixed gender groups with African Americans; and 3 groups were used for pre-testing the discussion guide and other materials. Participants in the groups were pre-screened to overrepresent youth who scored above the median on a measure of sensation-seeking.