By Ellen J. Hahn, Mary Kay Rayens, and Robert T. Rasnake(*)
From Foresight, Vol. 8, No.2
published 2001
Editor’s Note: In May, the Centers for Disease Control and Prevention released survey results showing that 22 percent of Kentucky’s middle school students reported smoking at least one cigarette in the past month. Compared to the national average, Kentucky middle schoolers are more than twice as likely to smoke cigarettes.
School-based prevention programs are an important element of a comprehensive approach to combat the increasing problem of alcohol, tobacco, and other drug (ATOD) use among youth. Every day, 6,000 young people under 18 years of age try cigarettes, and 3,000 become daily smokers.(1) According to the 1999 National Youth Tobacco Survey, nearly 35 percent of high school students and almost 13 percent of middle school students use some form of tobacco.(2) In 1998, 8.3 percent of youth ages 12-17 reported current marijuana use, representing a significant increase from 1996.(3) Although underage drinking has remained unchanged since 1994, more than one in five (21 percent) youth age 12-17 years were current alcohol users in 1998.(3)
In 1998, the U.S. Department of Education identified four principles of effectiveness that would govern the use of all grant funds from the Safe and Drug-Free Schools and Communities Act.(4) These principles required all funded ATOD programs to conduct a thorough needs assessment, set measurable goals and objectives, use effective research-based programs, and evaluate progress toward meeting goals on a periodic basis. The Centers for Disease Control and Prevention (CDC) recommends that schools provide tobacco use prevention education in kindergarten through 12th grade and that it be especially intensive in middle school and reinforced in high school.(5) The Kentucky Governor’s Youth Substance Abuse Prevention Initiative recommends the implementation of science-based practices and programs, and encourages widespread public/private collaboration in prevention activities.(6)
The purpose of this project was to assess the number and type of research-based drug prevention curricula available to Kentucky children enrolled in public and private middle and high schools. Schools that offered research-based curricula also were asked which grades taught the curriculum and whether all children in that grade received the lessons. Schools were asked if they were interested in assistance on research-based drug prevention curricula.
A list of accepted research-based alcohol, tobacco, and other drug (ATOD) curricula appropriate for grades 6-12 was obtained from the Kentucky Division of Substance Abuse. Ten alcohol, tobacco, and other drug prevention curricula developed and tested with students in 6th-12th grades were selected for this study. The following section briefly summarizes each curriculum.
Table: Summary of Research-based Alcohol, Tobacco, and Other Drug Curricula
ALL STARS aims to develop pro-social values, establish appropriate norms and beliefs about substances, build a strong commitment to not use substances, and create a positive social bond between the child and the school. The program uses highly interactive methods that get students involved including an active role for peer opinion leaders. A recent study of ALL STARS suggested a differential impact on substance use, violence, and mediating variables as a function of the type of program deliverer, student ethnicity, and time.(7)
Growing Healthy is a multimedia, comprehensive health program that promotes self-esteem and teaches decisionmaking skills to enable youth to adopt healthy attitudes and behaviors. Methods include a film, a “smoking machine” demonstration, videotapes, and two classroom experiments—a lung dissection for 5th graders and heart dissection for 6th graders. The curriculum stresses the multidimensional aspects of health and emphasizes personal, emotional and social health habits. Growing Healthy has resulted in a 29 percent reduction in tobacco use among middle school students.(8)
Here’s Looking at You 2000 (HLAY 2000) is a comprehensive K-12 risk reduction prevention curriculum that addresses the consequences of ATOD use and sources of influence, social skills development, and promotion of school, family, and community bonding. The program uses cooperative team-learning techniques, peer education, critical thinking, cultural sensitivity, and active parent involvement. HLAY 2000 has resulted in a decrease in the use of smokeless tobacco in grades 1-3, a decrease in the use of nicotine, alcohol and marijuana in grades 7-12, and a lower smoking rate in grades 10-12.(9)
Know Your Body consists of five basic components: (1) skills-based health education curriculum, (2) teacher coordinator training, (3) biomedical screening, (4) extracurricular activities, and (5) program evaluation. Methods include behavioral rehearsal, decisionmaking, goal setting, self-esteem building, self-monitoring, stress management, assertiveness training, and other communication skills. After six years of Know Your Body, the rate of cigarette initiation was significantly lower among middle school students than those from nonintervention schools.(10)
Kentucky Adolescent Tobacco Prevention Project (KATPP), based on the social influences model, focuses on tobacco prevention among middle school students in tobacco-producing counties.(11) The program addresses: (a) negative consequences of using cigarettes and smokeless tobacco with emphasis on immediate physical consequences and undesirable social consequences; (b) correction of students’ misperceptions regarding normative tobacco-use behaviors; (c) the use of trained peer leaders; (d) refusal skills and assertiveness; (e) types of appeals used by advertisers; (f) active student participation; and (g) student pledges to not use tobacco. KATPP addresses a number of goals and academic expectations mandated by the 1990 Kentucky Education Reform Act (KERA). One study reported a 23 percent reduction in current smoking as a result of KATPP with middle school-aged adolescents.(11)
The Life Skills Training Program (LST) is an ATOD prevention program that is based on a multi-factorial causal model of youth ATOD use and Social Learning Theory.(12)(13) The LST Program teaches resistance to social influences by addressing personal self-management skills and social skills needed to cope with the environment and to choose healthy alternatives to substance use.(14) The program is highly interactive and focuses on improving the child’s knowledge of peer and media pressure, encouraging positive self-image, strengthening communication and assertiveness skills, developing anxiety management skills, and promoting independent thinking to build healthy relationships and to handle social situations with confidence. More than a decade and a half of efficacy research on the LST Program has consistently shown a 50 percent reduction in drug use.(13)
Project ALERT is a video-based, social resistance approach to drug abuse prevention. Project ALERT enables students to: develop reasons not to use drugs, identify pressures to use them, counter pro-drug messages, learn how to say no to external and internal pressures, understand that most people do not use drugs, and recognize the benefits of resistance. Project ALERT reduced the initiation of marijuana and tobacco use by 30 percent and reduced heavy smoking among participants by 50 percent-60 percent.(15)(16)
Project Northland is a community-wide, research-based curriculum to prevent adolescent alcohol use. The three-year intervention program includes planned parental involvement, peer-led school-based programs, and community-wide policy changes. Project Northland reduced cigarette use by 37 percent, marijuana use by 50 percent, alcohol use in the past month by 20 percent, and alcohol use in the past week by 30 percent.(17)(18)
Talking with Your Students About Alcohol (TWYSAA), changed in 1999 to PRIME for Life!, targets young people who are either engaged in or likely to become involved in high-risk drinking. Using a combination of interactive presentation and small group discussion, the curriculum focuses primarily on alcohol, but there is a unit on marijuana and cocaine. Ninth graders who received TWYSAA were two times more likely to be nondrinkers by the end of 10th grade and were less likely to report heavy drinking than controls.(19)
Teenage Health Teaching Modules (THTM) is a comprehensive curriculum that addresses violence prevention, tobacco, alcohol, and other drug use, and HIV/AIDS, and allows integration with science, social studies, language arts and home economics classes. Exposure to THTM has resulted in reductions in cigarette smoking, alcohol consumption, and drug use.(20)
Methods. A list of all public and private schools that served children in grades 6-12 was obtained from the Kentucky Department of Education.(21) Interviewers were recruited from local health departments and from Eastern Kentucky University, and trained to use a standard phone interview protocol. Interviewers were trained in the ethics of interviewing including privacy protection, voluntary participation, and right to withdraw at any time. Interviewers called the schools, explained the purpose of the interview, and asked to speak with the school principal or other appropriate staff person. When contacting the principal or the designee, interviewers explained the purpose and projected length of the interview, invited them to participate, and discussed that findings would be used for program planning. If the principal or designee could not answer most of the questions, another person in the school was identified and invited to participate. The median length of the interviews was 5 minutes, with a range of 1 to 15 minutes.
Phone Interview Guide. An interview guide was developed with input from the Kentucky Department for Public Health, the Kentucky Division of Substance Abuse, and the Kentucky Department of Education. Information was collected on the type of school (public or private), grade level (elementary, middle, high), number of students enrolled, county, and date and length of interview. For each of the curricula, three questions were asked:
does your school teach the program?
if yes, in what grade levels is it taught?
if yes, do all children in the grade receive the curriculum?
An open-ended question was used to determine if other research-based ATOD curricula were offered. A final question assessed whether the school was interested in receiving information about research-based ATOD curricula.
Sample. A total of 761 schools serving children in grades 6-12 agreed to participate in phone interviews (participation = 63 percent). The median number of students enrolled was 405, with a range of 1 to 2,100. The majority of schools were public (78 percent) and 22 percent were private. The majority of respondents were principals, assistant or vice principals, administrators, deans, or headmasters (70 percent). Other respondents included guidance counselors (13 percent) and other personnel such as youth service center staff, secretaries, health teachers, and Title I coordinators.
Findings. To determine the number of schools offering a particular research-based ATOD curriculum, schools teaching the curricula in grades not appropriate for the particular program were not included in the analysis. Talking with Your Students about Alcohol (TWYSAA) was the most prevalent curriculum offered in Kentucky schools (14 percent), followed by Project ALERT (12 percent; see Figure 1). Of the 104 middle and high schools that reported offering TWYSAA in grades 5 through 12, 50 percent taught the curriculum with 7th-9th grade students. Almost all schools that offered TWYSAA (90 percent) reported that every child enrolled in the grade level received the curriculum. Of the 94 middle schools that reported offering Project ALERT in grades 6 through 8, over two thirds (69 percent) taught the curriculum with 7th and 8th grade students. Almost all schools that offered Project ALERT (92 percent) reported that every child enrolled in the grade level received the curriculum. ALL STARS, Project Northland, and Kentucky Adolescent Tobacco Prevention Program (KATPP) were the least frequently offered ATOD curricula.
Figure 1: Percent of Kentucky Schools Offering Selected Research-based Curricula, 1999-2000
When schools were initially contacted, there was confusion about the term, “Life Skills Training Program.” As a follow up to the initial interview, a random sample of 20 percent of the schools that reported teaching the LST Program was contacted to confirm that they taught LST. Only 7 of the 43 schools contacted again reported teaching the LST program. An estimated number of schools teaching the LST Program and an estimated range of schools with at least one research-based ATOD curriculum are reported here.
It is estimated that between 264 and 304 public and private schools serving children in 6th-12th grades (35 percent-40 percent) offer at least one research-based curriculum. The percentage of schools with at least one curriculum varied considerably by region in the state. Figure 2 displays the percentage of schools that offered at least one ATOD curriculum (not including the LST Program) in each of the state’s 15 Area Development Districts (ADDs), with a range of 13 percent in Purchase to 56 percent in Lincoln Trail. The association between ADD and percent of schools offering at least one ATOD curriculum was significant (c2 = 59.7; p < 0.001), indicating significant differences in prevalence of research-based ATOD curricula among the ADD regions. The majority of respondents (80 percent) were interested in receiving information on research-based ATOD curricula.
Despite the recent controversy about the effects of research-based ATOD curricula on reducing ATOD use,(22)(23)(24) schools can play an important role in preventing ATOD use among youth. While curricula are only one element of a comprehensive, community-wide prevention strategy, schools should choose programs that have been shown to be effective even if in the short-term. With limited funds and time, schools cannot afford to provide programs that have not been evaluated or shown to be effective. While curricula-enhancement tools such as school assemblies and computer-based prevention programs may be attractive alternatives, they are only appropriate if they complement a properly implemented research-based curriculum.
Schools can play a crucial role in changing pro-alcohol and pro-tobacco norms in Kentucky. Given that community norms, or standards, are influenced by public and private policies, media messages, and public opinion,(25) schools can adopt and enforce policies and mold public opinion that denormalizes alcohol and tobacco use. Site-based councils and school administration need to evaluate not only whether they provide research-based ATOD curricula, but also if the curricula are being properly implemented in a consistent and ongoing manner. It is not merely enough for schools to purchase ATOD curricula, but they must train and monitor the staff charged with implementing the curricula.
In addition to ATOD curricula, schools can adopt and enforce stringent anti-drug policies including tobacco-free environments. School policies that are inconsistently enforced or not enforced at all send a mixed message that ATOD use is socially acceptable. Schools that adopt tobacco-free policies send a powerful message to students, parents, staff, and the community that school leaders view tobacco prevention as important and that they actively discourage tobacco use.(26) The National Association of State Boards of Education recommends that school policies:
define the purpose and goals of tobacco prevention efforts;
link effective prevention education to a strictly enforced tobacco-free environment;
address staff and visitors as well as students;
identify strategies to help students and staff overcome tobacco addiction;
and promote coordination among all members of the school community.(26)
The link between ATOD curricula and strictly enforced drug-free policies sends a consistent message that clearly discourages ATOD use. Given that very few Kentucky schools offer research-based ATOD curricula, it is important that school personnel and prevention professionals work together to adopt research-based ATOD curricula and complementary school policies to discourage ATOD use in communities across the Commonwealth.
* Dr. Hahn is an Associate Professor in the University of Kentucky (UK) College of Nursing and School of Public Health. Dr. Rayens is a Research Assistant Professor in the UK College of Nursing, School of Public Health, and Department of Pediatrics, College of Medicine, and Associate Director of the Biostatistics Consulting Unit at Chandler Medical Center. Mr. Rasnake is a Research Assistant in the UK College of Nursing. Return to text.
1 Centers for Disease Control and Prevention (1998). Incidence of initiation of cigarette smoking—United States, 1965-1996. Morbidity and Mortality Weekly Report 47, 837-840. Return to text.
2 Centers for Disease Control and Prevention (2000). Youth risk behavior surveillance—United States, 1999. Morbidity and Mortality Weekly Report, 49, 1-96. Return to text.
3 Substance Abuse and Mental Health Services Administration (SAMHSA) Office of Applied Studies (1999). Summary of Findings from the 1998 National Household Survey on Drug Abuse. SAMHSA Office of Applied Studies: Rockville, MD. Return to text.
4 Federal Register (1998, June 1). Department of Education Safe and Drug-Free Schools Program Notice, 63(104), 29902-29906. Return to text.
5 Centers for Disease Control and Prevention (1994). Guidelines for school health programs to prevent tobacco use and addiction, MMWR, 43, 1-17 (NO. RR-2). Return to text.
6 Kentucky Incentive Project (2000, August). Kentucky youth substance abuse prevention strategy. Frankfort, KY: Kentucky Division of Substance Abuse. Return to text.
7 Harrington, N.G., Giles, S.M., Hoyle, R.H., Feeney, G.J., Youngbluth, S.C. (in press). Evaluation of the ALL STARS character education and problem behavior prevention program: Effects on mediator and outcome variables for middle school students. Health Education and Behavior. Return to text.
8 Dusenbury, L., Falco, M. (1997). A review of the evaluation of 47 drug abuse prevention curricula available nationally. Journal of School Health, 67(4), 127-132. Return to text.
9 Here’s Looking at You Evaluation and Research. AGC/United Learning 1560 Sherman Ave. Suite 100 Evanston, IL 60201 (available on-line, www.agcunitedlearning.com). Return to text.
10 Walter, H. J., Vaughan, R.D., Wynder, E.L. (1989). Primary prevention of cancer among children: Changes in cigarette smoking and diet after six years of intervention. Journal of the National Cancer Institute, 81, 995-999. Return to text.
11 Noland, M.P., Kryscio, R.J., Riggs, R.S., Linville, L.H., Ford, V.Y., Tucker, T.C. (1998). The effectiveness of a tobacco prevention program with adolescents living in a tobacco-producing region. American Journal of Public Health, 88, 1862-1865. Return to text.
12 Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. Return to text.
13 Center for the Study and Prevention of Violence (1998). Blueprints for Violence Prevention, Book 5: Life Skills Training. Golden, CO: Center for the Study and Prevention of Violence. Return to text.
14 Dusenbury, L., Botvin, G.J. (1992). Substance abuse prevention: competence enhancement and the development of positive life options. Journal of Addictive Diseases, 11, 29-45. Return to text.
15 Ellickson, P.L., Bell, R.M., McGuigan, K. (1993). Preventing adolescent drug use: Long-term results of a junior high program. American Journal of Public Health, 83, (6), 856-861. Return to text.
16 Project ALERT website: www.projectalert.best.org. Return to text.
17 Perry, C.L., Williams, C., Veblen-Mortenson, S., Toomey, T L., Komro, K., Anstine, P.S., McGovern, P.G., Finnegan, J.R., Forster, J.L., Wagenaar, A.C., Wolfson, M. (1996). Project Northland: Outcomes of a community alcohol use prevention program during early adolescence. American Journal of Public Health, 86 (7), 956-965. Return to text.
18 Perry, C.L., Williams, C., Forster, J.L., Wolfson, M., Wagenaar, A.C., Finnegan, J.R., McGovern, P.G., Veblen-Mortenson, S., Komro, K., Anstine, P.S. (1993). Background conceptualization, and design of a community-wide research program on adolescent alcohol use. Health Education Research: Theory and Practice, 8(1), 125-136. Return to text.
19 Prevention Research Institute (1988). Talking with Your Students About Alcohol, A Report to the Kentucky Cabinet for Human Resources (available on-line, www.askpri.org/under21_evaluations.htm). Return to text.
20 Ross, J.G., Nelson, G.D., Kolbe, L.J. (1991). Teenage Health Teaching Modules: Evaluation. Journal of School Health, 61(1), 19-42. Return to text.
21 Kentucky Schools Directory 2000-2001 (available on-line, www.kde.state.ky.us or www.k12.ky.us/bookstore). Return to text.
22 Peterson, A.V., Kealey, K.A., Mann, S.L., Marek, P.M., Sarason, I.G. (2000). Hutchinson smoking prevention project: Long-term randomized trial in school-based tobacco use prevention—Results on smoking. Journal of the National Cancer Institute, 92(24), 1979-1991. Return to text.
23 Clayton, R.R., Scutchfield, D., Wyatt, S.W. (2000). Hutchinson smoking prevention project: A new gold standard in prevention science requires new transdisciplinary thinking. Journal of the National Cancer Institute, 92(24), 1964-1965. Return to text.
24 Botvin, G.J. (2000). New study shows social influence approach doesn’t work (available on-line at www.lifeskillstraining.com, January 10, 2001). Return to text.
25 Hahn, E.J. (2000, November). Denormalizing alcohol and tobacco use in Kentucky. Paper presented at the Champions for a Drug-Free Kentucky Annual Workshop, Louisville, KY. Return to text.
26 Bogden, J.F., Vega-Matos, C.A. (2000, March). Fit, healthy, and ready to learn: A school health policy guide. Alexandria, VA: National Association of State Boards of Education. Return to text.