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Bühler A., Thrul J.
European Monitoring Centre for Drugs and Drug Addiction, 2015.
Based largely on existing reviews, this report for the German Federal Centre for Health Education comprehensively assesses substance use prevention approaches. Among its many conclusions are that approaches based solely on information provision are ineffective, in contrast to the more positive evidence for lifeskills and multi-component community programmes.
Summary This publication is a translation of a literature review for the German Federal Centre for Health Education published in 2013, updating and extending a report published in 2006. The Federal Centre for Health Education is a governmental authority within the Federal Ministry of Health. The translated report was produced by the European Monitoring Centre for Drugs and Drug Addiction, one of the European Union’s decentralised agencies. Its role is to provide the EU and its member states with a factual overview of European drug problems and a solid evidence base to support policy and practice.
This report originally written for the German Federal Centre for Health Education comprehensively assesses substance use prevention approaches based largely on existing reviews and meta-analytic amalgamations of research findings.
Among its many conclusions are that approaches based solely on information provision are ineffective, in contrast to more positive evidence for school-based lifeskills programmes and multi-component community programmes.
Development of substance use among high-risk populations can be prevented by family and parenting programmes and personalised brief interventions as well as some lifeskills programmes and other approaches.
Scientific evidence must be combined with experience, values, and an understanding of the context in which interventions are to be implemented.
The report is aimed at decision-makers in addiction prevention and people in charge of developing and/or implementing preventive measures. The reviewers assessed the effectiveness of interventions to prevent addiction mainly by drawing on high-quality reviews and meta-analyses. They defined ‘effectiveness’ as preventing, delaying or reducing consumption of tobacco, alcohol, cannabis or other illicit psychoactive substances through ‘universal’ or ‘selective’ approaches (these terms are defined below). They also outlined theoretical principles currently under discussion in various areas of addiction prevention.
The literature search was conducted in late 2012 and was restricted to studies and reviews published between 2004 and 2012. In all 64 were selected, including 17 meta-analyses and 38 systematic reviews.
Universal prevention measures are aimed at people who, as an overall group, display an average risk of later substance abuse (eg, the general population or whole school classes).
Particularly with regard to alcohol use, parental training and family programmes are recommended as an effective universal approach in the family setting.
School-based programmes which provide only information are not recommended. Proven universal school-based prevention programmes to prevent alcohol misuse include alcohol-specific interventions based on boosting certain social and lifeskills, as well as more general lifeskills programmes focused on substance use, and a generic classroom-based behaviour management programme. Similar interventions affect the smoking behaviour of all schoolchildren in a class, irrespective of previous smoking experience, but these interventions have not been shown to stop children starting to smoke. For school-based tobacco use prevention, recommended programmes focus on social influences on tobacco use or on lifeskills, ideally combined with measures to make the community environment less tobacco-friendly. Skills-oriented, comprehensive drug use prevention programmes based on interactive teaching methods should be used to prevent use of cannabis and other illicit drugs. Effective also are measures to improve the school’s social environment to make it more engaging for the pupils.
Effective universal approaches in leisure/recreational settings (eg, sports clubs, nightlife venues, peer and mentoring programmes) and targeted specifically at substance use have yet to be identified. However, high-quality generic programmes to improve personal and social skills, implemented in a non-school setting, have been found effective in some situations and with respect to use of some substances.
With regard to (mass) media interventions, there is now evidence for the effectiveness of internet- and computer-based universal prevention programmes, and further confirmation that tobacco use prevention through traditional mass media should not be a stand-alone measure, but supplemented by school-based programmes.
There is currently little research on prevention in healthcare settings; the few available studies show that effective universal approaches still need to be developed.
‘Community’ here is understood as a geographical or political entity such as a neighbourhood, municipality or region which is smaller, closer to individuals, and more amenable to influence by them, than a national or federal institution or area. There is now evidence that multi-component preventive measures in several settings are effective for alcohol and tobacco use and occasionally for illicit drugs. The relevant projects consist mainly of school-based interventions in conjunction with family training covering parenting, communication, and conflict resolution. Systematic cooperation between community stakeholders and authorities responsible for enforcing local alcohol regulations could augment effectiveness. Studies published since 2004 also support tobacco and alcohol control strategies that: raise prices for alcohol and tobacco products; lead to increased controls and sanctions on sales of tobacco and alcohol to minors; impose restrictions on alcohol advertising; impose smoking bans which restrict opportunities to smoke.
Selective measures are aimed at people who, as a group, display an above-average risk of later substance abuse such as children from families affected by addiction, children with behavioural problems, students, and certain groups of hospital patients. On the basis of the international literature reviewed for this report, the following measures can be recommended:
• In the family: the supervision and assistance of first-time parents by midwives; lifeskills training for children displaying problem behaviours and for their parents; family programmes for families affected by alcohol dependence.
• In schools: lifeskills programmes with additional elements for individual children aged 16–20 at high risk of illicit drug use.
• In colleges: personal, brief interventions; online and computer-based feedback of assessment or screening results and ‘normative’ feedback comparing the individual’s substance use with that of their peers; web-based programmes; gender-specific ‘expectancy challenge’ interventions which ‘challenge’ assumptions about the effects of drinking by asking participants to identify who (including themselves) has drunk alcohol versus an identical non-alcoholic drink; multi-component approaches consisting of providing information, motivational interviewing and feedback of assessment or screening results.
• In leisure/community settings: for alcohol, mentoring programmes with teenagers; for alcohol and illicit drugs, multi-component projects in family and leisure settings.
• In healthcare settings: for alcohol and cannabis, face-to-face brief interventions in hospitals.
When interpreting the results of this report, it should be borne in mind that its criteria for intervention effectiveness were based on a rather narrow perspective on evidence-based prevention, being confined to effects on consumption of drugs, alcohol or tobacco. Not considered were impacts on factors which might increase risk of addiction or be protective, or impacts on the consequences of substance use. Conclusions were also based solely on randomised trials or other trials which featured a comparator against which to benchmark the intervention’s impacts, not other types of studies.
Scientific knowledge of the effectiveness of preventive measures of the kind reviewed in this report is a central but not the sole resource for the design and implementation of measures to prevent addiction, especially since the research primarily originates from the USA, and context and value systems are as important as scientific knowledge. Three dimensions must be considered when planning and implementing health promotion and prevention activities:
• Values: basic (ethical) values and principles of health promotion and public health, such as avoidance of harm, respect for autonomy, equal opportunities for health, sustainability, and empowerment.
• Knowledge: systematically generated current scientific findings, knowledge from evaluations and reflection on science, and supplementary knowledge from experience, practice, and expert opinion.
• Context: capacities for mounting effective measures and laws and policy/cultural factors which influence the transferability of scientific findings and interventions to the particular context.
Last revised 25 October 2015. First uploaded 20 October 2015
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