Brian R. Flay

Reviewing Theories of Adolescent Substance Use: Organizing Pieces in the Puzzle

This article reviews 14 multivariate theories of experimental substance use (e.g., alcohol and marijuana use) among adolescents, including those theories that emphasize (a) substance-specific cognitions, (b) social learning processes, (c) commitment to conventional values and attachment to families, and (d) intrapersonal processes. Important similarities and differences among these theories are addressed, as are the conceptual boundaries of each theory. In an attempt to integrate existing theories, a framework is proposed that organizes their central constructs into 3 distinct types of influence (viz., social, attitudinal, and intrapersonal) and 3 distinct levels of influence (viz., proximal, distal, and ultimate). Implications for future theory development are discussed.

Standards of Evidence: Criteria for Efficacy, Effectiveness and Dissemination

Ever increasing demands for accountability, together with the proliferation of lists of evidence-based prevention programs and policies, led the Society for Prevention Research to charge a committee with establishing standards for identifying effective prevention programs and policies. Recognizing that interventions that are effective and ready for dissemination are a subset of effective programs and policies, and that effective programs and policies are a subset of efficacious interventions, SPR’s Standards Committee developed overlapping sets of standards. We designed these Standards to assist practitioners, policy makers, and administrators to determine which interventions are efficacious, which are effective, and which are ready for dissemination. Under these Standards, an efficacious intervention will have been tested in at least two rigorous trials that (1) involved defined samples from defined populations, (2) used psychometrically sound measures and data collection procedures; (3) analyzed their data with rigorous statistical approaches; (4) showed consistent positive effects (without serious iatrogenic effects); and (5) reported at least one significant long-term follow-up. An effective intervention under these Standards will not only meet all standards for efficacious interventions, but also will have (1) manuals, appropriate training, and technical support available to allow third parties to adopt and implement the intervention; (2) been evaluated under real-world conditions in studies that included sound measurement of the level of implementation and engagement of the target audience (in both the intervention and control conditions); (3) indicated the practical importance of intervention outcome effects; and (4) clearly demonstrated to whom intervention findings can be generalized. An intervention recognized as ready for broad dissemination under these Standards will not only meet all standards for efficacious and effective interventions, but will also provide (1) evidence of the ability to “go to scale”; (2) clear cost information; and (3) monitoring and evaluation tools so that adopting agencies can monitor or evaluate how well the intervention works in their settings. Finally, the Standards Committee identified possible standards desirable for current and future areas of prevention science as the field develops. If successful, these Standards will inform efforts in the field to find prevention programs and policies that are of proven efficacy, effectiveness, or readiness for adoption and will guide prevention scientists as they seek to discover, research, and bring to the field new prevention programs and policies.

Efficacy and Effectiveness Trials (and Other Phases of Research) in the Development of Health Promotion Programs

The concepts of efficacy and effectiveness are examined from the viewpoints of the traditions and philosophies of health-care research and social program evaluation. Consideration of the status of the program being assessed, its availability to, and its acceptance by the target audience leads to the derivation of four levels of health promotion program testing: efficacy trials, under optimum conditions of program implementation and recipient participation; treatment effectiveness trials, with expected variation in target audience acceptance; implementation effectiveness trials, under varying conditions of implementation; and program evaluation of previously untested programs. These four levels of testing, together with experience in one area of health promotion research (smoking prevention), suggest eight phases of research for the development of health promotion programs: basic research, hypothesis development, pilot applied research, prototype evaluation studies, efficacy trials, treatment effectiveness trials, implementation effectiveness trials, and demonstration evaluations. Issues of design, the use of random assignment, the use of blinding procedures, and of the role of process evaluation in these different research levels, particularly efficacy and effectiveness trials, are considered in light of the terminologies and methods of health-care and social program evaluation research. Suggestions are made for improved health promotion research.

Stages in the development of adolescent smoking

Many researchers have conceptualized smoking uptake behavior in adolescence as progressing through a sequence of developmental stages. Multiple social, psychological, and biological factors influence this process, and may play different functions at different points in the progression, and play different roles for different people. The major objective of this paper is to review empirical studies of predictors of transitions in stages of smoking progression, and identify similarities and differences related to predictors of stages and transitions across studies. While a number of factors related to stage of progression replicated across studies, few variables uniquely predicted a particular stage or transition in smoking behavior. Subsequently, theoretical considerations related to stage conceptualization and measurement, inter-individual differences in intra-individual change, and the staged or continuous nature of smoking progression are discussed.

Mass media and smoking cessation: a critical review.

Evaluations of 40 mass media programs/campaigns designed to influence cigarette smoking were reviewed. Information/motivation programs/campaigns generally produced changes in awareness, knowledge, and attitudes. Extensive national campaigns also produced meaningful behavioral change. Programs/campaigns designed to promote some specific smoking-related action produced mixed results, depending in large part on the type of promotion involved. Mass media cessation clinics were found to be effective, with media plus social support being more effective than viewing plus printed material, and either combination being more effective than viewing alone. It was concluded that mass media health promotion programs can be more effective than many academics may have thought, but that the knowledge necessary to ensure such success is seriously lacking. Research studies, rather than simple evaluations, are needed to improve our knowledge base and build a science of mass media health promotion.

Six-year follow-up of the first Waterloo school smoking prevention trial.

This paper reports six-year follow-up data from the first large-scale randomized trial of the social influences approach to smoking prevention. In 1979, 22 schools were randomly assigned to program or control conditions. Students in program schools received a social influences curriculum in six core and two maintenance sessions in grade 6, two booster sessions in grade 7, and one booster session in grade 8. All students were assessed at pretest (T1), immediate posttest (T2), end of grade 6 (T3), beginning and end of grade 7 (T4 and T5), end of grade 8 (T6), and grades 11 and 12 (T7 and T8). Ninety percent of study students were relocated and data obtained from over 80 percent of them at T8. Program effects on experimental smoking observed in grades 7 and 8 had completely decayed by T8, six years after the beginning of the program. Grade 6 smoking experience and social risk were each strong predictors of T8 smoking behavior. Subjects who had left school were smoking at more than twice the rate of subjects still in high school (grade 12) at T8. We discuss implications of the results.

Affective and Social Influences Approaches to the Prevention of Multiple Substance Abuse among Seventh Grade Students: Results from Project SMART

Two drug abuse prevention curricula were tested to determine their efficacy in preventing the onset of tobacco, alcohol, and marijuana use among adolescents. The first program focused on prevention through social pressure resistance training. The second featured affective education approaches to prevention. Curricula were tested on seventh grade students. Subjects were pretested just prior to the program and were post-tested at 12 and 24 months. Post-test analyses indicated that the social program delivered to seventh grade subjects was effective in delaying the onset of tobacco, alcohol, and marijuana use. No preventive effect of the affective education program was observed. By the final post-test, classrooms that had received the affective program had significantly more drug use than controls.

Cultural diversity in the predictors of adolescent cigarette smoking: The relative influence of peers

A culturally diverse sample of 4375 adolescents completed a self-report inventory assessing their current amount of smoking, and several psychosocial predictors of smoking (e.g., depression, anger, stress, smoking among peers, etc). Results revealed that Whites smoke more than Blacks, Asians, and less acculturated Latinos but not more than highly acculturated Latinos. Stepwise regression analyses of the predictors of smoking found significant ethnic and acculturation differences in the relative predictive power of 18 well-known risk factors. Smoking among peers was the best predictor of smoking for White adolescents (accounting for 23.5% of the variance) but accounted for only 15% of the variance for Latino youth, 9.6% of the variance for Asian youth, and none of the variance for Black youth. Results are discussed in terms of their implications for smoking prevention programs that focus on resisting peer influences.

The critical role of nurturing environments for promoting human well-being.

The recent Institute of Medicine report on prevention (National Research Council & Institute of Medicine, 2009) noted the substantial interrelationship among mental, emotional, and behavioral disorders and pointed out that, to a great extent, these problems stem from a set of common conditions. However, despite the evidence, current research and practice continue to deal with the prevention of mental, emotional, and behavioral disorders as if they are unrelated and each stems from different conditions. This article proposes a framework that could accelerate progress in preventing these problems. Environments that foster successful development and prevent the development of psychological and behavioral problems are usefully characterized as nurturing environments. First, these environments minimize biologically and psychologically toxic events. Second, they teach, promote, and richly reinforce prosocial behavior, including self-regulatory behaviors and all of the skills needed to become productive adult members of society. Third, they monitor and limit opportunities for problem behavior. Fourth, they foster psychological flexibility-the ability to be mindful of ones thoughts and feelings and to act in the service of ones values even when ones thoughts and feelings discourage taking valued action. We review evidence to support this synthesis and describe the kind of public health movement that could increase the prevalence of nurturing environments and thereby contribute to the prevention of most mental, emotional, and behavioral disorders. This article is one of three in a special section (see also Muñoz Beardslee, & Leykin, 2012; Yoshikawa, Aber, & Beardslee, 2012) representing an elaboration on a theme for prevention science developed by the 2009 report of the National Research Council and Institute of Medicine.

Effects of Program Implementation on Adolescent Drug Use Behavior The Midwestern Prevention Project (MPP)

This study evaluated the relationship between level of program implementation and change in adolescent drug use behavior in the Midwestern Prevention Project (MPP), a school- and community-based program for drug abuse prevention. Trained teachers implemented the pro gram with transition year students. Implementation was measured by teacher self-report and validated by research staff reports. Adolescent drug use was measured by student self-report; an expired air measure of smoking was used to increase the accuracy of self-reported drug use. Regression analyses were used to evaluate adherence; exposure, or amount of implementation; and reinvention. Results showed that all schools assigned to the program condition adhered to the research by implementing the program. Exposure had a significant effect on minimizing the increase in drug use from baseline to one year. Exposure also had a larger magnitude of intervention effect than experimental group assignment. Reinvention did not affect drug use. Results are discussed in terms of research assumptions about quality of program implementation, and possible school-level predictors of implementation.