ADDICTIVE

Pergamon BEHAVIORS
Addictive Behaviors 27 (2002) 1009-1023

Effective ingredients of school-based

drug prevention programs
A systematic review
Pim Cuijpers *
Netherlands Institute of Mental Health and Addiction, Trimbos Institute, PO. Box 725,
3500 AS Utrecht, The Netherlands

Abstract

Drug prevention in schools is a top priority in most Western countries and several well-designed
studies have shown that prevention programs have the potential of reducing drug use in adolescents.
However, most prevention programs are not effective and there are no general criteria available for
deciding which program is effective and which is not. In this systematic review of the literature, the
current scientific knowledge about which characteristics determine the effectiveness of drug
prevention programs is examined. Three types of studies are reviewed: meta-analyses (3 studies
were included), studies examining mediating variables of interventions ( 6 studies), and studies directly
comparing prevention programs with or without specific characteristics (4 studies on boosters, 12 on
peer- versus adult-led programs, and 5 on adding community interventions to school programs). Seven
evidence-based quality criteria were formulated: the effects of a program should have been proven;
interactive delivery methods are superior; the "social influence model" is the best we have; focus on
norms, commitment not to use, and intentions not to use; adding community interventions increases
effects; the use of peer leaders is better; and adding life skills to programs may strengthen effects.
© 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Drug education; Review; Prevention; School; Mediators

* Tel.: +31-30-297-1100; fax: +31-30-297-1111.

E-mail address: pcuijpers@trimbos.nl (P. Cuijpers).

0306-4603/02/$ - see front matter © 2002 Elsevier Science Ltd. All rights reserved.
PII: SO 3 0 6-4603 (02 )002 9 5-2
1010 P Cuijpers I Addictive Behaviors 27 (2002) 1009-1023

1. Introduction

Several well-designed studies have shown that school-based drug prevention programs
have the potential to reduce drug use in adolescents (Tobler et al., 2000). However, this
research has also demonstrated that most drug prevention programs are not effective (White
& Pitts, 1998). And, although a growing number of studies are examining which character•
istics determine whether a prevention program is effective or not, the precise ingredients of
effective prevention are not yet known.
At the same time, drug prevention in schools is a top priority in most Western
countries. Drug abuse prevention has been made part of the educational curriculum for all
youngsters in the age of 12-18 in most Western countries. In some countries, schools are
obliged by law to run a specific program or "message" about drug use, other countries
have adopted a simple "reference" in the national curriculum that attention has to be paid
to health promotion in general, including drug prevention. The reason for this high
priority for prevention programs is that drug use and abuse by youngsters is a major
public health concern in most Western countries and the political will to address this
problem is considerable.
Until now, there have been no objective criteria available for deciding which program
is effective and which is not. This makes it difficult for schools, but also for policymakers
and institutions that grant funds for such programs to make a well-founded choice among
the available programs. One option is to use only programs that have been proven to be
effective in well-conducted studies. Several of these programs are available, such as Life•
Skills Training (Botvin, Baker, Dusenbury, & Botvin, 1995), the programs of Project
Northland (Komro et al., 2001; Perry et al., 1996), Project STAR (Pentz et al., 1989), or
the "Healthy Schools and Drugs" Project (Cuijpers et al., 2001). However, most of these
effective programs are specifically developed for use in the United States and it is not
clear if they are suitable for use in other countries. They may not fit within other cultures,
or they may be not effective in other cultures. Furthermore, many of the programs that
have been proven to be effective are developed in research settings and may not fit easily
within the standard practice of schools. For these reasons, it is important to develop
quality standards in school-based drug prevention. These quality criteria can support not
only schools and teachers, but policymakers and prevention workers as well in their
choice of prevention programs. In this literature study, I systematically examine the
current scientific knowledge about which characteristics determine the effectiveness of
drug prevention programs.
There is no doubt that in the area of drug prevention, school-based interventions have been
examined most extensively. In recent systematic literature searches, hundreds of studies
examining the effects of school-based drug prevention were found, including dozens of well•
designed high-quality studies (Tobler et al., 2000; White & Pitts, 1998). It has been well
established in these studies that school-based prevention programs can result in significant
increases in knowledge about substances and in improved attitudes towards substance use.
Well-designed prevention programs are also capable to reduce the use of substances
significantly (Tobler et al., 2000), although these effects only last for a short period and
 P Cuijpers I Addictive Behaviors 27 (2002) 1009-1023 lOll

maybe should be regarded as a short-term delay in the onset of substance use by nonusers and
a short-term reduction in the amount of use by some current users.
Most research in this area, however, concentrates on the effectiveness of drug prevention
programs. Relatively few studies have examined which characteristics are related to the
effectiveness of the programs (Botvin, 2000). The number of studies examining the active
ingredients, on the other hand, is growing and this review will summarize what is currently
known about these ingredients.
In this study, I will concentrate on universal school-based drug prevention, aimed at
tobacco, alcohol, and illegal drugs.
Universal prevention is aimed at all students, whether they are at high risk for drug
use or not (Mrazek & Haggerty, 1994). Selective prevention (aimed at high-risk groups)
and indicated prevention (aimed at students with beginning drug problems) are not
included, as they focus only on subgroups of students. In this study, I focus on all
substances, including tobacco, alcohol, marihuana, and other illegal drugs. Studies that
aim at one substance and studies aimed at more substances at the same time are in•
cluded.
There are several categories of studies that contain relevant information about the effective
ingredients of drug prevention programs. In this review, I focus on three major categories of
studies:

1. Effect studies and meta-analyses. Studies exammmg the effects of school-based drug
prevention program can result in knowledge about types of programs that are effective and
types that are not effective. In this study, I focus on meta-analyses in which types of drug
prevention programs are compared to each other. In meta-analyses, the results of several
studies are statistically integrated and it is assumed that these meta-analyses result in a
better estimate of the real effect of interventions than individual studies (Rosenthal &
DiMatteo, 2001). If we can identify interventions that are effective and interventions that
are not effective, we can use this knowledge to define quality criteria.
2. Studies examining mediating variables of interventions. Some studies of school-based drug
prevention programs examine which "mediators" (defined as characteristics of the
programs) are causing the reduction in drug use.
3. Studies comparing prevention programs. Several studies have examined characteristics of
drug prevention programs, by comparing a program with the characteristic to the same
program but without the characteristic. For example, many studies have compared peer•
and adult-led prevention programs, prevention programs with and without booster
sessions, and with or without community interventions.

In the next three sections of this paper, I will present the information that each of these
three categories gives about the characteristics that determine the effectiveness of drug
prevention programs. Then I will summarize these results and decide which evidence-based
quality criteria can be defmed.
1012 P Cuijpers I Addictive Behaviors 27 (2002) 1009-1023

2. The results of effect studies and meta-analyses

Several hundred studies have examined the results of drug prevention programs in schools.
In these studies, many different interventions have been used. Most of these interventions are
complex, consist of many different components, use multiple intervention techniques and
strategies, and are based on many different theoretical models. Therefore, this large body of
research does not result directly in evidence about which characteristics determine the
effectiveness of the interventions.
Meta-analyses of these studies can generate knowledge about the active ingredients of the
programs. In a meta-analysis, the results of several studies are statistically integrated and this
results in a better estimate of the real effect of interventions than individual studies (Rosenthal
& DiMatteo, 2001 ). In recent decades, statistical techniques have been developed to examine
whether characteristics of interventions are related to the effects that are found in a meta•
analysis (Hedges & Olkin, 1985).
I conducted a systematic literature search to find meta-analyses of school-based drugs
prevention programs (in Pubmed and Psychinfo, keywords on drug prevention; e.g., health
promotion, health education, drug education, drug abuse prevention; combined with key•
words on meta-analysis; reference lists of retrieved studies were examined). I included only
those meta-analyses that were conducted after 1995 and that contained analyses of character•
istics of the prevention programs. Only three meta-analyses met these criteria.
The most comprehensive meta-analysis of school-based prevention programs was con•
ducted by Tobler et al. (2000). They examined 144 studies of 207 school-based drug
prevention programs. Most of these programs were conducted in the United States (19 studies
from other countries). Studies had to include a control group and focus on students from 12 to
18 years. They also made a selection of 93 high-quality studies ( e.g., random assignment to
conditions, no placebo control group, controlling for differences between conditions at
pretest).
This meta-analysis showed that certain programs did reduce substance use whereas
others did not. Programs that reduced substance use employed interactive methods, while
the others programs used noninteractive methods. Interactive programs provide contact and
communication opportunities for the exchange of ideas among participants and encourage
the learning of drug refusal skills (Tobler et al., 2000). Receiving feedback and constructive
criticism in a nonthreatening atmosphere enables students to practice newly acquired refusal
skills.
A thorough analysis of the contents of the drug prevention program by the researchers
resulted in eight types of programs, five noninteractive and three interactive. The
noninteractive programs included programs that focus only on knowledge of substances,
programs that focus on helping the individual develop insight into personal feelings and
behaviors (affective programs) and programs that focus on the individual's problem•
solving skills regarding personal drug use. These programs had a mean standardized
effect size of .03. This indicates that students participating in the prevention programs
improve .03 standard deviation compared to students in the control groups. This is a very
small effect.
 P Cuijpers I Addictive Behaviors 27 (2002) 1009-1023 1013

The programs using interactive methods are based on the social influence approach to drug
prevention. The social influence approach to drug prevention is based on the idea that
"inoculation" in the classroom against active or indirect social pressure to use drugs will help
prevent substance use (Donaldson et al., 1996). There are several components that are used in
social influence programs. Comprehensive life-skills programs also use the social influence
approach but add training of generic skills such as assertiveness, coping, communication, and
sometimes an affective component. Community-wide change programs also use the social
influence approach, but add components of community change ( community mobilization,
media campaigns, family programs). The programs combining interactive methods and a
social influence approach (or in combination with comprehensive life-skills training or with
system-wide change) have a mean standardized effect size of .16, which is considerably larger
than the effect size of the noninteractive programs. Tobler et al. (2000) examined whether the
difference between interactive and noninteractive programs remained significant while
controlling for other variables, such as leader (peer versus adult), more or less than 50%
minority students, substance (only tobacco, only alcohol, more substances combined), and
effects on substances (effects on tobacco use, alcohol use, marijuana use).
This study clearly shows that interactive and social influence prevention programs are
superior to noninteractive programs and to programs that focus on knowledge about
substances only. Unfortunately, it is still not clear which specific components of these
programs are responsible for the effects on substance use. However, it can be safely assumed
that interactive methods are more effective than noninteractive methods, and that social
influence programs are superior to programs focusing on knowledge, affective contents, or
values clarification. Adding comprehensive life-skills training to social influence programs
may possibly increase the effects (the mean effect size of social influence programs is .12; of
comprehensive life-skills programs .1 7). System-wide changes may possibly also increase the
effects of social influence programs (mean effect size of system-wide change is .27).
The second meta-analysis that met our inclusion criteria was conducted by Rooney and
Murray (1996). They examined 90 studies with 131 interventions. They selected only studies
using school-based peer-led and social influence programs, aimed at prevention of tobacco
use (sometimes in combination with a focus on other substances or health issues).
Furthermore, studies had to present follow-up data of at least 1 year. This is the only
meta-analysis I found in which a regression analysis was conducted in order to examine
which characteristics of the interventions are related to effect size. Such a meta-regression is
the best method for examining mediators in meta-analytic research (Cooper & Hedges, 1994;
Hedges & Olkin, 1985; Rosenthal & DiMatteo, 2001). However, because this study is only
aimed at tobacco use, the results cannot be generalized automatically to other drug prevention
programs.
The overall mean effect size of the programs at posttest was .11, which can be considered
to be small. It was found in this study that at posttest, larger effects were found for programs
that had 10 or fewer sessions, programs that had an untrained same-age peer as a leader,
programs that were distributed over a longer period, and programs that focused not only on
tobacco but also on other substances or other health issues. Combining these characteristics in
one program could increase the effect size of these programs up to . 72.
Table 1
Results of studies examining mediating variables in school-based drug prevention
Program Reference Summarized Substance Significant Nonsignificant
study design mediators mediators

Life-Skills Botvin 4 7 schools were T • smoking prevalence knowledge • self-efficacy

Training et al. randomly assigned
(1992) to Life-Skills Training
(15 sessions, Grade 7)
or control
Adolescent Alcohol Donaldson 124 schools (N=3077)
Prevention Trial et al. were randomly assigned
(AAPT) (1994) to resistance training,
normative education, both,
or information only
Drug Abuse(DARE) Hansen three cohorts of
Resistance McNeal Grade 8 students
Education (1997) (N= 1033, 1669, and 1556)
(DARE) receiving the
DARE program (17 lessons);
DARE had only very small
behavioral effects and
only on tobacco use
(not on alcohol, drugs)
• immediate consequences • self-esteem
knowledge
• social acceptability knowledge • decision making
• normative expectations for peers • assertiveness
• normative expectations for adults • psychological
well-being
A • better prevalence estimates • improvement of
and beliefs about acceptability resistance skills in
(the goals of normative education) resistance training did
did significantly predict no predict alcohol use
subsequent alcohol use
ATOD • change in commitment not • social skills
to use mediates the • normative beliefs
(small) behavioral effects • decision skills
• resistance skills
• self-esteem
• goal setting
Project Northland Komro 24 school districts were
et al. randomly assigned to
(2001) Project Northland
(3 years of school
intervention,
parent education,
community-wide activities)
A Total sample: • reducing access
• decreasing peer influence to alcohol
to use alcohol • decreasing family
• increasing parent-child problems
communication • perceived access
• decreasing the likelihood to alcohol
of developing
alcohol/drugs problems
Among nonusers at baseline:
• decreasing school problems :'ti
• increasing self-efficacy Q
;.::::-
to refuse offers of alcohol 'ti"
(I)

Midwestern Project MacKinnon 42 schools (N= 1607) ATOD • friends' reactions to drug use • resistance skills ;::;
<,

Prevention et al. were assigned to the • intentions not to use • perceived peer norms �
(1993) Midwestern project • negative consequences ...
, .,,
(18 lessons, parent program, of drug use �-
;€
mass media campaign,
b;i
community-wide activities) (I)
;,,-.
::,
or control ,::
5·
Alcohol Misuse Wynn, Schulenberg, 6th- through 10th-graders A • norm setting • refusal skills ;::;
Prevention Study Kloska, and Laetz (ns ranged from 232 to 371); "-'
'-l
(1997) random assignment; '0
and Wynn et al. normative+ resistance skills c::,
�.._
c::,
(2000)
c::,
T: tobacco; A: Alcohol; OD: other drugs.
'C
.!_
c::,
<"..-,,.',
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The overall mean effect size at I-year follow-up was found to be .10. Larger effects
were found for programs that targeted sixth graders, programs that were concentrated in a
short period or that offered booster sessions, and programs that included a trained teacher and
an untrained same-age peer leader. Combining these characteristics in one program could
increase the effect size of these programs by up to .76.
The third meta-analysis that met inclusion criteria was conducted by White and Pitts
(1998). They included a broader range of studies (aimed at students aged between 8 and
25 years; as well as non-school-based programs), but identified and included fewer studies
than Tobler et al. (2000). They selected 55 studies of school-based prevention and found
that only 15 of these had an effect on substance use. The authors compared the effective
to noneffective programs, but used no statistical tests or other systematic methods to
examine these differences. They found that both the effective and the noneffective
programs tried to increase the knowledge about substances to students, tried to change
beliefs about the prevalence of drug use, provided resistance skills, and tried to increase
self-esteem.
They found that the use of booster sessions or other additional components that are aimed
at strengthening the effects of the program (such as a community component or a mass
media campaign) could be related to effectiveness. Eight of the 10 effective programs used
booster sessions (or other additional components), compared to only 1 of the noneffective
programs. Another element that could be related to effectiveness is the intensity of the
program. The most effective programs (8 out of 10) were rather intensive (10 or more
lessons), although intensity does not guarantee effectiveness as most noneffective programs
were also intensive. These differences were not examined statistically, and as no significance
tests were conducted, their relationship to effect on substance use can only be regarded as
hypothetical.

3. Studies examining mediating variables of interventions

Another important source of information about the active ingredients of prevention

programs is found in studies examining the "mediators" of change (characteristics of
school-based drugs prevention programs that are related to the effects of the program on
drug use; Donaldson et al., 1996; MacKinnon & Dwyer, 1993). These studies examine
whether drug use is reduced by the intervention, whether the mediating variables are
influenced by the intervention, and whether the mediating variables do have a mediating
role in the reduction of substance use (MacKinnon & Dwyer, 1993).
I conducted a systematic literature search to find studies examining "mediators" (Pubmed
and Psychinfo, keywords on drug prevention; combined with keywords on mediators; again,
reference lists of retrieved studies were examined). I included only studies that showed
significant effects on substance use, and that systematically examined variables that were
related to the effects of the intervention (the mediating variables). Seven studies examining
mediating variables were found. A short summary of these studies and their results are
presented in Table 1.
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A strong point of these studies is their methodological rigor. They have been well•
designed, with adequate control groups, random assignment to condition, substantial
theoretical foundations, sufficient power, and other strong points. These studies are among
the best available in drug prevention research to show effectiveness. One problem in
interpreting the results of these studies is the large differentiation of possible mediators in
the studies. No comparable measures of mediators were used in more than one study.
Furthermore, the interventions and designs of the studies differ considerably.
Nevertheless, several important mediators of prevention programs are identified in these
studies. One of the most important mediators found in several studies is the focus on a
normative approach, including social prevalence knowledge, social acceptability knowledge,
normative expectations, and friends' reactions to drug use (Botvin et al., 1992; Donaldson,
Graham, & Hansen, 1994; MacKinnon et al., 1993; Wynn, Schulenberg, Maggs, & Zucker,
2000). These studies emphasize the need to focus in prevention programs on social influence
components, especially those that are aimed at the acceptability of drugs, knowledge about
the prevalence of drug use, and perceived peer approval of drug use. Other mediators that
were found to be associated with effects of prevention programs included commitment to not
use substances (Hansen & McNeal, 1997), intentions not to use (MacKinnon et al., 1993),
and increasing parent-child communication (Komro et al., 2001).
A mediator that is an important component of many interventions, but which was found
not be a significant mediator is resistance skills training. Other mediators that are sometimes
used in interventions, but which were found not to be significant mediators, include social
skills training, improvement of self-esteem, and psychological well being.
For some mediators, contradictory results are found: knowledge of negative consequences
and self-efficacy.

4. Studies that directly compare prevention programs with and without possible
mediators

Another important source of information about the effective ingredients of prevention

programs is found in studies that directly compare a program with a certain characteristic to
the same program but without the characteristic. I conducted a systematic literature search for
these comparative studies. The results of this part of this study will be described in detail in a
separate report, in which the literature search, the quality of the included studies, and the
methods of analyzing the studies will be described in detail. Here I will only summarize the
main results.
In short, I identified three possible mediators, each of which was examined in three or
more studies: peer leader versus adult leader, with or without booster sessions and school
interventions with or school interventions without community interventions. Several more
possible mediators were examined in only one or two studies. For this report, I will only
summarize the results of the mediators that were examined in three or more studies, as
these studies are most the important for the development of evidence-based quality
criteria.
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4.1. Booster sessions

The four studies examining whether adding booster sessions to drug prevention programs
yielded mixed results. Two studies showed positive effects of booster sessions (Botvin,
Renick, & Baker, 1983; Dijkstra, Mesters, De Vries, van Breukelen, & Parcel, 1999), while
another one showed no effect (Shope, Dielman, Butchart, Campanelli, & Kloska, 1992). The
fourth study in this area compared a peer-led program with booster sessions to a peer-led
program without boosters (Botvin, Baker, Filazolla, & Botvin, 1990). However, this study
also compared a teacher-led program with booster sessions to a teacher-led program without
boosters. Strong positive effects of the booster sessions were found for the peer-led
intervention, but the booster sessions resulted in worse outcomes for the teacher-led
intervention. Therefore, it cannot be concluded from these studies that booster sessions
increase the effects of drug prevention programs at school. It is likely that booster sessions
may increase the effects depending on other characteristics of the prevention program.

4.2. Peer- versus adult-led programs

Twelve studies compared peer-led drug prevention programs to the same programs led by
adults (Cuijpers, in press). The quality of these studies was not optimal, and the interventions
and target groups differed considerably among studies. Overall, peer-led programs were
found to be somewhat more effective than adult-led programs (standardized difference d=.24)
at the short term. One year after the intervention, no significant differences between peer- and
adult-led interventions were found. There were large differences between studies, with some
studies indicating greater effects for peer-led programs and other studies showing greater
effects for adult-led programs. This research suggests that the effectiveness of a prevention
program is determined by several characteristics of the programs. The leader may constitute
one of those characteristics.

4.3. Adding community intervention to school programs

Five studies compared school programs with the same school programs combined with
community interventions. The overall quality of these studies can be considered adequate.
The community interventions that were used in these studies differed considerably, varying
from media campaigns (Flynn, Worden, Secker-Walker, Badger, et al., 1994; Flynn, Worden,
Secker-Walker, Pirie, et al., 1994; Secker-Walker, Worden, Holland, Flynn, & Detsky, 1997;
Vartiainen, Paavola, McAlister, & Puska, 1998; Vartiainen, Pallonen, McAlister, Koskela, &
Puska, 1986) to community-wide interventions ( community task force and parent interven•
tions; Biglan, Ary, Smolkowski, Duncan, & Black, 2000; Stevens, Freeman, Mott, & Youells,
1993; Stevens, Freeman, Mott, Youells, & Linsey, 1996; Stevens, Mott, & Youells, 1996).
Overall, these studies demonstrate convincingly that the effects of the school programs can be
increased significantly when community components are added. This conclusion is m
agreement with a recent systematic review of this research area (Flay, 2000).
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5. Towards evidence-based quality criteria for school-based drug prevention

I reviewed three areas of research on effective characteristics of school-based drug

prevention programs. Several quality criteria for prevention programs can be described on
the basis of this research.
I assessed the strength of the evidence supporting each of the quality criteria, and
distinguished four categories in the strength of evidence:

1. Some evidence supporting the quality criterion (indicated by *); there is evidence from
one of the three sources of evidence that supports this criterion and the evidence is
convmcmg.
2. Strong evidence supporting the quality criterion (indicated by **); there is evidence from
two of the four sources of evidence that supports this criterion and/or the evidence leaves
little doubt that this an important criterion.
3. Very strong evidence (indicated by ***). The evidence is so strong that there is scarcely
any doubt that this is an important quality criterion.
4. Proven (indicated by ****). The evidence leaves no doubt at all that this is an important
quality criterion.

A major problem in this research is that many different interventions have been used, with
differing formats, targets, targeted substances, age groups, and theoretical models. There are
also large difference among studies in design, evaluation methods, and measurement of
substance use, and the results rely mainly on self-reported drug use, which is not always
reliable. Therefore, it is not possible to derive definite evidence-based quality criteria from the
research described in this report. I did not qualify the strength of evidence for any criteria as
very strong or proven (*** or ****; except for the first criterion).
I derived the following evidence-based quality criteria:

1. Proven effects. The effects of a program that is used in practice should have been shown in
well-designed scientific research. This is an important criterion, as most drug prevention
programs have been shown to have no effects on drug use or abuse. In particular, the meta•
analysis from White and Pitts (1998) has clearly shown that only a selected sample of drug
prevention programs is effective. This is the only criterion that is supported by evidence I
assessed to be very strong. This criterion has a different character as the other ones, as it
does not indicate a characteristic of the program itself, but requires that the effects have
been proven. However, it is an important criterion and is therefore retained in this list at the
first place. Strength of evidence: ** *
2. Interactive delivery methods. Universal school-based drug prevention programs should use
interactive delivery methods, instead of noninteractive delivery methods. Interactive
programs provide contact and communication opportunities for the exchange of ideas
among participants and encourage learning drug refusal skills (Tobler et al., 2000). In
interactive programs students receive feedback and constructive criticism in a non•
threatening atmosphere, enabling students to practice newly acquired refusal skills.
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Noninteractive programs focus mainly on knowledge provision and some discussion. The
meta-analyses from Tobler et al. (2000) have clearly shown the superiority of interactive
programs compared to noninteractive programs. Strength of evidence: * *
3. Based on the "social influence model." Prevention programs based on the "social
influence model" are the most effective programs that are available, and prevention
programs should use this model (Tobler et al., 2000). The social influence approach to drug
prevention is based on the idea that "inoculation" in the classroom against active or
indirect social pressure to use drugs will help prevent substance use (Donaldson et al.,
1996). Details of this approach are described in detail by Hansen (1993). Strength of
evidence: * *
4. Focus on norms, commitment not to use, and intention not to use. As part of the social
influence approach, prevention programs should focus especially on norms (social
prevalence knowledge, social acceptability knowledge, normative expectations, friends'
reactions to drug use), commitment of students to not use substances, and intentions not to
use. Research on mediating variables has shown norms, commitment, and intentions to be
vital mediating variables (see also the paper by Marlatt et al., in this issue). Strength of
evidence: * *
5. Adding community interventions to school-based interventions. This strengthens the effects
of school-based interventions. Community interventions include family interventions,
mass media campaigns, and community mobilizing committees. The strengthening effect
of community interventions has been demonstrate both in the Tobler et al. (2000) meta•
analysis and in comparative research. Strength of evidence: * *
6. Use of peer leaders. The use of peer leaders may strengthen the short-term effects of
prevention program, and programs should therefore use peer leaders in stead of or in
combination with adult leaders when possible (Cuijpers, in press; Rooney & Murray,
1996). Strength of evidence: * *
7. Adding life-skills training to social influence programs. This may strengthen the effects of
prevention programs, as was indicated by the meta-analysis by Tobler et al. (2000). There
is not sufficient evidence from research on mediating variables that social skills training,
enhancing of self-esteem, and focusing on psychological well being increase the effects of
prevention programs. Strength of evidence: *

There is no convincing evidence that prevention programs with the following character•
istics are more effective than other programs:

• Booster sessions. There is insufficient evidence that booster sessions in themselves

increase the effects of a program. Boosters probably do increase the effects for some
programs, but for other, they seem not to. And it is not clear in which programs boosters do
increase the effects and in which they do not.
• Resistance skills training. Research examining mediating variables and the relation
between mediating variables and effects of a program on substance use have not shown
that resistance skills training is a significant mediating variable.
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• Intensity. There is no definite evidence that intense programs are more effective than less
intense programs.

6. Discussion

I examined major categories of research on effective characteristics of school-based drug

prevention programs and used these for defining quality criteria for prevention programs.
This approach has several limitations. First, the interventions that are examined in the
research I described are, as indicated earlier, very different from each other. It is very well
possible that one mediating mechanism works in the context of one intervention, but not in
another intervention. In other words, the generalizability of the mediating characteristics and
mechanisms is not clear. Second, most research has been conducted in the United States and
the results may not be valid in other countries. Third, I relied on quick literature searches and
may have missed important references. Because of these limitations, the results of this study
have to be considered with caution. I tried to weigh the scientific evidence by assigning a
measure of strength of evidence to each of the defined quality criteria.
In this study, I have defined quality criteria on the basis of the research in this area. I did
not describe general quality criteria that are not based on scientific evidence but on face
validity. For example, a school should have enough resources for conducting prevention
programs, the teachers should have received sufficient training, and each school needs a
coordinator for the prevention program. This kind of quality criteria has not been described in
this report, but does require more research.
Several important issues in school-based drug prevention have not been described in this
paper. Dissemination of effective programs, the adequate implementation of programs at
school, the application of effective programs in different cultural settings, these are some of
the issues that have to be studied more extensively before effective programs can be
developed and disseminated.
Despite these limitations I have been able to define important quality criteria for universal
school-based drug prevention. Although the research has concentrated mainly on the question
whether prevention programs are effective, the research for mediating variables and active
ingredients has produced important knowledge. Although the scientific strength is not always
as substantial as desired, I think the quality criteria defined on the basis of this research can be
of considerable value for schools, policymakers, and prevention scientists in the improvement
of school-based drug prevention.

Acknowledgements

This study is conducted as a part of the "European Healthy School Project" and is
supported by the European Program on Community Action on the Prevention of Drug
Dependence.
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References

Biglan, A., Ary, D. V., Smolkowski, K., Duncan, T., & Black, C. (2000). A randomised controlled trial of a
community intervention to prevent adolescent tobacco use. Tobacco Control, 9, 24-32.
Botvin, G. J. (2000). Preventing drug abuse in schools: social and competence enhancement approaches targeting
individual-level etiological factors. Addictive Behaviors, 25, 887-897.
Botvin, G. J., Baker, E., Dusenbury, L., & Botvin, E. M. (1995). Long-term follow-up results of a randomized
drug abuse prevention trial in a white middle-class population. JAMA, the Journal of the American Medical
Association, 273, 1106-1112.
Botvin, G. J., Baker, E., Filazolla, A. D., & Botvin, E. M. (1990). A cognitive-behavioral approach to substance
abuse prevention: one-year follow-up. Addictive Behaviors, 15, 47-63.
Botvin, G. J., Dusenbury, L., Baker, E., James-Ortiz, S., Botvin, E. M., & Kemet, J. (1992). Smoking prevention
among urban minority youth: assessing effects on outcome and mediating variables. Health Psychology, 11,
290-299.
Botvin, G. J., Renick, N. L., & Baker, E. (1983). The effects of scheduling format and booster sessions on a broad•
spectrum psychosocial approach to smoking prevention. Journal of Behavioural Medicine, 6, 359-379.
Cooper, H., & Hedges, L. V. (1994). The handbook for research synthesis. New York: Sage Foundation.
Cuijpers, P. (2002). Peer-led and adult-led school drug prevention: a meta-analytic comparison. Journal ofDrug
Education, 32 (in press).
Cuijpers, P., Jonkers, R., De Weerdt, I., De Jong, A. (2002). "The effects of drug abuse prevention at school: the
Healthy School and Drugs" project. Addictions, 97, 67-73.
Dijkstra, M., Mesters, I., De Vries, H., van Breukelen, G., & Parcel, G. S. (1999). Effectiveness of a social
influence approach and boosters to smoking prevention. Health Education Research, 14, 791-802.
Donaldson, S. I., Graham, J. W., & Hansen, W. B. (1994). Testing the generalizability of intervening mechanism
theories: understanding the effects of adolescent drug use prevention interventions. Journal of Behavioral
Medicine, 17, 195-216.
Donaldson, S. I., Sussman, S., MacKinnon, D. P., Severson, H. H., Glynn, T., Murray, D. M., & Stone, E. J. (1996).
Drug abuse prevention programming; do we know what contents works? American Behavioral Scientist, 39,
868-883.
Flay, B. R. (2000). Approaches to substance use prevention utilizing school curriculum plus social environmental
change. Addictive Behaviors, 25, 861-885.
Flynn, B. S., Worden, J. K., Secker-Walker, R. H., Badger, G. J., Geller, B. M., & Costanza, M. C. (1994).
Prevention of cigarette smoking through mass media intervention and school programs. American Journal of
Public Health, 82, 827-834.
Flynn, B. S., Worden, J. K., Secker-Walker, R. H., Pirie, P. L., Badger, G. J., Carpenter, J. H., Geller, B. M.
(1994). Mass media and school interventions for cigarette smoking prevention: effects 2 years after com•
pletion. American Journal of Public Health, 84, 1148-1150.
Hansen, W. B. (1993). School-based alcohol prevention programs. Alcohol Health and Research World, 17,
54-60.
Hansen, W. B., & McNeal, R. B. (1997). How DARE works: an examination of program effects on mediating
variables. Health Education and Behavior, 24, 165-176.
Hedges, L., & Olk.in, I. (1985). Statistical methods for meta-analysis. Orlando, FL: Academic Press.
Kornro, K. A., Perry, C. L., Williams, C. L., Stigler, M. H., Farbakhsh, K., & Veblen-Mortenson, S. (2001). How
did Project Northland reduce alcohol use among young adolescents? Analysis of mediating variables. Health
Education Research, 16, 59- 70.
MacKinnon, D. P., & Dwyer, J. H. (1993). Estimating mediated effects in prevention studies. Evaluation Review,
17, 144-158.
MacKinnon, D. P., Johnson, C. A., Pentz, M.A., Dwyer, J. H., Hansen, W. B., Flay, B. R., & Wang, E. Y. I. (1993).
Mediating mechanisms in a school-based drug prevention program: first year effects of the Midwestern Pre•
vention Project. Health Psychology, 10, 164-172.
1023 P PCuijpers
CuijpersI Addictive
I AddictiveBehaviors
Behaviors2727(2002)
(2002)1009-1023
1009-1023 1023

Mrazek, P. J., & Haggerty, R. J. (1994). Reducing risks for mental disorders; frontiers for preventive intervention
research. Washington, DC: National Academy Press.
Pentz, M. A., Dwyer, J. H., MacKinnon, D. P., Flay, B. R., Hansen, W. B., Wang, E. Y., & Johnson, C. A. (1989).
A multicommunity trial for primary prevention of adolescent drug abuse. Effects on drug use prevalence.
JAMA, the Journal of the American Medical Association, 261, 3259-3266.
Perry, C. L., Williams, C. L., Veblen-Mortenson, S., Toomey, T. L., Komro, K. A., Anstine, P. S., McGovern, P. G.,
Finnegan, J. R., Forster, J. L., Wagenaar, A. C., & Wolfson, M. (1996). Project Northland: outcomes of a
communitywide alcohol use prevention program during early adolescence. American Journal ofPublic Health,
86, 956-965.
Rooney, B. L., & Murray, D. M. (1996). A meta-analysis of smoking prevention programs after adjustment for
errors in the unit of analysis. Health Education Quarterly, 23, 48-64.
Rosenthal, R., & DiMatteo, M. R. (2001). Meta-analysis: recent developments in quantitative methods for
literature reviews. Annual Review of Psychology, 52, 59-82.
Secker-Walker, R. H., Worden, J. K., Holland, R. R., Flynn, B. S., & Detsky, A. S. (1997). A mass media
programs to prevent smoking among adolescents: costs and cost effectiveness. Tobacco Control, 6, 207-212.
Shope, J. T., Dielman, T. E., Butchart, A. T., Campanelli, P. C., & Kloska, D. D. (1992). An elementary school•
based alcohol misuse prevention program: a follow-up evaluation. Journal of Studies on Alcohol, 53,
106-121.
Stevens, M. M., Freeman, D. H., Mott, L., & Youells, F. (1996). Three-year results of prevention programs on
marihuana use: the New Hampshire study. Journal of Drug Education, 26, 257-273.
Stevens, M. M., Freeman, D. H., Mott, L., Youells, F., & Linsey, S. C. (1996). Smokeless tobacco use among
children: the New Hampshire study. American Journal of Preventive Medicine, 9, 160-167.
Stevens, M. M., Mott, L., & Youells, F. (1996). Rural adolescent drinking behavior: three year follow-up in the
New Hampshire substance abuse prevention study. Adolescence, 31, 159-166.
Tobler, N. S., Roona, M. R., Ochshom, P., Marshall, D. G., Streke, A. V., & Stackpole, K. M. (2000). School•
based adolescent drug prevention programs: 1998 meta-analysis. Journal ofPrimary Prevention, 20, 275-336.
Vartiainen, E., Paavola, M., McAlister, A., & Puska, P. (1998). Fifteen-year follow-up of smoking prevention
effects in the North Karelia Youth project. American Journal of Public Health, 88, 81-85.
Vartiainen, E., Pallonen, U., McAlister, A., Koskela, K., & Puska, P. (1986). Four-year follow-up results of the
smoking prevention program in the North Karelia Youth Project. Preventive Medicine, 15, 692-698.
White, D., & Pitts, M. (1998). Educating young people about drugs: a systematic review. Addiction, 93,
1475-1487.
Wynn, S., Schulenberg, J., Kloska, D., & Laetz, V. (1997). Preventing alcohol misuse during adolescence: the
mediating influence of refusal skills. Journal of School Health, 67, 390-395.
Wynn, S., Schulenberg, J., Maggs, J. L., & Zucker, R. A. (2000). Preventing alcohol misuse: the impact ofrefusal
skills and norms. Psychology of Addictive Behaviors, 14, 36-47.