You've shown the program model is effective. Now what?

Rigorous tests of theory-based programs require faithful implementation. Otherwise, lack of results might be attributable to faulty program delivery, faulty theory, or both. However, once the evidence indicates the model works and merits broader dissemination, implementation issues do not fade away. How can developers enhance the likelihood that the program will be delivered as designed and thus get results close to what was possible under controlled conditions? How can they address program weaknesses without undermining conceptual integrity? What role can they play in making the program visible and attractive to institutional adopters? This chapter uses field experience from a theory-based program, Project ALERT, to suggest possible strategies for enhancing program attractiveness to potential adopters and users, facilitating program fidelity while maintaining room for adaptation and taking a program to scale.

Running away from home: a longitudinal study of adolescent risk factors and young adult outcomes.

Little is known about the adolescent risk factors and young adult health-related outcomes associated with running away from home. We examined these correlates of running away using longitudinal data from 4,329 youth (48% female, 85% white) who were followed from Grade 9 to age 21. Nearly 14% of the sample reported running away in the past year at Grade 10 and/or Grade 11. Controlling for demographics and general delinquency, running away from home was predicted by lack of parental support, school disengagement, greater depressive affect, and heavier substance use at Grade 9. In turn, runaways had higher drug dependence scores and more depressive symptoms at age 21 than non-runaways, even after taking these antecedent risk factors into account. Runaway status did not predict alcohol dependence risk at age 21. Results highlight the importance of substance use and depression, both as factors propelling adolescents to run away and as important long-term consequences of running away.

Long-term effects of drug prevention on risky sexual behavior among young adults.

OBJECTIVE: This study assesses the impact of a school-based drug prevention program, called Project ALERT, on risky sexual behavior among 1901 nonmarried, sexually active young adults who participated in one of two program variations as adolescents. It also tests for differences in program effect depending on program duration (middle school only vs. a combined middle school and high school program) and participants' gender. METHODS: Using survey data from a randomized controlled experiment conducted in 45 midwestern communities (55 schools), we assessed program effects on risky sexual behavior at age 21 with three measures-having unprotected sex because of drug use plus engaging in inconsistent condom use and having sex with multiple partners. RESULTS: Compared to control, Project ALERT reduced the likelihood of all risky sex outcomes except inconsistent condom use among these sexually active young adults, effects that occurred 5 and 7 years after program exposure. Program effects were partially mediated by reductions in alcohol and drug abuse. There were no significant differences in program effects by gender or by program duration compared to control. Implications for future prevention programs and research are discussed.

Recanting of life-time inhalant use: how big a problem and what to make of it.

AIMS: To establish the prevalence of recanting of life-time inhalant use, identify correlates of recanting to gain insight to its causes and develop a method for distinguishing recanters who truly are versus are not life-time users of inhalants. DESIGN AND SETTING: Longitudinal survey data from students in 62 South Dakota middle schools who were participating in a field trial to evaluate a school-based drug prevention program. MEASUREMENTS: At grades 7-8, participants reported on their life-time inhalant use, other drug use and drug-related beliefs, attitudes and behaviors. FINDINGS: Forty-nine per cent of students who reported life-time inhalant use at grade 7 recanted their reports a year later. Comparison of students who recanted inhalant use with those who did or did not report inhalant use consistently on drug-related beliefs, attitudes and behaviors at grades 7 and 8 suggested that, whereas some inhalant use recanting reflects denial of past behavior, some reflects erroneous initial reporting. Based on a latent mixture model fitted to the multivariate distribution of grade 7 and grade 8 responses of recanters and consistent reporters, we calculated the probability that each recanter was, in fact, a life-time inhalant user. An estimated 67% of the recanters in our sample appear to be life-time inhalant users who admitted use in grade 7 and then denied that use at grade 8; 33% appear to be students who reported use incorrectly at grade 7 and then corrected that error at grade 8. CONCLUSIONS: Inhalant use recanting is a significant problem that, if not handled carefully, is likely to have a considerable impact on our understanding of the etiology of inhalant use and efforts to prevent it.

Creating a developmentally sensitive measure of adolescent alcohol misuse: an application of item response theory.

This study, funded by the US National Institute of Drug Abuse, evaluates the usefulness of item response theory (IRT) to create a developmental alcohol misuse scale. Data were collected during 1997-2006 from 5,828 Midwestern US students who completed annual surveys at grades 7 through 11 and 2 and 4 years after high school. Seventeen alcohol misuse items were calibrated with IRT and examined for differential item functioning (DIF) across 5 study waves. Eight items displayed DIF; in most cases, properties for items assessed 2 years after high school were different from those assessed in grades 8-11. Implications and suggestions for future research are discussed.

Reducing early smokers' risk for future smoking and other problem behavior: insights from a five-year longitudinal study.

PURPOSE: To identify risk and protective factors during early and later adolescence that predict future regular smoking and multiple problem behavior among at-risk youth, defined as those who tried smoking by grade 7. METHODS: At grades 7, 10, and 12, data were collected from 2,000 early smokers drawn from California and Oregon. Multivariate regression analyses tested predictors of the two grade 12 outcomes in separate models using data from grades 7 and 10. Gender interactions and buffering of risk factors by protective factors were assessed. RESULTS: For at-risk youth, consistent protective factors against future smoking and problem behavior included living in an intact nuclear family (all four models) plus getting good grades and parental disapproval of smoking/drug use (three of four models). Consistent risk factors included exposure to substance-using peers (four models) and problems in school (three of four models). Adult substance use was a predictor during early, but not later, adolescence; pro-smoking/drug use beliefs were significant predictors during later adolescence. There were few differences across gender and no significant buffers against risk. CONCLUSIONS: At-risk youth would likely benefit from peer resistance training, parental involvement in prevention efforts, and efforts to improve educational performance during both middle school and high school. Changing pro-drug beliefs may be more effective among older adolescents.

Understanding differences in substance use among bisexual and heterosexual young women.

BACKGROUND: Numerous studies have documented higher substance use rates among bisexual than heterosexual young women, although little is known about the developmental factors contributing to these differences. Based on self-reported sexual orientation collected at age 23, this study identified similarities and differences between bisexual and heterosexual women in their substance use at ages 14 and 18, compared these groups at ages 14 and 18 on key psychosocial factors known to predict young adult substance use, and determined whether these psychosocial factors at age 18 could account for sexual orientation differences in substance use at age 23. METHODS: Longitudinal survey data from a West Coast cohort were used to compare heterosexual (n = 1,479) and bisexual (n = 141) women on their substance use and psychosocial characteristics. RESULTS: During adolescence, bisexual women were more likely to have been current and solitary substance users; reported stronger pro-drug beliefs and lower resistance self-efficacy; perceived greater parental approval of their substance use; had more exposure to substance-using peers; and reported poorer mental health. By age 23, bisexual women had higher rates of current substance use, greater quantity and frequency of use, and more problematic alcohol and drug use. Differences in problematic use at age 23 could be partially explained by risk factors assessed five years earlier at age 18, particularly pro-drug social influences and beliefs. CONCLUSIONS: Notwithstanding the lack of longitudinal data on sexual orientation, these results provide important insights regarding the drug prevention needs of bisexual women.

Growing up in a permissive household: what deters at-risk adolescents from heavy drinking?

OBJECTIVE: This study identified psychosocial factors that may deter adolescents living in permissive households from heavy drinking in Grades 9 and 11. METHOD: Longitudinal data were obtained from 710 youth who completed surveys from Grades 7 to 11. Permissive household was defined based on adolescent reports of whether the parents (1) would be upset if the adolescent drank or used marijuana, (2) knew their child's whereabouts when the adolescent was away from home, and (3) set curfews. Frequency of heavy drinking in the last 30 days was the number of days the adolescent had at least three alcoholic drinks. RESULTS: Three quarters of adolescents from permissive households reported heavy drinking at Grade 9, with less frequent heavy drinking among those who concurrently reported less exposure to peer and adult drinking, less peer approval of drinking, weaker positive beliefs about drinking, a stronger academic orientation, higher resistance self-efficacy, and less delinquency. Further, social influences and alcohol beliefs predicted the frequency of heavy drinking 2 years later among adolescents from permissive households. Although most of these factors were also relevant for adolescents from nonpermissive households, social influences, alcohol beliefs and resistance self-efficacy were stronger predictors of heavy drinking at Grade 9 among youth from permissive households. CONCLUSIONS: Growing up in a permissive household was associated with heavy drinking. Nonetheless, several psychosocial factors were associated with less frequent heavy drinking even within this at-risk population. Alcohol prevention programs that target pro-drinking peer and adult influences, positive attitudes toward drinking, and resistance self-efficacy may be particularly important in deterring heavy drinking among adolescents living in permissive households.

Developmental trajectories of substance use from early to late adolescence: a comparison of rural and urban youth.

OBJECTIVE: This study investigated differences in the development of heavy drinking and marijuana use among students in urban and rural areas and assessed whether any such differences can be accounted for by locality differences in racial/ethnic makeup, social disorganization/low social bonding, feelings of despondency and escapism, and the availability of drugs. METHOD: Drawn from 62 South Dakota middle schools involved in a drug prevention field trial, participating students were assigned to a locality category based on the location of their seventh-grade school. Schools in metropolitan areas were distinguished from schools in nonmetropolitan areas. Schools in nonmetropolitan areas were further distinguished into those in micropolitan (medium and large towns) and noncore (rural areas without towns and with small towns) areas. We used latent growth curve analysis to model the influence of locality on the development of heavy drinking and marijuana use from ages 13 to 19 and to determine whether differences in development across locality were attributable to location-based differences in race/ethnicity, social disorganization/bonding, feelings of despondency and escapism, and alcohol and marijuana availability. RESULTS: Heavy drinking increased at a faster rate among youth living in micropolitan areas compared with youth living in metropolitan areas. Marijuana use increased at a faster rate among youth living in metropolitan and micropolitan areas compared with youth living in noncore areas. Differences in the rate of change in heavy drinking were attributable to differences in the racial/ethnic composition of metropolitan and micropolitan areas. Differences in the rate of change in marijuana use were attributable to differences in residential instability and marijuana availability. CONCLUSIONS: This study underscores the diversity of drug use within rural communities, suggesting that living in a very rural area is protective against some forms of drug use but that living in a rural area that includes a medium or large town is not.

Temporal associations of cigarette smoking with social influences, academic performance, and delinquency: a four-wave longitudinal study from ages 13-23.

This study examined the temporal associations of cigarette smoking with prosmoking social influences, academic performance, and delinquency in a cohort of 6,527 adolescents surveyed at ages 13, 16, 18, and 23 years. Prosmoking peer and family influences were risk factors for future smoking throughout adolescence, with family influences perhaps also operating indirectly through the adolescent's exposure to prosmoking peers. There were reciprocal associations of youth smoking with parental approval, peer smoking, and poor grades (but not delinquency), with youth smoking emerging as a stronger antecedent than consequence of these psychosocial factors. Few gender differences in these associations were observed. Implications of these findings for efforts to prevent youth smoking are discussed.

Multiple trajectories of physical aggression among adolescent boys and girls.

Latent growth mixture modeling was used to identify discrete patterns of physical aggression from Grades 7 to 11 among a sample of 1,877 youth. Four trajectory classes adequately explained the development of physical aggression in both boys and girls: Low/No Aggression; Persistent High Aggression; Desisting Aggression, characterized by decreasing risk throughout adolescence; and Adolescent Aggression, characterized by low early risk that increases until Grade 9, levels out, and then declines in late adolescence. Girls were less likely than boys were to be in any trajectory besides the Low/No Aggression trajectory. Parental supervision, deviant peer association, academic orientation, impulsivity, and emotional distress at Grade 7 were all strongly associated with trajectory class membership. These associations did not differ by gender. These findings strongly suggest that the processes involved in the development of physical aggression in adolescence operate similarly in boys and girls.

Association of sexual abstinence in adolescence with mental health in adulthood.

We examined whether adolescent sexual abstinence predicts better adult mental health. 1,917 adolescents, recruited from middle schools at age 13, were surveyed at ages 13, 18, 23, and 29. In bivariate analyses, adolescent sexual abstinence was associated with better mental health at age 29 for females, but not males; three adolescent factors, educational prospects, family bonding, and unconventionality were investigated as explanatory variables of this relationship. The abstinence-mental health relationship was nonsignificant when educational prospects was included in multivariate models, and marginally significant when family bonding and unconventionality were included; all three explanatory factors accounted for significant proportions of the variance in adult mental health. Girls who are uninvolved in school, have weak family backgrounds, and exhibit unconventionality may have poor adult mental health, whether or not they abstain from sex in adolescence. Interventions that strengthen adolescents' connections to families and schools may reduce risk for long-term mental health problems.

School-based drug prevention among at-risk adolescents: effects of ALERT plus.

In a recent randomized field trial, Ellickson et al. found the Project ALERT drug prevention curriculum curbed alcohol misuse and tobacco and marijuana use among eighth-grade adolescents. This article reports effects among ninth-grade at-risk adolescents. Comparisons between at-risk girls in ALERT Plus schools (basic curriculum extended to ninth grade with five booster lessons) and at-risk girls in control schools showed the program curbed weekly alcohol and marijuana use, at-risk drinking, alcohol use resulting in negative consequences, and attitudinal and perceptual factors conducive to drug use. Program-induced changes in perceived social influences, one's ability to resist those influences, and beliefs about the consequences of drug use mediated the ALERT Plus effects on drug use. No significant effects emerged for at-risk boys or at-risk adolescents in schools where the basic ALERT curriculum (covering seventh and eighth grades only) was delivered. Possible reasons for gender differences and implications for prevention programming are discussed.

The role of substance use in young adult divorce.

AIM: To test the relationships between various forms of substance use during marriage and subsequent divorce among US young adults. DESIGN: Three waves of survey data collected at approximately ages 18, 23 and 29 years were used. Using multivariate logistic regression and controlling for factors present at the two early waves, we tested for prospective relationships between substance use at the second assessment and divorce by the third. PARTICIPANTS: A longitudinal panel following adolescents on the west coast of the United States into young adulthood. The analytic subsample consisted of the 454 individuals currently married at the age 23 survey. MEASUREMENTS: Predictors were past-year frequency of alcohol intoxication, marijuana use and cigarette use, as well as any hard drug use in the past year. Covariates included substance use prior to marriage, demographic and socio-economic factors, marital discord and religiosity. FINDINGS: Controlling for other factors, more frequent alcohol intoxication during marriage was an independent predictor of later divorce. Frequency of marijuana use had a significant bivariate relationship with divorce that was not significant in the multivariate model. CONCLUSION: These data are consistent with the notion that alcohol intoxication is related causally to divorce among young adults.

Early adolescent exposure to alcohol advertising and its relationship to underage drinking.

PURPOSE: To determine whether early adolescents who are exposed to alcohol marketing are subsequently more likely to drink. Recent studies suggest that exposure to alcohol ads has a limited influence on drinking in mid-adolescence. Early adolescents may be more vulnerable to alcohol advertising effects. METHODS: Two in-school surveys of 1786 South Dakota youth measured exposure to television beer advertisements, alcohol ads in magazines, in-store beer displays and beer concessions, radio-listening time, and ownership of beer promotional items during 6th grade, and drinking intentions and behavior at 7th grade. Multivariate regression equations predicted the two drinking outcomes using the advertising exposure variables and controlling for psychosocial factors and prior drinking. RESULTS: After adjusting for covariates, the joint effect of exposure to advertising from all six sources at grade 6 was strongly predictive of grade 7 drinking and grade 7 intentions to drink. Youth in the 75th percentile of alcohol marketing exposure had a predicted probability of drinking that was 50% greater than that of youth in the 25th percentile. CONCLUSIONS: Although causal effects are uncertain, policy makers should consider limiting a variety of marketing practices that could contribute to drinking in early adolescence.

High school drug use predicts job-related outcomes at age 29.

The present study examines the relationship between hard drug use in high school and occupational and job quality outcomes measured at approximately age 29. We use two different methods aimed at ruling out the possibility of spurious correlations between high school drug use and occupational outcomes: (1) directly controlling for pre-high school characteristics that may affect both high school drug use and later occupational characteristics (e.g., educational orientation, early drug use and deviant behavior); and (2) matching high school users with a subset of nonusers that have very similar characteristics and then estimating the difference in labor market outcomes for these two groups (i.e., propensity score matching). Overall, the results suggest that adolescent drug use is linked with poorer occupational and job quality outcomes as much as 10 years after high school. Interestingly, which job-related outcomes are affected by early hard drug use varies by gender. Females who use hard drugs as adolescents end up in lower skill, lower status jobs while males who use hard drugs as adolescents are more likely to end up in jobs with fewer benefits (e.g., health, retirement).

A discrete time hazards model of smoking initiation among West Coast youth from age 5 to 23.

OBJECTIVE: To identify factors associated with age of smoking initiation and distinguish vulnerable periods for initiation according to those factors. METHOD: Discrete time hazards analysis was used to model smoking initiation as a function of age (5-23), demographic and familial influence variables (measured at age 13), and their interactions in a cohort of 6255 youths who completed six assessments over a 10-year period from age 13 to 23 years. RESULTS: Half of the sample had initiated smoking by age 13, and the hazard for initiation was greatest between ages 13 and 15. In addition to differences associated with race/ethnicity, protective factors for smoking initiation included high parental education and having an intact family of origin. Having an older sibling and participant's exposure to smoking by an important adult were both risk factors, with the latter having a stronger effect for females and Blacks. For all effects, the strength of the association differed across the age range. CONCLUSIONS: The impact of demographic and family influence factors on smoking initiation varies over time. However, the maximum risk for initiation is during the early teen years, and the range of considerable vulnerability is during middle school and high school.

Does solitary substance use increase adolescents' risk for poor psychosocial and behavioral outcomes? A 9-year longitudinal study comparing solitary and social users.

This longitudinal study compared Grade 8 solitary cigarette smokers (n = 541), drinkers (n = 577), and marijuana users (n = 148) with adolescents who restricted their use of these substances to social settings (ns = 562, 1,426, and 388, respectively) on adolescent functioning and young adult outcomes. In Grade 8, solitary users held more positive beliefs about the consequences of substance use, earned poorer grades, engaged in more deviant behavior, and devoted less time to school and more time to social activities. By age 23, these solitary users had lower educational attainment, poorer self-rated health, and greater substance use problems. Results indicate the importance of better understanding and addressing the needs of this understudied group of high-risk youth.

Time trends and demographic differences in youth exposure to alcohol advertising on television.

OBJECTIVE: To examine trends in youth exposure to alcohol advertising on television across different demographic groups. METHODS: We used television ratings data on alcohol advertisements to examine trends in exposure between September 1998 and February 2002. Further, we explored the differences in exposure across demographic groups by examining group-level alcohol ad exposure across specific networks, program types, and times of day. RESULTS: We found that boys were more exposed than girls and African-Americans are more exposed than whites. Moreover, the race differential appeared to be increasing over time, whereas the gender differential appeared to increase with age. Differences in viewing patterns across race and gender contributed to the observed differences in exposure to alcohol advertising on television. CONCLUSIONS: These results provide guidance in identifying comparative vulnerabilities in exposure to alcohol advertising on television, and can aid in the development of strategies to inoculate youth against those vulnerabilities.