Recruiting Diverse Smokers: Enrollment Yields and Cost.

To help tobacco control research better include vulnerable populations, we sought to identify effective ways to recruit diverse smokers. In 2014-2015, we recruited 2149 adult cigarette smokers in California and North Carolina, United States, to participate in a randomized trial of pictorial cigarette pack warnings. The most effective means of recruiting smokers were the classified advertising website Craigslist (28% of participants), word of mouth (23%), Facebook (16%), and flyers or postcards (14%). Low-income and African American smokers were more likely to respond to interpersonal contact (including staff in-person recruitment and word of mouth) than were high-income and non-African American smokers (all p < 0.05). Hispanic and gay, lesbian, and bisexual smokers were more likely to be recruited by Craigslist than non-Hispanic and straight smokers (both p < 0.05). Of the recruitment methods requiring cost, the cheapest was Craigslist ($3-7 per smoker). The most expensive methods were newspaper ads in California ($375 per smoker) and staff in-person recruiting in North Carolina ($180 per smoker). Successfully recruiting diverse smokers requires using multiple methods including interpersonal, online, and other media. Craigslist and word of mouth are especially useful and low-cost ways to recruit diverse smokers.

Strength and Comprehensiveness of School Wellness Policies in Southeastern US School Districts.

BACKGROUND: In 2004, Congress passed legislation mandating that all public school districts participating in federal school meal programs develop a school wellness policy (SWP) to direct efforts related to nutrition and physical activity. We examined the extent to which SWPs varied in comprehensiveness and strength in a representative sample of school districts in the southeastern United States, the area of the country with the highest rates of childhood obesity. METHODS: Policies were assessed using an established 96-item coding tool by 2 raters to ascertain the comprehensiveness and strength of the policies as a whole, and across distinct subsections specified by federal legislation. In addition, variability in SWP comprehensiveness and strength was assessed based on district sociodemographic characteristics. RESULTS: Overall, SWPs in the southeastern states are weakly written, fragmented, and lack requirements necessary for healthy school environments. District size, which was the only sociodemographic factor related to policy characteristics, yielded an inverse association. CONCLUSIONS: To encourage continued promotion of healthy school environments, school districts will require technical support to improve the quality of their school wellness policies.

Assessing Community Coalition Capacity and its Association with Underage Drinking Prevention Effectiveness in the Context of the SPF SIG.

Community coalitions are a prominent organizational structure through which community-based substance abuse prevention efforts are implemented. There is little empirical evidence, however, regarding the association between coalition attributes and success in achieving community-level reductions in substance abuse behaviors. In this study, we assessed the relationship between coalition capacity, based on coalition coordinator responses to 16 survey items, and reductions in underage drinking prevalence rates. The coalitions were funded through the federally sponsored Strategic Prevention Framework State Incentive Grant (SPF SIG). We first examined whether coalition capacity increased over the life of the projects. Mean capacity scores increased for all 16 capacity items examined (N = 318 coalitions), the majority of which were statistically significant. Analysis of the associations between capacity and reductions in underage drinking was limited to coalitions that targeted underage drinking and provided usable outcome measures based on student survey data for either past 30-day alcohol use (N = 129) or binge drinking (N = 100). Bivariate associations between the capacity items and prevalence reductions for each outcome were consistently positive, although many were not statistically significant. Composite measures of correlated items were then created to represent six different capacity constructs, and included in multivariate models to predict reductions in the targeted outcomes. Constructs that significantly predicted reductions in one or both outcome measures included internal organization and structure, community connections and outreach, and funding from multiple sources. The findings provide support for the expectation that high functioning community coalitions can be effective agents for producing desirable community-level changes in targeted substance abuse behaviors.

Effect of Pictorial Cigarette Pack Warnings on Changes in Smoking Behavior: A Randomized Clinical Trial.

IMPORTANCE: Pictorial warnings on cigarette packs draw attention and increase quit intentions, but their effect on smoking behavior remains uncertain. OBJECTIVE: To assess the effect of adding pictorial warnings to the front and back of cigarette packs. DESIGN, SETTING, AND PARTICIPANTS: This 4-week between-participant randomized clinical trial was carried out in California and North Carolina. We recruited a convenience sample of adult cigarette smokers from the general population beginning September 2014 through August 2015. Of 2149 smokers who enrolled, 88% completed the trial. No participants withdrew owing to adverse events. INTERVENTIONS: We randomly assigned participants to receive on their cigarette packs for 4 weeks either text-only warnings (one of the Surgeon General's warnings currently in use in the United States on the side of the cigarette packs) or pictorial warnings (one of the Family Smoking Prevention and Tobacco Control Act's required text warnings and pictures that showed harms of smoking on the top half of the front and back of the cigarette packs). MAIN OUTCOMES AND MEASURES: The primary trial outcome was attempting to quit smoking during the study. We hypothesized that smokers randomized to receive pictorial warnings would be more likely to report a quit attempt during the study than smokers randomized to receive a text-only Surgeon General's warning. RESULTS: Of the 2149 participants who began the trial (1039 men, 1060 women, and 34 transgender people; mean [SD] age, 39.7 [13.4] years for text-only warning, 39.8 [13.7] for pictorial warnings), 1901 completed it. In intent-to-treat analyses (n = 2149), smokers whose packs had pictorial warnings were more likely than those whose packs had text-only warnings to attempt to quit smoking during the 4-week trial (40% vs 34%; odds ratio [OR], 1.29; 95% CI, 1.09-1.54). The findings did not differ across any demographic groups. Having quit smoking for at least the 7 days prior to the end of the trial was more common among smokers who received pictorial than those who received text-only warnings (5.7% vs 3.8%; OR, 1.53; 95% CI, 1.02-2.29). Pictorial warnings also increased forgoing a cigarette, intentions to quit smoking, negative emotional reactions, thinking about the harms of smoking, and conversations about quitting. CONCLUSIONS AND RELEVANCE: Pictorial warnings effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking over 4 weeks. Our trial findings suggest that implementing pictorial warnings on cigarette packs in the United States would discourage smoking. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02247908.

Reducing youth access to alcohol: findings from a community-based randomized trial.

Underage drinking continues to be an important public health problem and a challenge to the substance abuse prevention field. Community-based interventions designed to more rigorously control underage access to alcohol through retailer education and greater enforcement of underage drinking laws have been advocated as potentially effective strategies to help address this problem, but studies designed to evaluate such interventions are sparse. To address this issue we conducted a randomized trial involving 36 communities to test the combined effectiveness of five interrelated intervention components designed to reduce underage access to alcohol. The intervention was found to be effective in reducing the likelihood that retail clerks would sell alcohol to underage-looking buyers, but did not reduce underage drinking or the perceived availability of alcohol among high school students. Post hoc analyses, however, revealed significant associations between the level of underage drinking law enforcement in the intervention communities and reductions in both 30-day use of alcohol and binge drinking. The findings highlight the difficulty in reducing youth drinking even when efforts to curtail retail access are successful. Study findings also suggest that high intensity implementation of underage drinking law enforcement can reduce underage drinking. Any such effects of enhanced enforcement on underage drinking appear to be more directly attributable to an increase in perceived likelihood of enforcement and the resultant perceived inconveniences and/or sanctions to potential drinkers, than to a reduction in access to alcohol per se.

Predicting high risk adolescents' substance use over time: the role of parental monitoring.

We examined whether parental monitoring at baseline predicted subsequent substance use in a high-risk youth population. Students in 14 alternative high schools in Washington State completed self-report surveys at three time points over the course of 2 years. Primary analyses included 1,423 students aged 14-20 who lived with at least one parent or step-parent at baseline. Using hierarchical linear modeling, we found that high parental monitoring at baseline predicted significantly less use of alcohol, marijuana, downers, cocaine, PCP, LSD, and prescription drugs and drinking to intoxication at the first posttest. Approximately 1 year later, high parental monitoring at baseline predicted significantly less use of alcohol, cocaine, prescription drugs, uppers, and ecstasy and drinking to intoxication. Study results suggest that parental monitoring serves as a protective factor, even for high-risk alternative high school students. Including a parental monitoring component may increase the effectiveness of traditional drug prevention programs.

Are substance use prevention programs more effective in schools making adequate yearly progress? A study of Project ALERT.

This exploratory study sought to determine if a popular school-based drug prevention program might be effective in schools that are making adequate yearly progress (AYP). Thirty-four schools with grades 6 through 8 in 11 states were randomly assigned either to receive Project ALERT (n = 17) or to a control group (n = 17); of these, 10 intervention and nine control schools failed to make AYP. Students completed three self-report surveys. For lifetime cigarette use and 30-day alcohol use, Project ALERT was more effective in schools that made AYP. However, in these schools, Project ALERT negatively affected students' lifetime marijuana use. This study provided some preliminary evidence that prevention programming may not work as well in poorer performing schools; however, further exploration is needed.

Project success' effects on substance use-related attitudes and behaviors: a randomized controlled trial in alternative high schools.

Using a randomized controlled effectiveness trial, we examined the effects of Project SUCCESS on a range of secondary outcomes, including the program's mediating variables. Project SUCCESS, which is based both on the Theory of Reasoned Action and on Cognitive Behavior Theory, is a school-based substance use prevention program that targets high-risk students. We recruited two groups of alternative high schools in successive academic years, and randomly assigned schools in each group to either receive the intervention (n = 7) or serve as a control (n = 7). Students completed surveys prior to and following the administration of the program, and again 1 year later. Although participation in Project SUCCESS significantly increased students' perceptions of harm resulting from alcohol and marijuana use, students in the control group reported greater increases in peer support. We also found conflicting evidence in two opposing trends related to students' perceptions of the prevalence and acceptability of substance use. Therefore, the effects of Project SUCCESS on substance use-related beliefs and behaviors must be considered mixed.

The effects of No Child Left Behind on the prevalence of evidence-based drug prevention curricula in the nation's middle schools.

BACKGROUND: Concerns have been expressed that No Child Left Behind (NCLB) may be reducing the amount of classroom time devoted to subjects other than those for which students are tested. The purpose of this article is to explore whether NCLB legislation has affected the provision of evidence-based drug prevention curricula (EBC) in the nation's middle schools, a subject area that is not assessed by standardized tests. METHODS: Data were collected in spring 2005 and spring 2008 from a nationally representative sample of middle schools. Respondents completed a survey regarding their provision of EBC (2005 response rate: 78.1%). We also collected data on schools' adequate yearly progress (AYP) status as of 2005 as a measure of their compliance with NCLB targets. We restricted our sample to schools that responded to our survey in both waves (n = 1324, or 76.9% of those schools responding in 2005) and conducted logistic regression analyses to determine whether those schools not making AYP in 2005 were less likely to be using an EBC in 2008. RESULTS: Our results revealed no relationship between AYP status in 2005 and EBC use in 2008. Analyses of demographic characteristics showed that schools making AYP were more likely to be small and rural, and to serve majority White student populations whose families were characterized by lower levels of poverty. CONCLUSIONS: Our failure to find any relationship between AYP status and the provision of EBC suggests that concerns about the potential adverse effects of NCLB on drug use prevention have yet to be validated. Implications of our results are discussed.

Outlet density as a predictor of alcohol use in early adolescence.

INTRODUCTION: Recent national youth surveys suggest that alcohol availability plays a role in determining use. One measure of availability receiving recent attention is outlet density; however, few studies have examined the effects of outlet density in younger populations. METHODS: Data were collected from a national sample of the United States (N = 5,903) followed between 6th and 8th grades, as part of a study funded by the Office of Juvenile Justice and Delinquency Prevention (OJJDP). Measures of outlet density were also acquired. RESULTS: Students in high off-site density communities increased their alcohol use; however, students attending schools in low outlet density communities had higher initial levels of alcohol use that remained relatively stable. DISCUSSION: The implications and limitations of these findings are discussed.

The prevalence of evidence-based drug use prevention curricula in U.S. middle schools in 2008.

The No Child Left Behind Act mandates the implementation of evidence-based drug prevention curricula in the nation's schools. The purpose of this paper is to estimate changes in the prevalence of such curricula from 2005 to 2008. We surveyed school staff in a nationally representative sample of schools with middle school grades. Using a web-based approach to data collection that we supplemented by telephone calls, we secured data from 1892 schools for a response rate of 78.2%. We estimate that the prevalence of evidence-based drug prevention curricula rose from 42.6% in 2005 to 46.9% in 2008, and that the prevalence of schools that used these curricula most frequently increased from 22.7% to 25.9% over this period. In addition, the proportion of schools using locally developed curricula also rose, from 17.6% to 28.1%. This study suggests the success of efforts by the Office of Safe and Drug-Free Schools to increase the prevalence of evidence-based curricula, as well as the need to continue to track the prevalence of these curricula in response to any reductions in the Office's fiscal support for evidence-based drug prevention curricula in the nation's schools.

The prevalence of evidence-based substance use prevention curricula in the nation's elementary schools.

Current guidelines for school-based substance use prevention suggest that prevention efforts should begin in elementary grades, before students begin using substances. Previous research suggests, however, that the use of evidence-based curricula in these grades may be low. Using a 2005 survey of public school districts in the United States that include elementary grades (n = 1563), we assessed the prevalence of elementary curricula use, particularly those designated as evidence-based. We found that although 72% of districts administer a substance use prevention curriculum to their elementary students, only about 35% are using one that is evidence-based and only about 14% are using an evidence-based curriculum more so than any other prevention curriculum. We present prevalence estimates for specific evidence-based curricula and conclude by discussing possible reasons for and implications of our findings.

Project ALERT's effects on adolescents' prodrug beliefs: a replication and extension study.

This article represents a replication and extension of previous studies of the effects of Project ALERT, a school-based substance use prevention program, on the prodrug beliefs of adolescents. Specifically, the authors' research examined Project ALERT's effects on adolescents' intentions to use substances in the future, beliefs about substance use consequences, normative beliefs, and resistance self-efficacy. In all, 34 schools with Grades 6 to 8 completed this randomized controlled trial and 71 Project ALERT instructors taught 11 core lessons to 6th graders and 3 booster lessons to 7th graders (one grade level earlier than in previous studies). Students were assessed in 6th grade prior to the onset of the intervention, in 7th grade after the completion of the 2-year curriculum, and again 1 year later in 8th grade. The authors found no evidence to suggest that Project ALERT had a positive impact on any alcohol, cigarette, or marijuana prodrug beliefs. Implications for school-based substance use prevention are discussed.

Project SUCCESS' effects on the substance use of alternative high school students.

Project SUCCESS is a selective and indicated substance use prevention program that targets high risk students in secondary school settings. We evaluated the effects of Project SUCCESS on adolescents' substance use immediately following program implementation, and again one year later. Two successive cohorts of alternative high schools were randomly assigned to an intervention or control group, yielding seven schools per condition. Main outcomes included 30-day use of alcohol, marijuana, and illegal drugs excluding marijuana, and drinking to intoxication. We conducted exploratory analyses on 30-day cigarette use. Using Hierarchical Linear Modeling, we found that students in the control schools reported significantly less use of illegal drugs excluding marijuana than those in the intervention group at the first posttest; however, this effect did not persist one year later. There were no other outcome effects of even a marginal nature. While results of this study do not provide evidence of Project SUCCESS' effectiveness, students' program exposure was low. It is possible that Project SUCCESS would perform better in schools with higher and more regular rates of attendance.

The effects of Project ALERT one year past curriculum completion.

School-based drug prevention curricula constitute the nation's most prevalent strategy to prevent adolescent drug use. We evaluated the effects of one such curriculum, Project ALERT, on adolescent substance use. In particular, we sought to determine if a single effect on 30-day alcohol use, noted shortly following the completion of the 2-year program, could be detected 1 year later. We also looked for delayed effects on other outcomes of interest, namely lifetime alcohol use, and 30-day and lifetime use of cigarettes, marijuana, and inhalants. We employed a randomized controlled trial that used school as the unit of assignment. Thirty-four schools with grades 6-8 from 11 states completed the study. Seventy-one Project ALERT instructors taught 11 core lessons to sixth graders and 3 booster lessons to seventh graders. Students were assessed prior to the onset of the intervention, as sixth graders, after the completion of the 2-year curriculum, as seventh graders, and again 1 year later as eighth graders. This paper examines data from the pretest and final posttest. Using hierarchical nonlinear modeling, we found that our earlier effect on 30-day alcohol use did not persist. Further, we continued to find no effects for lifetime alcohol use and both the lifetime and 30-day use of cigarettes, marijuana, and inhalants. Our findings do not support the long-term effectiveness of Project ALERT, when delivered to sixth graders.

Implementing evidence-based substance use prevention curricula with fidelity: the role of teacher training.

It is widely recognized that teacher training affects the fidelity with which evidence-based substance use prevention curricula are implemented. We present the results of a 2005 survey of teachers from a nationally representative sample of 1721 public middle schools in the U.S. (78.1% response rate). We measured fidelity along two dimensions (adherence and dose) and also assessed the number of hours, recency, and perceived effectiveness of teachers' training, as well as the degree to which adherence was emphasized during training. Among teachers using evidence-based curricula, 35.3% reported following their curriculum guide very closely. The average proportion of lessons taught was 64.9%, and only 30.2% of teachers taught all the lessons in their curriculum. Analyses revealed that teachers whose training emphasized adherence were 5 times as likely to be more adherent. We present recommendations for training-related factors that may increase fidelity of implementation.

Project ALERT: a cluster randomized trial.

OBJECTIVE: To evaluate the effects of Project ALERT on adolescents' lifetime and 30-day use of cigarettes, alcohol, marijuana, and inhalants. DESIGN: Cluster randomized trial. SETTING: Schools from 11 states were enrolled in 2 successive cohorts from 2004 to 2008. PARTICIPANTS: All public schools in the United States that included grades 6 through 8 and enrolled at least 100 students in sixth grade were recruited. Of the 40 schools that began the study, 34 (17 per condition) completed it. Data were analyzed from 5883 unique participants. Intervention Project ALERT, a manualized classroom-based substance use prevention curriculum for the middle grades, was taught to sixth and seventh graders. MAIN OUTCOME MEASURES: Students were surveyed before the onset of the intervention, as sixth graders, and after the completion of the 2-year intervention, as seventh graders. Outcome measures included lifetime and 30-day use of cigarettes, alcohol, marijuana, and inhalants. RESULTS: At baseline, students in the intervention condition were slightly to moderately more likely to report use for each of the 8 measures examined than were students in the control condition. For all measures except lifetime use of cigarettes, these differences were less pronounced at follow-up and therefore were in the direction of favorable program effects. These changes were statistically significant, however, for only 1 outcome measure, past 30-day use of alcohol (reduction in the adjusted odds ratio from 2.07 at baseline to 1.32 at follow-up; P = .006). CONCLUSION: Project ALERT was not effective when delivered to the sixth grade population we targeted.

Responses to positive results from suspicionless random drug tests in US public school districts.

BACKGROUND: Little is known about the context in which school-based suspicionless random drug testing (SRDT) occurs. The primary purpose of the current study was to describe school districts' responses to students' first positive result in districts with SRDT programs. METHODS: Data were collected in spring 2005 from 1612 drug prevention coordinators in a nationally representative sample of 1922 school districts (83.9% response rate), of which 205 districts reported SRDT in high school grades. RESULTS: Respondents reported an array of consequences for students with an initial positive SRDT, including requiring parents or guardians to meet with school officials (88.4%) and requiring students to participate in an education, counseling, or treatment program (60.8%). However, some districts also reported consequences contraindicated by federal advisory guides, such as notifying law enforcement officials (45.1%) and suspending the student from an athletic team (65.0%) or from school (31.0%). Some respondents may have conflated their districts' responses to for cause and random tests. Districts generally had available key services for students testing positive, including professional counseling for substance use problems (87.3%) and referrals to counseling services (91.9%). CONCLUSIONS: More understanding is needed of schools' responses to students who test positive following the administration of SRDT, available advisory guides concerning best practices should be more effectively disseminated, and appropriate training and technical assistance should be available to schools with SRDTs.

The prevalence of evidence-based drug use prevention curricula in U.S. middle schools in 2005.

Since the promulgation of its Principles of Effectiveness in 1998, the Office of Safe and Drug-Free Schools of the U.S. Department of Education has promoted the use of evidence-based drug prevention programs in the nation's schools. We report the results of a survey, conducted in 2005, of a nationally representative sample of 1,721 schools with middle school grades. Respondents comprised the staff member in the school identified as most knowledgeable about the school's drug prevention programs. The total response rate was 78%. Respondents answered questions concerning which drug use prevention curricula they used, and, if they used more than one, which one they used the most frequently. Three federally-sponsored registries were used to specify which curricula were considered evidence-based. Findings from 2005 were then compared to earlier estimates based on a similar 1999 survey. We found that 42.6% of the nation's schools with middle school grades were using an evidence-based curriculum, an increase of 8% from our 1999 estimate. The two most prevalent curricula in use, at 19% each, were Life Skills Training and Project ALERT. We note, however, that only 8% of Life Skills Training users and 9% of Project ALERT users reported using those curricula the most, and that only 23% of respondents overall reported that they used an evidence-based curriculum the most. More information is needed as to why over three-quarters of the nation's schools with middle school grades continue to administer curricula that have not been identified as effective.

The prevalence of effective substance use prevention curricula in the nation's high schools.

Despite a substantial proportion of high school students who initiate substance use following middle school, the implementation of universal evidence-based prevention curricula appears to be scant. We report data collected in 2005 from 1392 school district-based drug prevention coordinators, from a national, representative study of school-based substance use prevention practices. Altogether, 10.3% of districts that included high school grades reported administering one of six such curricula that were then rated as effective by the Substance Abuse and Mental Health Services Administration's National Registry of Effective Programs and Practices or Blueprints for Violence Prevention, and 5.7% reported that they used one of these curricula the most. Only 56.5% of the nation's districts with high school grades administered any substance use prevention programming in at least one of their constituent high schools. Editors' Strategic Implications: The authors provide a powerful reminder that evidence-based prevention is not common in American high schools, in spite of federal mandates and the increasing availability of strong prevention programs. This should challenge researchers and government officials to improve dissemination and school officials to utilize evaluated programs.