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|Major Studies of Drugs and Drug Policy|
|Canadian Senate Special Committee on Illegal Drugs|
|Volume 2 - Policies and Practices In Canada|
Chapter 16 - Prevention
Preventing what and how?
Agreeing on the need for prevention
is a bit like agreeing on the importance of virtue. Yet, as we saw in the
introduction to this chapter, whether we all agree on the very concept of
prevention is not all that clear. The United Nations Office for Drug Control
and Crime Prevention glossary defines prevention as follows:
activities may be broad-based efforts directed at the mainstream population(s),
such as mass general public information and education campaigns,
community-focused initiatives and school-based programs directed at youth or
students at large. Prevention interventions may also target vulnerable and
at-risk populations, including street children, out-of-school youth, children
of drug abusers, offenders within the community or in prison, and so on.
Essentially, prevention addresses the following main components:
What this means, then, is taking
initiatives that alter the factors leading to drug abuse, where all use is
abuse in the case of an illegal substance or a substance controlled by
international conventions. The definition identifies as a factor in abuse
first-time use of drugs, on the premise that introduction – at least in people
considered to be “at risk” – leads to more frequent use or use of other
substances. The proposed areas of action indirectly identify other factors: the
absence of information on the adverse effects of drug use and social norms that
are insufficiently anti-drug, inadequate personal and social skills to resist
drug use, and unsatisfactory lifestyles that are not health oriented are other
factors in drug abuse.
But what do we know about the
reasons why people use drugs, marijuana in particular? We know that men use
more alcohol and drugs and that women use more prescription drugs. Do we really
know why? We think that there may be more than 150 million marijuana users
in the world, and we have said that there are approximately 3 million a year in
Canada; are we to conclude that those people lacked the personal and social
skills needed to resist drugs? When, at what point, does use become a problem?
Depending on the answers to those questions, the entire prevention strategy
will be different.
Genetic baggage aside, public health
factors are a function of:
[Translation] […] environmental factors related to the setting in which the person lives, from conception to death: the social as well as the physical environment. Education, employment, income, family and social relationships, and distribution of wealth are all factors that come into play. There is a close link between socio-economic status and health and well-being: that link is confirmed by data on hospitalization, disability, health problems and mortality in a given population. Other factors of course include lifestyle and behaviour, such as tobacco use and diet. Even though these are factors that can be changed and are often targeted by prevention, they are also largely conditioned by socio-economic factors. The last factor is health services, the level and organization of which vary from community to community and country to country. <![if !supportFootnotes]><![endif]>
It is true that epidemiological data
tend to show that young marijuana users are more likely to be from
disadvantaged socio-economic backgrounds, are more likely to smoke tobacco, and
probably have parents who smoke or even use marijuana. These are referred to as
environmental risk factors. According to some authors, regular or heavy users,
those who are at risk, also suffer low self-esteem, are more likely to drop out
of school or not finish high school, and do not perform as well academically.
These are personal risk factors.
Another term in the vocabulary of
prevention besides “risk factor” is “protective factor”. The United Nations
Office for Drug Control and Crime Prevention defines “protective factor” as
factor that will reduce the probability of an event occurring which is
perceived as being undesirable. This term is often used to indicate the
characteristics of individuals or their environments, which reduce the
likelihood of experimentation with illegal drugs. For example there is some
evidence from research in developed countries that each of the following are,
statistically at least, protective in relation to illicit drug use: being
female; of high socio-economic status; being employed, having high academic
attainment; practising a religion; and being a non smoker. <![if !supportFootnotes]><![endif]>
Epidemiological data show that use
is lower among women, non-smokers and people who practise a religion. However,
the data are not as clear in terms of the impact of socio-economic status or
level of schooling.
One of the key works in the
literature on prevention is without question the 1995 research by Hawkins et al.<![if !supportFootnotes]><![endif]> The authors give a comprehensive list of risk
factors related directly or indirectly to drug abuse, divided into five
categories: individual, family, school, peer and community environment. These
factors were identified based on a series of longitudinal studies that tracked
children and adolescents over long periods.
Recent longitudinal research has identified risk and protective factors in the individual and the environment that consistently predict drug involvement. Moreover, the evidence indicates that the likelihood of drug abuse is higher among those exposed to multiple risk factors and that the risk of drug abuse increases exponentially with exposure to more risk factors. The higher rates of drug abuse among criminal and homeless populations are consistent with studies of personal, social and environmental risk factors that are predictive of substance abuse. This line of research suggests that intervention to prevent drug abuse should focus on reducing multiple risk factors in family, school, peer, and community environments. <![if !supportFootnotes]><![endif]>
1. Individual factors
authors include among the individual factors identified by the research family
history, genetic history, biochemical characteristics, early and persistent
behavioural problems, alienation and rebelliousness, attitudes favourable to
drug use, and early introduction to drugs.
factors include parents who use or permit the use of substances, poor
parenting, poor parent-child relationships and family conflict.
factors include academic failure and a weak commitment to school; intelligence is
not a factor, but the school environment and learning difficulties have a
rejection in primary school and peers who use drugs are also factors related to
The availability of drugs, legal and cultural norms, poverty and an unstable living environment.
The authors identify as protective
factors individual characteristics (resilience, social and personal skills,
intelligence), the quality of childhood relations in the family and especially
at school, and individual and social objection to drug use.
These factors must not be confused with causes. They are statistical links that are themselves limited by methodological problems related to measurement of behaviour, evaluation of the impact of intervention, and other considerations.<![if !supportFootnotes]><![endif]>
A clear advantage of the protective/risk factor approach is the understanding that many social and health problems are linked by the same root factors – an understanding that can lead to better integration of strategies and economizing of resources. However, because a factor is linked to substance use problems does not necessarily mean that it causes such problems. Consequently, the actual preventive effect of addressing one or another of the protective or risk factors is not very clear and no doubt varies between the factors. Nevertheless, it appears that addressing protective or risk factors in several domains of a young person’s life (i.e., individual, school, family and community) can lead to positive outcomes. <![if !supportFootnotes]><![endif]>
Hawkins et al. reviewed a series of initiatives–prenatal and neonatal, and
preschool, primary school and secondary school–that were evaluated. They found
that the most promising strategies are multidisciplinary approaches involving
The evidence suggests that multistrategy approaches that address multiple risks while enhancing protective factors hold the most promise for preventing substance abuse. The current challenge for substance abuse prevention research is to test prevention strategies that empower communities to design and take control of their own efforts to explicitly assess, prioritize, and address risk and protective factors for substance abuse. <![if !supportFootnotes]><![endif]>
is not, however, a formula that can be used over and over in the exact same
way. The characteristics of local communities, existing social relationships,
and the strength of community organizations are among the factors that play a
key role in the success of preventive measures. There is growing consensus
among authors on a series of steps that are most likely to bring about success.
The compendium of best practices published by Health Canada proposes the
actions are proven and promising? The compendium lists a number of Canadian
intervention programs, but none has really undergone comprehensive evaluation.
number of people who spoke at our hearings, police officers in particular,
mentioned the DARE (Drug Abuse Resistance Education) program.
We use a revised, Canadian version of DARE, which is not the program most people have been hearing about for years. We are achieving success and acceptance with it. <![if !supportFootnotes]><![endif]>
We were unable to continue to fund Canadian programs, and to the credit of the RCMP and its members across the divisions, they turned to DARE, the Drug Abuse Resistance Education, from the United States. It was a pre-made, off-the-shelf program. Our budget still does not permit us to develop Canadian programs or to do evaluations. Unfortunately and embarrassing is that of the money that has gone to teaching Canadian police officers to instruct, a total of $750,000 has been paid for by the United States. The Canadian government has not funded any DARE training. <![if !supportFootnotes]><![endif]>
DARE was introduced in the United
States in the early 1980s by the Los Angeles Police Department. In 1996, the
program was being used by 70% of school districts and was serving 25 million
students. Some 25,000 American police officers were trained to deliver the DARE
program in schools. DARE is also used in 44 other countries around the world.
It includes a number of modules delivered in different ways depending on the
community. Basically, it entails a series of visits from kindergarten to grade
four in which the children are given short lessons on personal safety, respect
for the law, and drugs. The main 17-week program is designed for students in
grades five and six. A 10-week program for middle-school students focuses on
resistance to peer pressure, the ability to make personal choices, conflict
resolution and anger management. Another 10-week program for high-school
students focuses on personal choices and anger management. Finally, DARE+ is an
after-school program for high-school students built around recreational
activities. The main 17-week program for grades five and six is the one most
frequently used (81% of American school districts). It is delivered by a
uniformed police officer and focuses on the ability to resist drugs. It
provides information on drugs and their effects, self-esteem, and alternatives
to drugs. The program includes lectures, group discussions, audio-visual
presentations, exercises and role playing.
A document we received from the RCMP
shows that the DARE Program is being taught in 1,811 schools in 584 different
communities in Canada outside Quebec. Alberta leads the way with 150 school
districts, 583 schools and more than 21,400 students in 2001, followed by
Ontario (40 districts, 346 schools, 10,940 students) and British Columbia
(60 districts, 289 schools, 10,800 students). All these schools offer the main
17-week program. In 2001, the program served more than 53,000 students. In all,
the various components of the DARE program reached more than 65,000 Canadian
students in 2001.
We do not know how much the program
has been “Canadianized”. To our knowledge, there have been no studies to
evaluate the program’s impact. The document we received is the first phase of
an evaluation study that should, in the second phase, provide data on impact.
The first phase of the study deals with students’, teachers’ and parents’
opinions, preferences and perceptions.<![if !supportFootnotes]><![endif]> The study looked at all of the grade 5 and grade 7
students in the West Vancouver school district who took the program (500 and
570 students, respectively), as well as their parents and teachers. The
findings showed a very high level of satisfaction with the program:
These are only some of the findings.
The data are in line with what can be found on the DARE’s U.S. Internet site
and in a number of evaluations. However, those evaluations measured opinions,
perceptions and attitudes, not behaviour. To some extent, these results,
positive though they may be, are not really surprising.
In contrast, almost all of the
evaluations that have endeavoured to measure the impact of the DARE program on
behaviour, specifically the prevention or reduction of drug use, have shown
that the program had no impact or, at best, very little and very short-term
The compendium of best practices
produced for Health Canada contains a separate section on the DARE program
which states in part:
There have been many D.A.R.E. reviews and evaluations, but few rigorous scientific evaluations. While some evaluations show positive results, studies published in peer reviewed journals, including a 5-year prospective study and a meta-analysis of D.A.R.E outcome evaluations, have been consistent in showing that the program does not prevent or delay drug use, nor does it affect future intentions to use. On the positive side, it does seem to boost anti-drug attitudes, at least in the short-term, increase knowledge about drugs and foster positive police-community relations. Also, acceptance of the program is generally quite high among police presenters, students and their parents. <![if !supportFootnotes]><![endif]>
Of course, the absence of program
impact can be attributed to the requirements of the evaluation. However, these
requirements are the same as those used for other program evaluations.
In 1997, a major report on what
works, what does not work and what is promising in the area of crime prevention
was tabled in the United States Congress; Congress had commissioned the report
from a team of prominent researchers at a number of American universities.<![if !supportFootnotes]><![endif]> The report had the following to say about the
evaluations of the original 17-lesson core have been conducted. Many of these
are summarized in a meta-analysis of DARE’s short-term effects sponsored by NIJ
[National Institute of Justice]. This study located 18 evaluations of DARE’s
core curriculum, of which 8 met the methodological criterion standards for
inclusion in the study. The study found:
more recent reports, three of them longitudinal, have also failed to find
positive effects for DARE. Lindstrom (1996), in a reasonably rigorous study of
approximately 1,800 students in Sweden, found no significant differences on
measures of delinquency, substance use, or attitudes favoring substance use
between students who did and did not receive the DARE program. Sigler and
Talley (1995) found no difference in the substance use of seventh grade
students in Los Alamos, New Mexico who had and had not received the DARE
program 11 months before. Rosenbaum
et coll. (1994) report
on a study in which 12 pairs of schools (involving nearly 1,600 students) were
randomly assigned to receive or not receive DARE. Although some positive
effects of the program were observed immediately following the program, by the
next school year no statistically significant differences between DARE and
non-DARE students were evident on measures of the use of cigarettes or alcohol.
[…] These studies and recent media reports have criticized DARE for (a)
focusing too little on social competency skill development and too much on
effective outcomes and drug knowledge; (b) relying on lecture and discussion
format rather than more interactive teaching methods; and (c) using uniformed
police officers who are relatively inexperienced teachers and may have less
rapport with students.
In summary, using the criteria adopted for this report, DARE does not work to reduce substance use. […] No scientific evidence suggests that the DARE core curriculum, as originally designed or revised in 1993, will reduce substance use in the absence of continued instruction more focused on social competency development. <![if !supportFootnotes]><![endif]>
This information is in the public
domain. It has been available for many years. Considering the limited resources
available for the prevention of drug abuse in Canada, federal authorities and
the RCMP ought to have looked at that information before deciding to implement
even a Canadian version of the DARE program. Beyond the rhetoric that may
please some, there are in this case–and this is so rare that we must take
advantage–comprehensive studies which show that the program is not meeting its
The same study identifies other
programs that are much more likely to have a positive impact on drug use and
abuse, in particular programs that develop social skills. The Canadian
compendium also describes a number of programs that have undergone equally
comprehensive evaluation and have shown positive results.
Like one of our witnesses, we
seriously question the police-led practice used to deliver drug education in
I have a quick aside about police-led drug education. We, personally, have some concerns with police officers teaching many hours of drug education in the classroom. We do not think it is sustainable financially to have paid police officers in at every grade level teaching hours and hours of drug education. Teachers - classroom teachers - are trained to be educators and that includes how to build self-esteem, how to make kids feel more capable. In addition, we know there are good, well-intentioned police officers, but our concern is that some of them do not, in our view, have sufficient training to do the type of education that is required. I am also concerned that the DARE program in the United States is now starting a whole new initiative. […] they still are not addressing a very fundamental question, which is, ‘who is the best person to deliver these?’
We have heard concerns from students and teachers that police-led drug education can be more authoritarian and that it can come across not so much as helping kids to make their own carefully thought out choices, but more to lead them into one specific choice. <![if !supportFootnotes]><![endif]>
We believe that there is a need for education about psychoactive substances,
forms of use and the related risks. But we also believe that there is a need to
rethink the approaches being used and that police officers, if they must be
involved, should neither develop the programs nor deliver them to students.
Lists of risk and protective factors
and of successful programs aside, it is key to have a holistic vision of
prevention, because drugs are part of a complex social, cultural and historical
environment. Analysis of the debate over prevention and prevention practices
shows that one of the risks lies in putting forward a reductionist and
mechanistic view of personal and community health. We observed in Chapter 6
that the available data showed an increase in marijuana use among high-school
students. We also saw in Chapter 10 that public opinion is perhaps more
tolerant than it used to be. And we have seen in this chapter that little has
been done in the area of prevention. Does this mean, as the Canadian Centre on
Substance Abuse has said, that the increase in use is merely the result of all
these factors combined?
The resurgence of drug use we are now witnessing is led largely by mainstream youth, indicating that we may have paid a heavy price for changing our focus and neglecting this group in Phase II (of Canada’s drug Strategy). Ultimately we must aim our prevention messages at all youth. The Centre believes that all young people-drop-outs and A students alike-are vulnerable to drug use and should be viewed as an at-risk population. <![if !supportFootnotes]><![endif]>
it really the effect of the prevention initiatives taken in the first phase of
the strategy (1987-1992) that accounts for the relative decline in use during
that period? Is it really the absence of debate and prevention practices in the
1990s that accounts for the increase in use? Strictly speaking, no one knows.
Not only was there no evaluation of the first phase of the national strategy,
but even the most comprehensive evaluation might not have been conclusive. The
increase in use in the 1990s could just as easily have been the result of a
series of entirely different factors, such as cutbacks in government services,
the decline in the youth labour market or even globalization of world markets,
which makes people feel powerless to change their living conditions. There
might even be other factors of which we are not yet aware.
In the United States, the use of
illegal substances decreased between 1982 and 1991, then started to rise again
in 1993. Did policies and approaches change? Incarceration rates for drug-related
crimes certainly did not drop. At least as much money was spent on prevention
and education programs. The rate of alcohol use among youth under 17 also
decreased; can that be attributed to the same factors? Inversely, the
proportion of smokers in the population hardly changed at all despite equally
or more aggressive awareness and prevention campaigns. What do we make of this?
The decrease in illegal drug use may be attributable in part to “war on drugs”
policies, but that is by no means a completely satisfactory explanation. And we
also have to consider the social and economic cost.
The U.S. government’s ‘War on Drugs’ resulted in a tremendous expansion of resources applied to supply reduction and interdiction efforts focused on illegal drugs and in increasingly harsh criminal sanctions against users, including those caught in possession of relatively small amounts of illegal drugs. These policies have apparently had little effect on the availability of addictive drugs or on reducing abuse. They have fueled higher costs associated with prison construction and a tremendous increase in the prison population, leading some to call for legalization of currently proscribed drugs such as marijuana and cocaine. <![if !supportFootnotes]><![endif]>
Through all of this, there is little
room for a less mechanistic view of individuals. We were reminded of this by
J.F. Malherbe in the paper he wrote at our request:
The human experience is always complex and multifactorial, and no statement of risk referring to a single factor has any meaning for an individual subject (even though certain correlations appear to be well established). The future cannot be predicted for a singular individual on the basis of statistical information. We can therefore wonder at times about the level of scientific training (or honesty) of doctors who confuse "statistical correlation" with "risk factors" and "causes". It is true, however, that it is more convenient to "preach" to people about the causes of cancer than to support and inform them in the often chaotic advance of their freedom toward fuller responsibility for themselves, for others and for the fragile biosphere to which we belong. <![if !supportFootnotes]><![endif]>
Professor Malherbe went on to say:
The true harm, the worst of all, the most intolerable, the only one that must absolutely be repressed is wanting to make people happy by deepening their fear of disease and death, without asking each individual to make personal choices and realize his or her preferences. The true, the only harm stems from health ideology, from the furor sanandi, which sketches out our happiness without us being able to enjoy it.
Does this mean that everything should be permitted without distinction? Of course not. But the test is still to discover step by step through our trials and errors, and it cannot be imposed on us by experts – doctors or economists – in the name of a prior and death-causing order. The joy of fertile disorder is better for life than the boredom of a type of planning, the arbitrary nature of which equals nothing but sterility. <![if !supportFootnotes]><![endif]>
Moreover, prevention, especially in
schools, must provide a forum for open discussion that makes young people
accountable and permits the acculturation of substances. Demonization and
indoctrination can never take the place of education.
<![if !supportEmptyParas]> <![endif]>
UNDCP (2000), op. cit., page
Public Health Directorate, Les
inégalités sociales de la santé.
Rapport annuel 1998 sur la santé de la population. [social inequity
in health; 1998 annual report on public health], Montreal: Régie régionale de
la santé et des services sociaux de Montréal-Centre.
UNDCP, op. cit., page 60.
<![if !supportFootnotes]><![endif]> Hawkins, D.J., M.W. Arthur and R.F.
Catalano (1995), “Preventing Substance Abuse” in Tonry, M., and D.P. Farrington
(eds.), Building a Safer Society:
Strategic Approaches to Crime Prevention, Chicago: University of Chicago
Hawkins, D., op. cit., page
Hawkins D., et al., op. cit., pp. 363-367.
Roberts, G., et al. (2001), op. cit., page 24.
Hawkins, D., et al., op. cit., page 404.
Barry King, Chief of the Brockville Police Service, testimony before the
Special Senate Committee on Illegal Drugs, Senate of Canada, First Session, 37th
Parliament, March 11, 2002, Issue 14, page 83.
<![if !supportFootnotes]><![endif]> Chief Superintendent R.G.
Lesser, testimony before the Special Senate Committee on Illegal Drugs, First
Session, 37th Parliament, October 29, 2002, Issue 8, page 14.
Curtis, C.K. (1999), The efficacy
of the Drug Abuse Resistance Education program (DARE) in West Vancouver
schools. Part 1 – Attitudes toward DARE: An examination of opinions,
preferences, and perceptions of students, teachers, and parents, West
Roberts, G., et al., op. cit., page 171.
Sherman, L.W., et al. (1997), Preventing Crime: What Works, What Doesn’t, What’s Promising. A
Report to the United States Congress, Washington, DC: US Department of Justice.
Ibid., pages 5-33 to 5-35.
<![if !supportFootnotes]><![endif]> Art Steinmann, Executive Director,
Alcohol-Drug Education Service, testimony before the Special Senate Committee
on Illegal Drugs, First Session, 37th Parliament, October 29, 2002,
Issue 10, page 86.
Canadian Centre on Substance Abuse (1996), Canada’s Drug Policy. Brief to
the Standing House of Commons Committee on Health, Ottawa: author.
Hawkins, D.J., M.W. Arthur and R.F. Catalano (1995), “Preventing
Substance Abuse”, in Tonry, M., and D.P. Farrington (eds.), Building a Safer Society: Strategic
Approaches to Crime Prevention, Chicago: University of Chicago Press, page
Malherbe, J.F. (2002), The
contribution in defining guiding princples for a public policy on drugs.
Document prepared for the Special Senate Committee on Illegal Drugs, Ottawa:
Senate of Canada, page 7.
Ibid., page 10.
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