Program
Background
The Life Skills Training (LST) program
was developed to address the monumental problem of
substance abuse in this country. The adverse health,
social, and legal consequences of this problem have
been well documented. Cigarette smoking is a risk-factor
for heart disease, various cancers, and chronic obstructive
lung disease and accounts for over 430,000 deaths
per year. Alcohol is not only related to chronic diseases
such as cirrhosis of the liver, but is also a major
factor in auto fatalities and homicides. Beyond this,
adolescent drug use predicts a number of other undesirable
outcomes such as reducing traditional educational
accomplishments and job stability, increasing the
likelihood of marrying and having children at younger
ages, and increasing the likelihood of engaging in
criminal behavior.
Despite considerable public attention and the expenditure
of well over a billion dollars in the past few years
alone, little if any progress has been made toward
reducing drug abuse. At present, drug use among American
youth is a problem of enormous proportions and it
is getting worse. Since 1991, according to national
surveys, drug use has increased by more than 30 percent
leading some experts to believe that we are on the
verge of a new drug epidemic. Figure 1 illustrates
this trend in annual prevalence (proportion of users)
of illicit drug use for twelfth grade students since
1975. According to the most recent national survey
data, the following proportions of high school students
have used alcohol, cigarettes, and illicit drugs at
least once (Johnston, O'Malley & Bachman, 1995):
| |
Alcohol |
Cigarettes |
Illicit Drugs |
| 8th Graders |
56% |
46% |
26% |
| 10th Graders |
71% |
57% |
37% |
| 12th Graders |
80% |
62% |
46% |
Results from the same survey indicated that during
the past 30 days, the following proportions of high
school students used the following substances one
or more times:
| |
Alcohol |
Cigarettes |
Illicit Drugs |
| 8th Graders |
26% |
19% |
11% |
| 10th Graders |
39% |
25% |
19% |
| 12th Graders |
50% |
31% |
22% |
For some of these teens, use may be discontinued
after a brief period of experimentation. However,
for many, initiation of cigarette smoking, drinking,
or drug-taking may lead to patterns of use which result
in both psychological and physical dependence. In
general, programs designed to help individuals quit
smoking, drinking, or using drugs have only been moderately
effective. Quite simply, once any type of substance
use habit is acquired it is extremely difficult to
break. Scientific evidence now suggests that the development
of effective prevention programs may offer the greatest
potential for impacting this important health problem.
Unfortunately, reviews of the prevention research
literature and meta-analytic studies show that many
widely used drug abuse prevention approaches are ineffective.
The most common approaches to substance abuse prevention
over the past two decades have involved either the
presentation of factual information concerning the
dangers of substance use or what has been referred
to as "affective" education.
Approaches relying on the provision of factual information
are based largely on the assumption that increased
knowledge about psychoactive substances and their
adverse consequences would be an effective deterrent.
Affective education approaches are designed to enrich
the personal and social development of students through
class discussion and experimental classroom activities.
Both of these approaches have proven to be largely
ineffective because they do not address the factors
promoting the initiation and early stages of substance
use/abuse.
The LST program is a drug abuse prevention program
that is based on an understanding of the causes of
smoking, alcohol, and drug use/abuse. The LST intervention
has been designed so that it targets the psychosocial
factors associated with the onset of drug involvement.
With this in mind, the program impacts on drug-related
expectancies (knowledge, attitudes, and norms), drug-related
resistance skills, and general competence (personal
self-management skills and social skills). Increasing
prevention-related drug knowledge and resistance skills
can provide adolescents with the information and skills
needed to develop anti-drug attitudes and norms, as
well as to resist peer and media pressure to use drugs.
Teaching effective self-management skills and social
skills (improving personal and social competence)
offers the potential of producing an impact on a set
of psychological factors associated with decreased
drug abuse risk (by reducing intrapersonal motivations
to use drugs and by reducing vulnerability to pro-drug
social influences).
Theoretical Rationale/Conceptual
Framework
Many theories have been advanced to explain drug abuse.
The most prominent among these focus on social learning,
problem behaviors, self-derogation, persuasive communications,
peer clusters, and sensation-seeking. However, the
etiology of drug abuse involves a dynamic process
which unfolds over many years. A common limitation
of most theoretical models is that they are essentially
snap-shots of the etiology of drug abuse and do not
adequately capture the complexity of the problem.
We now know that the initiation of drug use is the
result of the complex combination of many diverse
factors. There is no single pathway or single variable
which serves as a necessary and sufficient condition
for the development of either drug use or drug abuse.
With this in mind, the LST approach to drug abuse
prevention is based on a person-environment interactionist
model of drug abuse. Like other types of human behavior,
drug abuse is conceptualized as being the result of
a dynamic interaction of an individual and his/her
environment. Social influences to use drugs (along
with the availability of drugs) interact with individual
vulnerability. Some individuals may be influenced
to use drugs by the media (TV shows and movies glamorizing
drug use or suggesting that drug use is normal or
socially acceptable as well as advertising efforts
to promote the sale of alcohol and tobacco products),
by family members who use drugs or convey pro-drug
attitudes, and/or by friends and acquaintances who
use drugs or hold attitudes and beliefs supportive
of drug use. Others may be propelled toward drug use
or a drug-using peer group because of intrapersonal
factors such as low self-esteem, high anxiety or other
dysphoric feelings, or the need for excitement.
Since there are multiple pathways leading initially
to drug use and later to drug abuse, a more useful
way of conceptualizing drug abuse is from a risk-factor
perspective similar to that used in the epidemiology
of chronic diseases such as cancer and heart disease.
From this perspective, the presence of specific risk
factors is less important than their accumulation.
As more risk factors accumulate so does the likelihood
that an individual will become a drug user and eventually
a drug abuser. Thus, the presence of multiple risk
factors is associated with both initial drug use and
the severity of drug involvement.
It has also been well established that the prevalence
of drug use generally increases with age and progresses
in a well-defined sequence. Drug use typically begins
with the use of alcohol and tobacco first, progressing
later to the use of marijuana, and, for some, to the
use of stimulants, opiates, hallucinogens, and other
illicit substances. Not surprisingly, this progression
corresponds exactly to the prevalence and availability
of these substanceswith alcohol being the most prevalent
form of drug use and the most widely available, followed
by tobacco (cigarettes) and marijuana. Because alcohol,
tobacco, and marijuana are among the first substances
used, they have been referred to as "gateway"
substances. The use of these "gateway" substances
significantly increases the risk of using illicit
drugs other than marijuana.
Taking this into account, the LST prevention program
targets those "gateway" substances (tobacco,
alcohol, and marijuana) that occur at the beginning
of the developmental progression. Thus, LST offers
the potential for interrupting the normal developmental
progression from use of these substances to other
forms of drug use/abuse. A second reason for targeting
this type of drug use is that the use of these substances
accounts for the largest portion of drug-related annual
mortality and morbidity.
Brief Description of Intervention
Overview
The LST prevention program is a three-year intervention
designed to be conducted in school classrooms. Based
on the theoretical framework discussed earlier, the
LST program was developed to impact on drug-related
knowledge, attitudes and norms; teach skills for resisting
social influences to use drugs; and promote the development
of general personal self-management skills and social
skills. Consistent with this, the LST prevention program
can best be conceptualized as consisting of three
major components. The first component is designed
to teach students a set of general self-management
skills. The second component focuses on teaching general
social skills. The third component includes information
and skills that are specifically related to the problem
of drug abuse. The first two components are designed
to enhance overall personal competence and decrease
both the motivations to use drugs and vulnerability
to drug use social influences. The problem-specific
component is designed to provide students with material
relating directly to drug abuse (drug resistance skills,
anti-drug attitudes, and anti-drug norms). A complete
description of each LST component may be found in
the section labeled "Program as Designed and
Implemented."
Program Structure
The LST program consists of fifteen class periods
(roughly 45 minutes each) and is intended for middle
or junior high school students, depending upon the
structure of the school. A booster intervention has
also been developed which consists of ten class periods
in the second year and five class periods in the third
year. This means for school districts with a middle
school structure, the LST program can be implemented
with students in the sixth grade, followed by booster
sessions in the seventh and eighth grades. If the
LST program is implemented in a junior high school
setting, students receive the program in the seventh
grade, and the booster sessions in the eighth and
ninth grade, respectively. The rationale for implementing
the LST program at this point concerns a variety of
factors concerning the developmental progression of
drug use, normal cognitive and psychosocial changes
occurring at this time, the increasing prominence
of the peer group, and issues related to the transition
from primary to secondary school.
Drug experts have established that early adolescence
is a time of increased risk for experimenting with
one or more psychoactive substances. Children first
typically experiment with alcohol during the sixth
and seventh grades. The greatest proportional change
in cigarette smoking occurs between the seventh and
eighth grades. Correspondingly, the greatest change
in marijuana use takes place between the eighth and
ninth grades. Adolescence is also a time of increased
reliance on the peer group, separation from parents
as they develop a sense of independence and autonomy,
and changes in the way individuals think. For example,
during this time, individuals begin to shift from
a concrete style of thinking that includes a clear
sense of right and wrong or absolute rules of behavior
to one that is more relative and hypothetical. This
enables the adolescent to accept deviation from established
rules and to recognize the frequently irrational and
inconsistent nature of adult behavior. In addition,
it has been noted that the transition from primary
to secondary school can be a source of stress that
increases risk from problem behaviors such as tobacco,
alcohol, and illicit drug use. Finally, the strongest
evidence concerning the effectiveness of drug abuse
prevention programs is based on evaluation research
with programs implemented with individuals during
this period.
While the program is effective with just the one
year of primary intervention, research also has shown
that prevention effects are greatly enhanced when
booster sessions are included. For example, two studies
have shown that one year of the primary intervention
of LST produced reductions of 56-67 percent in smoking
without any additional booster sessions; but for those
students receiving booster sessions, these reductions
were as high as 87 percent. In addition, the booster
sessions enhance the durability of prevention effects,
so that they do not decay as much over time. LST has
been shown to be effective using a variety of service
providers including outside health professionals,
regular classroom teachers, and peer leaders. Peer
counselors are often slightly older (high school)
and almost always work in conjunction with a trained
adult provider.
Evidence of Program Effectiveness
Overview
Considerable prevention research has been conducted
over the past twenty years. Despite the best efforts
of educators, health professionals, and drug abuse
prevention specialists, a large number of evaluation
studies have failed to demonstrate that the prevention
approach being utilized was able to produce a measurable
impact on drug use behavior. Some studies have demonstrated
reductions in attitudes toward drugs and drug use.
Others have demonstrated increases in knowledge about
drugs or the consequences of using drugs. But, efforts
to demonstrate that prevention programs could impact
on actual drug use have been disappointing.
Research with the
Life Skills Training Program
More than one and a half decades of research with
the LST program have consistently shown that participation
in the program can cut drug use in half. These reductions
(relative to controls) in both the prevalence (i.e.,
proportion of persons in a population who have reported
some involvement in a particular offense) and incidence
(i.e., the number of offenses which occur in a given
population during a specified time interval) of drug
use have primarily been with respect to tobacco, alcohol,
and marijuana use. These studies have demonstrated
that this prevention approach can produce reductions
in drug use that are long-lasting and clinically meaningful.
For example, long-term follow-up data indicate that
reductions in drug use produced with seventh graders
can last up to the end of high school. Evaluation
research has demonstrated that this prevention approach
is effective with a broad range of students including
White, middle-class youth and poor inner-city minority
(African American and Hispanic/Latino) youth. It has
not only demonstrated reductions in the use of tobacco,
alcohol, or marijuana use of up to 80 percent, but
evaluation studies show that it also can reduce more
serious forms of drug involvement such as the weekly
use of multiple drugs or reductions in the prevalence
of pack-a-day smoking, heavy drinking, or episodes
of drunkenness.
The bar chart on page 12 shows the results from four
published studies testing the LST program. The first
three focus on either tobacco, alcohol, or marijuana
use. Results are presented for students who received
the LST program during the 7th and 8th grades when
compared with control students who did not receive
the program. The last set of bars presents long-term
follow-up data for students at the end of the 12th
grade who received LST during junior high school in
grades 7 through 9 when compared with controls in
terms of polydrug use (here defined as tobacco, alcohol,
and marijuana) one or more times per week. In all
four studies, drug use among the LST students was
at least half that of the control group.
