Delaying the Onset of Alcohol and
Substance Use Among Youth:
Summary of principles of promising practices
in the literature
Prepared by:
Phuc-Nhi Phuong
Muriel Vandepol, RN
Carol Perkins, RN
Dan Vandebelt
Injury & Substance Misuse Prevention Team
Region of Waterloo Public Health
2011
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Table of Contents
Introduction .............................................................................................................................. 3
Delaying Onset Background and Rationale ............................................................................. 3
Early Initiation Impact ..................................................................................................................................... 3
Connection Between Use of Alcohol and Substances ................................................................................... 3
Primary Prevention and Early Intervention ..................................................................................................... 4
Principles of Promising Practices ............................................................................................ 4
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Ensure Interventions are Evidence-based with Underlying Theory ........................................................ 4
Ensure Interventions are Outcome Focused .......................................................................................... 4
Base Interventions on Local Context ...................................................................................................... 5
Target Prevention With Youth Prior to Age of Onset of Substance Use ................................................ 5
Utilize Appropriate Interventions for Age/Stage of Development ........................................................... 5
Target Intermediaries Connected to Youth ............................................................................................. 6
Ensure Youth Engagement and Buy-in .................................................................................................. 6
Address the Continuum of Prevention .................................................................................................... 7
Utilize Appropriate, Trusted, and Trained Facilitators ............................................................................. 8
Incorporate Skill-based Interventions...................................................................................................... 8
Provide Accurate, Realistic and Relevant Information ............................................................................ 9
Address Risk Factors, Build Protective Factors and Resiliency ........................................................... 10
Ensure Sufficient Program Duration & Intensity ................................................................................... 11
Incorporate Interactive Program Strategies .......................................................................................... 11
Ensure Safe Environments ................................................................................................................... 12
Ensure Consistent Messaging .............................................................................................................. 12
Address Social Norms........................................................................................................................... 12
Consider Sustainability ......................................................................................................................... 12
Utilize Multi-faceted and Comprehensive Approaches ......................................................................... 12
Intervention Focus: School ................................................................................................................... 13
Intervention Focus: Family .................................................................................................................... 14
Intervention Focus: Community ............................................................................................................ 18
Intervention Focus: Policy ..................................................................................................................... 19
References ............................................................................................................................ 21
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Introduction
This summary of the literature was completed in order to inform future Region of Waterloo Public Health primary
prevention planning in the area of substance misuse. Based on the literature regarding the impact of delaying onset of
alcohol and substance use and a mandate to focus on upstream prevention, this summary of evidence-based literature
focuses on delaying onset of alcohol and substance use in youth. This document summarizes the specific related articles
in the literature review screening tool working document (DOCS_ADMIN-#864769-LITERATURE REVIEW DELAYING ONSET
OF ALCOHOL USE FOR YOUTH) While some of the articles and findings focus only on alcohol or a particular substance use,
there is significant overlap and indications of impact that cross various substance interventions.
In terms of the local context and data, several reports have documented statistics related to alcohol and substance use
and related harm in Waterloo Region. These will be summarized in an Evidence and Practice-based Planning Framework
(EPPF) in 2012.
Delaying Onset Background and Rationale
The literature is clear that the early initiation of substance use has significant individual health and behavioural
consequences as well as social implications and that preventing or delaying the onset of substance use by youth is an
important way to promote healthy behaviours and avoid serious health and economic costs down the road.
Early Initiation Impact
Early initiation of substance use has been found to be predictive of longer-term problem substance use for both males
and females (D’Amico et al., 2001; Health Canada, 2001f; Manning et al., 2001; Simkin, 2002; Sung, Erkanli, Angold and
Costello, 2004; Usher, Jackson and O’Brien, 2005; NCPC, 2009). One of the strongest predictors of adult substance abuse
disorders is alcohol and other drug involvement during the teen years (Tuttle, 2002). In fact, the younger a person starts
using a drug, the more likely they are to have problems – such as chronic dependence – with substances later in life
(Brook, 1998). Children and youth that use alcohol before age 14 are much more likely to develop alcohol dependence at
some point in their lives, compared to those starting after 21 years (Matsen, 2008). In a community sample of youth
interviewed at age 12 and again several times before the age of 30, those who drank at an earlier age were more likely to
develop alcohol use problems. Heavy first-time use was predictive of greater problems with alcohol (Warner and White,
2003). An American research study found that for every year that alcohol-use initiation was delayed among youth the
odds of alcohol dependence decreased by 14% and odds of alcohol abuse decreased by 8% (Grant & Dawson, 1997). Early
onset of tobacco and other substances are not only associated with future substance use but a clustering of health risk
behaviours (DuRant, 1999)
Connection Between Use of Alcohol and Substances
Early onset impacting later substance issues isn’t only the case with alcohol or with specific substances. The use of any
substance, be it legal or illegal, early in adolescence is a reliable predictor of more intense and problematic substance use
in young adulthood (CARBC, 2006). Early onset and a rapid escalation of substance use patterns have also been identified
as risk factors for subsequent addictions (AACAP, 2005). Early drinkers are also more likely to develop problems with
alcohol and other drugs (Brown and D’Amico, 2001; Grant, Stinson and Harford, 2001; Stueve and O’Donnell, 2005).
Deferred initiation of cannabis and tobacco use also decreased the likelihood of developing subsequent problem
substance use (Ellickson and Morton, 1999; Gil, Wagner and Tubman, 2004; Grant et al., 2001). Studies suggest that early
initiation of drug use (before the age of 14) is associated with greater risk for subsequent alcohol and poly-drug use as
well as injection drug use (Ellickson, Tucker, Klein and Saner, 2004; Grant et al., 2001; Storr, Westergaard and Anthony,
2005; Sung et al., 2004).
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Primary Prevention and Early Intervention
Early onset or frequent substance use is associated with developmental harm. This highlights the importance of
prevention and early intervention programs that focus on delaying the age of onset of drug experimentation, reducing the
number of young people who progress to regular or problem use and encouraging current users to minimize or reduce
risky patterns of use (Lubman, 2007). Intervening early to reduce or delay substance use initiation is therefore likely to
have positive long-term health outcomes (CARBC, 2006). Prevention programs that are grounded in research can be cost
effective. Research on prevention programs (Pentz, 1998; Hawkins, 1999; Spoth et al., 2002a) has shown that “for each
dollar invested in prevention, a savings of up to $10 in treatment for alcohol or other substance abuse can be seen”
(NIDA, 2003).
Principles of Promising Practices
The literature on delaying onset of alcohol and other substance use in youth provides many principles of promising
practices. Taken together, they become a strong foundation for planning interventions. Overall, there is strong evidence
of the effectiveness of substance prevention programs that are well-designed with clear objectives (PHRED, 2005).
1. Ensure Interventions are Evidence-based with Underlying Theory
Prevention interventions should be evidence-based (MacPherson, 2001) and supported by high quality research and
evaluation data (Ripley, 2006). Furthermore, it is important to establish a solid organizational context to support the
successful development of the program. Organizations should provide processes and opportunities to develop and share
knowledge of alcohol prevention among youth (Department of Health Promotion and Protection, 2007). Providing
learning or training opportunities for staff related to the topic areas is essential (Department of Health Promotion and
Protection, 2007). Organizations should also explore the opportunities for integrating the alcohol prevention project with
other existing programs internally (UN, 2004).
Alcohol prevention planners should use a framework to guide the development of their program (OIPRC, 2008; Ripley,
2006). Best practice guidelines for developing substance misuse prevention programs are summarized in the Canadian
standards for youth substance use prevention for school-based (CCSA, 2010a), community-based (CCSA, 2010b) and
family-based interventions (CCSA, 2010c). Programs should also be theory-based. The most promising approaches are
based on social learning theory (using a social influence model that combines information, resistance skills training and
normative education) (Ripley, 2006). Communities who adapt programs to meet community needs, norms or cultural
needs should retain the core elements of the original researched intervention (program structure, content and delivery)
(NIDA, 2003).
2. Ensure Interventions are Outcome Focused
Alcohol prevention programs need to strive for accountability by being results driven and guided by process and outcome
evaluations (MacPherson, 2001). The program should have clear and realistic goals which are monitored and evaluated
throughout the duration of the program (Ripley, 2006). Goals, objectives and activities should address local
circumstances, be linked logically and be specific, measurable, attainable, relevant and time-limited (“SMART”) (Health
Canada, 2001). Program planning should address sustainability of the program benefits from the beginning. Creating
appropriate short- and long-term objectives and conducting outcome evaluations to measure them will provide insight on
whether the program has worked as intended. Process evaluations can be used to evaluate how well the program was
implemented, and results can be used to guide future delivery of the program.
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3. Base Interventions on Local Context
Alcohol prevention programs should also appropriately target local substance use patterns. Accurate information on the
nature and extent of substance use and associated problems is an important basis for prevention program development
(Health Canada, 2001). Gathering insight into the rapidly evolving local youth culture is important (Roberts, 2006).
4. Target Prevention With Youth Prior to Age of Onset of Substance Use
Early alcohol prevention efforts to should be targeted just prior to the average age of onset of alcohol use (Roberts,
2006). The literature varies in terms of the age of onset of use, however all sources agree that interventions should occur
before high school (before grade 9) (Health Canada, 2001; City of Vancouver, 2007; CAMH, 1999; OIPRC, 2008; PHRED,
2005).
Health Canada’s Compendium of Best Practices (2001) indicates that the age of first alcohol use varies by regions in
Canada, but it appears that a significant minority have experimented with alcohol by grade 7 (age 12-13). Other sources
(PHRED, 2005; CAMH, 1999) agree that average onset of alcohol use occurs in grade 7. Peak alcohol use occurs in the last
years of high school (Health Canada, 2001). Male use of alcohol is higher; however women have a lower threshold of
effects from alcohol (Health Canada, 2001). Targeting prevention strategies prior to the age of onset of alcohol use
(grade 6 or earlier) is ideal as by the time youth reach the age of 15, their experience, role models and environment have
already formed many of their ideas, attitudes and expectations regarding alcohol (City of Vancouver, 2007).
5. Utilize Appropriate Interventions for Age/Stage of Development
Much of the research on early alcohol prevention indicates that programs should be tailored based on the developmental
stage of youth (Child Trends, 2008; CARBC, 2006). Developmental factors such as social development, mental health, and
self awareness and control need to be considered when designing strategies appropriate to a young person’s own context
and life situations (Ripley, 2006). Drug education should therefore be linked to the cognitive, emotional, and social
development of students and to their use pattern (Roberts, 2006). Programs should strive to address the traits that can
arise as a result of the adolescence time period (e.g. risk taking behaviour, questioning authority, desire to be part of a
peer group, seeking novel and exciting experiences, a lack of caution, need to satisfy curiosity) (Roberts, 2006).
Specifically, paying attention to transition points at which problems from substance use often emerge is important. Times
of transition are viewed as vulnerable times and there is some concern when children do not receive enough support or
scaffolding that they need to make successful transitions to adolescence and adulthood (Masten, 2008). The key
developmental stages include: pre-natal / post-natal period, the transition to school, adolescence and the transition to
high school, transition to independence (going to college or entering the work force), and transitions relating to family
and occupation (CARBC, 2006). In the school environment, grades 4, 7, 9 and 11 are key transition points (Ripley, 2006).
Specifically, entry into middle school is a significant event for most children as they enter a larger, unfamiliar school
farther from home that is filled with older students (Guilamo-Ramos, 2005). At the same time, these students are moving
through puberty and the changes that come with this transition and some young people will turn to alcohol and binge
drinking among other coping strategies (Guilamo-Ramos, 2005).
Alcohol prevention practitioners should develop programs aimed at ensuring a smooth transition to independence and
adult life and responsibilities. For example, this can be accomplished by promoting programs that provide youth
opportunity to engage in volunteering in order to develop employability skills and social responsibility (CARBC, 2006). In
addition, increasing access to community supports and training programs that target young adults and address financial
matters, positive relationships, and independent living can facilitate the transition period for youth (CARBC, 2006). It is
important to note that not all adolescents progress through the phases of psychosocial development and these are the
persons most at risk of substance-use harm (Health Canada, 2001). Selective programs are therefore needed for high-risk
youth who continue to show signs of identity confusion during adolescence (Health Canada, 2001). Multi-faceted
indicated programs with harm reduction components are also needed for the sub-sets of adolescents where risk factors
linked to dysfunctional psychosocial development have already led to the onset of substance use (Health Canada, 2001).
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Prevention programs need to be “tailored” for risk factors based on the audience’s gender and ethnicity, in addition to
age, to improve the program’s effectiveness (NIDA, 2003).
Table 1 outlines the key stages of development during childhood & adolescence, and the appropriate intervention
characteristics for each stage.
Table 1: Age-appropriate interventions to delay the onset of substance use
Age / Stage of
Development
Childhood
(Elementary school)
Late Childhood & PreAdolescence
(~Grades 4-6)
Intervention
Goal: prevent or delay onset of substance use
Activities: Building emotional awareness, communication, social problem solving and social control skills
Goal: prevent or delay onset of substance use. Preventive efforts need to especially give attention to those in grades 4-6
(before onset of use begins).
Activities: Basic prevention education aimed at smoking, alcohol and cannabis; relationship building and social-emotional
skills rather than drug and alcohol use information. Present general knowledge and skills on substances and risk (grade
4-5) and provide practical information and skills on abstaining from alcohol use (grade 6-7).
Adolescence
(~Grades 7-12)
Goal (Grades 7 & 8): prevent or delay onset of substance use and reduce risk or harmful effects of alcohol use
Goal (Grades 9-12): reduce risk of harmful effects of alcohol use
Activities: Increase academic and social confidence by targeting communication skills, study habits and academic
support, peer relationships, self-efficacy and assertiveness, as well as substance use education. Prior to grade 9, generic
programs focusing on tobacco, alcohol and cannabis are most relevant, while from grade 9 to 12, separate programs have
most success. Harm minimization messages for relevant substances should to be embedded in these programs.
Sources: Health Canada, 2001; CARBC, 2006; Roberts, 2006; Ripley, 2006
6. Target Intermediaries Connected to Youth
Alcohol prevention practitioners may find it worthwhile to target the intermediaries that are connected to the youth
population. These trusted intermediaries are important role models for children and adolescents. Parents, relatives,
teachers, faith leaders, other adults and peers are in a position to influence youth and may facilitate the transfer of
alcohol prevention messaging.
Siblings and parents are especially important role models for adolescents. The relationship between sibling drinking and
drug-taking behaviours and those of adolescents are stronger and more consistently supported than those of parents
(Tuttle, 2002). Alcohol prevention practitioners should strive to strengthen links with parents by providing practical
advice on youth substance use and family skills-based training. It will also be beneficial to work with teachers to increase
their conceptual understanding of alcohol use and prevention, and skills that can be implemented to delay the onset of
use among their students. Working with peers in a school system can also help to create healthy contexts to reduce
perceived favourable norms concerning alcohol use (CARBC, 2006). More information on early alcohol and substance
prevention strategies targeting the school and family systems will be presented in subsequent sections of this report.
7. Ensure Youth Engagement and Buy-in
Youth are integral partners in designing and implementing any initiative targeting them (CCSA, 2010a). Best practices
literature on preventing youth substance misuse widely suggest that to be effective, programs need to consult with youth
to inform program design, implementation and evaluation (Ripley, 2006; CARBC, 2006; CCSA, 2010a; CAMH, 1999; Health
Canada, 2001; UN, 2004).
It is recommended to involve youth in the design of the program (MacPherson, 2001). By giving the end-users a genuine
opportunity to influence the direction of the project, the team can quickly build broad support for the work (UN, 2004). A
good way to initiate planning is to hold brainstorming or consultation meetings (possibly attached to a social event) with
strong representation from potential community partners and young people (UN, 2004). A community engagement
process can also assist in: identifying gaps in alcohol-related knowledge and practice, and developing a plan to address
these gaps; establishing collaborative links with partners in ongoing and new alcohol research projects to address
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knowledge gaps; and identifying, monitoring, and updating the best and most promising practices and standards (Nova
Scotia, 2007).
Involving youth from the outset ensures buy-in, leading to increased program effectiveness. Youth who are involved in
data gathering, program planning, modification, implementation and evaluation are less likely to drop out of the
intervention, thereby increasing the possibility of it having the intended effect (Health Canada, 2001). They are also more
likely to be motivated to actively develop new skills as they are provided with opportunities to manage new
responsibilities (Health Canada, 2001; CCSA 2010a). The engagement process itself, regardless of the outcome, can be a
powerful experience in building personal and group capacity for change among youth (Health Canada, 2001).
Involving youth means nurturing trust and working cooperatively with the youth population as they clarify the problems;
determine goals, and design, possibly deliver, and help to evaluate the prevention program or activity (Health Canada,
2001). It is also important to have the supportive involvement of adults to facilitate and supervise program activities and
to put youth in touch with resources (Health Canada, 2001).
8. Address the Continuum of Prevention
Early prevention of alcohol use is well supported by the literature (Guilamo-Ramos, 2005) and alcohol prevention
practitioners should continuously encourage stakeholders and other practitioners to adopt a population health approach.
Alcohol strategies need to be comprehensive and address the continuum of prevention – the “four pillars approach”:
health promotion, treatment, enforcement and harm reduction (OIPRC, 2008). In other words, initiatives should pay
equal attention to early and later interventions, including strategies for promoting healthy development and preventing
problems, strategies for intervening early to address problems as soon after onset as it’s feasible and strategies to assist
with severe ongoing problems (CCSA, 2010a).
Different approaches should be used for various subgroups and the program needs to vary according to target groups of
prevention (Universal, Selective and Indicated) (CAMH, 1999; Health Canada, 2001). Table 2 outlines the various levels of
prevention for delaying the onset of alcohol use.
Table 2: Levels of prevention for delaying the onset of alcohol use
Level of
Prevention
Universal
Target Audience
Goal
Examples
Whole population groups (i.e. school, community,
parents/families, etc.) and not identified on basis of risk.
To prevent young people from starting
use or delaying the use of substances
Selective
Sub-groups whose risk of developing a problem with
substance is higher than average, identified by presence of
biological, psychological, social or environmental risk
factors.
To reduce the influence of these risk
factors and to prevent or reduce
substance use problems by building on
strengths such as coping strategies and
other life skills.
Health promotion programs
such as awareness
campaigns, school drug
education programs,
parenting programs.
After school program for
children with behavioural
problems, family-based
programs to improve family
functioning and reduce antisocial behaviours.
Indicated
The following are at heightened risk for substance abuse:
Aboriginal youth, youth disengaged from school and
community activities, gay lesbian bisexual and transgender,
new Canadian students, youth with less access to the
‘social determinants of health’ (unemployment, low income,
poor living conditions), youth with mental health issues.
Youth who have already initiated alcohol use, but do not
meet DSM-IV criteria for dependence.
Be aware of and minimize the possibility
of labelling and stigmatizing individuals.
The stigma associated with being
targeted may result in the initiative
having more harm than benefit.
To engage and work with high risk youth
to minimize the harm associated with
their lifestyle.
Counselling, intensive
treatment, case
management, family therapy.
Often involves outreach component and collaborating with
the treatment sector to target interventions for these youth.
Sources: Health Canada, 2001; Ripley, 2006; Degano, 2007; CCSA, 2010a; CCSA, 2010b
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9. Utilize Appropriate, Trusted, and Trained Facilitators
A systematic review (PHRED, 2005) indicates that the characteristics of the leader or facilitator of a program may impact
the program outcomes. It was not crucial that the facilitator was a peer or other figure, but it was important how well
they facilitated the group (i.e. taking a facilitative rather than directive role) (Health Canada, 2001).
It is important that the facilitator of the prevention program is trusted and respected by youth. Students need to trust
the person delivering the material, and the information should be presented factually, in an unbiased manner that doesn't
appear as propaganda (Ripley, 2006). Acceptance of the facilitator by youth is more likely if the leader is comfortable
with the program’s content and process (Health Canada, 2001). Facilitators should demonstrate competence in the
material they are presenting, as well as show empathy to youth, and engage them interactively (Health Canada, 2001).
Leaders who had skills and training are more effective (PHRED, 2005). Program planners should ensure comprehensive
education and training on substance use (alcohol and other drugs) for their facilitators (City of Toronto, 2005). Facilitator
training needs to offer demonstration of interactive teaching techniques and ample opportunity to practice these skills
(Health Canada, 2001). Organizations should also provide initial and ongoing training in areas such as team building,
leadership program development and research-based alcohol prevention approaches (Ripley, 2006). From a program
delivery perspective, facilitator training is helpful in ensuring programs are conducted consistently and as they were
designed to be delivered (Health Canada, 2001).
A variety of individuals can be effective facilitators for a youth alcohol prevention program. Classroom teachers are
important messengers as they have first-hand knowledge of student needs, developmental level, and ability to integrate
drug/alcohol education at appropriate times (Ripley, 2006). They also have the advantage of being available on a daily
basis to youth, and as such are well-trusted (Health Canada, 2001).
Teachers as facilitators can also be effective with assistance from peer student leaders (CAMH, 1999). Students,
partnered with teachers, can help to create an appropriate environment and initiate discussion (Health Canada, 2001). It
is important to choose peer leaders carefully, as rigid social groups exist among students and some may be turned off or
alienated by choice of peer leader (CAMH, 1999).
Health professionals have also been shown to be effective as facilitators, particularly with high school students (Health
Canada, 2001). If delivering the program in a school setting, guest presenters need to be able to address curricular goals
and work interactively with the students, rather than present an isolated session unconnected with the curriculum
(Roberts, 2006). Again, it is important that the health professional partner with the teacher to deliver the program
(Ripley, 2006).
10.
Incorporate Skill-based Interventions
It is well established in the substance abuse prevention literature that skills-based interventions can be effective in
shifting substance use behaviours while information or knowledge-based only approaches generally are not (CCSA,
2010c). It is recommended for programs to combine information provision and skill-development for delaying the onset
of alcohol use.
Skill development needs to be a central element in alcohol prevention programs, accompanied by accurate, objective
information (Health Canada, 2001). It is important to give individuals practical skills and knowledge, which build
confidence and increase opportunities for making healthier decisions (City of Vancouver, 2007). Based on social learning
theory, the types of skills covered in a broad life skills program can include decision-making, goal setting, stress
management, assertiveness and communication skills (Health Canada, 2001). Mastery of these skills can enhance the
young person’s self-confidence in dealing with various situations and transition periods (Health Canada, 2001). A
strengths-based approach is recommended that emphasizes and builds on one’s capabilities rather than focusing on
deficits and limitations (CCSA, 2010b). Young people therefore are seen as active agents with capabilities to be
strengthened rather than passive agents with problems that need to be fixed (CCSA, 2010b).
Information only drug education programs have been found to have no effect on substance use (Roberts, 2006). It’s not
recommended to provide information only on the affective personal problems such as low self-esteem and poor values
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nor information on the negative health risks and long-term consequences of alcohol use (Ripley, 2006). Information
should be provided only if useful and relevant as young people will dismiss information that they perceive as
contradictory to their personal experiences (Ripley, 2006).
The most effective programs teach skills to help young people refuse drug offers, resist pro-drug influences, correct
misperceptions that drug use is normative, and enhance social and personal competence skills (Botvin, 2007). Programs
should provide tools to help youth make their own decisions whether to use alcohol or drugs (City of Vancouver, 2007).
An area of best practice that was specified was strength-based youth development (Cheon, 2008).
11.
Provide Accurate, Realistic and Relevant Information
Alcohol prevention educators should provide credible and honest information about substances that is scientifically
based, accurate and balanced through media that are trusted by youth (Ripley, 2006; UN, 2004). A program that
promotes abstinence of alcohol use as the only viable option may not be taken seriously by students (Roberts, 2006;
CAMH, 1999).
Programs looking at prevention need to look at all forms of drug use and poly drug use. This would include underage use
of legal drugs (such as tobacco or alcohol), illegal drug use, inappropriate use of legal substances (e.g. inhalants),
prescription and over the counter drugs (NIDA, 2003). Educators should promote the low risk drinking guidelines,
generate knowledge about risks associated with alcohol misuse (socially, mentally, and legally), and increase awareness of
the injuries associated with alcohol misuse (OIPRC, 2008). The content should focus on the short-term and preferably
social consequences, rather than longer-term effects, as young people have difficulty personalizing risks that may occur
decades later in life (Roberts, 2006). Furthermore, educators should discuss reasons people use drugs (e.g. for selfdiscovery, self-expression or some perceived benefit), present alternatives to drug use, and discuss and correct
perceptions regarding occasional or social use (CAMH, 1999).
The following are strategies on developing credible messages targeting youth substance use, from Health Canada’s
Compendium of Best Practices (2001).
 Most important is for drug information to be scientifically accurate, objective, non biased and presented
without value judgement (maintains credibility with youth as they learn more).
 Important for programs to discuss the reasons people use drugs and present alternatives to drug use.
Address both dangers and benefits, focus on short-term consequences.
 Fear arousing messages accompanied by incorrect or exaggerated information are not effective, and can
generate scepticism, disrespect and resistance toward any advice on substance use or other risk behaviour.
These messages can erode motivation to deal with a problem, particularly when there are no accompanying
coping strategies presented.
 Simplistic messages that young people believe to be unrealistic (e.g. “Just say No”) or not feasible (“Play
Sports” when there are no readily facilities available) will not be seen as credible.
 Programs need to give greater attention to ‘here and now’ social consequences that can be avoided, such as
being less attractive, smelling of tobacco, and doing things that will be regretted afterwards. Discussion of
these consequences as risk need to be presented in an accurate and unbiased manner.
 It will be important to integrate new messages with respect to risky behaviours and safe use (i.e. doesn’t
drink and drive). Inclusion of these messages can support a harm reduction program goal.
 There are core features to youth culture, such as rapid change, non-linear thinking, and low respect for
prescribed authority and for second-hand adult attempts to be ‘cool’. Messages that connect substance use
to these issues, aspirations and values are more likely to be attended to.
 Provocative messages that trigger strong affective responses and interpersonal discussions have been found
to be effective with young girls. Boys will likely be more influenced by themes relating to action, competition,
bodily sensations and peer group membership.
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12.
Address Risk Factors, Build Protective Factors and Resiliency
Risk factors, protective factors and resiliency are interrelated concepts that are important considerations in
understanding the target population and in designing a program to delay the onset of alcohol use (Health Canada, 2001).
Addressing protective or risk factors in several domains of a young person’s life (individual, school, family, and
community) can lead to positive outcomes (Health Canada, 2001). Protective factors are aspects of a person and
environment that enhance well-being while serving to reduce the risk for a range of problems (Health Canada, 2001;
CCSA, 2010b). For example, protective factors can include strong parental monitoring, social skill development,
availability and participation in social/recreational activities, positive connection to school, etc. (Ripley, 2006). On the
other hand, risk factors are aspects of a person and their environment that make the development of a given problem
more likely (Health Canada, 2001). Resiliency is the ability to cope with adversity or a situation that is not readily
amendable to change (Health Canada, 2001; CCSA, 2010b). It is important to identify youth experiencing risk factors with
a view to reduce these factors or to foster more protective factors in their lives (CCSA, 2010b) and build resiliency. Some
risk factors tend to be more important for girls (e.g. influence of peers, negative self-image, weight concerns, higher levels
of anxiety or depression) as well as protective factors (parental approval/support, consistent discipline or self-control)
(CCSA, 2010b).
Fostering environments in which youth are encouraged to become involved and assume increasing responsibility for their
own lives and others will help to build protective factors and resiliency (CCSA, 2010b). Programs that increase contact
and activities in the community are a critical part of providing an environment where young people can receive support,
engage in meaningful activities, and connect with others (City of Vancouver, 2007). The Search Institute’s resources on
developmental asset-building can offer strategies, tools, insights and capacities to prevent early onset of alcohol and
other drug use, regardless of a young person’s socioeconomic, family or ethnic background. Table 3 outlines some of the
risk and protective factors that should be considered in planning an alcohol prevention strategy for youth.
Table 3: Risk and protective factors linked to youth substance youth problems (risk and protective factors):
Personal
Factors
Family Factors
School Factors
(throughout
school years)
School Factors
(in
adolescence)
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Risk Factors
 Genetic make-up
 During pregnancy, exposure to alcohol, tobacco, or other substances
 In childhood, childhood behaviour problems (including mental health)
 In late childhood or early adolescence, use of tobacco and alcohol.
 In adolescence, a sensation-seeking personality and internalized
problems (such as anxiety or a sense of hopelessness), delinquency
and conduct problems, conflict with parents or parental substance use
problems; low involvement with adults; peers engaging in problematic
substance use; school failure; mental health problems
 Early deprivation (e.g. neglect, maltreatment, or lack of affection from
caregivers)
 Parental influences:
o Negative communication patterns (e.g. criticism, blaming, lack of
praise)
o Laissez faire parental attitude toward substance use
o Chaotic home environment, parental conflict
 In late childhood and adolescence, insecurity, transitions or significant
changes in family life (e.g., moving to a new neighbourhood or school,
loss of a close family member or parental separation)
 In adolescence, parents or siblings with abuse use problems or
favourable parental attitudes toward substance use
 In adolescence, extreme approaches to discipline and family rules (i.e.
being either too permissive or to punitive)
 Learning disabilities
 Early school failure, ,
 Disengagement with learning and poor relationships with peers and
teachers (e.g. being bullied, feelings of not belonging)
 Peer influence, perception that substance use is common or ‘normative’
in social networks.
 High availability of a particular substance (physically or financially)
 Bullying and violence
 Media influence
Protective Factors
 Throughout childhood & adolescence, social and emotional
competence (e.g. ability to trust, confidence in oneself and one’s
ability to meet demands, the ability to take initiative), social and
emotional competence, shy and cautious temperament, parental
harmony, social and emotional capacities (e.g. competence, selfconfidence, connectedness, character, caring and compassion),
 In adolescence, cautious temperament, attachment to family
school and community; involvement in faith community; parental
harmony and good child-parent communication
 Family bonding and family time
 Secure and health parent/child attachment
 Parenting competence (e.g., ability to listen, set reasonable
expectations, monitor child’s activities and model healthy
attitudes and behaviours)
 Parental supervision and monitoring
 Consistent and effective discipline
 Communication of healthy family values and expectations
 Supportive parenting (e.g. emotionally, cognitively, socially,
financially)
 Family problem-solving and coping skills
 Helping children develop dreams, goals and purpose in life.
 Positive teacher, learning and social connectedness
 Perceptions of higher risk v. benefit associated with a particular
substance
 Religious or spiritual engagement
 Active involvement in healthy recreational activities
 Taking increasing responsibility in community affairs
 Media influence
10
Community
Factors
(across life
stages)







Levels of substance use in the community
Availability of substance
Media influence
Poor economic conditions (e.g. inadequate income, employment)
Lack of availability and low quality of housing
Poor working conditions (e.g. jobs with boring tasks, lack of supervision)
Poor community conditions (e.g. poorly maintained schools, poor public
transport)
 Lack of access to recreation and community services
 Crime, public drug use and social disorder
 Social and economic factors can affect individual and population health
and substance use patterns (e.g. growth in part-time and casual jobs,
lack of affordable housing, widening gap between the rich and poor in
Canada, and a strained work-family life balance are risk factors) and are
in turn affected by government and corporate policies
Sources: CARBC, 2006; CCSA, 2010b; CCSA, 2010c
13.
 High quality of social support networks
 Strong community cohesiveness and ability to solve common
problems (i.e. social capital)
 Strong cultural identity
 Access to positive social activities
Ensure Sufficient Program Duration & Intensity
As previously discussed, alcohol prevention programs are most effective when delivered prior to initial experimentation
and during the period when most youth are experiencing initial exposure to substances (Ripley, 2006). Specifically,
preventive efforts need to give attention to 9-10 year olds (before onset of use begins) and the minimum intensity is one
45-60 minute contact a week for at least 10 weeks (Health Canada, 2001).
In addition to timing, program planners also need to ensure sufficient program duration and intensity. There should be
sufficient contact time with program participants and coverage needs to occur through childhood, and adolescence and
needs to be intensified and reinforced as the risks of participants’ increases (Health Canada, 2001). For example, school
alcohol prevention programs need to be ongoing from kindergarten to secondary school and reinforced additional
elements such as family-based, community or mass media (Health Canada, 2001; Ripley, 2006). As time passes, program
effects erode, therefore some of the literature suggests that programs can offer ‘booster sessions’. Programs that
provide booster sessions in subsequent years to reinforce earlier lessons have been shown to be more effective (Health
Canada, 2001). Booster sessions should involve a greater number in the initial year of the program, and fewer sessions in
subsequent years (Ripley, 2006). For school programs, researchers recommend providing three to five booster sessions in
each subsequent year (Roberts, 2006).
14.
Incorporate Interactive Program Strategies
Methods of communicating prevention messages to youth are important. Alcohol education should be more than
teaching and learning, as the intent is to build young people’s engagement and connectedness through interactive,
activity oriented strategies (Ripley, 2006). This strategy leads to learning through real life applicability and through
experiences of others, creating an open dialogue between the facilitator and youth, and among youth themselves (Ripley,
2006). Interactive approaches appear to be critical in obtaining behavioural goals (Health Canada, 2001). They are best
conducted in small groups and appear effective across drug type and across ethnicity (Health Canada, 2001). The size of
interactive programs do matter as larger program sizes become less effective (Tobler, 2000). Facilitators should
emphasize active learning and use interactive delivery such as small group discussions, role playing, simulations,
brainstorming and peer to peer discussion, rather than relying on passive lectures or films (CAMH, 1999, Health Canada,
2001). Furthermore, if teaching life skills, sessions should include a demonstration of the skill, discussion on applying it,
and ongoing modelling of the skill (Health Canada, 2001). Meta-analysis has found that “interactive programs are
successful in other cultures” (Tobler, 2000).
The DARE (Drug Abuse Resistance Education) program, delivered by police officers in schools, has been shown to not be
effective in preventing or delaying drug use or affecting future intentions to use, with the method of instruction and lack
of peer interactivity being factors (Ripley, 2006). Although not linked to behaviour change, DARE has shown to boost antidrug attitudes, increase knowledge about drugs and foster positive police community relations.
DOCS#909354
11
15.
Ensure Safe Environments
During discussions, it is important for the environment to feel safe and supportive to youth, so they can explore attitudes
and perceptions about alcohol use, and try out skills in a safe environment and be comfortable with asking questions
(Ripley, 2006; NHS, 2007; UN, 2004; CCSA, 2010c). Programs also need to be both sensitive to and relevant to the culture
of the target audience (Dusenbury, 2000).
16.
Ensure Consistent Messaging
Programs on alcohol prevention need to ensure that messages being delivered are consistent, across and within programs
(Ripley, 2006; CCSA, 2010c). There is a need for drug and alcohol messages that are similarly echoed by various mediums
(school, family, community, policy, etc.). Program deliverers should collaborate to ensure they are presenting the same
information and communicating the message consistently.
17.
Address Social Norms
A young person’s perception of how common or “normative” use is can be an important influence on his or her own use
of substances and if there is a sense that most of their friends drink, they are more likely to drink (Health Canada, 2001;
Department of Health Promotion and Protection, 2007). Youth tend to minimize their risks associated with their own
substance use and perceptions of risk by young people appear linked to rates of use (Health Canada, 2001). Social
marketing techniques can be used to counteract social norms. It is suggested for alcohol prevention planners to develop,
support and promote interventions using best practices in social marketing techniques which include: maximizing the
attractiveness of the ideal behaviour and highlighting the flaws in messages which try to make negative behaviour
appealing, using more than one type of media when communicating messages, promoting messages using wording which
will generate interest for individuals of all ages, gender and ethnicities, working in partnership with key stakeholders
including policy makers, researchers and media (OIPRC, 2008).
18.
Consider Sustainability
Few studies have demonstrated long-term results that would lead to recommendations for practice (Loveland-Cherry,
2005) and similarly, many programs fail to demonstrate long-term behavioural outcomes (Ripley, 2006). It is therefore
suggested to address program sustainability from the beginning (Health Canada, 2001). From the outset, alcohol
prevention planners should work toward long-term sustainability, integrating the program into core activities of relevant
organizations in the community (Health Canada, 2001).
To be sustainable over long-term, it may help to infuse the initiative into a larger framework or structure (CCSA, 2010a).
In addition, programmers can embed health promotion values into key policy documents and weave them into practices
and processes of the target setting (e.g. school, community organization) (CCSA, 2010a). Furthermore, continuing to
provide training and orientation about the initiative, documenting and publicizing interim markers of the program’s
success can help with sustainability (CCSA, 2010a). It is also recommended to roll out the initiatives in a manageable
sequence to minimize strain on resources and maintain interest (CCSA, 2010a).
19.
Utilize Multi-faceted and Comprehensive Approaches
In general, prevention efforts are most effective when multi-faceted (i.e. when media messages are used in tandem with
prevention programs involving schools, communities and families) and sustained over time (CCSA, 2010c). Specifically,
much of the literature indicates that programs designed to delay the onset of alcohol use should be multi-faceted (City of
Toronto, 2005; Tawana, 2008; Health Canada, 2001; CCSA, 2010a; Ripley, 2006; VCHA, 2006; OIPRC, 2008; Wettlaufer,
2011). Single-intervention efforts are less likely to succeed and tend to fragment resources (CCSA, 2010a; OIPRC, 2008).
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In addition, multi-faceted programs are better positioned to address a greater range of factors, influencing not only
individual factors but also environmental and social factors (CCSA, 2010a). A range of factors contribute to substance use
initiation and continuation, so it’s important that programs identify and address relevant factors through a number of
activities (Health Canada, 2001). In addition, comprehensive programs may be more cost-effective than single
interventions, and may be easily adopted by schools, health clinics, and communities (Lemstra, 2010).
Comprehensive programs should reach adolescents through a variety of different approaches such as school, family,
community, faith-based organizations, outside of school activities and media campaigns (Tawana, 2008; Ripley, 2006).
Early alcohol prevention strategies should take a comprehensive approach to the issue, including education and
awareness, policy and legislation, enforcement and modifications to products and the environment (OIPRC, 2008).
Comprehensiveness ensures that the various parts of the youth population, from lower risk to higher risk are being served
(Health Canada, 2001).
It is suggested that alcohol prevention planners tie program activities to complementary efforts by others in the
community, and seek support through agency policy and municipal and other government regulation (Health Canada,
2001). Prevention professionals should participate in ongoing planning with the community for the purposes of
information sharing, resource and referrals and support (VCHA, 2006). Joint planning in community coalitions will avoid
duplication of services and increase the resources that can be brought to the initiative (Health Canada, 2001).
Comprehensive Program Focuses
The following sections go into further detail around offering effective school, family, community and policy approaches
for delaying the onset of alcohol and substance use among youth. It is important to note that not one setting alone will
be effective to delay use among youth, and that multiple strategies delivered across many mediums should be considered
when planning a community-wide initiative.
If planning an approach targeting schools, the community or the family, substance prevention practitioners should refer
to the Canadian Standards for School-Based Youth Substance Abuse Prevention (CCSA, 2010a), the Canadian Standards
for Community-based Youth Substance Abuse Prevention (CCSA, 2010b) and the Canadian Guidelines for Family Skills
Programs (CCSA, 2010c). These documents are evidence-based and represent best practice. They are the result of
rigorous methodology consisting of a thorough search and review of the scientific literature, ongoing direction from the
Canadian Standards Task Force and a national bilingual online consultation with individuals involved in parent or family
training/education programs across the country (CCSA, 2010c).
20.
Intervention Focus: School
The issue of dealing with transitions is a major part of moving through school and indicators of successful achievement
such as school attachment and receiving good grades are associated with less adolescent alcohol use (Loveland-Cherry,
2005). Schools are an appropriate setting for youth interventions as the large majority of youth attend school. Alcohol
prevention initiatives in schools can take various forms. While the scope of possibilities is broad, most school-based
prevention initiatives involve one or more of the following:
A. Universal classroom instruction for all students in a grade, where substance use education is presented within
an integrated multi-issue health education curriculum (classroom instruction is termed “universal” because it is
provided to all students without regard to their relative risk).
B.
Targeted programs for selected students seen to be at risk either because of factors in their lives or their current
level of substance use. These initiatives may have a classroom instructional focus or a counseling focus (in school
or in the community).
Prevention interventions should be ongoing from Kindergarten to the final year of high school, and intensive just prior to
the age of first use (grade 5, 6) (Ripley, 2006) and should be integrated into the curriculum (City of Toronto, 2005).
Research has found that “drug education is best taught within the health component of the school curriculum” ensuring
programs in a classroom setting and that reinforcement of drug education occurs at “critical times over several years”
(Stockwell et al., 2005). Evidence-based guidelines for drug education need to be blended with educational philosophy
without loss of effectiveness in order to achieve success (Stockwell et al., 2005). The school approach should involve
staff, parents, and students and cover multifaceted approaches from policy development and the social environment to
DOCS#909354
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the professional development of and support for staff (NHS, 2007; Degano, 2007). Students should be involved in the
planning stages of the strategy. It is important to cultivate a positive health-promoting school climate and support school
safety, positive relationships, participation by students and staff, high expectations, fairness and clarity of rules regarding
substance use, and responsibility in school tasks and decisions (CCSA, 2010a; Ripley, 2006).
Research suggests teachers are for the most part, appropriate vehicles for school drug education (Roberts, 2006).
Teachers need to be competent with small group interactive instructional methodology, which will normally be achieved
through pre- or in-service training (Roberts, 2006). Professional development for teachers can also focus on increasing
teachers' conceptual understanding of drug use and prevention, of normal patterns of drug use onset and
experimentation, how to identify students who may be at risk in their class and how to assist them, as well as training on
research-based prevention strategies (Ripley, 2006). The role of teacher is to set an open, non-judgmental atmosphere,
manage the process as a facilitator (rather than as a presenter), maximize the opportunity for peer interchange and skills
practice and correct misinterpretations that may arise and offer utility information as needed (Roberts, 2006). Teachers
should integrate drug and alcohol into their curriculums, supplemented by components of other approaches, such as peer
programs, health professionals, and use of outside experts such as police and addiction professionals (Ripley, 2006). If an
external professional is to deliver the education session, it is important that they be able to address the curriculum
objectives and work interactively with the students (Roberts, 2006). Some research indicates that peer-led prevention
programs are as or more effective than teacher-led programs (NHS, 2002; Roberts, 2006), but some indicate that peer
teaching works when combined with teacher facilitation (Degano, 2007).
Substance prevention planners should refer the Canadian Standards for School-based Youth Substance Abuse Prevention
(CCSA, 2010a) when creating a program. These standards outline guidelines and best practices in each of the various
phases of an intervention. See the Canadian Standards for School-based Prevention resource for additional detail on the
following 17 guidelines (organized by phases):
A. Assess the Situation
1. Account for current activities
2. Determine local substance use patterns and harms
3. Learn relevant protective and risk factors
4. Clarify perceptions and expectations
5. Assess resources and capacity to act
B. Prepare a plan and build capacity
6. Ensure goals address priority harms and relevant factors
7. Engage students in the initiative
8. Strengthen links with parents and other partners
9. Conduct ongoing professional development and support
10. Address sustainability of the initiative
C. Implement a comprehensive initiative
11. Cultivate a positive health-promoting school climate for all
12. Deliver developmentally appropriate classroom instruction at all levels
13. Implement targeted activities within a comprehensive continuum
14. Prepare, implement and maintain relevant policies
D. Evaluate the initiative
15. Conduct a process evaluation of the initiative
16. Conduct an outcome evaluation of the initiative
17. Account for costs associated with the initiative
21.
Intervention Focus: Family
Family environments have been shown to impact initiation of drinking as well as regular use (Hill, 2010). Family-based
approaches may include, but are not limited to, parent training, children’s skills training, and family skills training to
improve family interaction. This will result in reducing children’s problem behaviours and their intentions to use alcohol
and tobacco (CAMH, 1999).
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Most of the family factors associated with substance abuse are also linked to other health and social issues, such as
mental health problems, violence, criminal behaviour and risky sexual practices, so these programs can have broad effects
(CCSA, 2010c). Substance prevention practitioners should focus on family skills as these approaches address a number of
factors key to youth development and substance abuse prevention, are supported by a strong evidence base (that
includes Canadian research), have found to be cost effective, can be adapted to a variety of cultural contexts, and can
potentially serve a broad range of families in a community (CCSA, 2010c).
Family-based programs can be effective in reducing or preventing substance use. Programs that shared an emphasis on
active parental involvement and on developing skills in social competence, self-regulation and parenting were considered
the most effective (Pretrie, 2007). Assessing parenting styles and providing guidance and support to parents is
recommended to increase protective factors among youth (Tuttle, 2002). Family related factors are crucial because they
can increase or decrease the effect of other influences (e.g. peers, media) (CCSA, 2010c). For family protective and risk
factors, refer to table 3.
Parenting programs should be made widely available through media, information lines and worksite and school programs
and should be entrenched in a neighbourhood over the course of a number of years, rather than a “one-off” session
(Health Canada, 2001). Programs should provide support to parents and help them in: clarifying and explaining values to
their children, modeling healthy behaviours, understanding children’s needs and self-concept, communicating effectively
with their children, developing problem-solving skills, providing appropriate reinforcement and consequences, using
behavioural contracts, and fostering a democratic environment in the family (Health Canada, 2001). Parents also need to
acquire accurate information on the various substances of abuse and their side effects, so they can discuss them
knowledgeably with their children (Health Canada, 2001; UN, 2004; Roberts, 2006; Degano, 2007).
It is also important to emphasize to parents, relatives and older siblings that they should be positive role models to youth,
and follow the low risk drinking guidelines (City of Vancouver, 2006; Degano, 2007). Creating a culture of moderation
must begin with adults who fashion the templates for the attitudes and practices of the younger generation (Degano,
2007).
To begin planning for a family-based strategy to delay the onset of alcohol and substance use, prevention practitioners
should refer to the Canadian Guidelines for Family Skills Programs (2010c). These guidelines provide direction to teams
wishing to design their own family skills program, strengthen an existing program or adopt a published program. In this
document, family skills programs are defined as multi-session skills-based programs directed to groups of parents or
families with children 0-18 years, which include in their objectives the prevention of substance abuse among the children
in those families (CCSA, 2010c). These guidelines are best suited to universal and selective populations and are to be led
by trained prevention facilitators who, rather than focus on individual problems, employ strength-based techniques to
encourage personal exploration of shared parenting concerns (e.g. communicating, discipline) (CCSA, 2010c). See the
guidelines for more detail regarding:
1. Build cultural competence into the program
2. Clarify needs, resources, targets and aims
3. Identify theory to guide design, implementation and evaluation
4. Establish a solid organizational and community context for the program
5. Pay attention to facilitator selection, training and support
6. Ensure active recruitment of participants
7. Implement evidence-based programming with fidelity
8. Take steps to retain participants
9. Monitor, evaluate and revise the program accordingly
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Table 4 provides detail about the guidelines for family-based interventions including tips for implementing each guideline.
Table 4: Summary of Canadian Guidelines for Family Skills Programs, Canadian Centre on Substance Abuse, 2010
Guideline
1. Build
cultural
competence
into the
program
2. Clarify
needs,
resources,
targets and
aims
3. Identify
theory to guide
design,
implementation
and evaluation
4. Establish a
solid
organizational
and community
context for the
program
5. Pay
attention to
facilitator
selection,
training and
support
DOCS#909354
Key points
 Activity will be enhanced if the team sees cultural
competence as a priority
 Cultural competence: a set of congruent behaviours,
attitudes and policies that come together in a system,
agency or among professionals, enabling them to
work effectively in cross-cultural situations
 Aim of community assessment is to determine
whether there is need and interest for a family skills
program
 Community assessment can include: focus groups,
interviewing key informants, administering a brief
survey among parents in a neighbourhood,
community or school
 Program aims should be clear: Long-term –
prevention of substance abuse among youth. Short
term could be more specific (i.e. preventing older
youth and health and social problems, promoting
youth development, family well being or social capital
in the community).
 Family skills programs often draw on social learning
theory; it proposes that people learn from one another
in social contexts by observing, imitating and
modelling others.
 Two other theories are used:
a) Adult Learning Theory – adults are most likely
to learn when material is relevant to their lives and
helps them address actual situations or problems
b) Stages of change theory – people go through
several stages when changing behaviour; parents
who are not ready to change may not derive as
much benefit from a family skills program.
 It is preferable that programs find a ‘home’ in a lead
or host organization that is credible and broadly
acceptable to the community and will offer solid
organizational support.
 Addressing to some extent, the interests of different
groups in the partnership is imperative.
 A trusted person from the community or target group
who is a good role model, a parent, and possesses
strong facilitation skills should be effective as a
facilitator
 Relevant university or college preparation in social
work, or adult education is an asset but not essential
 Continuity and relationship development are
important in family skills programs, therefore a
commitment by the facilitator to complete the program
is important
 The task of the facilitator is to recognize the diversity
in the group and instil a ‘group culture’ that works for
everyone
 Facilitator training is important
Tips
Team principles related to cultural competence:
 We are committed to including persons from diverse communities in all aspects of our work
 We honour and respect families and youth of diverse cultures
 We recognize the strengths, skills and resiliency of diverse families and youth
 Best informants are those who work closely with children and families – (e.g. guidance
counsellors, school parent council representatives, social workers, family lawyers, child, family
or youth service workers, police and clergy)
 Knowledge of other community resources to refer parents to appropriate services or resources
can facilitate parent participation in the program
 Communicating the general aim of the program will help parents understand what they can
expect
 It’s important that programmers have a reasonable understanding of the theories they choose
to employ and evaluate their particular use of the theories


A context in which community partners work with youth and their parents in a collaboration is
ideal
Develop programs that cut across issue areas and address multiple goals and outcomes
concurrently
Facilitator training may include:
 Reliable, updated knowledge of child development, family systems, family stress and
substance abuse-related protective and risk factors
 Adult education, group facilitation methods, strength-based communication
 Theory base or concepts underlying the program
 Ethics, confidentiality and practice addressing sensitive situations
 Information on effective methods of recruiting and retaining families
 Availability of written and video resources and of other services in the community.
Important forms of organizational support:
 Enough time for preparation
 Maintaining an inventory of community resources for the facilitator’s use with families
 Ongoing training to keep knowledge up to date and to hone facilitation skills
 Help in identifying indicators and collecting monitoring data
 Regular updating of manuals and program materials based on evaluations
16
6. Ensure
active
recruitment of
participants
 Once recruited, most parents attend most sessions,
but typically few are enticed to the opening session
 Provide parents with a variety of options in how they
participate in the program
 Parents may be more ready to participate at
important transition points for their children
(starting/switching schools, moving, family changes)
 Be aware that some parents may otherwise be
interested but may be overwhelmed by other more
pressing concerns (job seeking, childcare, housing,
food, legal issues, family health issues – so an
understanding of other family support resources in
the community will allow recruiters to suggest
appropriate resources or referrals.
7. Implement
evidencebased
programming
with fidelity
 Teams can be more confident of positive outcomes
when they adopt or adapt an evidence-based
program compared to designing their own from
scratch
8. Take steps
to retain
participants
 To promote ongoing attendance and relevant
learning, it is important to give high attention to
implementation issues, which means preparing and
implementing an evidence-based program that
emphasizes:
 Empowerment: people respond more positively
and become more engaged, when they are
approached on the basis of their strengths
instead of their deficits
 Relationships
 Commitment to diversity and cultural
competency
 Learning
9. Monitor,
evaluate and
revise the
program
accordingly
 It is important to confirm that family skills programs
are effective in various Canadian cultural and
community contexts. Regardless of whether they
have been adapted, adopted or started from scratch,
these programs can benefit greatly from evaluation.
DOCS#909354
Ways to address barriers and increase participation:
 Promote in health care facilities, at schools, on community bulletin boards, religious/faith
meetings, on service organization websites, at sports and other recreational venues and
worksites
 Use social media to promote the program
 Provide detailed information on what can be expected, highlighting the evidence in support of
these programs
 Present program as being universally relevant rather than for ‘failing’ parents (e.g. ‘we’ve all
made mistakes, but we all possess strengths as parents”)
 Incorporate substance use related aims into a program aiming to address broader youth
development aims to stimulate great interest (e.g. better academic performance for your child)
 Present the program as fun, relaxing and informal
 If there is an insufficient number of parents to conduct a program, explore alternatives (e.g.
connect through videoconferencing)
 Use personal approach to build rapport and motivation
 Plan the program around other regular meetings that occur in a community such as faith
meetings or parent-teacher meetings
 Minimize the time between enrolment and the first session
 Offer multiple incentives such as help with transportation, food, refreshments or childcare, or
combining the program with a literacy component
 Use a location that is familiar, non-threatening and convenient for participants (minimal travel
time, public transport)
 Strive for flexible scheduling and convenient times
 Minimize initial time commitments by organizing ‘taster’ sessions (i.e. a drop-in information
session or one-time workshop)
 Emphasize opportunities for parent-to-parent peer support and interaction
 Target existing groups who share common experiences (e.g. parents of a music program or
minor sports team)
 Phone calls, emails or social networking tools can provide an opportunity to answer questions,
clarify expectations and bolster attendance
 An interactive, family-centred approach (rather than expert/professional delivered) works best.
Engage and empower parents through participatory techniques.
 Building opportunities for informal social interaction into the program can strengthen social
support among participants.
 Length of program varies for prevention type:
 Universal prevention: 4-8 sessions most effective
 Selective prevention: 10-15 sessions most effective
 Many tips to retain participants are similar to those used to recruit
 Involve participants in setting goals for the program to immediately build a sense of ownership
 Emphasizing partnership (i.e. doing things with parents rather than to them)
 Making concerted efforts to fine-tune parents’ own ideas rather than emphasize program’s
ideas
 Encouraging reciprocity in giving and receiving help
 Ensure participant input or feedback is incorporated in a transparent manner
 Once the basic elements of the program have been presented, moving towards collaborative
problem solving and inviting parents to apply newly learned knowledge and skills
 Providing recognition or awards for completion of the program
 Start with ‘safe’ or relatively easy activities that allow participants to warm up to one another
and experience the group as friendly and trustworthy
 Practice active listening and non-judgemental/empathic approaches
 Ensure confidentiality and privacy
 Clarify and facilitate appropriate sharing of personal experiences
 Encourage creation of informal support networks within the group
 Incorporate a family meal into each program session, allowing families to spend relaxed time
together, including supportive extended family
 Minimize staff turnover
 Use facilitators who will be perceived to be similar to the group (e.g. sex, ethnicity)
 Culturally adapting programs
 Program documentation – to ensure program is delivered consistently and understand which
components are contributing to positive outcomes.
 Logic model – helpful to show the program’s logic and build documentation for the program
(creating indicators to measure process and outcomes)
 Program monitoring – during the program, to determine if the program is delivered as planned,
allows for timely modifications to the program as needed
 Process evaluation – conducted after the program, to assess the quality of implementation –
helpful for delivering future sessions.
 Outcome evaluation – conducted after the program – to determine the impact of the program
on desired outcomes or indicators
 Cost-effectiveness – to weigh the costs of the program with its benefits, to determine worth
and efficient use of resources
17
22.
Intervention Focus: Community
As previously discussed, comprehensive community approaches are more promising than the single preventative
strategies, and thus require the participation from various sectors of the community (CAMH, 1999). A systematic review
suggests that the scope of alcohol prevention should include the community more broadly rather than simply focusing on
established relationships within the school environment (Wood, 2006). Broader community components, such as media,
community services and alcohol retailers appear promising in increasing the impact of school-based interventions (Wood,
2006). Coordination and cooperation among community agencies can lead to the development of important prevention
efforts for youth at risk (City of Vancouver, 2007).
A review recommends applying community participatory models for intervention development related to alcohol
prevention in order to increase public health impact (Spoth, 2008). A reasonable fit is necessary between a community’s
level of readiness and the type of prevention initiative implemented; otherwise the initiative will not be supported by the
community (CCSA, 2010b). Community readiness to support an initiative is best nurtured by ongoing communication and
engagement with the community throughout the duration of the initiative (CCSA, 2010b). Several strategies can be used
to build partnerships and community capacity to deliver an alcohol prevention strategy for youth. First, it is important to
ensure sufficient knowledge and skills of decision-makers, health service providers, the general public and other
stakeholders so they can effectively act to prevent and respond to alcohol-related harms (Department of Health
Promotion and Protection, 2007). Further, it is important to provide clear, accessible, multi-lingual information to the
community about existing substance use programs and services (City of Toronto, 2005). For example, a team could
develop a new or promote an existing evidence-based, practical alcohol prevention tool kit for use by community leaders,
health professionals, prevention specialists, stakeholders (Department of Health Promotion and Protection, 2007).
Another way to build community capacity is to hold an annual alcohol forum to focus on best practices, related
knowledge development, and skill building consistent with preventing and reducing alcohol-related harm (Department of
Health Promotion and Protection, 2007). Professionals also enjoy regular opportunities to share experiences related to
preventing and reducing alcohol-related harm among colleagues (Department of Health Promotion and Protection, 2007).
Mass media and social marketing strategies are the more common community-wide interventions for prevention.
Parents, youth and other adults identify mass media and advertising to promote certain behaviours as being primary
reasons for adolescent use of alcohol, tobacco and other drugs (Williams, 1998). Mass media (print, radio, TV, billboard,
magazine, and internet), combined with other strategies can be effective in increasing knowledge and awareness, and has
shown modest success in affecting attitudes and behaviours (Ripley, 2006). It is easier to implement mass media
strategies with universal substance prevention aims (targeting general populations) rather than with selective or indicated
prevention (i.e. targeted prevention and harm reduction) (Ripley, 2006). Mass media campaigns can help to set the
agenda for public discussion and assist with shaping cultural norms (e.g. making drinking and driving socially
unacceptable) (CAMH, 1999). Social marketing campaigns utilizing mass media can be used to reinforce other substance
prevention messages, and have the potential to encourage less harmful behaviours, and influence attitudes and norms
(CARBC, 2005). Programmers should use social marketing principles to develop and implement a substance prevention
strategy for youth, and establish appropriate links with relevant communications and social marketing initiatives
(national, provincial, regional) where possible (Department of Health Promotion and Protection, 2007). Social marketing
can be used to promote the low risk drinking guidelines, generate knowledge about the risks associated with substance
misuse and increase awareness of the injuries associated with misuse. Lastly, it is important that social marketing and
mass media messages need to be coordinated within a community to ensure correct and consistent messaging is being
delivered.
To begin planning for a community-based strategy to delay the onset of substance use, prevention practitioners should
refer to the Canadian Standards for Community-based Youth Substance Abuse Prevention (2010b). These standards
outline guidelines and best practices in each of the various phases of an intervention. See the Canadian Standards for
Community-based Prevention resource for additional detail on the following 17 guidelines (organized by phases):
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A. Assess the situation
1. Determine youth substance use patterns and associated harms
2. Learn factors linked to local youth substance use problems
3. Assess current activities, resources and capacity to act
B. Organize the team and build capacity
4. Engage youth partners in the initiative
5. Develop organizational structure and processes
6. Build and maintain team capacity
7. Clarify member’s perceptions and expectations
C. Plan a logical and sustainable initiative
8. Ensure plan addresses priority concerns and factors, and current capacity
9. Develop logic model showing how initiative will bring desired change
10. Plan for sustainability of the initiative
D. Coordinate and implement evidence-based activities
11. Promote quality of existing and planned initiatives
12. Strengthen coordination among local initiatives
13. Give attention to community policies and processes
14. Monitor the initiative
E. Evaluate and revise initiative accordingly
15. Conduct a process evaluation of the initiative
16. Conduct an outcome evaluation of the initiative
17. Account for costs associated with the initiative
18. Revise initiative based on evaluations
23.
Intervention Focus: Policy
Policy approaches have been shown to be effective in reducing problems related to substance use, particularly when
combined with other educational and community approaches (CAMH, 1999). Various strategies related to policy can be
implemented by public health practitioners to delay the onset of substance use among youth. Public health can work
with schools, workplaces and municipalities to create supportive policies to prevent substance misuse. Public health
practitioners can also play a role in policy advocacy by lobbying for changes to governmental policies.
Schools cannot solve the problem of early alcohol and substance use alone, but a uniform policy on substance use and
possession on school property is an important component of a comprehensive prevention strategy for youth (CAMH,
1999). A substance use policy provides an opportunity for a school to bring together its values, goals and activities (CCSA,
2010a). Such a policy can contribute to positive school norms (CCSA, 2010a). They are most effective when linked to
schools academic and health aims, when students participate in developing the policy, and when the policy is well
communicated (CCSA, 2010a). Punitive school policies (e.g. “zero tolerance”) are not effective in preventing or curbing
substance use since imposing sanctions for use may further alienate those students already at risk, and discourage those
who are experimenting, or at risk, from seeking help (CAMH, 1999). Public Health practitioners can collaborate with
school boards to develop and recommend evidence-based school alcohol/substance policies.
In addition to working with schools, public health practitioners can also partner with local workplaces to create healthy
alcohol/substance policies. The workplace is a major location that captures many people in the heavier drinking groups
(NHS, 2002). Promoting and supporting the inclusion of alcohol policies as part of comprehensive occupational health
and wellness programs would help to establish societal norms about the proper use of alcohol and can be a subsequent
influence on delaying the onset of substance use among youth.
Various legislative polices can impact the early onset of substance use among youth. It is suggested that substance
prevention practitioners recommend, monitor, and support substance-related policies that reflect a balance among the
interests of health protection and harm prevention, the health benefits of moderation, and the costs and benefits to the
economy (ASATG, 2007). Specifically, practitioners can recommend and advocate for evidence-based policies that will
reduce the opportunities for minors to access alcohol (ASATG, 2007). Examples of such policies can include:
o Increasing enforcement with retailer compliance (Degano, 2007; CARBC, 2006; CAMH, 1999);
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o
o
o
o
Banning and monitoring alcohol promotion to youth (this has been successful in the field of
tobacco control) (Degano, 2007; CAMH, 1999);
Increasing the price or taxes of alcohol (Degano, 2007; CAMH, 1999);
Increasing the minimum drinking age (CAMH, 1999); and
Imposing restrictions for young or new drivers (CAMH, 1999).
Finally, as the factors related to alcohol and substance use are complex, public health practitioners should create
opportunities to address the broad social determinants. Examples of such opportunities can include, but are not limited
to: Improving access to education and employment and addressing income inequalities; implementing policies and
services that improve access to psychosocial supports such as parenting support, crisis intervention and grief counselling;
and giving special attention to deprived neighbourhoods, communities and regions when implementing interventions
(CARBC, 2006).
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