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Underage Drinking

Philippe De Witte
Mack C. Mitchell Jr.

Chapter 3. Prevention of Alcohol Use and Misuse in Youth: A Comparison of North American and European Approaches

Sherry H. Stewart, Patricia J. Conrod, Antti Latvala, Reinout W. Wiers et Helene R. White

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1The current chapter provides a review of the different prevention approaches targeting alcohol use in young people. A number of systematic reviews on this issue are available, particularly through the Cochrane Review library (see Foxcroft & Tsertsvadze, 2011a-c). What these former reviews do not offer is a comparison across the different types of approaches to alcohol prevention. Therefore, we review the theoretical bases of the different approaches to alcohol prevention, and we describe some programmes with the strongest evidence-base and review their efficacy to facilitate comparisons of the evidence across approaches. In reviewing specific programmes, our intent is to be representative rather than comprehensive. Furthermore, special attention is dedicated to the cultural context in which a particular programme or approach has been evaluated to provide policy makers with recommendations on how alcohol prevention might be implemented in new cultural contexts.


2• The goals of alcohol prevention programmes often vary according to cultural context. While most U.S.-based programmes have abstinence as their primary goal, most European programmes include reductions in alcohol use as a viable outcome.

3• Delivering alcohol prevention in the school context captures a larger percentage of youth and yields the most consistent effects, relative to programme delivery within the community or family context. The most effective universal school-based programmes are comprehensive, concurrently addressing normative attitudes about drinking, and teaching generic and alcohol refusal skills.

4• The most effective family-based programmes for preventing or reducing alcohol use in young people emphasise active parental involvement and work to develop parenting skills to enhance competence and self-regulation in children. Family-based programmes have small effects, but their effects are generally consistent and lasting.

5• Selective interventions targeted towards at-risk groups (e.g., high personality risk for alcohol use disorders) have been shown to be effective in reducing alcohol use in young people. Such programmes can also delay drinking onset if introduced in early adolescence prior to the onset of alcohol use.

6• Personalized feedback interventions are designed to correct misperceptions about drinking norms in college and high school students. Such programmes are indicated as a strategy for reducing drinking in those whom have already started drinking, especially those who drink more heavily.

7Adolescence and young adulthood is a critical period of social and emotional development (Spooner, Mattick, & Noffs, 1996), a time when young people move toward independence and autonomy and decrease dependence on families and schools. For these reasons, this developmental period is also the time when acceptance by peers becomes more important and when risk-taking behaviour is high. It is also a period when individual differences in risk for psychopathology begin to manifest themselves in substance misuse and other psychiatric symptoms. If left untreated, adolescent-onset disorders can become chronic and can cause severe disability (Andrews, Henderson, & Hall, 2001). It is therefore important that prevention programmes be implemented prior to onset of psychiatric symptoms and before social and emotional influences come into full effect. Furthermore, such programmes should be introduced before initial exposure to alcohol, to reduce the adverse impacts of alcohol use on the developing brain. Implementing alcohol prevention programmes early will ensure young people are provided with the knowledge and skills they need to make responsible and informed decisions about drinking (Dielman, 1995) and programmes that can effectively delay onset of drinking, particularly heavy drinking, will ensure that alcohol is not interfering with this critical period of social, cognitive, and neural development.

8Alcohol prevention can be delivered in the school, to the family, and/or in the community. Prevention programmes can be universal (offered to all members of the population), selective (offered to only those who are at high-risk for the disorder), or indicated (offered only to those who already show signs of the disorder); the latter two types are often collectively referred to as targeted approaches. Approaches to alcohol prevention can vary widely based on the desired end goal of the intervention whether it be abstinence, reduction in drinking quantity, reduced alcohol-related problems, or delayed onset. Desired outcomes may vary across cultural contexts. For example, while most U.S.-based prevention programmes have abstinence as the primary goal, European prevention trials typically are more tolerant and include reductions in alcohol use as a viable treatment outcome. We organise our chapter around the location in which the intervention is delivered (e.g., school-based context), but consider whether the intervention described is universal, selective, or indicated, and what type(s) of alcohol-related outcomes are used to assess efficacy.


9School-based alcohol prevention programmes offer numerous advantages over other prevention approaches because attending school is a mandatory requirement in most Western countries and is where young people spend over a quarter of their waking lives (Cuijpers, 2002). Schools offer a location where educators are able to reach large audiences at one time, keeping costs low and retention relatively high (Botvin, 1999; Botvin, 2000; Cuijpers, 2003; Gottfredson, Gottfredson, & Skroban, 1996; Jones, Sumnall, Burrell, McVeigh, & Bellis, 2006; Shin, 2001; Wenter et al., 2002).

10School is also where youth experience most peer interaction and influence, which can both positively and negatively influence alcohol-related behaviours and attitudes. It is primarily in the school-age years when drinking behaviours have their onset (Botvin & Griffin, 2003; Sharma, 2006). Alcohol prevention programmes can be easily implemented in the school context (Berkowitz & Begun, 2003) and school research suggests that it is best to deliver prevention in sequential and developmentally-appropriate stages (Ballard, Gillespie, & Irwin, 1994; Dusenbury & Falco, 1995; Meyer & Cahill, 2004). School-based alcohol and drug prevention programmes have been shown to be appealing both to students and educators over and above other types of prevention delivery (Lisnov, Harding, Safer, & Kavanagh, 1998). Other practical and economic advantages to delivering prevention in schools include: being able to capture large numbers of youth at one time, availability of educational resources, and that programmes can be easily tailored and delivered to different development stages (McBride, 2003).

11Universal prevention addresses the entire population within a particular setting, regardless of their level of risk for alcohol use and aims to delay the onset of alcohol use by equipping individuals with the information and skills that they need to prevent use. In schools, universal programmes focus largely on teaching awareness education (knowledge and harms), normative education, social and drink-refusal skills, and promoting pro-social peer relationships. Universal programmes offer the advantage of being delivered on a large scale and, as such, they have the potential ability to reduce alcohol use and related harms to a greater audience (Jones et al., 2006; Midford, 2008). Importantly, they avoid the risk of stigmatising individuals, given the sensitive nature of alcohol use disorders and risk (Offord, 2000).

12A recent review of school-based universal prevention has identified some effective programmes (Foxcroft & Tsertsvadze, 2011a). Many effective programmes of this type incorporate a social influence or skill development approach to prevention.


13The ‘social influence approach’ to prevention was developed in the 1980s and is based on Bandura’s (1977) social learning theory and McGuire’s (1964, 1968) social inoculation theory. The approach is based on the assumption that young people start to use alcohol as a result of social and psychological pressure from peers, family, and the media (Donaldson et al., 1996). The goal of social influence programmes is to teach young people to avoid using alcohol by resisting external pressure and increasing alcohol-related coping skills (Botvin, 2000). The social influence approach emphasizes three major components: information, normative education, and resistance-skills training (Botvin, 2000). The emphasis in the information component is to highlight short-term rather than long-term consequences of alcohol use since the short-term corresponds to the typical thinking style of young people (Berkowitz & Begun, 2003). The component of normative education is based on findings that heavy drinking adolescents generally overestimate the prevalence of alcohol and other substance use in peers (Perkins, 2007). Therefore, one main component is to correct perceptions by providing students with the most current and accurate data, usually from large and relevant population-based surveys. This approach has been shown to change students’ beliefs about the prevalence and attitudes about acceptability of alcohol use by young people, and delay the onset of alcohol use (Botvin, 2000; Botvin & Griffin, 2007; Cuijpers, 2003; Cuijpers, Jonkers, Weerdt, & Jong, 2002; Hansen & Graham, 1991b; Moskowitz, 1989).

14The social influence approach also addresses the findings on how pro-alcohol social influences from peers and the media also influence youth drinking by teaching alcohol resistance skills. This generally involves teaching students how to recognise, handle or avoid high-risk situations, increasing students’ awareness of media influences, and training them in drink refusal skills. The inclusion of resistance skills training in school-based prevention has been associated with enhanced effectiveness (e.g., Botvin, 2000). However, in the absence of normative education, resistance skills training has been found to be relatively ineffective and potentially iatrogenic (Hansen et al., 1991b), possibly because the social normative component is necessary to motivate students to utilise peer-resistance strategies.

15Until recently the most well-documented, school-based alcohol and other drug prevention programme based on the social influence approach was the Drug Abuse Resistance Education (DARE) programme. The DARE programme is typically taught in the fifth grade (10 years of age). What distinguishes the programme from others is that it is taught by police officers. Although some early studies found the programme to impact positively on alcohol and drug-related attitudes, knowledge and behaviour, these studies have since been criticised for their weak or inadequate research methods (Rosenbaum & Hanson, 1998). More recently, studies with stronger designs and analytic methods have shown the DARE programme to have minimal or no impact on reducing alcohol and drug use (Birkeland, Murphy-Graham, & Weiss, 2005; Ennett, Rosenbaum, Flewelling, & Bieler, 1994; Rosenbaum, Flewelling, Bailey, Ringwalt, & Wilkinson, 1994; Rosenbaum & Hanson, 1998). The ineffectiveness of the DARE programme has been suggested to result from the instructional, non-interactive method of delivery by authority figures (Tobler & Stratton, 1997; White & Pitts, 1998).

16Aside from the DARE programme, a considerable number of studies have examined the efficacy of other social influence programmes in preventing alcohol use when delivered by other members of the community, including teachers. When delivered in this way, the social influence approach has been found to be effective in not only increasing knowledge and attitudes towards alcohol, but importantly in reducing the use of alcohol as reviewed in the evidence section below (e.g., Botvin, Griffin, Paul, & Macaulay, 2003; Cuijpers, 2003; Cuijpers et al., 2002; Faggiano et al., 2008; Hansen, 1992; Midford, 2000; Perry & Kelder, 1992; Roona, Streke, Ochshorn, Marshall, & Palmer, 2000; Shope, Copeland, Marcoux, & Kamp, 1996; Soole, Mazerolle, & Rombouts, 2005; Tobler, Lessard, Marshall, Ochshorn, & Roona, 1999; Tobler et al., 2000).


17Social influence programmes generally assume that young people use alcohol as a result of peer influence and a lack of drink refusal skills. However, they fail to take into account other factors which can influence alcohol use such as dealing with low self-esteem, depression, or anxiety. Comprehensive programmes were designed to take such etiological risk factors into account. This approach is also known as the competence enhancement approach to prevention (Botvin, 1999; Botvin et al., 2003), but differs from selective or indicated programmes by promoting generic skills in the general population. Selective programmes, by contrast, promote specific skills in youth identified as lacking these specific skills and/or requiring specific learning conditions.

18The comprehensive approach is based on Bandura’s (1977) social learning theory and Jessor’s (1977) problem behaviour theory. The approach conceptualises alcohol misuse as a socially learned behaviour that results from the interplay of a variety of social factors (such as modelling and imitation) which influence personal factors (such as beliefs, attitudes, and pro-alcohol cognitions) (Botvin, 2000). Teaching general personal and social skills in the absence of other components of the social influence approach such as drink refusal skills training and normative education has only been found to have a minimal impact on alcohol use (Caplan et al., 1992). However, when elements of the social influence approach are included into the model, effects appear to be more robust (Botvin, 2000). Another essential ingredient of the comprehensive approach to prevention is an interactive delivery style which generally involves class discussions, instruction and demonstration, group feedback and reinforcement, role-plays, and practice (Botvin et al., 2003).


19In a recent Cochrane review of universal alcohol prevention programmes, Foxcroft and Tsertsvadze (2011a) identified 11 alcohol-specific prevention programmes that involved a rigorous randomised controlled trial. Of these, five trials showed no significant differences between their experimental and control groups (Duryea, 1984; Goodstadt & Sheppard, 1983; Newman, Anderson, & Farrell, 1992; Sheehan, Schonfeld, Ballard, & Schofield, 1996; Williams, DiCicco, & Unterberger, 1968) and in the other six trials some significant differences between groups were reported (Dielman, Shope, Butchart, & Campanelli, 1986; McBride, Midford, Farringdon, & Phillips, 2000; Morgenstern, Wiborg, Isensee, & Hanewinkel, 2009; Perry & Grant, 1988; Vogl et al., 2009; Wilhelmsen & Laberg, 1994). These six trials were conducted with children across the world, all living in developed countries, such as Germany, Norway, Switzerland, Australia, and Chile. The programmes all involved in-class alcohol education and drink refusal skills training ranging in duration from four to ten+ sessions. Results showed significant reductions in drinking and binge drinking in intervention groups and effects were observed up to 12 months post-intervention. However, in two of these six trials, effects were limited to subgroups such as girls or those who were not drinkers at baseline. And, as with all systematic reviews, there is the potential lack of inclusion of ‘file drawer’ results (i.e., negative findings that are simply never published and thus not accessible to the reviewers).

20Alcohol non-specific prevention programmes addressing all substance use outcomes were also evaluated by Foxcroft and Tsertsvadze (2011a) for their effects on youth drinking behaviour. Twenty-four trials showed no significant differences between their experimental and control groups (Allison, Silverman, & Dignam, 1990; Beaulieu & Jason, 1988; Bond et al., 2004; Botvin et al., 2003; Brewer, 1991; Clayton, Cattarello, & Walden, 1991; D’Amico & Fromme, 2002; Durrant, 1986; Ellickson & Bell, 1990; Furr-Holden, Ialango, Anthony, Petras, & Kellam, 2004; Goldberg et al., 2000; Hansen, Johnson, Flay, Graham, & Sobel, 1988; Hansen & Graham, 1991a; Johnson, Shamblen, Ogilvie, Collins, & Saylor, 2009; Koning et al., 2009; Moskowitz, Malvin, Schaeffer, & Schaps, 1984; Perry et al., 2003; Ringwalt, Ennett, & Holt, 1991; Ringwalt, Clark, Hanley, Shamblen, & Flewelling, 2009; Spoth, Redmond, Trudeau, & Shin, 2002; St. Pierre, Osgood, Mincemoyer, Kaltreider, & Kauh, 2005; Sun, Dent, Sussman, & Rohrbach, 2008; Werch, Moore, & DiClemente, 2008; Werch et al., 2010) and 14 trials showed significantly greater reduction in alcohol use when comparing intervention and control groups (Botvin, Baker, Renick, Filazzola, & Botvin, 1984; Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995; Botvin, Griffin, Diaz, & Ifill-Williams, 2001; Caplan et al., 1992; Cook, Lawrence, Morse, & Roehl, 1984; Eisen, Zellman, Massett, & Murray, 2002; Ellickson, McCaffrey, Gosh-Dastidar, & Longshore, 2003; Faggiano, Richardson, Bohrn, & Galanti, EU-Dap Study Group, 2007; Griffin, Holliday, Frazier, & Braithwaite, 2009; Hecht et al., 2003; Kellam et al., 2008; Scaggs, 1985; Schinke, Tepavac, & Cole, 2000; van Lier, Huizink, & Crijnen, 2009). Two studies showed comprehensive programmes to be effective over the medium-long term (Botvin et al., 1995; Scaggs, 1985) and three studies showed this approach to be effective over the longer term (i.e., over three years; Botvin et al., 1995; Schinke et al., 2000; Spoth, Redmond, & Shin, 2001). Most of these studies, with the exception of the European Unplugged programme, were conducted in the U.S.

21The most popular and most well-evaluated of the comprehensive programmes is the Life Skills Training (LST) model developed by Botvin (1998). The LST was identified in the Foxcroft and Tsertsvadze (2011a) Cochrane Review as having the strongest evidence-base of the comprehensive programmes. This programme emphasises personal and social risks that underpin lifestyle and health behaviours and aims to teach students ways to avoid these risks. This is done by teaching decision making and problem-solving skills, assertiveness training, skills to resist peer and media influences, techniques to communicate effectively and develop healthy personal relationships, ways to enhance one’s self-esteem, and ways to manage stress and anxiety (Botvin, 2000). Various formats of the LST programme have been developed and evaluated, but the most common format consists of 15 lessons in year seven, and ten booster sessions over years eight and nine. Numerous studies testing the efficacy of the LST competence enhancement approach on alcohol use have found the programme to significantly reduce drinking behaviours (e.g., Botvin, 1998; Botvin, Baker, Dusenbury, Tortu, & Botvin, 1990; Botvin et al., 2001; Botvin & Kantor, 2000; Eisen, Zellman, & Murray, 2003; Faggiano et al., 2008; Soole et al., 2005). First tested in primarily white middle class communities in the U.S., the programme was shown to have consistently significant effects. However, these effects were small, accounting for only 10% of the variance in drinking outcomes (e.g., Botvin et al., 1995). More recently, the programme has been evaluated in minority populations, inner-city minority populations, and high-risk youth (i.e., those reporting high-risk characteristics at baseline, such as having peers who have initiated use or low academic achievement). These studies all indicate that the LST programme can be modified to different cultural contexts and is effective, and possibly more effective when delivered to high-risk youth. One study by Botvin et al. (2001) reported over 50% fewer binge drinkers in the intervention group at follow-up relative to the control group when the study sample consisted primarily of inner-city African-American youth. There is also evidence that the LST programme is slightly more effective when it is adapted to the cultural context in which it is delivered (e.g., Botvin et al., 1995) and when delivered in higher risk populations (e.g., Griffin, Botvin, Nichols, & Doyle, 2003).

22Another important test of the reliability of an intervention effect is when a programme is evaluated by a research team that is independent of the original evaluator (as programme evaluator has been shown to have significant effects on treatment outcome studies). Spoth et al. (2002) evaluated the LST programme against a combined condition that included both LST and a family-based programme or a control condition. Drug initiation outcomes (alcohol, tobacco, and cannabis) were evaluated one year after cluster-randomization in a sample of rural Midwestern American high school students. The LST intervention was found to be effective on a substance initiation index (combining all substances). However, when alcohol initiation was evaluated separately, LST was not shown to significantly prevent onset of drinking in adolescents. Effects of the LST intervention on binge drinking or drunkenness were not reported in this study. The evidence in favour of the LST programme has also been criticised by Gorman (2002) who highlighted problems with the sampling methodology of the most prominent LST effectiveness study. Botvin and colleagues (2000) reported a six-year follow up of a randomised controlled trial of the LST programme but restricted the analysis to only a small subset, namely 7.5% of participants in the study, thus violating the fundamental principles of intent-to-treat analyses (Gorman, 2002). Hence, the longterm effectiveness of the LST programme may be less conclusive than originally thought and caution should be used when making inferences about the robustness of such programmes in producing long-term effects on alcohol and other substance-related behaviour. In addition, a large study in the U.S. was conducted recently to evaluate the effectiveness of the Take Charge of Your Life (TCYL) programme, a comprehensive universal programme delivered by trained police facilitators of the DARE programme. Results from this study found an overall negative effect of the TCYL programme, with intervention students reporting an increase in their use of alcohol and cigarette use, and no differences between groups reported for cannabis use (Sloboda et al., 2009). The authors are actively studying the effect of the intervention on mediators and modifiers in order to explain the reason for these disappointing findings; however, it appears that the more reasonable explanation is that the providers of the intervention were law enforcement officers, and that this could have reduced the possible effect of intervention among at-risk students.

23More recent evidence for the comprehensive approach comes from the European ‘Unplugged’ Programme, a school-based curriculum against youth alcohol and other substance use which includes components such as normative education and resistance skills (Van Der Kreeft et al., 2009). The programme was packaged into standardised materials and adapted for seven European countries (Belgium, Germany, Spain, Greece, Italy, Austria, and Sweden) and it was evaluated within the frame of the European Drug Addiction Prevention (EU-Dap) study, a randomised controlled community trial, conducted between September 2004 and May 2006. The first follow-up was conducted three months after the end of the delivery and showed that the programme was associated with a reduction of episodes of drunkenness, but not drinking problems, or drinking frequency or quantity (Faggiano et al., 2008). At the 18-month follow-up, the effect on drunkenness survived statistical tests (Faggiano et al., 2010): the intervention was associated with a 20% reduced prevalence of any drunkenness (prevalence odds ratio=0.80) and a 38% reduced prevalence of frequent drunkenness (prevalence odds ratio=0.62). Relative reduction rates for alcohol initiation and weekly drinking were not significant (Faggiano, 2009). This programme has subsequently been shown to be ineffective for students attending schools classified as having medium or high socio-economic status, and more effective for those attending schools classified as having low socioeconomic status. Once this important moderator is considered, this programme was shown to have significant effects on any drinking, weekly drinking, and problem drinking symptoms (Caria, Faggiano, Bellocco, & Galanti, 2011). Finally, another moderator analysis revealed that this programme was more effective in preventing onset of binge drinking in boys, but that the programme was equally effective in preventing progression to regular drunkenness in boys and girls (Vigna-Taglianti et al., 2009). However, it is unclear if this finding is a reflection of how girls drink (progressing more quickly to heavy drinking; see Stewart, Gavric, & Collins, 2009) or of gender-specific effects of the intervention.

24Another European-based trial of the effectiveness of the LST programme was conducted by Morgenstern et al. (2009). They reported that the intervention significantly reduced risk of lifetime binge drinking at 4 month and 12 month follow-ups with an adjusted odds ratio of 0.56 at four months, suggesting a 44% reduction in binge drinking prevalence, and 0.74 at 12 months, suggesting a 36% reduction in binge drinking prevalence.

25In summary, the comprehensive approach, particularly the LST programme, can be culturally adapted for new contexts and produces reliable effects on binge drinking, but limited effects on drinking initiation or frequency of drinking. Overall effects on drinking behaviours are small (10%-30% relative reductions), with little support for the effects on drinking initiation, drinking frequency, or drinking problems and stronger support for effects on drunkenness or binge drinking. Furthermore, these reductions have been shown to last up to three years. The programme appears to be effective for both minority populations and majority populations, in both the U.S. and European contexts, and for both girls and boys. There is some evidence suggesting that the more at-risk the population, the greater the effects of the programme (e.g., Botvin et al., 2001; Caria et al., 2011). Another feature identified but not systematically tested as a potential moderator of programme efficacy is the extent of the intervention deliverer’s affiliation with law-enforcement (Sloboda et al., 2009).


26Like drink refusal skills training, peer-led interventions are based on the idea that altering peer influences can have beneficial effects (Velleman, 2009). In the peer-led intervention context, peers are trained to become educators and attitude-formation leaders. The rationale is that peers have the power to influence one another’s attitudes and behaviour if given the information and skills to do so. Moreover, people of the same age feel freer to talk to one another. There is some evidence that peer-led interventions do not always work, however. For example, one study showed no effects of a peer support programme on adolescents’ knowledge, attitudes, or use of alcohol (Webster, Hunter, & Keats, 2002). Interestingly, some research suggests that peer-led interventions may work more for those delivering rather than those receiving the intervention (Sumnall et al., 2006). One study demonstrated the possibility of interactions between peer education and the makeup of the peer network (Valente et al., 2007). Specifically, deleterious effects of the peer-led interventions were found among those with peer networks that support alcohol and drug use.


27Considering the large literature on childhood risk factors for early onset drinking and problems with alcohol (reviewed in Chapter 2), and the results reviewed above showing possible beneficial effects of universal programmes in higher-risk populations, there is an argument for developing and delivering prevention programmes that target specific populations. Selective interventions have the advantage of allowing the focus of limited resources to be used on those most at need. They also address individual needs of homogeneous at-risk groups and offer an opportunity to tailor interventions to the etiological processes implicated in different risk profiles (Conrod, Castellanos-Ryan, & Strang, 2010; Conrod, Mackie, & Castellanos, 2008; Conrod, Stewart, Comeau, & Maclean, 2006; Thush et al., 2007). Selective prevention programmes are often overlooked due to their practical limitations. It is not only difficult to initially identify those individuals at greatest risk, but finding suitable, cost-effective ways to screen and deliver interventions can also be challenging (Offord, 2000). However, in recent years we have seen the development of selective programmes which are showing that these ethical and practical obstacles can be overcome.

28One such approach, known as the Personality-Targeted Approach, is a brief, selective programme that presents a novel approach to alcohol and other substance misuse prevention by targeting personality risk factors for early-onset drinking or illicit drug use. It is the first and only school-based alcohol and drug prevention programme that has been shown to prevent growth in alcohol and substance misuse in three separate trials across Canada (Conrod et al., 2006) and the United Kingdom (Conrod et al., 2010; Conrod et al., 2008; Conrod et al., in press; O’Leary-Barrett, Mackie, Castellanos-Ryan, Al-Khudhairy, & Conrod, 2010), through targeting youth with elevated scores on four personality risk factors for early-onset alcohol/drug misuse and other risky behaviours: Hopelessness, Anxiety Sensitivity, Impulsivity, and Sensation-Seeking (Battista, Pencer, McGonnell, Durdle, & Stewart, in press; Krank et al., 2011; Woicik, Stewart, Pihl, & Conrod, 2009). Youth are screened in classroom settings during school hours, and those scoring one standard deviation above the school mean on one of these four personality traits, as measured using the Substance Use Risk Profile Scale (Battista et al., in press; Krank et al., 2011; Woicik et al., 2009), are invited to participate in coping skills workshops. Each of the four personality-specific interventions involve adolescents selected for particular personality profiles to work together over two 90-minute group sessions guided by a trained facilitator and co-facilitator at school. The interventions are manualised and incorporate psycho-educational, motivational enhancement, and cognitive-behavioural components, and include real life ‘scenarios’ shared by high-risk youth in specifically-organised focus groups. A novel component to this intervention approach is that all exercises discuss thoughts, emotions, and behaviours in a personality-specific way.

29Three separate randomised-controlled trials have shown that this intervention approach is associated with reduced drinking, binge drinking, and problem drinking symptoms in high-risk youth over six months (Conrod et al., 2010; Conrod et al., 2008; Conrod et al., 2006; O’Leary-Barrett et al., 2010), with one of these trials, the Preventure Trial, showing two-year reductions in problem drinking symptoms and illicit drug use in high-risk youth (Conrod et al., 2010; Conrod, Castellanos-Ryan, & Mackie, 2011). A recent cluster-randomised trial, known as the Adventure Trial, replicated the preventative effects of personality-targeted interventions on alcohol use when delivered by trained school-staff (Conrod et al., in press; O’Leary-Barrett et al., 2010), thus suggesting that this intervention approach can operate within an implementation model that has a higher likelihood of being adopted by schools in a sustainable manner. The results of this recent study are central to the development of an effective (as opposed to merely efficacious) intervention. This trial demonstrates that targeted interventions can be successfully delivered by educational staff who have been trained and supervised, and that targeted interventions have the potential to become a sustainable school-based prevention model.

30Effect sizes for binge drinking from the Adventure trial were similar to those from previous clinician-run personality-targeted intervention trials, with odds ratios between 0.4 and 0.5 across all trials for youth who had already consumed alcohol by 13 years of age (i.e. a particularly high-risk group). These odds ratios correspond to a 50-60% decreased likelihood of binge drinking six months post-intervention. The corresponding odds ratios for a sample including youth who were non-drinkers at baseline were 0.65-0.7, representing a 30-35% decreased likelihood of reporting binge drinking six months later. ‘Numbers Needed to Treat’ across the three trials for baseline alcohol users ranged from four to six, indicating that four to six individuals are required to receive an intervention in order to prevent one case of binge drinking. These effect sizes are remarkable given that the most effective universal alcohol prevention programmes have ‘Numbers Needed to Treat’ values from nine to 30 (Faggiano et al., 2008), which requires targeting at least double the number of adolescents in order to prevent one case of binge drinking. A more recent two-year follow-up of this programme which involved two-part latent growth models to evaluate onset and progression to heavier drinking over time indicated long-term effects of the intervention on drinking rates, binge drinking rates, and growth in binge drinking and problem drinking in high-risk youth, such that high-risk youth showed 43% reduced odds of binge drinking and 29% reduced odds of reporting problem drinking over the course of the trial (42% reduced odds of problem drinking at the two-year follow-up; Conrod et al., in press). High-risk youth were also shown to benefit from the interventions over the 24-month follow-up on drinking quantity, and growth in binge drinking frequency. Furthermore, some herd effects in (untreated) low-risk youth were observed, specifically on drinking rates and growth of binge drinking. In this context, herd effects refer to risk reduction in untreated individuals secondary to reductions in drinking among treated individuals in the population. The idea is that because drinking has been reduced in the high-risk youth through the targeted intervention, this can result in reduced drinking/binge drinking even among untreated low-risk youth by reducing modelling of drinking, and peer pressure and opportunities to drink within students’ social networks. This study reported that the intervention was associated with a 29% reduced odds of drinking over the course of the trial in students attending intervention schools relative to students in control schools which compares favourably to some of the best results from universal comprehensive programmes. Importantly, however, the effect only required intervening upon 45% of the population. There is also an added benefit of this approach: by targeting underlying personality risk factors for alcohol/drug misuse that are also implicated in vulnerability to other mental disorders, this programme also produces benefits in mental health outcomes, such as depression, anxiety, and conduct disorder symptoms (e.g., Castellanos & Conrod, 2006).

31Another selective programme worth mentioning is one developed in Quebec, Canada which targets high-risk boys with persistent aggressive tendencies in childhood (Tremblay, Pagani-Kurtz, Mâsse, Vitaro, & Pihl 1995; Tremblay & Schaal, 1996). This programme was evaluated within a longitudinal study of primary school children in which 172 boys attending kindergarten in low socio-economic neighbourhoods of Montreal underwent a randomised controlled trial for disruptive behaviour. The intervention was delivered for two years (when the boys were seven to nine years old). It consisted of two main components: a) social and problem-solving skills training for the boys in a group setting, and b) parent training on effective child-rearing skills. Adolescent substance-use, up to eight years post-intervention, was shown to be reduced in those who received the intervention, with effect sizes ranging from.46 to.67, suggesting large effects. More importantly, findings showed that the intervention effect on alcohol-use frequency at 14 years and on growth in number of different drugs used across adolescence (1417 years) were explained, respectively, by reductions in both antisocial behaviours and affiliation with less deviant peers, and by a reduction of impulsivity during pre-adolescence (11 to 13 years; Castellanos-Ryan, Vitaro, Parent, Tremblay, & Seguin, 2012).

32In summary, the selective personality-based approach to alcohol prevention appears to be highly effective for youth with personality risk factors for early onset alcohol misuse and evidence exists for both the North American and European contexts. There is also preliminary evidence that this approach might also indirectly delay onset and growth of drinking in the general lower-risk population.


33In contrast to selective prevention programmes carried out with groups at-risk for alcohol problems, indicated prevention programmes are those that are carried out with individuals who are already showing signs/symptoms of an alcohol use disorder. Since indicated interventions hold much in common with alcohol use disorder treatment, they are generally beyond the scope of this chapter on alcohol prevention. Nonetheless, there are some school-based indicated programmes that are worthy of mention here. In the next sections, we briefly review the evidence for the efficacy of brief interventions for college students, like the Brief Alcohol Screening and Intervention for College Students (BASICS; Dimeff, Baer, Kivlahan, & Marlatt, 1999), as well as expectancy challenge interventions. It should be noted here that while these interventions are often used as indicated interventions, many are used with volunteers (sometimes heavy drinkers) or universally. In fact, several randomised controlled studies of these approaches deliberately screen out problem drinkers when testing intervention efficacy. Thus, while these interventions are classified as indicated approaches within our review, they do not fit readily within the universal/selective/ indicated organizational framework.

Brief Interventions for College Students

34Because the legal drinking age in the U.S. is 21, there are many underage drinkers on U.S. college campuses. As U.S. youths transition from high school to college, they often experience significant increases in their prevalence, frequency, and quantity of drinking (Bachman, Wadsworth, O’Malley, Johnston, & Schulenberg, 1997; White, Labouvie, & Papadaratsakis, 2005), especially if they leave their parents’ home (White, McMorris, Catalano, Fleming, Haggerty, & Abbott, 2006). Along with these increases comes a host of alcohol-related negative consequences, including fatal and nonfatal accidents, academic failure, violence and other crime, and unsafe sexual behaviour (Hingson, Zha, & Weitzman, 2009; Presley, Meilman, & Cashin, 1996; Wechsler, Lee, Kuo, & Lee, 2000; Wechsler, Lee, Nelson, & Lee, 2001). Therefore, college campuses have developed numerous prevention programmes to reduce the harms associated with heavy drinking by college students. These programmes target factors associated with student drinking, such as alcohol expectancies and perceived norms for other student drinking and acceptance of drinking (similar to the social norms approach discussed earlier), as well as attempt to increase protective behavioural strategies and motivations to change drinking behaviour (Cronce & Larimer, 2011). Because most of this report focuses on drinking earlier in adolescence, we only briefly discuss these prevention programmes here (for greater detail, see Cronce & Larimer, 2011). Note, however, that some of these programmes could be modified for use with younger adolescents.

35Larimer and Cronce (2002, 2007), and Cronce and Larimer (2011), reviewed individual-based alcohol prevention programmes for college students. Overall, they found a lack of support for education and awareness programmes, which were solely didactic (instructive) or used values clarification approaches. On the other hand, they found consistent support for the efficacy of brief, personalised, individual motivational feedback interventions, alcohol expectancy challenge interventions (see next section), other types of skills training (e.g., self-monitoring), and stand-alone personal feedback interventions. In addition, there was some limited support for multi-component alcohol education interventions if they included elements of personal feedback (for greater details on these types of interventions, see Cronce & Larimer, 2011).

36As stated above, one type of brief intervention that has been particularly effective with college students is brief personalised feedback interventions. Personalised feedback interventions provide written and graphical feedback on a student’s drinking pattern relative to other college students (i.e., normative feedback), peak blood alcohol concentration, alcohol-related problems, and personal risk factors (e.g., dependence symptoms, family history of alcoholism) (Cronce & Larimer, 2011; Dimeff et al., 1999). Some feedback sheets also include protective behavioural strategies and/or highlight consequences that are especially salient for students, such as the calories they gain from drinking and the amount of money they spend on alcohol.

37Although personalized feedback interventions are sometimes used as stand-alone interventions, they are often provided within the context of a brief motivational intervention. Brief motivational interventions, which are usually delivered in one or two sessions, aim to increase the student’s motivation and readiness to change their drinking behaviour. The motivational interview context relies on motivational enhancement techniques to increase students’ readiness for change and to help guide them through the change process (Dimeff et al., 1999). They are also dependent on the student being pre-identified as having experienced a problem related to their alcohol use (e.g., identified in the emergency room, through mass screening, or through university security). Facilitators use a motivational interviewing style, which presents feedback in an empathetic, non-judgmental manner (Miller & Rollnick, 2002). Brief motivational interventions often also include presentation of general alcohol education (e.g., effects at various BACs, cognitive effects of alcohol) as well as a discussion of harm reduction strategies (e.g., how to pace drinks) (Cronce & Larimer, 2011).

38Overall, evaluations of personalised feedback interventions for college students within the context of a brief motivational intervention and as stand-alone interventions (e.g., written feedback only or web-based feedback), have found them to be more efficacious than educational interventions or assessment-only control conditions (for reviews, see Carey, Scott-Sheldon, Carey, & DeMartini, 2007; Cronce & Larimer, 2011; Larimer & Cronce, 2002, 2007; Walters & Neighbors, 2005; White, 2006). Support for brief personalised feedback and motivational interventions have also been found for students attending Further Education Colleges in the United Kingdom when delivered by trial therapists or trained professionals in the college setting (Grey, McCambridge, & Strang, 2005; McCambridge & Strang, 2004). However, in one study in the U.K., the effects reported for brief interventions were short-lived (McCambridge & Strang, 2004), did not generalise to all drinking outcomes, and were more effective for those reporting greater alcohol use at baseline. Furthermore, according to a more recent trial, there is little evidence that this approach will be effective for universal prevention of alcohol misuse in college students. McCambridge, Hunt, Jenkins, and Strang (2011) recently reported the results of a cluster randomised trial investigating whether brief motivational interviewing could be effective for universal preventions, that is, for students who had not necessarily initiated use or begun to experience problems with alcohol or other substances. This trial which involved 416 students aged 16-19 years old recruited in 12 London Further Education Colleges, and compared the effect of a one-session individualised motivational intervention with a standard practice classroom-delivered Drug Awareness intervention. No group differences in prevalence, initiation, and cessation of alcohol consumption were reported at 3 and 12 months post intervention. On the other hand, findings have been inconsistent in the U.S. as to whether these interventions are better for heavier than lighter drinkers, and some have shown long-term benefits (Mun, White, & Morgan, 2009). More research is needed to: 1) identify the components of feedback that are necessary and sufficient and the best methods for delivery to enhance the preventative effects of brief motivational interventions; 2) evaluate potential mechanisms of intervention efficacy; 3) understand why the intervention is only effective for heavier drinkers; and 4) identify ways to prolong the long-term effects of these interventions (Cronce & Larimer, 2011; Walters & Neighbors, 2005; White, 2006). There is some limited research indicating that personalised feedback interventions may be efficacious with adolescents (e.g., D’Amico & Fromme, 2002). However, much more research is needed to test brief individualised interventions with underage drinkers.

Expectancy-Based Interventions

39As discussed in Chapter 2, positive alcohol expectancies and motivations to drink are risk factors for drinking among adolescents. One important implication of the notion that alcohol-related cognitions are a central construct in the prediction of drinking in young people, is that they would be a prime target for prevention and early intervention (Goldman, 1999). Indeed, both explicit and implicit alcohol-related cognitions (see Chapter 2) have been targeted in interventions. Expectancies have been targeted using alcohol expectancy-challenge procedures (Darkes & Goldman, 1993; Darkes, Greenbaum, & Goldman, 1998). These procedures involve comparing the actual effects attributable to alcohol to those which an individual expects from drinking alcohol, to make drinkers more aware of the degree to which their drinking behaviours and responses to drinking are impacted by expectancies (Cronce & Larimer, 2011). Because alcohol expectancy challenge procedures often involve actual and perceived alcohol administration, they are rarely used with underage drinkers for legal and ethical reasons. Instead, they have been used mainly with young adults. The alcohol expectancy challenge procedure has been shown to lead to changes in explicit expectancies, but to have minimal impact on implicit cognitions (Wiers, van de Luitgaarden, van den Wildenberg, & Smulders, 2005). Two studies tested whether the change in explicit expectancies ‘mediated’ or helped explain a change in drinking behaviour, with one reporting a positive result (Wiers et al., 2005), and one a negative result (Wood, Capone, Laforge, Erickson, & Brand, 2007). In other targeted prevention programmes, expectancies are also discussed (e.g., BASICS; Dimeff et al., 1999). Motives to drink are a prime target in Motivational Interviewing. Motivational Interviewing has been shown to be a successful intervention in adults (Miller, 1998) and college students (Cronce & Larimer, 2011), but has yielded more mixed results with adolescents (Grenard, Ames, Pentz, & Sussman, 2006). Motivational Interviewing does not appear to affect implicit cognitions (Thush et al., 2009). It is worth noting that some alcohol expectancy challenge studies use videotapes of other people drinking and would, therefore, be amenable for use with underage drinkers (for greater detail, see Darkes et al., 1993, 1998).

40Recently, researchers have begun to directly target implicit cognitive processes in addiction through cognitive retraining programmes. For example, an attentional bias for alcohol (i.e., the tendency to selectively attend to alcohol-related cues) has been successfully re-trained, with positive results on drinking outcomes in adult problem drinkers (Fadardi & Cox, 2009) and in alcoholic patients (Schoenmakers et al., 2010). Similarly, an approach bias for alcohol (i.e., the automatic tendency to approach alcohol) has been successfully re-trained in hazardous drinking university students (Wiers, Rinck, Kordts, Houben, & Strack, 2010). Positive alcohol associations (i.e., the automatic tendency to associate alcohol cues with positive outcomes) have also been successfully changed through evaluative conditioning procedures, with positive results on drinking in the short-term (Houben, Havermans, & Wiers, 2010). Finally, recent research also indicates that training executive control may be helpful in problem drinkers (Houben, Nederkoorn, Wiers, & Jansen, 2011). Although these results are promising, it should be noted that none of these studies have included adolescents as of yet and none have been shown to prevent either the onset of drinking or harmful drinking.

Effective principles for school-based alcohol prevention

41Newton, Vogl, Teesson, and Andrews (2011) recently reviewed the principles that have consistently been associated with effective alcohol prevention programmes in schools (Ballard et al., 1994; Cuijpers, 2002; Dusenbury & Falco, 1995; Meyer & Cahill, 2004; Midford, Munro, McBride, Snow, & Ladzinski, 2002). Effective programmes were identified as being: evidence-based and theory driven, targeted to risk factors for substance use and psychopathology, developmentally appropriate, implemented prior to harmful patterns of use being established, part of a comprehensive health education curriculum, based on a skill-building approach (which must include providing resistance skills training, and normative education), immediately relevant to students, interactive, but keeping teacher as the central role, sensitive to the cultural characteristics of the target audience, able to provide adequate initial coverage and continued follow-up in booster sessions; and delivered within an overall framework of harm minimization, rather than being abstinence-based.

Obstacles to effective drug education in schools

42There are many barriers or ‘obstacles’ which can impede the effectiveness of prevention programmes even when they are evidence-based (Botvin, 2004; Dusenbury & Hansen, 2004; Elliott & Mihalic, 2004; Kaftarian, Robinson, Compton, Davis, & Volkow, 2004). A number of issues, particularly those related to implementation and dissemination of programmes, have been identified as causing the greatest obstacles and interfering with programmes being able to have an impact on behavioural outcomes (Cahill, 2007; Castro, Barrera, & Martinez, 2004; Ennett et al., 2003; Greenberg, 2004; Pentz, 2004; Rohrbach & D’Onofrio, 1996).

43The dissemination of alcohol prevention programmes into schools is not always entirely successful (Botvin et al., 2003; Cuijpers, 2003), but can be achieved with extensive training and close supervision (O’Leary-Barrett et al., 2010). Two large studies recently reported that less than 15% of schools in the U.S. implemented evidence-based programmes or reported following a programme guide or manual very closely (Ennett et al., 2003; Ringwalt et al., 2003), and one of these studies reported that one-fifth of teachers reported not using a curriculum/ programme guide at all when delivering drug and alcohol prevention. It is well established that programmes delivered with high fidelity lead to superior outcomes for students and programmes delivered with poor fidelity lead to poorer outcomes (e.g., Dane & Schneider, 1998).

44Internet-based technology offers a practical means of improving implementation fidelity while delivering evidence-based programmes. Computer-based drug prevention programmes have been designed for both universal (Duncan, Duncan, Beauchamp, Wells, & Ary, 2000; Gregor et al., 2003; Gropper, 2002; Schinke, Schwinn, DiNoia, & Cole, 2004; Williams, Griffin, Macaulay, West, & Gronewold, 2005) and targeted populations (Bosworth, Gustafson, & Hawkins, 1994; Schinke, Schwinn, & Ozanian, 2005) and involve youth navigating through simulated real life scenarios (Gregor et al., 2003; Schinke et al., 2004). There is a small literature to suggest that such programmes are both feasible and acceptable (Bosworth et al., 1994; Duncan et al., 2000; Gregor et al., 2003; Schinke et al., 2004; Schinke et al., 2005; Williams et al., 2005).

45While computerised alcohol prevention programmes are showing promise in terms of affecting behaviours proximal to alcohol use outcomes (e.g., increase alcohol-related knowledge and attitudes; decrease pro-drinking attitudes; Gropper, 2002; Marsch, Bickel, Badger, 2006; Newton, Teesson, Vogl, & Andrews, 2010; Newton, Andrews, Teesson, & Vogl, 2009; Newton, Vogl, Teesson, & Andrews, 2009; Schinke et al., 2004; Williams et al., 2005), the evidence for behavioural change is more limited as most studies have failed to collect behavioural measures (Duncan et al., 2000; Gregor et al., 2003; Gropper, 2002). Of course, this criticism applies to many alcohol prevention programmes delivered in a variety of formats and the lack of behavioural outcome data is not unique to web-based interventions. One Internet-based programme which has demonstrated positive effects in reducing actual alcohol and other drug use is the series of Climate Schools programmes for alcohol and drug prevention specifically designed to overcome factors which typically compromise programme efficacy. The modules are contemporary, cartoon-based, educational programmes based on a social influence approach to prevention, and consistent with the effective harm minimisation framework (McBride, Farringdon, Muleners, & Midford, 2006). Each Climate Schools module consists of six 40-minute lessons. The first half of each lesson is completed individually online where students follow a cartoon storyline of teenagers experiencing real life situations and problems with alcohol and cannabis. The cartoon storylines are used to engage and maintain student interest and involvement over time (Schinke et al., 2004). The second part of each lesson is a predetermined activity delivered by the teacher to reinforce the information learned in the cartoons.

46The efficacy of the Climate Schools model has been demonstrated for stress reduction (Van Vliet & Andrews, 2009) and alcohol misuse (Newton, Andrews et al., 2009; Vogl et al., 2009). In one study (Newton, Vogl et al., 2009), the Alcohol module of Climate Schools was more effective than usual classes in decreasing average alcohol consumption, frequency of binge drinking (drinking in excess), and alcohol-related harms. A feasibility trial of the Climate Schools programme in the United Kingdom is ongoing and will provide data on the acceptability of this universal programme in the European setting (Newton & Conrod, in preparation).

47These findings suggest that the Internet offers a promising delivery method for preventing alcohol and other drug use in adolescents. While there is a strong push to adapt programmes for this delivery method, we also caution that this work should be done with careful evaluation of effects on behaviour, considering the results of studies in which small modifications to the implementation of evidence-based prevention programmes led to iatrogenic effects on behaviour.

Family-based prevention programmes

48Universal prevention programmes have also been delivered in the family setting. These approaches typically aim at supporting the development of parenting skills including parental support, nurturing behaviours, clear communication, establishing and enforcing clear boundaries or rules, and parental monitoring. In addition, universal family-based prevention can include components focused on the adolescent such as the development of social skills, peer resistance skills, and appropriate behavioural norms. However, unlike school-based programmes, the latter skills and norms are instilled indirectly, via parents and family, rather than directly to the adolescents themselves. The underlying assumption of family-based prevention is that if young people have a positive family environment, and develop good peer resistance and social skills, they are more likely to develop and adopt the behavioural norms displayed within their families and to be resilient against external influences such as peer pressure (Foxcroft & Tsertsvadze, 2011b).

49At least two systematic reviews have assessed the efficacy of various family-based programmes (Foxcroft & Tsertsvadze, 2011b; Petrie, Bunn, & Byrne, 2007). Petrie et al. (2007) conducted a systematic review of controlled studies of parenting programmes to prevent substance abuse in children and adolescents under the age of 18 years. Data were collected on actual or intended use of alcohol and other substances (tobacco and/or other drugs), and associated risk or antecedent behaviours. Twenty studies met their inclusion criteria. Of these, five focused exclusively on alcohol (Loveland-Cherry, Ross, & Kaufman, 1999; Park et al., 2000; Perry et al., 2002; Werch, Owen et al., 2003; Williams, Grechanaia, Romanova, Komro, Perry, & Farbakhsh, 2001), and nine on alcohol and tobacco and/or other drugs (Bauman, Foshee, Emmett, Hicks, & Penberton, 2001; Forman & Brondino, 1990; Hawkins, Catalano, Kosterman, Abbott, & Hill, 1999; Johnson et al., 1990; Lochman & Wells, 2003; Pentz et al., 1989; Spoth et al., 2001; Perry et al., 2003; Spoth et al., 2002). Of these 14 studies focusing on alcohol outcomes, 13 were conducted in the U.S. and the remaining study was conducted in Russia (Williams et al., 2001). None were conducted in Europe. Unqualified statistically significant reductions of alcohol use were found in six of these 14 studies (Lochman & Wells, 2003; Park et al., 2000; Pentz et al., 1989; Perry et al., 2002; Spoth et al., 2001; Spoth et al., 2002). Three others showed significant reductions in alcohol use, but only for certain subgroups (i.e., for boys only, Perry et al., 2003; only in a school where kids were bussed in, Werch, Owen et al., 2003; only for those students with no alcohol use prior to the intervention, Loveland-Cherry et al., 1999). One of the 14 studies showed a statistically significant increase in alcohol use, but only for those young people who had already started drinking by the time of the intervention (Loveland-Cherry et al., 1999). Thus, parent-based prevention programmes can be effective in reducing or preventing alcohol use. This review concluded that the most effective approaches are those that emphasise active parental involvement as well as developing skills in social competence, self-regulation, and parenting (Petrie et al., 2007). However, the authors also noted significant heterogeneity in the methodology of the studies, and stressed that more work is needed to investigate further the long-term effectiveness of parenting programmes.

50Of the trials included in the Petrie et al. (2007) review, the only non-North American study was conducted in Russia, with materials based on the American ‘Project Northland’ programme (Perry et al., 1996). Although the programme increased parent-child communication and led to increases in students’ knowledge about the negative consequences of underage drinking, there were no changes in adolescents’ actual alcohol use rates by the end of the first year of the three-year programme (Williams et al., 2001). This is in spite of efforts to make the intervention culturally appropriate for the Russian context such as starting a year earlier due to Russian young people’s earlier onset of drinking relative to North American youth (Williams et al., 2001). At first glance, this may appear to suggest that other important cultural differences were neglected in the attempted transfer of this parent-based prevention programme, developed in Minnesota, to a non-North American context. However, the original American ‘Project Northland’ did not achieve changes in students’ alcohol use until the third year of the intervention by which time a multi-component intervention had been implemented in addition to the parent-based programme (Perry et al., 1996). We cover multi-component interventions in a later section.

51Recently, Foxcroft and Tsertsvadze (2011b) conducted a Cochrane systematic review of evidence on the effectiveness of universal family-based prevention programmes in preventing alcohol misuse in school-aged children and adolescents. Twelve randomised controlled trials evaluating universal family-based prevention programmes and reporting outcomes for alcohol use in students 18 years of age or younger met their criteria and were included in the analysis (Bauman et al., 2002; Brody et al., 2006; Haggerty, Skinner, MacKenzie, & Catalano, 2007; Koning et al., 2009; Loveland-Cherry et al., 1999; O’Donnell, Myint, Duran, & Stueve, 2010; Schinke, Cole & Fang, 2009a; Schinke, Fang, & Cole, 2009b; Schinke, Fang, & Cole, 2009c; Spoth, Lopez Reyes, Redmond, & Shin, 1999; Stevens et al., 2002; Werch et al., 2008). As this review was conducted more recently, only one of the 14 trials covered by Foxcroft and Tsertsvadze (2011b) (i.e., Loveland-Cherry et al., 1999) overlapped with the studies reviewed by Petrie et al. (2007). This review also built upon the review by Petrie et al. (2007) by examining persistence of effects over the longer term in addition to immediate post-treatment outcomes. The authors found that the reporting quality of trials was poor, and that inadequate reporting of the method of randomization and programme allocation concealment was common. Incomplete data was adequately addressed in about half of the trials and this information was unclear for close to one-third of the trials. Due to extensive heterogeneity across interventions, populations, and outcomes, the results were summarised only qualitatively. Eight of the twelve trials showed statistically significant evidence of effectiveness compared to a control or other intervention group, with persistence of effects over the medium and longer-term (i.e., Brody et al., 2006; Loveland-Cherry et al., 1999; O’Donnell et al., 2010; Schinke et al., 2009a; Schinke et al., 2009b; Schinke et al., 2009c; Spoth et al., 1999; Werch et al., 2008). Four of the effective interventions were gender-specific, focusing on young females and (primarily) their mothers (O’Donnell et al., 2010; Schinke et al., 2009a; Schinke et al., 2009b; Schinke et al., 2009c). One study, with a small sample size, showed positive effects that were only marginally significant at p =.10 (Bauman et al., 2002), and three studies with larger sample sizes reported no significant benefits of the family-based intervention for reducing alcohol misuse (Haggerty et al., 2007; Koning et al., 2009; Stevens et al., 2002). In fact, the Stevens et al. (2002) study suggested the intervention resulted in a larger proportion of ‘ever drinkers’ at the three year follow up relative to a control intervention focusing on other safety behaviours (e.g., helmet, seatbelt use). Taken together, these findings led the authors to conclude that the effects of family-based prevention interventions are small but generally consistent, and also persistent into the medium- to longer-term (Foxcroft & Tsertsvadze, 2011b). The authors also noted that although the effects may be small in magnitude, even small effects can be important from a public health perspective (Foxcroft & Tsertsvadze, 2011b).

52All of the studies included in the Foxcroft and Tsertsvadze (2011b) review, save one, were conducted in the United States. The exception was a single European trial, conducted in the Netherlands, which focused on parental rule-setting around their offspring’s alcohol use (Koning et al., 2009). This parent intervention was modeled after the Swedish ‘Orebro Prevention Programme’ which had been tested previously in a quasi-experimental study and which had been shown to be effective in reducing underage drunkenness in Sweden (Koutakis, Stattin, & Kerr, 2008). Koning et al.’s (2009) objectives were to test this intervention more rigorously (in a randomised controlled design), and to examine the generalizability of the effects of this parental intervention in a context where adolescent drinking is much more prevalent than in Sweden (see Chapter 1). In the Dutch study, the parental intervention was compared to a school-based, youth-focused intervention, each provided alone or in combination in a two by two factorial design. Unlike the Swedish findings (Koutakis et al., 2008), the parental intervention alone had no significant effects on any of the alcohol outcomes (heavy weekly drinking, weekly drinking, drinking frequency) at either 10 or 22 months post-intervention. The results suggest that parental rule setting alone may be less effective in deferring the onset of adolescent drinking in countries with more liberal alcohol policies and lower legal drinking ages (e.g., the legal drinking age in the Netherlands is 16 years and there is weaker enforcement of laws that prohibit selling of alcohol to minors). It would be interesting to see if parental interventions are any less effective in Canada than in the U.S. given the differences between these two North American countries in legal drinking age. Despite the absence of any evidence of efficacy of the parental intervention alone in the Koning et al. (2009) study, there were clear and persisting effects of the combined parent- and child-focused intervention on a variety of alcohol outcomes. The findings of this study are discussed in the next section, and suggest that both parents and children should be targeted simultaneously in multi-component interventions to achieve best results, at least in the Dutch context.

53Before concluding this section, it is worth reiterating that two of the trials reviewed by Petrie et al. (2007) and Foxcroft and Tsertsvadze (2011b) showed evidence of increases in alcohol use in the experimental group receiving the family-based intervention (i.e., Loveland-Cherry et al., 1999; Stevens et al., 2002). These findings warn of the potential for iatrogenic effects of these interventions in certain cases. But as Foxcroft and Tsertsvadze (2011b) caution, the possibilities that these effects may have arisen by chance, or that they are secondary to differential attrition across groups or to confounding factors, need to be ruled out before we can conclude any iatrogenic effects of particular family-based interventions.


54Multi-component prevention approaches are programmes where the intervention is delivered in multiple different settings. For example, the intervention might occur in both family and school settings, potentially combining a parental intervention with school-based prevention curricula, as described in earlier sections. Thus, in school settings, a multi-component prevention typically takes the form of alcohol awareness education, social and peer resistance skills training, normative feedback, and/or development of behavioural norms, and positive peer affiliations. The family-based component often aims to support the development of parenting skills and parental monitoring, and/or helping parents to establish clear rules around alcohol use (Foxcroft & Tsertsvadze, 2011c). The parent- and child-focused components are most commonly delivered simultaneously.

55A Cochrane systematic review was recently conducted on universal multi-component programmes in preventing alcohol misuse in school-aged children and adolescents (Foxcroft & Tsertsvadze, 2011c). The authors identified 20 parallel-group randomised controlled trials evaluating prevention programmes where the intervention was delivered in more than one setting and reported outcomes for alcohol use in students up to age 18 years (i.e., Brown, Catalano, Fleming, Haggerty, & Abbott, 2005; Eddy, Reid, & Fetrow, 2000; Furr-Holden et al., 2004; Hawkins et al., 2009; Komro et al., 2006; Koning et al., 2009; Perry et al., 1996; Perry et al., 2003; Reddy et al., 2002; Schinke et al., 2004; Shortt, Hutchinson, Chapman, & Toumbourou, 2007; Simons-Morton, Haynie, Saylor, Crump, & Chen, 2005; Slater et al., 2006; Spoth, Redmond, Trudeau, & Shin, 2002; Spoth et al., 2007; Werch, Pappas et al., 2000; Werch, Moore et al., 2003; Werch, Moore, DiClemente, Bledsoe, & Jobli, 2005a; Werch et al., 2005b; Wu et al., 2003). Of these 20 trials, two were previously reviewed by Petrie et al. (2007) (i.e., Perry et al., 2003; Spoth et al., 2002) and one was previously reviewed by Foxcroft and Tsertsvadze (2011b) (i.e., Koning et al., 2009). As in the previous systematic reviews, the methodological quality of the trials and reporting of study details was noted to be poor, and extensive heterogeneity across interventions, populations, and outcomes was once again found. In 13 of the 20 trials reviewed by Foxcroft and Tsertsvadze (2011c), some evidence of effectiveness was found for the multi-component intervention compared to a control or other intervention group (Brown et al., 2005; Eddy et al., 2000; Hawkins et al., 2009; Koning et al., 2009; Perry et al., 1996; Reddy et al., 2002; Schinke et al., 2004; Slater et al., 2006; Spoth et al., 2002; Werch, Pappas et al., 2000; Werch et al., 2005a; Werch et al., 2005b; Wu et al., 2003). The comparison groups included a no intervention control, educational booklets, face to face interviews, and parent post cards. Four of the 12 effective interventions only assessed immediate post-treatment outcomes (i.e., Brown et al., 2005; Hawkins et al., 2009; Perry et al., 1996; Reddy et al., 2002) while the others assessed and demonstrated durability of effects ranging from three months (Werch et al., 2005b) to three years (Eddy et al., 2000; Schinke et al., 2004) post-treatment.

56Assessment of the additional benefit of multiple versus single component interventions was possible in seven of the 20 trials reviewed by Foxcroft and Tsertsvadze (2011c). Only one of them clearly showed a benefit of having multiple components. Interestingly, this was the Dutch trial (Koning et al., 2009) discussed earlier in the review of family-based preventions. This trial found the combined, multi-component, student-parent intervention to show substantial and statistically significant effects on heavy weekly drinking, weekly drinking, and frequency of drinking at post-treatment and sustained effects on weekly drinking and frequency of drinking at 22 month follow up. The systematic review by Foxcroft and Tsertsvadze (2011c) thus concluded that there is some evidence that multi-component interventions for alcohol misuse prevention in young people can be effective. They also concluded, however, that there is little evidence that interventions with multiple components are more effective than those with a single component (Foxcroft & Tsertsvadze 2011c).

57Of the 20 studies reviewed by Foxcroft and Tsertsvadze (2011c), 17 were conducted in the U.S., one in the Netherlands (Koning et al., 2009), one in Australia (Shortt et al., 2007), and one in India (Reddy et al., 2002). Of those conducted outside of the U.S., two showed evidence of efficacy of the multi-component intervention (Koning et al., 2009; Reddy et al., 2002). The Dutch trial has been discussed previously. The Indian trial, conducted in New Delhi, was a school- plus family-based intervention focused on improving children’s cardiovascular health through better nutrition, better diet, and decreased smoking; alcohol use was not a focus of the intervention. The multi-component intervention was compared to the school-based intervention alone and to a no treatment control. The school-based programme was multifaceted and included training in refusing offers to smoke. The family-based intervention consisted of a series of six booklets containing information and family activities focused on improving children’s cardiovascular health. The family booklets were culturally adapted from those used in similar previous work in the U.S. (Luepker et al., 1996; Perry, Luepker, Murray, & Hearn, 1989). Even though the intervention did not focus on alcohol, significant effects of the two interventions were found relative to the control group in terms of reductions in proportion of children reporting ever using alcohol and those intending to drink as adults. The authors speculated that these effects on alcohol outcomes may have been due to the fact that since alcohol and tobacco use are very often co-occurring behaviours, an intervention which is effective in reducing tobacco use may also delay alcohol use (Reddy et al., 2002). There were no differences between the school-based only intervention and the multi-component intervention indicating that there was no additional benefit on alcohol use of sharing the booklets with the families. This may have been due to an insufficient dose of the family-based component, the unsupervised nature of the booklet activities, and/or the lack of interactive intervention with the parents.

58The Australian trial (Shortt et al., 2007), conducted in Melbourne, examined the outcome of the Resilient Families intervention which involved both school-based and parent-based components. For the school based component, the student curriculum included communication skills, relationship problem solving, emotional awareness training, peer resistance skills building, and conflict resolution skills among the adolescents. The parents were offered both brief and extended training in enhancing parenting skills and encouraging a more positive relationship between parents and their adolescents (Shortt et al., 2007). Although the Resilient Families programme did increase within-family connectedness and problem solving skills as intended, and although it was associated with improvements in both the educational and family environments, intervention effects were not statistically significant predictors of student alcohol use after controlling for other important influences (e.g., peer influences). There are several potential explanations for the lack of significant effects of this multi-component intervention on student alcohol use outcomes. First, the intervention may need to be implemented earlier given the high prevalence of alcohol use in the sample. Second, it is possible that effects still may be observed as this analysis was only for the first year of the intervention. Third, it is certainly possible that the failure to observe effects was due to the lack of interventions focusing specifically on alcohol (e.g., no training for parents in monitoring children’s alcohol use, nor in setting rules about their children’s alcohol use; no specific training for students in drink refusal skills). Finally, not all parents attended the parent sessions. Those who did were already higher in family connectedness, potentially reducing the usefulness of these sessions for these particular families. Future work might examine cross-cultural similarities and differences in the efficacy of multi-component interventions involving both school-and family-based components in preventing, or decreasing (heavy) alcohol use in adolescents.

59Besides parents and the family, multi-component approaches can also involve a broader community initiative, such as consultation with the police, health professionals, city officials, or local residents, to formulate and support the intervention. Wood, Shakeshaft, Gilmour, and Sanson-Fisher (2006) conducted a systematic review of school-based prevention trials that also involved the community. The authors reviewed 16 studies (Abbey, Pilgrim, Hendrickson, & Buresh, 2000; Aseltine, Dupre, & Lamlein, 2000; Cuijpers et al., 2002; D’Amico & Fromme, 2002; Dedobbeleer & Desjardins, 2001; Dixon & McLearen, 2002; Ellickson et al., 2003; Peleg, Neumann, Friger, Peleg, & Sperber, 2001; Perry et al., 2002; Perry et al., 2003; Schinke et al., 2000; Spoth et al., 2001; Spoth et al., 2002; Werch, Carlson, Pappas, Edgemont, & DiClemente, 2000; Werch, Owen et al., 2003; Williams et al., 2001), 15 of which examined alcohol use outcomes (i.e., all but Abbey et al., 2000). Several of these studies were included in previously discussed systematic reviews (Perry et al., 2002; Perry et al., 2003; Spoth et al., 2001; Spoth et al., 2002; Werch, Owen et al., 2003; Williams et al., 2001). The authors’ goal was to describe and critique the methodologies of multi-component intervention studies that were school-based, but also incorporated a broader community intervention component. Like previous reviews, the authors identified that reviewed studies were often methodologically lacking (Wood et al., 2006). These authors did not conduct a full meta-analysis because of the poor methodological quality of the studies and the heterogeneity in alcohol outcome measures employed. But they did include a brief analysis of effect sizes for the 15 studies that examined alcohol use (i.e., lifetime use, past year use, use in past week or month, initiation into drinking, or binge drinking) as an outcome. In general, limited effectiveness was found, with initial effect sizes that were relatively small in magnitude. However, Wood et al. (2006) noted that most studies used relatively few community components (e.g., only three studies used more than six community components). Thus, they suggested that there is a need for additional studies that attempt to enhance the efficacy of school-based programmes by including broader community components such as media, community services, and alcohol retailer involvement (Wood et al., 2006). In fact, from a more theoretical viewpoint, it has been argued that effective long-term prevention programmes for the reduction of youth drinking require strategies for the wider community and societal change (Wagenaar & Perry, 1994).

60Of the 15 studies reviewed by Wood et al. (2006), 11 were conducted in the U.S., one was conducted in the Netherlands (Cuijpers et al., 2002), one in Canada (Dedobbeleer & Desjardins, 2001), one in Israel (Peleg et al., 2001), and one in Russia (Williams et al., 2001). The Russian trial was discussed previously. The Israeli study involved randomising grade ten youth to an active intervention or no intervention control. The multi-component intervention involved collaboration between the schools and the community and was put on by school staff and the psychological counseling service in Israel. The intervention took place over three days and included guest lectures by experts as well as adolescent workshops, on topics such as peer pressure, effects of advertising on behaviour, and taking responsibility for one’s actions. Students viewed relevant films and took part in role plays. Efficacy of the intervention was examined at one and two year follow-up. While there was growth in alcohol use in the control group, there was no significant change from baseline in the intervention group over the follow-up, suggesting that the intervention reduced growth in alcohol use over time. The results thus support the efficacy of a multi-component school- plus community-focused intervention in the Israeli context (Peleg et al., 2001).

61The Dutch study was a quasi-experimental study of the Healthy School and Drugs project (Cuijpers et al., 2002). This programme is run by a coordinating committee (including school and community representatives) and involves parents. The student-focused component involves three lessons about alcohol (information, development of a healthy attitude towards alcohol use, and drink refusal skills). Schools develop clear policies on alcohol use at school and school events, plans for early detection of students with alcohol problems, and provision of support and counseling for identified students. Significant effects of the intervention on alcohol use were found which persisted at two years following the intervention (Cuijpers et al., 2002).

62The Canadian trial, however, provided less promising results regarding the efficacy of multi-component interventions involving both the school and community in changing adolescent alcohol use. Dedobbeleer and Desjardins (2001) studied the efficacy of the multi-component ‘Coalition for Youth Quality of Life Project’ which was designed to prevent alcohol use and misuse among multi-ethnic youth in Montreal. The intervention was delivered through four channels: schools, community organizations, local government, and families. They targeted sixth and eighth graders who were followed up at 18 and 30 months. Although the programme led to significant effects on several hypothesised mediators (e.g., higher self-esteem and superior peer-resistance skills in the younger students; more leisure alternatives to alcohol and other substance abuse in the older students), the programme had no significant effects on alcohol use. Several possible explanations were considered by the authors including differential attrition across treatment arms, insufficient power, insufficient dose of intervention, and lack of booster sessions (Dedobbeleer & Desjardins, 2001). Since this particular programme has only been assessed in Canada, it is difficult to know to what degree cultural factors might play a role in the failure of this multi-component intervention to exert effects on adolescent drinking behaviour. However, considering the lack of strong cultural effects on other school-based programmes, it is not likely that the cultural context can entirely explain these null findings.


63There are several contexts in which youth alcohol prevention can be delivered. The school context appears to capture a larger percentage of the target population and yields the most consistent effects relative to other contexts, such as the family context or the community. The school-based programmes that are most effective are comprehensive programmes which concurrently address normative attitudes about drinking and teach generic and alcohol refusal skills. Universal programmes delivered in high schools to students before the normal age of onset of drinking show consistent effects on drinking behaviour, mostly binge drinking, and have been shown to have effects in the North American, European, and Australian contexts. However the effects are small, accounting for only 10% of the variance in drinking behaviour, and there are signs that these programmes might be more effective if delivered to populations at greater risk for early drinking and problem drinking. There is new research from Australia suggesting that the effectiveness of universal, comprehensive programmes might be enhanced with the addition of web-based resources. However, web-based programmes have not been tested in Europe and the U.S. high school context, with a number of pilot studies and ongoing trials suggesting that this modification is feasible and might lead to improved fidelity when implementing evidence-based universal intervention programmes.

64Effective selective prevention strategies include those that target youth with known individual risk factors for alcohol misuse, including personality risk factors or behavioural problems prior to the onset of alcohol use. These programmes show stronger and long-term effects on drinking onset, binge drinking onset, and problem drinking symptoms in high-risk populations. Two studies show that they might also benefit peers in the broader social network of high-risk youth. Therefore, while these evidence-based selective programmes only target a portion of the adolescent population, they might also have universal effects. The selective approach has been shown to be equally effective in the North American and European contexts and shows some advantages relative to other approaches in that it is also effective in reducing and preventing mental health problems that tend to co-occur with alcohol misuse. Large trials of personality-targeted interventions for high school students are currently being conducted in Canada, the Netherlands, and Australia to address some outstanding questions, such as how does this approach compare to, and combine with, evidence-based universal programmes?

65While not all indicated prevention programmes were reviewed in this chapter, brief interventions with college students who show early signs of heavy drinking or problem drinking do show promise. Specifically, interventions that include personalised feedback and normative feedback, as well as some brief motivational principles do show some effects on drinking behaviour among college students, and there is some limited research indicating that this approach could be effective with adolescents. There is also some experimental research on expectancy challenges and cognitive control training, but the evidence is limited so far, with more rigorous research needed to support this approach over and above other evidence-based approaches.

66The family is another context in which prevention programmes are delivered. These are delivered to parents alone or in combination with a child-focused intervention (multi-component). While the family-based approach is less practical and economical to deliver than the school-based approach, one advantage is that it has the potential to address underlying family factors implicated in a number of alcohol and behavioural problems. The evidence in favour of the approach is consistent and suggests small effects that are persistent over the medium to long term. However, the evidence is only positive for the U.S. context and no study has yet shown this approach to be effective outside the U.S. as a single component programme. Finally, comparative studies in the U.S. and Europe suggest that parent training does not offer any incremental effects over an effective school-based comprehensive programme.

67Several conclusions can also be drawn about the use of multi-component programmes (school plus family; school plus community). First, multi-component interventions can be effective for alcohol misuse prevention in young people. However, generally speaking, interventions with multiple components are no more effective than those with a single component, raising questions as to cost-effectiveness of multi-component programmes. Nonetheless, multi-component programmes may be particularly useful in some cultural contexts. For example, there is some limited evidence that both parents and children should be targeted simultaneously in countries like the Netherlands with more liberal alcohol policies and lower legal drinking ages.


68While some comparative research has been conducted to investigate the relative and incremental effects of these approaches, much more research is needed in this regard. It will be important to investigate how universal comprehensive programmes compare and combine with selective prevention approaches to improve outcomes in low- and high-risk adolescents. The Australian Climate Schools and Preventure (CAP) Study (Newton, Teesson, Barrett, Slade, & Conrod, 2012; is one trial that begins to address these questions. Furthermore, research on the mediators and moderators of these evidence-based programmes will help us better understand how they are having their effects on youth drinking behaviour, which might also lead to more refined and more effective interventions. Another question worthy of further investigation is how web-based materials and resources enhance evidence-based universal and selective approaches. However, as with all preventative interventions, this should be done with careful evaluation, given the potential for negative effects of poorly implemented programmes. Finally, while some experimental research is showing that cognitive and behavioural control training might improve outcomes for alcoholics and problem drinkers, there is a need to investigate how interventions that target some of the implicit and automatic aspects of addiction vulnerability can further improve outcomes for the general adolescent population and those at-risk.

69To improve implementation of evidence-based alcohol prevention programmes, many jurisdictions have developed and disseminated prevention standards. For example, the Canadian Centre on Substance Abuse (CCSA) has developed a portfolio of Canadian Standards for Youth Substance Abuse Prevention. These consist of three separate documents outlining school-based standards (CCSA, 2010a), family skills-based standards (CCSA, 2010b), and community-based standards (CCSA, 2010c), respectively. Each was developed following a review of the evidence by a panel of experts. A useful future direction would be to create a set of standards that apply to youth alcohol prevention in the international context. Such international standards could include guidelines for adapting alcohol prevention programmes that have been demonstrated effective in one context, for use in new cultural contexts.


70With the direct and indirect costs of alcohol misuse being somewhere in the range of U.S. $500-$1500 per capita (Rehm, Patra, Gnam, Sarnocinska-Hart, & Popova, 2011), there is clearly an argument for government investment in the evidence-based programmes highlighted in this chapter. Studies involving health economic analyses of alcohol and drug prevention programmes have estimated that for every dollar invested in prevention, five to ten dollars are directly returned (e.g., Spoth, Greenberg, & Turrisi, 2008). Therefore, even programmes that yield small effects can be justified economically and will lead to real public health benefits. Nevertheless, prevention programmes often comprise less than 1% of government alcohol-related costs (Rehm et al., 2006). In addition to more research on the incremental effects of evidence-based interventions, health-economic data on these programmes are needed to help guide policy makers around improving children’s access to these effective intervention programmes. As shown in this chapter, we now have many North American and European programmes that have been demonstrated to be effective in alcohol prevention among youth which now can be disseminated. Further research on these approaches needs to go hand-in-hand with a massive implementation strategy in order for youth to maximally benefit from these programmes.



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Ph.D., Professor of Psychiatry and Psychology
Psychology Department
Dalhousie University, 1355 Oxford Street
CA – Halifax, Nova Scotia

Ph.D., Senior Lecturer and Consultant Clinical Psychologist
Department of Psychological Medicine and Psychiatry
Institute of Psychiatry
King’s College London
4 Windsor Walk, Denmark Hill
UK – London, SE5 8BB
Ph.D., OPQ, Chercheure Agrégée, Psychiatrie
Centre de recherche du CHU Ste-Justine
Université de Montréal, Bureau 1551
3175 Chemin de la Côte Sainte-Catherine
CA – Montreal, H3T 1C5

Department of Public Health
Hjelt InstituteUniversity of Helsinki
FI – 00014 Helsinki
Department of Mental Health and Substance Abuse Services
National Institute for Health and Welfare
FI – 00271 Helsinki

Ph.D., Professor
Addiction, Development, and Psychopathology (Adapt)
Department of Psychology
University of Amsterdam
Weesperplein 4
Nl – 1018 XA Amsterdam

Ph.D., Professor II
Center of Alcohol Studies
Rutgers University
607 Allison Road, Piscataway
USA – New Jersey 08854-8001

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