Adolescent Substance Use: Etiology

Abstract

This paper will review the trends in illegal substance use in the student population of Oregon and more specifically the 6^th and 8^th grade student population of Lake County Oregon, a frontier population during the years of 1998 through 2000. Historically, Lake County has a perceived alcohol abuse history that has been verbalized as a cultural “right of passage” by many local residents. “Hard living’ and “ hard drinking” in a sparsely populated frontier ranching community, has been evidenced by statistical outcome measuring provided by the State of Oregon which, based on past meta analysis, has shown Lake County Oregon Youth as having a higher than the State median average for the use of alcohol. I will review the primary causal factors associated with the early onset and subsequent development of adolescent substance use and misuse. The sources used will consist of published literature, personal observation and local data collection of pre and post testing “non identifiable” evaluations that were used during this project. I will discuss a fundamental approach to prevention of substance abuse that was introduced in Lake County during a 3 year time period. This paper will conclude with a preliminary assessment of the efficacy of the Botvin’s Life Skills Training Program on the 6^th and 8^th grade student population (evidenced based time frame when most substance abuse begins) in rural Lake County over a 3 year period from 1999 through 2000.

Introduction

Youth drug use and abuse is becoming a growing social and a public health problem. There are many substances blamed to be of use and abuse by adolescents. Substances are categorized into licit or lawful (bought legally as tobacco and alcohol) and illicit or illegal as heroin, cocaine, amphetamines, or cannabis. This has influenced public and individual perception to the whole problem. Public perception on a drug being a licit one there is no enough cause to face its consumption. Second, being licit, it is available for adolescents’ wide use; yet, the harm is still cropping up. There are three main patterns of how people look at an adolescent drug user. First, the user is a morally or religiously defective person (committing a sin or a social offense). The second pattern views the user as an ill person who needs medical or psychiatric help. The third pattern considers the user as a socially injured person who passed or is passing through hardships. However, all these interpretations focus on the individual. Proper understanding of adolescents’ substance use mandates dealing with all sides of the problem, which are the drug, the individual, and the environment (Fagg, 2006).

It is important not to avoid dealing with the problem of adolescents’ drug use, since it results in harmful effects on the individual’s behavior, personality with resultant serious social outcomes. Besides the substance’s health adverse effects, adolescents are in a stage of behavior and brain functioning development. Therefore, the results may affect the present individual’s life and in the future (Watkins and others, 2006). According to Burrow-Sanchez (2006), there are four areas to deal with this problem on an individual level. First, a counselor, peer, or a family member needs to setup a valid relationship with the adolescent. Second, authorities have to evaluate the problem from all sides, about the substance, the individual, and the social environment. Third is, for social workers to realize the possibility of recurrence (relapse). Finally, a counselor needs to consider the various treatment approaches based on a comprehensive assessment if the adolescent passes to abuse or dependence. Figure (1) elicits the problem volume and shows Drug use rates by age in the US (based on National Household Survey on drug use, 2000, cited in the report of the Office of National Drug Control Policy (a), 2002).

The aim of this thesis is to review the problem of adolescent drug use about volume of the problem (epidemiology), risk and protective factors, and etiology. In addition, the thesis aims to provide a preliminary assessment of the efficacy of Dr. Gil Botvin’s Life Skills Training Program for the student population of Oregon. Specifically as applied to the 6^th and 8^th grade student population of Lake County Oregon as a frontier community during the years of 1998 through 2000.

Definitions

On reviewing the literature on adolescent substance use, there is little agreement to the terms that point to various patterns of drug use. Terms of substance or drug use, abuse, and dependence are erratically used instead of one another. For this thesis’ purposes of discussion a drug definition is as suggested by Fagg (2006). A drug is a psychoactive substance that acts on the central nervous system influencing the mood, behavior and thought (Fagg, 2006). Drug use definition is as in the WHO (World Health Organization) expert committee report on drug dependence (2003). A substance use is the intentional taking in of a substance that influences the individual’s behavior, way of thinking, feelings, or insight. Figure (2) shows licit and illicit substance use among US adolescents in 2008 based on data of the National Survey on Drug Use and Health (SAMHSA), 2007 (Dawes and others, 2008).

According to Australian Statement of Principles concerning drug dependence and drug abuse No. 16 of 2008, this substance should not result in habituation (psychological indigence), or addiction (physiological indigence). The individual is always capable to control the amount used. Finally, this substance should not result in extraordinary effects on the individual’s mental, physical health, and life functioning (work or social).

Based on the definitions cited in the Australian Statement of Principles No. 16 of 2008, the definition related to drug abuse is. A psychiatric state fulfills the following. It should be a poorly adapted pattern (prototype) associated with drug use resulting in a notable afflict or harm. The individual shows one or more of the following criteria within 12 months of drug use. Repeated drug use results in failure to fulfill a principal commitment (work, school, social, or family). The individual does not refrain from using the drug in possibly risky situations as driving or working on a machine. Other signs include repeated use of the drug despite exposure to legal problems, social or family problems caused by, or aggravated by using the drug.

Drug dependence is the psychiatric state that fulfills at least three (or more) of the following signs on condition, they take place within 12 months of drug intake. First is the tolerance, it takes one of two forms, second , either there is a need to take increasing doses to get the wanted effect or continued intake of the same dose results in reduced effect. Third, drug withdrawal results in symptoms relieved by drug intake. Fourth, is despite continuous urge to stop the drugs but repeated trials persistently failed. Fifth, longtime, persistent, repeated and failing efforts spent trying to control of the drug intake are signs of drug dependence. Other signs are reduction or missing significant activities whether social, work related, leisure related, because of the individual keeps on taking the drug (Australian Statement of Principles concerning drug dependence and drug abuse No. 16 of 2008).

A frontier community definition, as stated by the National Center for Frontiers Communities (2000) is a community with a population density of less than, or up to 20 persons per square mile. It should be located at a great distance or travel time from the nearest sizable service center (education, or medical) or market. However, this definition does not consider the population characteristics as senior population, income, or health conditions. Nor does it consider whether service centers and markets are within the state borders or not. Therefore, the National Center for Frontiers Communities recommended that states should take part in both defining and designing a frontier community. According to this definition, nine million US citizens live in frontiers communities, twenty-seven states have 97 counties to consider as frontiers communities (The National Center for Frontiers Communities, 2000).

In 2003, the United States Congress passed the public law 107-251 assigning the Secretary of Health and Human Services to define what a frontier area is. The objective was to use the definition in Telehealth programs authorized in that law. The definition bases were mainly population density, and travel distance to the nearest medical facility. The expert panel assigned to examine the definition suggested that frontier areas are those zip code areas fulfilling the following conditions. They should be 60 miles or more far from a nonfederal hospital of at least 75 beds along the fastest paved road. Alternatively, an area on 60 minutes travel time from a similar health facility is a frontier area. Finally, a frontier area should not be a part of a larger rural town of 20000 inhabitants (Center of Rural Health at the University of North Dakota, 2006).

Epidemiology of adolescent substance use

Evelyn and McKnight (2007) stated that in 2001, 1.9 million US adolescents (between 12 and 20 years) were heavy alcohol drinkers. The cut off point is 14 drinks a week or 4-5 drink at a sitting for males and female heavy drinkers were those who had seven drinks a week or three drinks at a sitting. While 4.4 million were not heavy but overdo drinkers. The problem is not a US problem solely, Evelyn and McKnight (2007), reviewed UK, and Brazilian epidemiological studies and inferred that in UK, 20% of adolescents at 12-13 years consume alcohol. The rate rises with increasing age to reach 50% by the age 14-15, and 70% at the age of 17. In Brazil about 90% of students between 8^th to 11^th grades reported trying alcohol.

Klein, Shane, and Barry (2003) reviewed the results of 2002 National Survey on Health. They pointed to more than 17% of adolescents aged 12-17 years included in the sample reported drinking alcohol once during the last 30 days before the survey. Over ten percent of the sample’s adolescents reported, overdo drinking, and another 2% reported heavy drinking. About illicit drugs, 11.6% of adolescent included in the survey reported using illicit drugs at least once during the last 30 days before the survey. Over eight percent reported marijuana and 5.7% reported methamphetamine or other drugs. There were no significant differences between males and females about alcohol or illicit drugs use. Twelve percent of eighth grade adolescents reported drinking alcohol at least once in the last two weeks before the survey. More than three percent of 12^th grade adolescents reported drinking alcohol daily for the past month before the survey. For illicit drugs, 10.4% of 8^th grade adolescents reported illicit drug use in the last month before the survey. The survey also showed that 21.5% of 12^th grade adolescents reported using marijuana at least once in the last month before the survey. Overall 6% of adolescents included in the survey sample used marijuana on daily basis during the last month. Klein and colleagues (2003) reported that black adolescents used alcohol less than white and Hispanic (23.7%, 50.4%, and 49.2% respectively). Further, 13.3% of adolescent included in the survey reported driving after drinking alcohol, and 31% reported being with someone driving after drinking alcohol at least once in the month before the survey (Klein and colleagues 2003).

In 2006, the National Survey on Drug Use and Health displayed that 25% of adolescents between 12-20 years were current alcohol consumers. Besides, 20% drove under the influence of alcohol in the last 12 months before the survey. Further, the survey showed that 1900 deaths under 21 years take place yearly in car accidents under the influence of alcohol. The survey showed that 30.3% of adolescent included drank alcohol in their homes. More than ten percent of males drank in a club or a restaurant compared to 20% of females included. The report called to increase parent mentoring and to readjust current prevention tools (The NSDUH Report, 2008).

Although drug use varies among frontier, rural, suburban, and urban communities, yet some characteristics of frontier communities make the depiction taken. These features are poverty, as 50 of the poorest counties in the US are frontier counties, adolescent under 18 years represent 26.7% of the population (compared to 25.7% in other areas of the US).

Opposite to public perception and to the picture drawn by the media, adolescent in frontier communities are at similar or even greater risk of drug use. They are prone to the same stresses and persuasions as their counterparts all over the US. In addition, frontier counties’ adolescent have lower rates of finishing school study and attending colleges (The National Clearinghouse for Frontier Communities, 2003).

Based on the report of the National Clearinghouse for Frontier Communities, 2003, alcohol use by frontier communities’ student is similar to their counterparts all over the US. In addition, as it is the case all over the US, alcohol drinking and tobacco smoking dominates over illicit drugs use. The association between drinking and driving is higher in adolescents of frontier communities. This is because of lesser means of entertainment, and greater distances to the nearest activity centers. Particular to frontier communities with large population of Indian Americans and Alaska natives is the higher rate of illicit drugs use, 23% of these adolescents between 12-17 years used illicit drugs.

Drug use on regular basis is of smaller rates among adolescents in frontier communities. Forty eight percent of adolescents who smoke are prone to use illicit drugs compared to 5.3% of nonsmokers. Further, 65.3% of adolescents who drink alcohol are prone to illicit drugs use compared to 5.1% of non alcohol users (The National Clearinghouse for Frontier Communities, 2003).

Risk and protective factors for adolescent substance use

Awareness of risk and protective factors besides reducing risk and enrichment of protective factors (encouraging buoyancy or resilience) are the center of any prevention program (Office of Drug Control Policy (b), 2002). Based on the Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking Report (2007), a risk factor is the quality, characteristic, or vulnerability factor. This factor makes an individual more prone to develop a disorder more than a randomly selected individual from the general population. Risk factors should, therefore, precede the onset of the disorder; they are dynamic, which means they are changeable because of individual’s development or a newly evolving stressor in an individual’s life. Risk factors assigned to the individual, family, society or institution (work, education, prison…). Risk factors can be unchanging, like gender or family history or altered by interventions, like education level or exposure to maltreatment. Protective factors are those which improve an individual’s response to a stressor, in other words they produce a better adaptive adjustment and influence the response to risk factors. Buoyancy or resilience construction correlate more to protective factors, as well to the individual’s competence to withstand a stress or recover from psychological trauma induced by others. Recognizing risk factors is essential to identify populations where intervention is likely to produce best results. Thus prevention depends on marking risk factors that are more compliant to alter by intervention, and seeking out protective factors to augment and improve (the Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking, 2007).

Risk and protective factors to adolescent substance use

Beman (1995) recognized risk factors that make adolescents more vulnerable to drug use and abuse. They are population’s characteristics (demographic), collective communal, behavioral, and individual risk factors. Wright and Pemberton (2004) summarized the risk and protective factors for drug use in adolescents as follows, based on data taken from the 1999 National Household Survey on Drug Abuse.

Factors related to community

The survey showed that adult neighbors strongly disapprove their neighbor adolescent smoking cigarettes daily, drank alcohol daily, or tried marijuana. Ratios ranged between 75% and 65% and were highest on trying marijuana, and lowest on daily smoking. Easy getting hold of marijuana reported by 57% of adolescents, and there was no difference between White, Hispanic and Black adolescents. However, White adolescents reported more local community orderliness and less ineptitude (Wright and Pemberton, 2004).

Family related factors

Most parents disapprove their children smoking cigarettes, drinking alcohol or trying marijuana. Rates ranged between 95% for trying marijuana, to 85% on smoking cigarettes. Fifty seven percent of adolescents reported they have had a conversation, at least once, with one of their parents on the hazards of drug use during the 12 months before the survey. Whites and Hispanics reported parent communication on the subject more than Black counterparts. About parent mentoring, 81% of adolescents reported parents’ help in homework, but 39% reported parents limiting TV watching time (Wright and Pemberton, 2004).

Factors of the individual realm

Almost two thirds of the adolescents included in the survey (64%) reported they would strongly disapprove their counterparts trying marijuana. On the other hand nearly the same rate (63%) reported their friends would strongly disapprove them trying marijuana, repeatedly drinking alcohol or heavily smoking. Most adolescents included (57%) reported they realize the hazards of smoking marijuana even once or twice a week. About religious beliefs, the survey results displayed that 80% of adolescent think that religious belief is an important part of their lives, and 74% reported they influenced their decision in various sides of life. Further 37% reported that their friends share the same concepts about religious beliefs. Male adolescents reported less appreciation of the hazards of substance use and abuse than female counterparts. Adolescents aged 15-17 years showed higher perception and more positive outlook to substance use than their 12-14 years counterparts. About aggressiveness, 22% of adolescents included in the survey reported they had a serious fight whether at school or workplace during the last 12 months before the survey. Interestingly, 8% reported they attacked someone intending to induce injury during the same period (Wright and Pemberton, 2004).

School factors related to substance use

Most adolescents included in the study reported they would have serious troubles in schools if found using marijuana, drinking alcohol, or smoking with rates of 95%, 86%, and 63% respectively. Despite that, 23 % of adolescents reported their friends in the school have used marijuana at least once. On the bright side, 77% of adolescent reported receiving at least one school notice about hazards of substance use. White adolescent reported lesser bond to school rules than their Hispanic or Black counterparts (Wright and Pemberton, 2004).

Wright and Pemberton (2004) inferred that after adjusting the variables of age, gender, ethnicity, and community demographic differences, there is a strong association between risk and protective factors. Prevention message from the school and church have strong influences on adolescents. Also, parental communication, mentoring, stronger controls on substance use in school have strong influences on adolescents about substance use. Table (1) summarizes the risk factors for adolescent drug abuse among other psychosocial phenomena (Catalano and Hawkins, 1996).

Risk and protective factors to adolescent substance use in frontier communities

The 2003 report of the National Clearinghouse for Frontier Communities points to the following key issues about specific risk and protective factor for substance use in frontier adolescents. The literature researching high risk behavior in frontier adolescents is deficient. It also overlooks specific issues of risk and protective factors to drug use in frontier adolescents. The report included data on rural areas’ adolescents in many areas where data on frontiers adolescents are not available. The report pointed to the relationship between poverty and serious emotional disturbances among frontier’s adolescents which may lead to substance abuse. The report also represented the lack of trust of frontier’s adolescents in health professionals to discuss their problems and assigned this to frequent turnover of health professionals in these communities.

Frontier communities’ poverty and behavioral health problems reflect on the family life of these adolescents. Besides, gun carrying being more acceptable in these communities and rural ones marks the problem of increased societal hazards of drug use. Finally the report associates violence and drug use irrespective of the degree of drug use involvement. Another area where specific data on frontier communities are deficient is the education drop out rate. Although data suggest slight differences between rural, frontier, and urban education drop out rates. However, return to education after dropping out is higher in urban and suburban communities than others. Many expect schools in frontier communities to provide an individualized mentoring and guidance than those of urban communities. However, the trend of combining schools into a single education mass (school consolidation) disrupted this advantage (the National Clearinghouse for Frontier Communities, 2003).

Etiology of adolescents substance abuse

Etiology is to describe a disorder’s causes. It reflects the scientific research into the disorders’ origin on biological, psychological, or socio-cultural basis. What adds to the etiology complexity of a disorder is often the presence of a combination of many causes. An understanding of the causes is important for effective treatment and specific for psychology, a comprehensive understanding is critical for behavior modification (Benner and Hill, 1999). In exploring the huge landscape of gathered data about the etiology or casual factors of adolescent substance use, the factors responsible for inappropriate substance behaviors are complex and multifaceted. The processes and interactions of various factors which may predispose or lead an adolescent to engage in substance use are ambiguous. For the sake of briefness, the four basic approaches of research into understanding the etiology of substance use and misuse will be reviewed. These four considerations are the biological-genetic, the psychological, the psychosocial, and the sociocultural considerations.

The biological-genetic considerations

One major part of the biological research has postulated a theory which suggests the genetic or hereditary familial transmission of alcoholism (Cotton, 1979, Goodwin 1986, Dawson, Harford, and Grant 1992). The theory is based mainly on the high correlation found between the incidences of alcoholism among the offspring of known alcoholics. The research interpretations signal that biological sons of alcoholics are four times more likely to become alcoholics than those sons whose biological fathers were not alcoholics (Goodwin 1984). The twin studies conducted in Sweden and Finland, and the adoption studies in Denmark beginning in the 1970’s support such a view. The data from the twin studies displayed a higher evidence of alcoholism among identical twins than non identical twins. The results of the adoption studies further underscored the validity of the theory of genetic transmission. It was found that biological sons of alcoholic fathers, adopted in the first few weeks after their birth, were still four times more likely to develop alcoholism regardless of who raised them (Monteiro and Schuckit, 1988). Based on this study, a further distinction can be made, suggesting a clear outline between familial transmission, and the possible impact of environmental factors. The eventual alcoholism syndrome appears uninfluenced by the environment of the substitute family as shown with adopted sons (Goodwin 1986). Although the data suggests a strong genetic factor, it is significant to note how genes are transmitted and how environmental factors interact with inborn traits to cause the disorder is not yet known. It is also noteworthy that purely genetic factors cannot fully explain the etiology (Dinwiddie and Cloninger, 1991).

The second major part of biological research into the etiology of substance use focuses on specific organs or organ systems. Research endeavors to find out the genetically programmed effects mediating or influencing biological functioning are not yet complete. Researchers have suggested that genetic origins have affected some functions in such a way to influence individuals having certain vulnerabilities or tendencies to develop substance abuse (Schuckit and Smith1996). The effects of low levels of aldehyde dehydrogenase, and the responsiveness to the chemical neurotransmitter serotonin are examples of the factors considered as probable influences to develop a tendency to alcoholism (Schuckit 1994).

The principal hypothesis of biological and genetic etiology for drug use is parent transfer genetic tendency to substance use to their children. It shows in adolescent temperament, brain response to different doses whether large or small, and susceptibility to unfavorable outcomes (Sheckter, 2000). Silberg and colleagues (2003) examined genetic and environmental inclination to substance use; their results showed that genetic transmission was more prevalent in female adolescents with substance use. Genetic factors were also important in the association between substance use, conduct disturbance and depression in female adolescents. Environmental factors evinced by family failure to provide a healthy environment and abnormal company influenced adolescent males more than genetic factors. However, about association of substance use, conduct disturbance, and depression genetic factors played a role, but environmental factors were dominant.

Spears (2002) reviewed the biological basis of brain development in adolescents and the influence of neural changes on the tendency of alcohol use and abuse. Spears (2002) suggested the main characteristics of adolescent brain are developmental changes of the prefrontal cortex, stressor sensitive areas in the forebrain that are dopamine dependent. These areas are part of the neural network responsible for adjusting the incentives for alcohol use. Another characteristic suggested by Spears (2002) was adolescent brain shows signs of augmented stressor reaction. Of equal importance adolescent brain shows modified sensitivity to alcohol effects. The author inferred there is a need for further studies to examine if alcohol use during adolescence results in disturbing maturation of alcohol sensitive brain areas.

The Psychological considerations

Psychological factors influencing substance use in adolescents refer to the models and patterns of thinking and behavior. Examples are personality characteristics, self-image, and adjustment skills (Deas and Thomas, 2002). Sheckter (2000) reviewed the various psychological theories that influence adolescent risk to develop substance use problem, these are:

Considerations on self-image, social-image, and self-disparagement (derogation)

Adolescent self-image and social image about substance use mainly smoking and alcohol drinking are affected by three factors, first is the consistency factor, which is self-ideas and concepts are consistently related to the substance used (consistency hypothesis). Second, is whether adolescents’ ideal self-image relates to the substance use, this is the self-enhancement hypothesis that is improving one’s image or adding strength, worthiness or a desirable characteristic. Third, is whether substance use impresses friends, and this is the impression management hypothesis (Chassin and others, 1985). Chassin and other (1985) analyzed the drinking behavior in 266 adolescents in a suburban high school and inferred alcohol drinking behavior follows both consistency and self-enhancement theories. They also inferred that male adolescents’ intent to continue drinking alcohol relates to consistency and impression management theories, while adolescents’ females intents relates to neither of these theories.

Self-disparagement (derogation) hypothesis correlates to self-confidence (self-esteem) reasoning. This means the personal need of augmenting positive self-attitude skills or knowledge (Sheckter, 2000).

Personality hypothesizes

They consider substance abuse a display of a personality disorder. In Freud scholars’ terms, substance abuse reflects a passive, dependent personality, which suffers oral frustration (expression of explanation). In mid 1950s, the domain of personality disorders became important in identifying users. In this framework, the Minnesota Multiphasic Personality Inventory, 1969 represents a cornerstone. Based on this inventory, there are five personality traits related to substance use, insubordinate, feeling inferiority leading to passive belligerence, chronically distressed personality, and demanding personality (Sheckter, 2000).

Tension lessening hypothesis

Based on this hypothesis, states like stress and anxiety give reason to act aggressively. Such conditions can be an enough steer for substance use and abuse (Sheckter, 2000).

The psychosocial considerations

Lee and colleagues (2004) suggested that social learning is the main psychosocial theory that determines adolescents’ drug use among other unacceptable behaviors. The central hypothesis of this theory is development of behavior takes place through observation and underpinning. In other words an individual learns new behaviors by watching a model presentation, be present at the onset, and is impressed by the behavior to reproduce it. Sheckter (2000) explains this theory’ influence on adolescent substance use, not only about picking up the habit of substance use but also in picking up the behavior and conduct associated by mimicking those accompanying in the primary involvement. Social learning theory has two principal constituents (as suggested by Sheckter (2000), self-efficacy and expectancies. Self-efficacy is connected to individual expert skill and complete self-control. Expectancies explain the most probable results accompanying a certain behavior. Sheckter (2000) described a practical example, if Y watched X having few drinks then successfully asked a young woman for a date, then if Y drinks alcohol it may improve the chances for similar successful results.

The second hypothesis is the social control theory first described by Hirschi (1969) (after Sheckter (2000). The hypothesis assumes that unfavorable adolescents’ behavior is not an eccentric abnormality. Alternatively it is an inherent trait of adolescents. In this sense, unfavorable adolescent behavior does not merit explaining and efforts should be directed to explain its consistency. Based on Hirschi’s hypothesis conventionality or consistency of such a behavior comes from attachment, commitment, involvement, and belief (Sheckter, 2000).

Third is the reputation enhancement hypothesis. The key assumption of this hypothesis is that adolescents choose the social distinctive image they want to promote in their community. The key percept is that defining a unique identity for an adolescent depends on persuading others to define him or her in the way an adolescent wishes. The essential tools to achieve this are the alternatives an adolescent considers, descriptions and details and justifications given (Sheckter, 2000). Fourth is the problem-behavior hypothesis. It is the behavior that is far from accepted socially and legally and is disapproved by members of society and institutional authorities. The principal objectives of this hypothesis are three shared socio-psychological prominent schemes, the personality scheme, the behavior scheme, and the recognized environment scheme (Sheckter, 2000). These schemes interact to produce susceptibility to problem behavior (Sheckter, 2000).

Morton (2007) examined the eventual relationship between adolescents and friends’ substance use (smoking, drinking and using marijuana) and parenting patterns of actions on 2453 6^th to 9^th grades students. The results showed adolescents’ and friends’ substance uses are reciprocally predictable. Parenting patterns of actions turned negative with increased number of substance using friends. Morton (2007) inferred that adolescents’ selection and socialization tendencies are an important part of parenting practice to provide substance use protection.

The sociocultural considerations

Coleman (1980) suggested that drug-taking behavior is a function of certain variables that emerge from the psychosocial environment of the family. Family theories don not focus on individual dynamics as the source of one’s need for drugs. Instead, they focus on the family links, interactions, and functioning patterns as principal factors for compulsive drug abuse. As a subset of psychosocial theory, family systems theory explains how the family through defective behaviors encourages, reinforces, and helps drug-seeking behavior.

Johnson (1980) suggested a theory of drug subcultures to adolescents’ substance use and abuse. The concept of subculture is not the same as a subsociety or the social build up. It does not express a statistical collective (as adolescents aged 12 to 18); and it is not uniform, inert, or closed. Subcultures come about from, preserved by, and change through a complicated progression of interaction including many individuals and groups whether directly or indirectly connected.

Stanton (1980) believed that a family theory of drug abuse explains many behavioral traits of drug abusers that lack explanation by other theories. These traits are the recurring, repeated nature of addiction with associated frequent treatment drop out rates. The family hypothesis looks at changes of patterns of drug use and abuse occurred during a given period, it also explains interpersonal and background variables of drug abuse.

Social learning or modeling experiences, especially negative ones, are causal links to adolescent substance use. Within this construct are the influences of modeled behaviors, expectations concerning the role of alcohol use and their experiences surrounding substance use. Among high risk children several consistent social maladaptive behaviors are implicated. Low parental concern about alcohol use, low parental concern about adolescent alcohol use, and unawareness of the negative outcomes are of significance (Scheier, Botvin and Baker 1997). Mimicking displayed parent’s behaviors, siblings, extended family members, media images, and friends, that suggests that substance use as suitable means of coping with the problems of life. Alternatively, substance use modeling suggests the avenue to becoming admired, attractive, an adult, stylish, or hardy. All the previous demonstrations of actions influences may lead to developing a maladaptive adolescent personal schema (Botvin and Botvin, 1992).

The biological approach suggests a genetically influenced tendency to alcoholism exists in some individuals, especially the offspring of alcoholics. Assuming this theory is correct; alcohol related behaviors should present genetic influence as well. Later alcohol related behaviors become encouraged by the individual’s surrounding social and cultural norms. The surrounding social and cultural norms are those influences produced by the immediate family, extended family, friends, ethnic group, and the larger society (Schuckit, 1996).

In a social and cultural environment where the use of alcohol is usually an accepted delinquency mechanism it is an approved social norm. Further, it is a behavior which carries an inherent expectancy of good times, social reward, and social status. Into such a culturally approved norm, add the relentless advertising on TV aimed at the younger generation, the social roles and clear rewards modeled in various other media formats. With the prevalence of use in adolescents’ immediate surroundings including their community, it is not surprising that adolescents engage in such illegal maladaptive substance behaviors. In contrast, in families and cultures where social use is unacceptable, and alcohol is not readily available, such as in Muslim nations or among religious ethnic communities such as Orthodox Jews and Conservative Christian groups. The incidence of adolescent use is nonexistent or minimal outside a religious context (Carson, Butcher, and Mineka 1998).

Anderson (2000) suggested a cultural identity theory for drug abuse, whose objective is to address substance abuse etiology through appreciating how the adolescent traits and societal environment affect building up drug related unique individuality and drug abuse. In this sense, the hypothesis suggests that drug use and abuse are results of seven change processes of drug related distinctiveness. These are individual lack of attention or will (called marginalization), individual self-esteem problems, and individual limits in identifying an identity. On societal level, two processes are worthy considering, society lack of attention (marginalization), and lack of recognition of what is a drug in subcultural groups. On the wider community level, the notions of popular culture, economic potential and educational facilities play an important role.

Choice among multiple theories in frontier communities

Analyzing the various psychological, psychosocial, and sociocultural hypothesis of adolescent drug use in frontier communities one has to consider features particular to these communities. Compared to urban, suburban, and rural communities, frontier population is poorer and with lower income, as all the 50 poorer US counties are frontiers. Second, the main economic activity in most of these communities is agriculture with the lowest US rate of medical insurance. The frontiers population has the highest rates of behavioral health problems in the US (Frontiers Education Center, 2003).

Another community related factor that needs further examination is the demographic and epidemiological changes that took place overtime. This created an issue of cultural diversity and influenced the social and sociocultural notions of frontier communities (Manson, and Altschul, 2004).

Bokhan and Gusamov (2006), examined adolescents’ mental and behavior disorders leading to substance use in Alaska, and inferred that tension lessening hypothesis, insubordinate personality besides absent motivations are the leading psychological consideration for substance use in that frontier community.

Why frontier communities

American people characteristics date back to their experiences gained during the first 300 years needed to settle in the New World of vast free land and a frontier nature. The succession from a frontier to a mature civilization was not an easy march; it was the frontier experience that heightened the nationalism inner-self and the American individuality. This is simply how frontier contributed to form the American character or frontier theory as explained by Frederick Jackson Turner’s in 1893 (Billington, 1958).

Review to adolescent substance use in Lake County, Oregon

Unique to the State of Oregon is the clear demographic division between the geographic regions east and west of the Oregon Cascades. Population numbers, social norms, political ideology, and lifestyle display the differences. As a result, these differences should influence many surveys of a given population in the State of Oregon. This creates a statistical bias toward reflecting the attitudes, norms and behaviors of the more populated urban areas west of the Cascades (O Hara, 2007).

Recognizing this inherent confounding factor influences on economy, social, and psychosocial impact. Abbott (2006) pointed to assessment of adolescents in such communities in the lights of co morbidity of substance use with other possible coexisting psychological disorders. In addition, Oregon government directed the Northwest Professional Consortium (1998) to assess the Eastern adolescent student population separately. Labeling it as Region 5 currently identified as EOHSC (Eastern Oregon Health Services Consortium) in their research outcomes. This lead Oregon Government to adjust the state general fund division to $17 US a head in Eastern Oregon compared to $2 US a head in Central Oregon (Center for Substance Abuse Treatment, 2006).

Yet within Eastern Oregon region (EOHSC), exists one of the largest, most isolated and least populated counties in Oregon, Lake County. Demographically the county is unlike many of its Eastern County neighbors because of its small population (less than 7,500), its rural isolation, conservative ideology, mostly Caucasian population (tables 2, 3) and severely depressed economy (table 4). Because of its uniqueness, and to achieve statistical accuracy, Lake County populations should be considered separately even from Region 5 (Department of Human Services-DHS, Lake County DataBook, 2002).

Adolescent substance use profile in Lake County

Epidemiological profiles aim to sum up the nature and extent of alcohol, tobacco, licit and illicit drug use and related results in Lake County.

The Oregon Healthy Teens survey is a try to examine the health and welfare of adolescents. Lake County school districts started to take part in the survey in 2004.

First survey (2005-2007) included 65 percent of 8th grade and 69 percent of 11^th grade adolescents. Figure (3) shows the previous month (to survey date) use of licit and illicit substances in 8^th grade and 11^th grade adolescents (2008 Epi Reports of Oregon counties). Figures (4 and 5) show the trends of substance use in the previous month to survey date (2008 Epi Reports of Oregon counties). The survey displayed that alcohol is the most widely used substance in Oregon (DHS report (a), 2008). The review on substance use profile among Lake County adolescents will fulfill alcohol, tobacco, and illicit drugs use.

Alcohol use profile among Lack County Adolescents

Based on data of the DHS (a) report (2008), 430 people in Lake County are alcohol abusers or alcohol dependent. Of them, 34 are adolescents (12 to 17 years), and 129 are 18 to 25 years old. Lake County adolescents start using alcohol before they are 13 years old. In 2006, 36% of eighth grade adolescents reported drinking alcohol in the last month and 15% reported over-drinking. About 11^th grade adolescents, 56% reported drinking alcohol during the same period, 30% reported over-drinking, and further 13% reported driving after drinking alcohol. Comparing 2004 and 2006 figures, eighth grades adolescents’ alcohol use surpasses Oregon state average, while over-drinking is higher although less than state average. For 11^th grade adolescents both last month figures and over-use surpass state average although over-use in 2006 is less than 2004 (DHS report (b), 2008) (figure 6). Comparing data from 2001 to 2007 for Oregon State adolescents, alcohol use among eighth grade adolescent increased significantly. For 11^th grade adolescents the rate of alcohol use is rising with young women showing higher rates than boys do (DHS report (c), 2008). There are three factors to blame for underage alcohol use among adolescents in Lake County. First is easy to access, 51% of eighth grade adolescents and 81% of 11^th grade counterparts reported it is easy to get beer or liquor. Second is, recognized risk of alcohol use, which is low among Lake County adolescents. Third is, parent’s disapproval, most adolescents report parent’s disapproval to smoking more than to alcohol use (DHS report (a), 2008).

Tobacco use profile among Lake County adolescents

Figure (7) shows the prevalence of tobacco use among Lake County adolescents. Eighth grade teen shows a higher rate compared to Oregon adolescent of the same age group. For 11^th grade adolescents the rate is nearly the same. Interestingly, the use of smokeless tobacco has much higher rates for both Lake County eighth and 11^th grade adolescents with young women forming 2% of 11^th grade adolescents using smokeless tobacco. The rate adolescents begin smoking before 13 years in Lake County is almost double that of their counterpart anywhere else in Oregon state in 2004 and 2006. Although buying cigarettes is illegal before 18 years, yet most teens report easy availability from retailers, friends, and parents. In 2004 and 2006, cigarettes availability for Lake County adolescents is higher than that in the rest of Oregon. Perception of smoking hazards is less in Lake county eighth grade adolescents than in the rest of Oregon state counterparts while it is nearly the same for 11^th grade teens. Parent disapproval to smoking is almost the same in Lake County as the rest of Oregon State (DHS (a) report, 2008).

Illicit drug use profile among Lake County Adolescents

In Lake County, nearly 195 individuals aged 12 years or more abusing or dependent on illicit drugs, of them 35 adolescents are between 12-17 years, and 72 are between 18-25 years. Rates of marijuana use are less among eighth and 11^th grades’ Lake County adolescents than the average state rate (6% and 13% for eighth and 11^th grades adolescents respectively). For eighth grade adolescent, inhalant illicit drugs come in second place after marijuana, and for 11^th grade adolescents prescription drugs come in second place (DHS (a) report, 2008).

Epidemiology and risk factors data about Lake County adolescents substance use

Based on data available in the Oregon’s YRBR (Osborn, and Draghia, 1997), the age at which an adolescent starts using a substance is a major risk factor. The Youth Risk Behavior Report (1997) shows that alcohol, tobacco, and marijuana adolescents’ use start before 13 years (29%, 21%, and 11% for alcohol, tobacco, and marijuana respectively). American Indian Oregonian youth showed the highest incidence of starting before 13 years (42%, 37%, and 25% for alcohol, tobacco, and marijuana respectively).

Based on data from data from the U.S. Census Bureau, 2000 and 2001 Supplementary Surveys, and 2002 to 2007 American Community Survey, the Annie E. Casey foundation report on Oregon youth risk factors looked at the following.

1. Income (Poverty): According to poverty level, many adolescents live in families with low income rates than the average US family income rate. The report shows nearly 40% of adolescents below 18 years living in families with incomes lower than 200% of the US federal poverty limit.
2. The report recognized that starting age of substance use is a risk factor and provides recent data that prevalence among Oregon youth is lower than Counterpart adolescent US average for smoking, alcohol, and illicit drugs use.
3. Although the rates of adolescents neither attending schools nor working is almost the same or slightly higher than the US average in 2007, yet the report recognizes low-level education as a risk factor.

In Lake County, there are many high risk factors related to adolescent population. These high risk factors have been used to predict reliably the early onset of substance use and abuse. Among those identified easy availability of drugs and alcohol, the sensed unlikelihood of being caught by the police, expectation of a minor impact if caught, and the prevalence of improperly performing family systems come on the top of the list. Therefore, it is not surprising that despite the recognized conservative, friendly, caring character of the Lake County population, the rates of substance use in the adolescent population are very high. The Department of Human Services-DHS (Lake County DataBook, 2002) summarized adolescent risk and protective factors as they relate to Lake County adolescents. Both groups correlate to community, family, school, and peer or individual domains (Appendix A).

In 2000, the Oregon research Institute in Eugene conducted a survey using the combined tools of OADAP, and the YRBS. Therefore, survey results of 1998-2000 are not parallel to those of 2000-2002, however, the information found are still functional in prevention planning (Department of Human Services-DHS, Lake County DataBook, 2002).

Alcohol is the most prevalent substance used by US adolescent, and Lake County adolescents are no exception. In 2002, more than quarter (25.4%) of Lake County eighth grade adolescents used alcohol within 30 days before the survey compared to 24% of Oregon eight grade adolescents. Among Lake County eighth grade adolescents, 45.4% used tobacco within the same period compared to 44.7% of eighth grade Oregon adolescents. About illicit drugs, 16.9% of Lake County eighth grade adolescents reported using illicit drugs within the same period compared to 18.3% of eighth grade Oregon adolescents. Among 11^th graders, almost half Lake County adolescents (45.4%) reported using alcohol within 30 days before the survey compared to 44.7% of 11^th grade Oregonian adolescents. About illicit drugs, 24% of 11^th grade adolescent used illicit drugs within the same period compared to 26.5% of 11^th grade Oregon adolescents. Interestingly, depression scale among eighth and 11^th grade Lake County male teens was 17.2% compared to 18.7% of their counterpart adolescents in Oregon State. Among female eighth and 11^th graders the depression scale was 36.3% compared to 35% of their adolescents counterparts in Oregon State (Department of Human Services-DHS, Lake County DataBook, 2002).

In 2004, 49% of Lake County eighth grade teens used alcohol at least once during the 30 day before the survey compared to 29% of their counterpart Oregonian adolescent. In 2006, the ratio dropped to 36% compared to 32% of Oregonian teens counterparts. For 11^th grade adolescents the ratio was 54% compared to 45% Oregonian counterparts. In 2006, the ratio increased to 56% compared to 44% Oregonian counterparts. About tobacco, 13% of eighth grade adolescents in Lake County smoked during the 3o days before the survey compared to 8% of Oregon State counterparts. In 2006, the ratio was almost the same for Lake County and Oregon eighth grade adolescents. For 11^th grade adolescents, in 2004 28% reported smoking during the same period compared to 17% of their Oregonian counterparts. In 2006, the ratio dropped for 16% of 11^th grade Lake County adolescents reported smoking during the same period compared to 15% of their Oregonian counterparts. In 2004, 6% of eighth grade Lake County adolescents reported smoking marijuana 1 or more time during the 30 days before the survey compared to 10% of their Oregonian counterparts. In 2006, the ration remained the same for both categories. For 11^th graders, in 2004 20% reported the same frequency of marijuana smoking during the same period; in 2006 13% reported smoking marijuana during the same period compared to 19% of their Oregonian counterparts (DHS (a) report, 2008).

Some of the above figures show improvement as alcohol drinking among eighth and 11^th graders (as shown in figure 6). However, whether these changes are significant or not remains a query. In 2007, the Office of Applied Studies, Substance Abuse and Mental Services Administration, US Department of Health and Human Services conducted an analysis to examine changes in prevalence rates of drug use. The report examined data of 2002-2003 and 2004-2005 surveys across the US. The report used the statistical p value to examine the null hypothesis. About Oregon State, alcohol use, tobacco, and illicit drug use reported in the last month, by age group did not show any statistically significant difference, as p value was always more than 0.05. The overall rate of awareness of the risk of marijuana smoking was significantly different because of different perception of the older age group (26 years and older). This was not reflected in younger adolescent age groups. Alcohol use and ping alcohol use did not show any statistically significant differences in all age groups as reported in last month before the surveys. Tobacco use did not show any statistically significant change (Office of Applied Studies, 2007).

Apart from numbers and figures, a real assessment of changes of epidemiological patterns should include the outcomes of prevention and treatment programs. Abstinence, education drop out, rate of car accidents because of substance abuse, less arrests related to substance use. In addition, improved school behavior and academic performance are among the outcome parameters to be included. Thus noting outcome measures is an important part of understanding the numbers (Governor’s Council on alcohol and drug abuse programs, 2007).

Introduction to the Botvin Lifeskills Training Program

There are two principal approaches to deal with adolescent substance use, the interactive and non interactive. The interactive approach centers mainly on interpersonal interactions. The underlying belief is peer influence is one of the most powerful causal factors in developing illegal substance use. This approach postulates that acquisition and practice of interpersonal skills, the incorporation of appropriate intrapersonal beliefs and processes. Conjunction of developed skills with increased substance knowledge; makes adolescents develop a strong anti-drug value system. They will also acquire a more positive personal schema and the appropriate skills necessary to resist influences to engage in such maladaptive behaviors. The Interactive approach is characterized by small group participatory interactions between adolescent peers rather than the didactic or lecture format evidenced in Non-Interactive programs. The instructor in the Interactive program format serves as an initiator, informer, facilitator, and supporter in the implementation of new skills by the students. In small groups, the students discuss and hopefully acquire the newly revealed skills or understandings through applications and practice in simulated real life situations (Tobler 1986).

The foundations of Botvin lifeskills training (LST) program efficacy are:

1. Botvin LST program is evidence based, as 25 years of research and evaluation provide evidence base support to the program.
2. The program adopts a cognitive behavioral approach to develop adolescents’ skills on what they know (cognition), and what they are up to (behavior). In this way as adolescents take part in the program, a change to their health risk behavior crops up.
3. The reasons of why youth become involved in health risk behavior are many and interconnecting. The LST program works on developing three cognitive behavioral skills realms.
4. Repeating and supporting skills is an important technique to attain a lifelong learning experience. Therefore, the program recognizes supplementary booster teaching meeting to increase its efficacy.
5. For learned skills to be a part of the individual’s behavior and become useful, instructive and informative (didactic) approaches are not enough. Practicing these learned skills is the key to success. Therefore, LST program recognizes interactive teaching methods as facilitation, coaching, and feedback to crop up at effectively lifelong practiced prevention skills.
6. Information is important in any prevention program; however, this is true if the learner picks up information that matter stresses it importance. Extra unneeded information may arouse curiosity to try; thus, LST program identifies the principle of less (selected) is more (National Health Promotion Associates, Inc. 2002).

The theory behind lifeskills training is complex and interacting. LST roots in children and adolescents development theories, learning, and behavior theories, which all take part in the development of LST. Each theory provides part of the basis explaining skills development, and a different viewpoint to why these skills are important. Cognitive theories centered on gaining skills view this objective an aim by itself, since developing the capability in problem solving, intercommunication are important for healthy adolescent development. On the other hand, theories centered on behavioral outcomes, view skills development as a means to progress an adolescent to the behavioral, cultural, and social expectations. Lifeskills training has the advantage of making adolescents take part in solving their own problems, and sharing in the process of building up the social norms. From this brief theoretical base, there are three key elements of LST (figure 8). The role of program planners and executives is to configure the teaching logic and strategies needed to develop skills; this is why training on their part is important (Mangrulkar and colleagues, 2001).

Based on the same foundations, Colby and Witt (2000) suggested that lifeskills can be applied in HIV/AIDS, prevention, and to induce nutrition and hygiene behavioral changes among children and adolescents. They also suggested that it is a program to adopt by schools looking for quality outcomes through applying quality educational programs.

Education including lifeskills supports positive actions to develop healthy behaviors. It portrays a special type of developing psychosocial, cognitive, aptitude, and interpersonal skills (decision making, critical thinking, and self-management). The United Nations Office for Drug Control and Crime Prevention (2003) describes LST as a good quality education, which is suitable to probe many UNICEF social, and health themes.

Botvin LifeSkills Training (LST) program is a school based training program aiming to prevent substance abuse and violence. Its target adolescents are those in upper elementary, middle, and high schools. It is fulfilled in one year, however, a two years booster is recommended. LST program has three components that cover the domains necessary to build up skills needed for prevention of substance abuse, mainly resisting friends’ and colleagues’ persuasions and pressures (peer). Besides skills needed to avoid or correct high risk behaviors through an interactive approach. The program’s components are building up drug resistance skill making adolescent identify and confront ideas promoted by friends and media about alcohol, tobacco, and other drugs (ATOD). Second is building personal self management skills in a positive way that is to set aims and maintain their path of progress, and improving decision making by learning how to analyze a problematic situation, and considering the alternatives. Finally, is teaching students general social skills necessary to communicate with others, and to think of healthier choices, in brief how to meet social ideals and how to mix socially with the community. The program requirements are 30 sessions over three years, the first year includes 15 classes, the second year includes 10 and the third year includes five classes, each class is about 45 minutes. On course program assessment is by measuring the outcomes through pre and post questionnaires, fidelity check lists (assess program implementation by teachers), and classroom evaluation following each lesson (National Center for Mental Health Promotion and Youth Violence Prevention, 2007). The program design is suitable to all students irrespective of previous substance use and utilizes various information delivery techniques. Teaching skills is by either instruction or demonstration; skills analyzed to components and delivered through video sessions, an instructor, or a peer-leader. Students are encouraged to practice the skills learned and provide their feedback to help improving skills. The program can be delivered by health professional for purposes as sex education, and AIDS/HIV prevention. Finally, the LST program displays a preference for violence prevention (National Health Promotion Associates, Inc. 2002).

There are many promising and seemingly effective substance-abuse prevention programs; however, evaluation research difficulties are many. These difficulties include inability to generalize the findings, different programs approaches, different target populations, and different outcome measures. Meta-analysis is a quantitative statistical procedure that analyzes findings of many studies, thus, overcoming the problems of small samples and varied results and programs. Meta-analysis provides answers to the critical questions in planning program prevention: What works, and How does it work? Nancy Tobler conducted three meta-analysis studies to evaluate the efficacy of interactive versus interactive approaches in drug abuse prevention. Tobler’s selection criteria were all studies included used quantitative measures to express the results; all studies were on sixth to 12^th grade adolescents, and a matching control group. All studies stated a principal prevention aim (Tobler and Stratton, 1997).

The first Meta analysis study (Tobler, 1986) spotlighted the content of the programs examined. It included 98 studies covering 143 prevention programs strategies. Based on their contents; the programs were categorized into five categories, knowledge only; where the teacher presents the hazardous effects of drug use. Affective only programs relating to an external expression of emotion associated with an idea or action (as self-respect, societal values), third, is combined knowledge, and affective (these type are non interactive). Fourth, are peer programs that encourage colleagues and friends to reject drug use, support developing decision making and communication skills. Fifth are alternatives that include community service, work or job skills, building expert skills, providing outdoor experiences, and support groups. The last two categories adopt interactive strategies, result showed programs adopting any or a combination of the non interactive policies are nearly ineffective. Programs adopting interactive strategies are effective in terms of drug use directly or indirectly by measuring drug use correlates as increasing skills, and favorable behavior changes.

The second Meta analysis study (Tobler, 1993), Tobler examined 595 studies including 120 programs and indicator for success included only self reported drug use results. In this study, interactive strategies were characteristically successful. Tobler inferred interactive prevention programs produce clinical and statistical success rates far more superior to non interactive programs. Interactive success rates were equal for both licit and illicit substances, and community spread interactive programs are even more successful. Finally, it was clear to the author that the program process is pompous to the program content, which explains why interactive programs are more successful.

The third Tobler’s Meta analysis study supported the results of the previous two, besides showing the smaller the program target population, the better the results (Black, Tobler, and Sciacca, 1998). This probably makes interactive programs valuable in preventing substance abuse in frontiers communities as Lake County.

Roona and others (2001) in their Meta analysis study built on earlier studies by Tobler confirmed that lifeskills prevention programs are more effective than social influences programs. However, their results suggested that lifeskills are more effective among preliminary and high schools adolescents but not among middle school teens.

In 2005, the Federal Office of Justice awarded Oregon State one of three unrestricted grants to center adolescent alcohol use prevention efforts on EUDL. The Enforcing Underage Drinking Laws program (EUDL) applies now in Lake County, Wallowa County, and Newport City. A federal contractor and the Pacific Institute for Research and Evaluation provide training and technical help to community alliances addressing the problem of youth underage alcohol use and youth access to alcohol (Department of Human Services 2007).

Since prevention programs need considerable effort and resources to achieve success, most if not all these programs have a political module for sustaining and support. Occasionally, the scientific evidence may be undermined, if the program planners cannot communicate the program basis or get enough support, they cannot implement the program and will get a limited impact (Gilchrist, U.S. Department of Education, n.d.).

Lake County Botvin Lifeskills Training Program

Method

Subjects

Before the actual implementation of the early phase of the proposed three year program, the entire 6^th grade student population (102) of Lake County was given the self-report Life Skills Training Student Survey (1998).

Apparatuses

The survey, prepared by Cornell University, consisted of 50 questions. The questionnaire measured the student’s past and present illegal substance use, perceptions surrounding the prevalence of use among their peers, drug refusal skills, decision making skills, advertising knowledge and resistance skills, anxiety reduction skills, and communication skills.

Procedure

From the 102 surveys, a random sample of 80 was drawn. The weighted number of Lakeview students compared to the small number of North County students (20 in total) was adjusted to grant including all the students of the North County based on percentages of total population represented. The survey was administered again after completing the first part of instruction, in February 2000. The sampling was again random, and the percentages were adjusted to include all the North Lake County student populations. It was noticeable that no detected significant difference between the students in the North County and the Lakeview students.

It became obvious that no statistical data on the effects of the Life Skills Training program in a 6^th grade rural population existed anywhere in the country. A subsequent decision was to bring together a control group of demographically similar 6^th grade students with which to compare our students. All efforts taken to seek cooperating of school principals of comparable student populations immediately outside Lake County such as in Modoc County, California and Harney, Oregon were unsuccessful. Thus, the efficacy of the program had to be determined by the comparison of the self-reported data gathered before and after the instruction period in the same population of students.

Results

Outcomes

The self-reported data gathered from the students before and after the period of Life Skills Training instruction in rural Lake County suggests an overall positive affect in reducing illegal substance use by the 6^th grade student population (Fig. 9). The difference between the before and after survey measures of knowledge, and various related skills were not significant enough to graph. However, the self-reported illegal substance use at the survey interval displayed exceptional declines in all four categories previously measured (Fig 10, vs. Fig 11). Self-reported alcohol use rate decreased by 26%, and cigarette use rate decreased by 37.5%, while marijuana use rate decreased by an astounding 100%. The 6^th grade use of inhalants dropped a significant 20%.

If the course of instruction is evidenced by the pre and post testing results, the program obviously displays a huge reduction in illegal substance use in this student population (Fig 11). In reviewing the post-instruction data survey outcomes, it becomes clear that Lake County 6^th grade student population is way below the substance use norms evidenced in the surveys taken in 1997-1998 (Fig. 10) when compared to the 2000 data collected by the State of Oregon post Lifeskills (LST) training. This again underscores the positive impact of the Botvin LST program has in reducing maladaptive substance use behavior by the 6^th grade Lake County students (Fig. 10, and Fig.11). Appendix B shows the detailed results of this study.

Considering the overall trend in illegal substance use, the evidence points to a significant reversal with increase in use among all the student populations of Oregon compared to the rates of the early and mid nineties. The 6^th and 8^th grade populations of Lake County have also shown similar increased illegal substance use comparable to the norms shown in the State and Region 5 data (Department of Human Services-DHS, Lake County DataBook, 2002).

The data suggest the need to adopt a multi factor approach to understanding the etiology of illegal substance use by adolescents. Despite the many theories, based on biological, psychosocial and sociological research; yet, the complex interactions the different casual factors of substance use are still unknown. At the same time many factors consistently link to an increased tendency to engage in illegal substance use. The data further points to the superiority of the Interactive approach in prevention efforts (8.5 times more successful) over the programs of the Non Interactive type (Roona and others, 2001). In assessing the data collected on the efficacy of the Botvin Life Skill Training program in the 6^th grade population of Lake County, it shows positive affects in reducing illegal substance use by adolescents. The piled up information over the past sixteen years suggests on completing phase three, two years from now. The present group of 6^th grade students should display a significantly lower incidence substance use than previously surveyed 8^th grade students. They should also display more positive adaptive behavior skills, and show an overall sense of positive personal well-being, influencing the youth’s ability to avoid the choice to use alcohol and other drugs.

Other research (United Nations Office for Drug Control and Crime Prevention, 2003) suggested the longer youth can delay or avoid the use of alcohol and-or other drugs; the lesser the risk for substance abuse as an adult. Overall, a lifeskills interactive approach is a more favorable activity approach to Substance Abuse Prevention (Roona and others, 2001). The local Lake County Survey supports the research that suggests the Middle School is the most favorable time for preliminary substance abuse prevention.

Discussion

Understanding substance use in adolescents

Although the use of many substances among adolescents shows some decline in recent years; yet, the pattern of use has changed; and new substances such inhalants and steroids display recent periodic increased use among adolescents. In 2004, the American Academy of Child and Adolescent Psychiatry (aacap) reviewed community studies about substance use. The review showed that alcohol abuse at all age groups In the US ranged from 0.4% to 9.6%. The (lifetime) overall rate of alcohol dependence among all age groups ranged from 0.6% to 4.3% in Oregon State. The lifetime US dominance of drug abuse or dependency varied from 3.3% in 15-year-olds to 9.8% in 17- to 19-year-old adolescents. The review data showed, the age at which trying substances begins has been gradually declining, especially for inhalants (aacap, 2004).

Wu and others (2003) reviewed incidence and prevalence studies on drug use and inferred there is no agreement about definition of lifetime term. Second is definition of the terms; initial use, first time use, and onset of experimentation is controversial. Determination of the age of use is also a subject of variability, is it the age of first trial, or the age at which the first symptom (s) appears? Third observation is, both longitudinal and cross-sectional studies have design and sampling limits, of importance is the risk and protective factors variability across time was undetermined in both studies categories. For longitudinal studies, there are some specific limits including the cost, time-consuming, and drop of individuals for follow up. Therefore, Wu and colleagues (2003) suggest that interpreting studies’ results should be enlightened by the methods used.

Why Lake County?

Examining demographic data and epidemiological data of Lake County displays the following figures. Adolescents up to 17 years age represent 23.6% of Lake County population, of them 19.5% of population below 15 years. Fifty nine percent of Lake County population live at 200% or more below the federal poverty level, of them nearly 25% are in need for prevention services. Less than 2% of Lake County population is receiving treatment for alcohol and other drugs abuse, and nearly 3% receive treatment for mental health disorders other than substance use. Alcohol, tobacco, or other illicit and licit drugs use by Lake County adolescents and adults are higher in than the average of Oregon State (Department of Human Services-DHS, Lake County DataBook, 2002).

Why adolescents?

An analyst should look at substances use as a mass problem among adolescent and adult populations. Adolescents represent an asymmetrical share of this problem as nearly 29% of drug users belong to the young adult and adolescent population. It is true that a minority of drug user adolescent population passes to the dependence or addiction phase; however, substance use is a leading cause to violence, fraud and other illegal activities. Concerns about adolescents’ drug use are because of their impact on cognitive functioning, learning, mood, and concentration. The health effects of these substances shows only after chronic use, so although symptoms of ill health may not show early the expectancy of having an ill adult in the future is high. At some point in development, adolescents experience physical changes, cognitive, emotional, and social functioning developments. Therefore; dealing with adolescents substance use needs conservative, interactive, and innovative approaches (Polich and others, 1984). An observer must recognize that risk factors for adolescents’ substance use are different from those influencing adults’ use. Also, the different standards social acceptance of adolescents’ substance use, and the variability of co morbidity with other psychological problems add to the specifics of adolescents’ substance use. These are the reasons we should prevent adolescents’ substance use before maladaptive patterns become permanent lifetime behavior (aacap, 2004).

Understanding risk factors

An outstanding feature of drug research over the last few years is the increased numbers of various models and theories to explain the problem of drug abuse. In fact, this rapid growth is a sign for the need for a single, summarized, and applicable theory that would allow interested researchers to identify the existence, multiplicity, convergence, and intricacy of the problem. Current theoretical perception of risk factors is a blend of one’s relationship to self, others, society, and nature (genetic or biological). Current theories’ components are; first, initiation, substance use starts as an outcome of involvement with drug using peers (mates). An adolescent who is easily driven (inceptively or influenced), principally with access to drugs, living in a tolerant environment to drug use is especially prone to drug use. Second is the continuation, which is the self-craving to keep on using drugs, with unawareness or carelessness about the outcomes. Third is, transition from use to abuse that is to move from an occasional irregular user in recreational occasions to a regular frequent user. This is the real hazard and is the red line, which if crossed, the adolescent passes to addiction. Because of this, an adolescent needs to engage in prevention program to help cessation. Keeping in mind that relapses are characteristic to addiction but drug users may suffer relapses, as they may occur with preventions of problems other than drugs as obesity (Lettieri and others, 1980).

Risk and protective factors, are principal targets for preventive intervention. The strength of the relationship between exposure to risk factors and the increasing possibility of developing of various behavior problems is outstanding. However, the question is the number of risk factors present is the authoritative predictor of problem behavior or present specific risk factor (s). Therefore, concurrent measurement of a wider selection of risk and protective factors is necessary to forecast the questions of starting and continuation of adolescents’ problem behaviors. Based on research evidence reducing risk factors and supporting protective ones became the focus of many prevention programs (Arthur and others, 2002).

Prevention research still needs instruments to evaluate the broad array of risk and protective factors. Monitoring is one tool; self-reported measures are a different tool that is suitable to adolescents’ surveys. Besides being cost-effective, can measure a broader array of risk and protective factors, they can be designed to suite risk and protective factors specific of a certain geographic area. Further, analysts can use self-report tools to identify changes in risk and protective factors; thus adjust priorities. However, there is no single standard self-report survey tool either for prospective or longitudinal research (Arthur and others, 2002).

Arthur and colleagues (2002) conducted a pilot study of a survey tool designed to suite Oregon State adolescents in sixth, eighth, and 11^th grades. They inferred low correlation between risk and protective factors with demographic variables. Delinquency correlates better with risk and protective factors, in the peer-individual realm, risk and protective factors displayed the highest correlation with substance use. In different domains (community, laws, and social norms) risk and protective factors displayed moderate correlation with substance use. Availability of substances displayed the highest association with substance use. Within the family realm, poor supervision and discipline, and family tolerance to problem behavior showed moderate association with substance use. Low academic achievement and low school commitment proved moderate association with substance use but were the strongest risk factors in the school realm.

Understanding prevention

A prevention program is one directed to a targeted population, but does not address different groups included. An intervention is a program directed to a population subgroup considered at higher risk (Kellam and Langevin, 2007). Thus for every prevention program, there should be a frame or a structure and a strategy. The program skeleton should deal with problems of implementation and upholding (sustainability) (Nebraska Health and Human Service System, 2004).

There are two working prevention outlines; the risk and protective factors frame, and the IOM (Institute Of Medicine) prevention classification based on traits of targeted population (Nebraska Health and Human Service System, 2004).

The principal objective of the risk and protective factor prevention frame is to recognize risk factors and finds ways to minimize risks. With this, the frame focuses on and augments the protective factors that act as barriers to engaging in problem behavior. Risk factors and protective factors exist in central areas of adolescents’ lives as family, school, peers, and the community. Therefore, such a prevention program has to cover communal and cultural, personal and person-to-person relation factors. The risk and protective factor structure includes combined society efforts at all stages of planning and implementation. Such a program works in four domains namely; community, family, school, and individual-peer domain (Nebraska Health and Human Service System, 2004).

As one approach may not work for every group of the target population, different approaches may be necessary to deal with different population groups. The IOM system identifies three different approaches to choose the approach most suitable to the target group. The universal approach, the selective approach, which targets a subgroup considered at high risk. Third is the indicated approach that aims at the subgroup showing early signs of substance use (as those trying with more than one substance) (Nebraska Health and Human Service System, 2004).

Whatever the structure chosen, the structure of a prevention program aims to suit the target population; however, it may include initiatives aiming to change environmental, communal, economic, or policy circumstances. Based on this comprehensive view, a prevention program differs from a prevention policy or a prevention practice. Strategy in its simplest definition is to recognize the consummate way to achieve the advantageous outcomes expected (Nebraska Health and Human Service System, 2004).

Prevention program evaluation

Evaluation is the procedure of analyzing performed to know if the program outcomes are right, to understand the barriers, and recognize defects. In other words it is a process aiming to identify the efficacy of current strategy functioning (Nebraska Health and Human Service System, 2004).

There are three basic units for evaluation: 1) accountability: it is the ability to display to authorities involved that a program works and uses the funds effectively to achieve the aims and outcomes wished (Chinman and other, 2004). 2) Fidelity (reliability), it is the extent of applying the principal components of the prevention program (Chinman and other, 2004). Adjustment (adaptation) that is the ability to change components because of changes in strategy as the program goes on (Chinman and other, 2004). 3) Results (outcome) sustainability, it is the ability to uphold outcomes into the future (Nebraska Health and Human Service System, 2004). A functional prevention program should have a satisfactory sample size for outcome evaluation. It should also cover at least 80% of the targeted population. It should be evidence-based, and should have provided staff training adding to their experience (Nebraska Health and Human Service System, 2004).

Evaluation of Botvin’ LifeSkills Training (LST) program (1982-1995)

Interim effects on smoking

Social influence frame of LST program showed efficacy in short-term smoking prevention. Many showed a smoking reduction rate between 30% and 50% at short- term. Tobacco smoking (experimental or regular) or nonsmoking use as chewing tobacco showed significant reduction in overall prevalence. Testing the improving skill approaches showed 40 to 75 % improvement in smoking rates compared to controls. These studies show that generic skills training approaches to drug abuse prevention can cut cigarette smoking from 40% to 75% (Botvin, 1996). Botvin and Eng (1982); inferred that LST program can reduce regular smoking by 56% to 66% at the end of 1-year follow up. Booster sessions increase the rate to 87% (Botvin, 1996).

Results of studies examining both social influence frame and improving skills approach for interim alcohol and marijuana prevention were similar to smoking. A closer look shows that prevention effects were stronger for cigarette smoking and marijuana use than alcohol. However, about consistency, prevention was more consistent for alcohol use (Botvin, 1996).

Long-Term (enduring) effects

Results from social influence approach follow up studies vary about long-term periods of smoking reduction ranging from one to four years, one study reported long-term smoking prevention for 7 years. However, most studies inferred long-term smoking prevention for 1-2 years (Botvin, 1996). These results cast shadows of doubt that school-based social influence prevention approach is not efficient to produce enduring results. In a randomized control study by Botvin and colleagues (1995), performed on seventh grade adolescents in 56 New York State public schools, LST program reduced smoking, alcohol, and marijuana use rates by 44%. When compared to controls, prevalence rates were 66% less for individual and multiple substance use (Botvin and others, 1995).

Botvin (1996) explained the factors that affect enduring LST program efficacy. First is the duration of intervention, second is the frequency of booster sessions (wearing away of the prevention approach), third is defective fidelity, finally LST program implantation based on confusing or faulty assumptions (Botvin, 1996). Botvin (1996) suggested that LST program is applicable to all ethnic population variations because of the overlap in risk and protective factors affecting substance use in adolescents among ethnic variations. Several studies confirmed this generalizability hypothesis perhaps with some adjustment to suite cultural differences (Botvin, 1996).

Findings of studies on seventh grade adolescents

Botvin and Eng (1982) carried out a study of the LST program on smoking among 426 seventh grade teens from two schools in suburban New York City. The students’ traits were mainly white and belong to middle class families. They excluded pretest smokers; they divided the remaining students into two groups, 120 in the treatment group and 144 forming a control group. Posttest data were collected twice, at three months and one year later after the program started. Botvin and Eng (1982) inferred the first posttest at three months showed less past month smokers compared to the control group (8% and 19% respectively). Last week smoking did not show any significant differences between the two groups. Results showed the opposite trends after one year.

Another study by Botvin, Renick, and Baker (1983) compared the relative efficacy of two different frameworks of LST in prevention of smoking initiation. Their aim was to provide an efficiency test, and to examine the efficacy of booster sessions. The sample consisted of 902 seventh graders from seven public schools in suburban New York; however the student had the same traits as in the previous study. The study showed that past month smoking is significantly less in test group than controls (7% weekly group students compared to 13% in control group). At one year follow up fewer adolescents reported last month smoking (10% to 22% in control group). The study confirmed improvement of cognitive, personal attitude and behavioral changes related to non smoking.

In another study, Botvin and others (1984a) studied alcohol use in a group of 239 seventh grade adolescents from two high schools in New York. Students included were ethnically matched. The study included 94 adolescents as the treatment group and 73 matching teen in the control group. At three months, posttest did not show any significant difference between test and control group; however, six months posttest showed less reported last month alcohol use (12% in treatment group, compared to 26% in control group). Treatment group also showed lesser frequency of alcohol use than the control group.

Botvin and others. (1984b) evaluated the effects of the LST program on smoking, drinking, and marijuana use among 1311 seventh grade students from ten junior high schools in suburban New York. The students’ traits were similar to the previous studies. The authors modified the LST to suite the school where it is carried out so, they peer-led LST in four schools, teacher-led LST in four other schools and the remaining two were control schools. They collected posttest scores four months after the preliminary pretest; thus, they included 1185 students in the analysis. Results of this study display the role that peers play, the study compared two groups one led by peers, and the other was teacher led. Self-reported last month smoking was significantly less in peer led group (15% smoked compared to 22% of the second group). Weekly and daily smoking self-reports did not show significant differences. At four months posttest, alcohol use was also significantly reduced among peer led adolescents, and marijuana adolescents’ use followed the same pattern.

Botvin and others (1990) performed a six-year follow up (longitudinal study) of the efficacy of LST on smoking among seventh grade adolescents that included 5954 adolescents. The schools involved were 56 schools in New York State, and the program was adjusted to schools’ environments with 22 schools as controls. Posttest data were collected just after and one year after program completion (Botvin and others, 1990). They performed a follow up study six years later included 60% (3597) of the adolescents initially at seventh grade and became 12^th graders at the time follow up. They inferred no result erosion occurred after six years among both the treatment and control groups (Botvin and others, 1995a). Results of the first study (1990) showed reduced rates of monthly, weekly, and daily smoking than in controls. This study highlighted the role of peers, as the peer led booster sessions’ group showed significantly less alcohol use than teacher led or control. Marijuana use followed the same pattern. In the six years follow up study (1995a), the lower rate of smoking was not eroded, and heavy smokers rate (pack or more a day) was significantly lower than controls. The six years longitudinal (follow up) study (Botvin and others, 1995a) also showed significant difference between the treatment and control groups about alcohol use but not marijuana use.

In 1989, Botvin and others (1989a) performed another study on 608 seventh grade adolescents in urban North New Jersey. This sample was mainly African-Americans (87%) and 10% Hispanic. Five hundreds and twenty teens completed the program. Results showed fewer last month smoking among the treatment group.

Botvin and others (1989b) performed another study on LST program prevention of tobacco use among 471 seventh grade adolescents in New York. Hispanic adolescents comprised 47% of the sample. A preliminary posttest collected 3.5 months displayed the need to adjust the program because of difference in teachers’ strength of program implementation. Overall smoking was less in the treatment group, and the teachers’ strength of program implementation had a marginal significance. Further insignificant differences observed between control group and low teachers’ strength group.

Another study by Botvin and colleagues (1992) tested LST program efficacy on a larger Hispanic adolescents’ sample of 3153 teens in New York City. They belonged mainly to low income families with different schools’ environments and educational cultures. Posttest data were available after four months from the onset of the program implementation. Four months posttest showed significant less self-reported last month smoking among the treatment group (5.2%) compared to 7.2% among adolescent of the control group. Results of self-reported past week or past day smoking showed insignificant differences between the two groups.

In 1994, Botvin and colleagues studied the LST program efficacy on alcohol and marijuana use among mixed African-American (48%) and Hispanic (37%) 757 seventh grade adolescent. They were all of low income backgrounds, and despite these differences. Botvin and others (1994) applied the same LST program applied on white middle class adolescents; however, the program was adjusted to become culturally centered. In 1995, Botvin and others (1995b) performed a two-year follow up to this study that included 60% of adolescents started the study in 1994. Statistical analysis of the follow up data showed no erosion of the results of the first study. At two years, the skills training group and the culturally adjusted intervention group showed significant difference in the rate of alcohol use. Compared to the control group, results were10%, 6%, and 13 % last month self-reported alcohol use in both groups respectively. Marijuana use showed insignificant differences among the three groups (Botvin and others, 1995b).

In 1997, Botvin and others evaluated the efficacy of LST program on 833 seventh grade multisubstance user adolescents (70% Hispanic, and 26% African-Americans) in New York City. Three months after starting the program, the research team collected posttest data from 87% of contributing adolescents. Botvin and others (1997) showed that LST program resulted in significant lesser adolescent alcohol use about frequency of use; amount used, and reduced drunkenness rates among adolescents of the treatment group compared to control. The study also showed that three months posttest pointed to significant reduction in the frequency of marijuana use.

More recently, Botvin and colleagues (2001a) studied the efficacy of LST program in a large sample of 5222 seventh grade teens (61% African-American, 22% Hispanic). In this study two different prevention programs were implemented, LST for the treatment group followed by booster sessions at eighth grade (2144 teen in 16 schools). The control group composed of 1477 seventh grade adolescents of 13 schools received a regular prevention program. In the treatment group posttest data were collected at 3 months and one year intervals. For the treatment group no erosion of program outcomes occurred because of the booster sessions. At three months posttest there were insignificant differences between treatment and control group about frequency and amount of alcohol use. At one year follow up, both frequency and amount of tobacco used were less in treatment group which points to how important booster sessions are. About alcohol use, irrespective of school environment differences, the frequency of drunkenness not alcohol use was less in the treatment group. At one year follow up, adolescents’ self-reports displayed less frequent alcohol use, lesser amounts used and less frequency of drunkenness. Normalizing the results about the schools’ differences, there were no significant differences about marijuana use in the treatment and control groups at three months and one year posttests.

Botvin and colleagues (2001b) followed up the same adolescents’ sample in their eighth and ninth grades. Fifty eight percent of the starting sample continued both the one and the two years follow up assessment. At one year follow up only binge alcohol users were significantly less, and at two years follow up, the binge users’ rate remained low.

Spoth and others (2002) tested the efficacy of LST on 1664 seventh grade teens from 36 rural schools in the Midwest. However, the research team applied Strengthening Families program (SFP) in conjunction to LST. After one year the research team collected posttest data from 83% of the student sample included. After one year of program implementation, Spoth and colleagues found no significant difference between treatment and control groups concerning initiation of smoking. About alcohol use, combined LST and Strengthening Family Program resulted in significant lower rates of alcohol use in the treatment group. While the LST only adolescent less significant program outcome. About marijuana, the rate of new users was significantly lower in the combined programs treatment groups.

Griffin (2003) applied Botvin methods used in the (2001a) study to examine the efficacy of Botvin’ LST program in a group of identified high social risk adolescent. The sample consisted of 15% of Botvin’s 5222 sample (2001a). At one year follow up, Griffin and colleagues reported significantly reduced rates of alcohol use but not marijuana among the treatment group.

One last word

The previous discussion might appear confusing about the usefulness of Life skills as a prevention approach, however successful implementation of the program needs providing apt information about substance use. Implementation of Life skills needs sociocultural community readiness that is the extent of how a community is prepared to plan for, take action, and contribute to solve a problem. Readiness is an essential association to strategy selection, since different prevention strategies are suitable for various levels of community readiness. The principal questions about Life Skills are how to measure its outcome, and of equal importance, what are the outcomes sought. There may different viewpoints about the satisfactory outcomes, some think they are to stop substance use, and some think it is what to drink rather than how to drink. An inherent problem not only for Life Skills is adjustment to psychosocial and person-to person variables (WHO, 2003). Another factor that might be responsible for the variability of results is the diversity of program providers, as some are colleges’ students; some are members of research teams, or schoolteachers. It is clear from the previous review that peer leadership is important to achieve satisfactory outcomes, so selection and training of program providers is an essential part of a successful LifeSkills Implementation (Botvin, 1996).

A successful Life Skills or any other substance abuse prevention program needs long-term instrument, research, and funds, besides active student involvement, user-friendly materials and peer leadership modules. It remains that LifeSkills contributes to behavior development building up a positive behavior to adjust effectively to the stress of daily life. It can be useful in prevention of other youth problems as violence, and self-destructive behavior. Sex education based on Life skills may contribute to prevent AIDS/HIV spread (WHO, 2003).

Early adolescence (6^th to 8^th graders) represent a crucial time for adolescents to engage with, motivate, and guide young teens. During early adolescence, teen often experiment new behaviors and develop attitudes. Without guidance and support, these experimental behaviors may lead to life changing outcomes. Sixth to eighth graders are particularly potentially prone to dangerous peer influences. In addition, because of developmental concerns; they are vulnerable to health effects of substance abuse (Spencer and others, 2006).

The key to a successful prevention program for this age group is to overlook the linear psychological health model, with risk factors at one end and outcomes at the other. Instead, a successful program should consider the social settings and life course between these two points (Spencer and others, 2006). At this age, family involvement is important; Spencer and others (2006) inferred that at this age family criticism of a behavior correlates more to stress than encouragement.

Conclusion

Alcohol, tobacco, and other drug use are important public health problems that start during adolescence to produce its bad aftermath in adult life. Reviewing the literature shows, those programs carried out for drug abuse prevention achieved some success in the past 20 years, and evidence shows that interactive strategies are more effective than non interactive. Besides programs with multicomponent prevention that address risk and protective factors specific for the target population produce better results. In addition, programs addressing multiple substance use have more impact. Programs designed to address other specifics, as age, ethnicity, and other population characteristics are more favorable. It is also obvious peers play an important risk influence or protective role, so they should be included within the program strategy. Programs that strengthen protective factors and decrease the influence of risk factors are most successful. Program supervisors should not be deceived by short-term results; as relapses may occur, and changes of risk factors may mandate changes in strategies. Therefore, programs designed for substance abuse should keep satisfactory length to achieve desirable results. Suitable duration of program implementation ensures better long-term results, prevents relapses, and of more importance guards against the transition from substance use to abuse and dependence.

The LifeSkills training program (LST) is an interactive key program for adolescent substance abuse. The program works on reducing the effects of risk factors and supporting the protective factors, more important it teaches skills connected to social resistance and augments personal resilience. The reviewed finding of LST evaluation studies (small groups, large groups), in various adolescent populations display that LST program induces consistent positive behavior outcomes on substance use. Fidelity, accountability, and continuous evaluation of risk factors are key units for a successful LST program implementation.

Future research should focus on some defective realms in understanding programs designed for substance use prevention and implementation. Research should address the arbitrary instruments through which LST and other programs are efficient. The most advantageous program length to produce enduring impact, an instrument that addresses identifying the most influential risk factors is other areas of needed research. Research needs also to address the problem of transition from substance use to abuse, especially about the deciding factors, program modifications to meet this hazard. Besides, what specific interventions needed to face this problem or prevent it?

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Appendix (A)

Risk and Protective Factors as they apply to Lake County Adolescents

Appendix B

Botvin Lifeskills: 2002 Pre/post test evaluation:

Barbara J. Kiely, Program Manager Lake County Mental Health/LCSNW Alcohol & Other Drug Abuse Programs 526 Center Street Lakeview, OR 97630 (541) 947-6021 ext.31 [email protected].

About how often (if ever) do you:Smoke cigarettes, drink alcohol, smoke marijuana, sniff inhalants or use other drugs?

How many people your age do you think? Smoke cigarettes, drink alcohol, smoke marijuana, use cocaine or other hard drugs, and sniff other things to get high?

How many adults do you think? Smoke cigarettes, drink alcohol, and smoke marijuana, use cocaine or other hard drugs?

How likely would it be for you to say “No” when someone tries to get you to: Smoke cigarettes, drink alcohol, smoke marijuana, use cocaine or other hard drugs, or inhale other things to get high?

If someone asked you to smoke, drink, use marijuana or other drugs, would you: tell them no, tell them not now, I don’t want to, make up an excuse and leave?

When I have a problem or need to make an important decision: I Get more information needed to make the best choice, think of ways to solve the problem, think what will happen for each choice before doing it, make the best choice and then do it.

When I see or hear an advertisement: I think about whether what the Ad says is true, remind myself that the Ad is trying to get me to buy what they are advertising, and tell myself that advertisements are not always truthful.

When I see or hear a cigarette Ad: I tell myself that smoking cigarettes will not make my life better.

When I see or hear an alcohol Ad: I tell myself that drinking wine, beer or liquor will not make my life better.

When I feel anxious: I relax my muscles in my body, imagine myself in a peaceful place, tell myself to feel clam and not worry, breath slowly while I count 4 in and 4 out, practice doing whatever makes me feel nervous until I feel more confident.

When I want people to understand me: I make sure what I say matches my tone of voice, how I stand, and the expression on y face, talk in a way that is clear and specific.