2. Schools-Based Drug Prevention and Education
Outcomes from drug education and prevention in schools
In order to determine 'what works' in drug prevention and education, an understanding is needed of what outcomes are being sought from drug education and prevention in schools. The main aim of prevention interventions delivered to children and young people in schools is not simply to increase knowledge and understanding of the issue, but also to deter or to delay the onset of substance use by providing all individuals with the information and skills necessary to prevent the problem  . The EMCDDA states the primary outcomes are: Reduction of substance use (in both the short term and long term), reduction of risky behaviour and reduction of intention to use. The EMCDDA do not include outcomes related to knowledge and/or awareness of drugs risks, despite often being included in studies, as these are 'surrogate' ones, i.e. there is no evidence that awareness or knowledge has an impact on drug use. Other outcomes used include delayed initiation of drug use and prevention of the transition from experimental use to addiction (Strang et. al., 2012).
Models of drug prevention in schools
There has been considerable change in the approach taken towards drug education and prevention since the 1960s, both in Scotland and abroad. The fear based and consequences approaches were discredited in the 1970s and generally replaced by the provision of factual information (De Haes and Schuurman, 1975). More recently, evidence has shown the importance and promise of programmes that combine life skills, resistance skills and normative education approaches.
There are numerous models for approaches to universal schools-based drug prevention, based on different theories about the most significant factors determining drug use. The most recent classification used in the Cochrane review by Faggiano et. al. (2014) was developed by Thomas (2013) and is based on the categories used in the companion Cochrane review of smoking. This is not the only categorisation - there is no universally agreed categorisation of programmes, by theory, content or process (James, 2011). In reality programmes often do not fit neatly into one category or another (particularly when implemented by those who did not design the programme), often conflating with other approaches, which makes it difficult to unpack the key elements of an effective approach (Stead and Angus, 2004). However, this categorisation does provide a framework to understand which programmes show more or less evidence of effectiveness. The descriptions are verbatim from Faggiano et. al. (2014):
1. Knowledge-focussed curricula (courses of study) give information about drugs, assuming that information alone will lead to changes in behaviour. Knowledge-focussed interventions are based on the assumption that a deficiency of knowledge regarding the risk and the danger of substance use is the cause of use and abuse, and that increasing knowledge should influence and lead to a change in attitudes toward drugs (from positive to negative) and consequently influence behaviour.
2. Social Competence curricula are based on the belief that children learn drug use by modelling, imitation and reinforcement, influenced by the child's pro-drug cognitions (perceptions), attitudes and skills. These programmes use instruction, demonstration, rehearsal, feedback and reinforcement, etc. They teach generic self-management personal and social skills, such as goal-setting, problem-solving and decision-making, as well as cognitive skills to resist media and interpersonal influences, to enhance self-esteem, to cope with stress and anxiety, to increase assertiveness and to interact with others. Social competence approaches are based on the assumption that youth with poor personal and social skills (poor self-esteem, low assertiveness, poor behavioural self-control, difficulties in coping with anxiety and stress) are more susceptible to influences that promote drugs (Griffin 2010). These interventions teach general problem-solving and decision-making skills, skills for increasing self-control and self-esteem, adaptive coping strategies for relieving stress and anxiety, and general social, communication and assertive skills.
3. Social Norms approaches use normative education methods and anti-drugs resistance skills training. These include correcting adolescents' overestimates of the drug use rates of adults and adolescents, recognising high-risk situations, increasing awareness of media, peer and family influences, and teaching and practising refusal skills. Social norms approaches are based on the assumption that substance use is a consequence of an inaccurate perception and overestimate of substance use among peers. This overestimate can lead to the perception that substance use is a normative behaviour, which could increase social acceptability among peers. This kind of intervention also teach strategies to recognise and resist peer and media pressures, for example resistance skills training and 'say no' techniques (Griffin 2010).
4. Combined methods draw on knowledge-focused, social competence and social influence  approaches together.
Findings on universal school-based prevention for illicit drug use
The aim of the Cochrane review by Faggiano et al. (2014) was to evaluate the effectiveness of universal school-based interventions in reducing drug use compared to usual curricula activities or no intervention. The review found that programmes based on a combination of social competence (which aim to improve personal and interpersonal skills) and social influence approaches (focussed on reducing the influence of society in general on the onset and use of substances, by normative education for example) had better results than the other categories and showed, on average, small but consistent protective effects in preventing drug use. Information provision alone, or knowledge based interventions were not found to be an effective strategy and showed no differences in outcomes, apart from knowledge, which was improved amongst participants in the programme.
Most of the programmes included in the studies evaluated were based on a social competence approach. These programmes showed a similar tendency to reduce the use of substances and the intention to use, and to improve knowledge about drugs, compared to the usual curricula, but the effects were rarely statistically significant. Programmes based on social influence approaches were assessed in eight studies and showed weak effects that were rarely significant. With regards to 'hard drugs' (heroin, cocaine and psychedelics), only 2 of the 51 studies analysed in the review found that universal school based programmes had significantly slowed the frequency of use of hard drugs and these were variations in the same US programme. It was unclear whether this effect was due to the programme itself or the quality of delivery /specialists compared to normal teachers delivering comparison cases  .
Some programmes also showed counterproductive effects, for example the affective strategy of the Smart Program (SMART, 1988), which demonstrated a significant increase in the use of marijuana, and ‘ALERT’ which demonstrated an increase in the use of other drugs (ALERT, 2009).
These findings are consistent with those in the alcohol and tobacco Cochrane reviews, and while useful in demonstrating what type of approach is likely to be more effective, the effects of school based programmes are small. The authors state that these findings cannot be used to conclude that all programmes using the combined social competence and social influence approach will be effective, as they observed considerable variability in the results within the same approach (possibly because of the variability in outcomes and scales across the studies). Since the effects of schools based programmes are small, Faggiano et. al. conclude that these should form part of more comprehensive strategies for drug use prevention, in order to achieve population level impact. The authors also suggest that what really matters is the programme itself, and named some programmes as showing consistent patterns of positive results that can be recognised as effective, such as 'Life Skills Training' and 'Unplugged'. See section on manualised and licensed evidence based prevention programmes (page 25) for more detail.
Components of effective schools based drug education and prevention
Besides getting the right theoretical model of drug education and prevention delivered in schools, other components determining effectiveness also need to be considered, such as how, by whom and to whom the programme is delivered. It is difficult to unpick the key components of effective programmes but the following are considered central. Firstly, the delivery process and methods of programme delivery are integral to the success of education and prevention interventions. Interactive programmes are those with a higher amount of participation by students, through discussion, brainstorming or skills practice (Stead and Angus, 2004). The most interactive programmes include all participants and include participation between peers, while the least interactive comprised of teachers presenting information or leading discussions (see chapter 3 for discussion of peer-led interventions). There is strong evidence to show that programmes which include student to student interaction and active learning are more effective at influencing drug use behaviour than non-interactive (passive and didactic) programmes (Stead and Angus, 2004).
Secondly, Stead and Angus (2004) find from their review of the literature that there is modest evidence to show that multi-component drug education programmes (those that include a school curriculum as well as other components, e.g. a media campaign, parent programme or policy activity) or those which target a young person's environment (school, family or community) are more likely to be effective than single component programmes that target just the individual. There is also evidence that environmental interventions - those which target the school teaching environment rather than the individual - can be effective in reducing other risk taking behaviours in young people (Stead and Angus, 2004).
Thirdly, the timing of interventions is important and need to be age appropriate, as the age at which the intervention is delivered can have an impact on the programme's effectiveness. Chowdry, Kelly and Rasul (2013) write that timing is important in any intervention to reduce risky behaviour, and it needs to be early enough to be preventative (before young people begin to experiment and engage in the risky behaviour) but also timed to be relevant, as intervention too early can be a wasted effort. McBride (2002) echoes this but also stresses the importance of drug education continuing as young people mature, so they have the knowledge and skills to deal with risky scenarios as they present more regularly as they grow older (McBride, 2002 in Midford and Munro eds., 2006). Stead and Angus (2004) reviewed the evidence on effectiveness of drug education at specific ages and found that it does not appear to be more or less effective at particular ages. However, Midford and Munro (eds., 2006) state that the research evidence shows the transition from primary to secondary school is the best time to start drug education (Midford and Munro eds., 2006, p220). They also argue that timing of drug education should be influenced by drug use prevalence data for the target student population, as these can indicate 'critical change points'. While most drug education programmes are targeted in the early years of high school (12-13 years old typically), often no rationale for this choice of age group is given (Midford and Munro eds., 2006, p220).
Fourthly, in terms of who delivers the intervention, there is evidence that peers should be involved in (although not necessarily lead in) programmes, and also that trained teachers and health professionals can be effective (Stead and Angus, 2004; UNODC, 2015). It is likely that the success of the 'delivery agent' will be closely bound up with the type of programme being delivered, the amount and quality of training they receive, how credible the person delivering the programme is considered to be by those receiving the programme, and importantly, how well the programme is implemented.
Faggiano et. al. (2014) assert above that what really matters is the programme itself. The point about how well the programme is implemented is therefore instrumental. Chapter 4 goes on to look at manualised and licensed prevention programmes and considers 'implementation fidelity' - whether interventions are delivered as intended, which is critical to the successful translation of evidence-based interventions into practice.
Finally, while the evidence does not show clear findings about how long or concentrated a programme show be, there is agreement that programmes need to be of sufficient intensity and duration to influence change and no reviews suggest the use of a one off single session  (Stead and Angus, 2004). See below the summary by UNODC on characteristics associated with positive prevention outcomes:
Characteristics associated with positive prevention outcomes
Available evidence indicates that the following characteristics are associated with positive prevention outcomes:
√ Using interactive methods
√ Delivered through a series of structured sessions (typically 10-15) once a week, often providing boosters sessions over multiple years
√ Delivered by trained facilitator (including also trained peers)
√ Providing an opportunity to practise and learn a wide array of personal and social skills, including particularly coping, decision making and resistance skills, particularly in relation to substance abuse
√ Impact perceptions of risks associated with substance abuse, emphasizing immediate consequences
√ Dispel misconceptions regarding the normative nature and the expectations linked to substance abuse
UNODC, International Standards on Drug Use Prevention (2015), page 21.