Considerations for policy makers
Before commissioning any prevention activity, there are important considerations for policy makers. Firstly, the EDPQS (2015) have proposed certain principles that should underpin all prevention activities and which should be considered at the outset. According to these, prevention should:
- Respect participants' rights and autonomy
- Provide real benefits for participants ( i.e. ensuring that the programme is relevant and useful for participants)
- Cause no harm or substantial disadvantages for participants
- Obtain participants' consent before participation
- Ensure that participation is voluntary
- Tailor the intervention to participants' needs
- Involve participants as partners in the development, implementation, and evaluation of the programme.
Commissioners of prevention activities should be mindful before commissioning a prevention programme that drug and substance use prevention is likely to have only limited effects as a standalone activity. Prevention activities should be embedded in general strategies that support development across multiple life domains ( ACMD, 2015). The ACMD (2015) recommends that authorities commissioning prevention programmes should consider drug and substance use prevention as part of a more general strategy supporting all aspects of users' lives.
Prevention should adhere to quality standards - The EDPQS, UNODC and Mentor- ADEPIS are amongst those who provide quality standards. These should be used when developing or introducing new interventions and/or improving existing interventions. The EDPQS focus on structural aspects in their quality standards, so that these are relevant in different contexts and in relation to different types of interventions ( EDPQS, 2015).
Prevention projects should incorporate high quality evaluation, and be developed from the findings of evaluation (ideally with economic evaluation). The UNODC advise that a scientific monitoring and evaluation component is required to assess the effectiveness or otherwise of an intervention, and recommend collaborations with academic and research institutions to achieve this, alongside the use of an experimental or quasi experimental design. They write, "In the field of medicine, no intervention would be used unless scientific research had found it to be effective and safe. The same should go for drug prevention interventions and policies" ( UNODC, 2015).
Randomised Control Trials ( RCTs) clearly play a key role in providing evidence of effectiveness, particularly in the field of healthcare. However, given the importance of context and geography in influencing drug education and prevention programmes, there is also a case for theory-driven evaluations, which seek to unpack why an evaluation or programme works, giving a contextualised understanding of effectiveness and which elements are effective and ineffective in improving the chances of programmes exporting successfully to other contexts (Davies et. al., 2000). A mixture of randomised and theory driven approaches to assessing 'what works' is likely to be advisable (Davies et. al., 2000).
Those working in the prevention field should be encouraged to use a common language (both in the UK and internationally) to help make prevention strategies more coherent ( ACMD, 2015). The IoM Prevention taxonomy is proposed as a first step towards a common prevention language.
Ineffective or iatrogenic programmes - when considering commissioning prevention programmes, caution is urged as without clear evidence of effectiveness, some programmes may be associated with unanticipated harmful outcomes. Programmes without clear evidence of effectiveness should only be delivered as part of a research programme, where there is well-developed programme logic, and where costs and harms associated with a lack of action are considered to be high ( ACMD, 2015). The EDPQS go further and argue that ineffective or iatrogenic programmes and approaches should not be funded, even if they are considered popular (The EDPQS, 2015). As above, quality standards and guidelines on intervention development and delivery are recommended to guide such actions. The EDPQS for example, provide guidance and toolkits for 'developing, organising and delivering prevention activities'  . Where commissioners are uncertain, NICE and Public Health England ( PHE) provide resources to help easily understand the evidence. PHE have provided a summary of the UNODC prevention standards and provide examples of relevant and UK guidelines, programmes and interventions available in England  .
Faggiano et. al (2014) present an ambitious proposition for a European central, transparent, and evidence-based process for behavioural prevention interventions (Faggiano et. al, 2014). They state that currently across Europe no prior evaluation is required before implementing a prevention intervention, and this can lead to widespread dissemination of 'potentially ineffective or harmful interventions'. Such a standardised approval process, they argue, would lead to positive outcomes for practice, the dissemination of effective interventions in Europe and more impactful prevention at a time of scare economic resource (Faggiano et. al, 2014).
Economic analysis can provide important information on the cost effectiveness of interventions, and whether prevention programmes represent good value for money compared to other approaches, or to doing nothing at all ( ACMD, 2015). There is a lack of data on the cost effectiveness of drug prevention programmes in the UK, and economic evaluations in prevention is difficult, but economic analysis has been conducted in the US, including one of the GBG, where the programme shows a cost benefit ratio of 1:26 (Mentor- ADEPIS, 2014a). What evidence there is on cost effectiveness suggests that programmes do not have to show considerable impacts to be cost effective (James, 2011). The ACDM stress that there is a need for economic analysis from the UK, where prevention programmes have been rolled out, but foresee barriers to achieving this given the long periods required to demonstrate positive benefits.
The ACMD also recommend viewing prevention approaches as inter-related and emphasise the need to consider context and to take a wider view of the prevention system. The ACMD write "Commissioners and prevention providers should be aware that although not understood well, actions in one part of the overall prevention 'system' may have beneficial or untoward effects in another. To understand the likely effects of a prevention initiative, the action must be located in an overall framework which includes (but is not limited to) such factors as the influence of national policy (which may be positive or negative in effect), national and local delivery systems, professional competencies, available resources and services, competing and compatible actions, and public acceptability of the action" ( ACMD, 2015).
The review has shown that the evidence supports embedding universal drug prevention actions in wider strategies that aim to support healthy development and wellbeing in general ( ACMD, 2015). The ACMD propose that prevention is part of a 'complex system' of policies, interventions and activities and suggests that "the greatest preventative benefits may be obtained through policies and actions that target multiple risk behaviours, of which substance use is just one". The ACMD report also notes the UK Drug Policy Commission's statement regarding prevention in their final report ( UKDPC, 2012), which advised against 'drug-specific education' and highlighted the importance of supporting schools to implement broader programmes that aimed to build self-efficacy, help with impulse control and teach life skills, preferably as part of the national curriculum.
Implications for prevention activity in Scotland
There is a lack of knowledge around what prevention and educational interventions are currently being carried out in schools in Scotland, and how this compares with the findings above on 'what works' and what is ineffective. However, there are findings from a large scale evaluation of the effectiveness of drug education in Scottish schools, carried out on behalf of the Scottish Executive and published in 2007 (Stead, et al., 2007). The focus was on (illegal) drug education, and not inclusive of smoking and drinking, or New Psychoactive Substances, which were not an issue at the time the research was conducted. The evaluation compared findings from a literature review of what is likely to be effective in drug education (Stead and Angus, 2004) with what was being delivered in Scottish schools in 2004 and 2005 (through a survey of teachers and observations). In line with the findings above, the study found that drug education using highly interactive and social influences approaches, specifically including resistance skills and normative education elements are consistently found to be more effective than other approaches (Stead et al., 2007). The research found that while the vast majority of schools in Scotland were providing drug education, information provision predominated and that drug education lessons were not as interactive as they could be. Only a minority of lessons used social influence approaches and virtually none used normative education approaches. Substantial use was also made of external visitors (police, drug enforcement agency, nurses, theatre groups), which raises questions as to whether these included 'fear appeals' and ex-addicts, also shown to be ineffective or to have counterproductive effects.
New work is needed to understand what is currently being delivered in schools and the third sector in Scotland, and whether approaches have shifted towards social influence and social competence approaches and more generic resilience building approaches in line with the evidence. It is also important to know whether current approaches maximise scarce resources and are cost effective. A mapping exercise of what is being delivered in Scotland will show whether school-based drug education in Scotland still comprises mainly of information provision alone - a possibility given that many schools may have traditionally viewed their role as purely educational. Guidance and support for schools to incorporate more components associated with preventive outcomes discussed above may be required.
Stead et. al.'s recommendations from 2007 regarding schools-based drug education are likely to still be relevant, including: "more can be done to enhance its effectiveness, particularly through clearer guidance on evidence-based methods and approaches, and on continuity and progression; further training and support to boost teachers' knowledge, skills and confidence; and more attention to resources". On the first point mentioned, Stead et. al. make a more specific recommendation to "Give consideration to providing schools with an annotated list of recommended drug education programmes which are based on effective approaches and have been evaluated." These are useful considerations and other more strategic approaches such as targeting decision-makers at the council level, as well as schools, also merit consideration.