HARM REDUCTION IN PREVENTION POLICY: A PUBLIC HEALTH PERSPECTIVE ON HIGH-RISK YOUTH BEHAVIOR

Rodney Skager, Ph.D.[1]

As long as people drive automobiles there will be accidents and associated harm to people and property. The only way to eliminate this source of harm would be to outlaw automobiles. But this is clearly not an acceptable solution. The fallback strategy has been to enact laws regulating driving and install traffic signals, warning signs, divided roads and, more recently, seat belts and air bags. In other words, while we cannot eliminate the source of harm, we can reduce or even minimize the harms that do result.

Harm reduction is a fundamental principle of public health. It is represented in occupational safety codes and regulation of environmental pollution. Banning smoking in the work place and developing low tar and filter tip cigarettes are harm reduction strategies. In health policy, harm reduction is widely applied and usually evokes little or no controversy.

In contrast, in my country harm reduction measures are vehemently opposed when applied to use of alcohol and illicit drugs, especially when the users are young people. In this area of health policy harm reduction is regarded as the back door to legalization or worse. This view reflects the principle of “zero tolerance,” the ideological foundation of drug policy in the United States. Zero-tolerance inevitably endows law enforcement with the lead role in the so-called War on Drugs.  As a result, penalization, rather than intervention and assistance, is the dominant strategy. Yet, despite many years and much treasure spent on the millennial goal of a “drug-free America” and the stern policies associated with that goal, use of alcohol and illicit drugs persists at significant levels among both young people and adults.

Prevention education in the USA is hamstrung by the zero-tolerance principle. Federal guidelines specify that drug education programs give only “no-use” messages. This means that the following advice may not be given to young people:

“We view drugs as harmful. We discourage you from using them, and we are eager to help you quit if you have started. But if you will not quit using drugs, we can help you to use them less harmfully.” (McCoun & Reuter, p. 391)

Under zero-tolerance giving advice that could reduce harm to those who choose to drink or use is strictly verboten, and this comprises about half of the older teen population who sample or use illicit drugs and close to eight out of ten in the case of alcohol.  Supporters of zero-tolerance maintain that providing information on safety “gives the wrong message” because young people will interpret such advice as giving permission to try drugs. Since this assertion is self-evident to those who deliver it, no scientific test of its validity is deemed necessary.

The “wrong message” response is the standard objection to all harm reduction proposals, not only for prevention education, but also for every other facet of drug policy. It is used against needle exchange, medical use of marijuana, sober driver programs for young people, and for virtually all interventions that treat substance abuse as a public health rather than criminal justice problem.

For the sake of argument, perhaps overall drug use would increase if information promoting safer use were included in prevention education. However, “no-use” prevention programs have their own downside, and these will be enumerated shortly.  If the benefits of current politically correct prevention education are slight or even nil, harm caused by these government-blessed programs might outweigh gain. This should not be surprising, since several decades of the drug war should have taught us that no drug control strategy is a magic bullet and that all are associated with negative side effects.

Under zero-tolerance so-called prevention education has consistently delivered biased and even false information. At best, the message is one sided. As a result, we deliver indoctrination instead of education, and indoctrination falls flat in the face of experience common among young people in the USA. Most are aware that that the majority of people who try drugs do not suffer permanent harm. They view marijuana as a “soft” drug despite having been warned as children that it will lead to addiction to cocaine or heroin, brain damage, and, worst of all, sexual dysfunction. That such “scare tactics” do not work and are if anything counterproductive has been rediscovered at least three times in the 100-year history of drug prevention in the USA, beginning long ago in the alcohol temperance movement.[2]  To their credit developers of current prevention programs mainly avoid exaggerated scare tactics, although the same cannot be said for expensive anti-drug television messages sponsored by the Federal government and probably for naïve parents who are exhorted to “talk to their children about drugs.”

Indoctrination about the dangers of drugs also backfires with most young people because it fails to take into account a basic principle of adolescent mental development—that adult reasoning ability is achieved early in the teen years. This means that young people think independently, detect bias in what they are told, evaluate messages in the light of their own experience, and identify hypocrisy, especially from adults. A recent text on adolescent development proposed that it would be more useful to view adolescence as the first phase of adulthood rather than as an “intermediate period between childhood and adulthood.”[3] The difference between adults and adolescents is in life experience rather than mental capacity. [4]

Indoctrination also backfires because drug experimentation has long been normalized in the teenage social world. Most high school students believe that the majority of their peers have tried alcohol and marijuana including many admired or even envied peers such as athletes, social leaders and even honor students. Most teens thus view substance use as a normal part of teen social life even when they choose to abstain themselves.

Developers of current prevention programs as well as officials in the federal Center for Substance Abuse Prevention appear to be unaware of normalization and its implications. There are likewise oblivious to the reactions of young people to politically correct prevention education. To “get real” they would have to engage in authentic dialog with youth—to listen to young people in other words. If they did, these are examples of what they would hear.[5]

“In high school drugs were around and my friends and I knew where to get them. People accepted it as a part of high school life.” (Community college student)

“Smoking pot for my friends was like watching TV for me. It was just as normal.” (University student, abstainer)

“So many teenagers try pot only a couple of times during their adolescence and then it’s forgotten. It’s like high school ends and so does the pot smoking. Or people smoke it once in awhile but it doesn’t mess up their lives.” (University student)

These statements illustrate how achieving adult reasoning ability and normalization of use in youth culture work together to generate rejection of biased prevention messages. Even if they are abstainers, young people acquire information about drugs from peers or by observing what goes on around them. They are aware that some people have problems relating to use, but that most users or drinkers do not. They learn that for many peers getting high can be a lot of fun. Many are curious about what it feels like to get high, and act accordingly in a social milieu that is quite tolerant of individual choice.

Even though current social influence programs such as Life Skills Education avoid obvious scare tactics, they must focus entirely on abstinence. For example, the approach taken in Life Skills Education is described as follows, “…information salient to adolescents…was taught including information concerning the immediate negative consequences of drug use, the decreasing social acceptability of use, and actual prevalence rates among adults and adolescents.”[6]  Unfortunately, this transparently one-sided message must compete against awareness among the majority of young people that alcohol or marijuana use can deliver benefits such as “kicking-back,” “bonding with friends,” or “having a blast,” as well as their perception that most peers including members of student elites have tried marijuana and that some may even use it regularly.
The following is typical of many affirmations of this point.

“Some very high profile students in my school did marijuana…including the captain of the football team and the president of the student body.” (University student)

Current programs are grounded on false ideas about why most young people try drugs. Life Skills Education and similar social-influence programs assume that young people use drugs because they have personal deficits, perhaps by virtue of being young. In the case of Life Skills Education this theory assumes a deficit in “self-efficacy” or lack of confidence in specific personal social skills or other aspects of living. This assumption seems highly improbable when substance use is common among youth elites.

In emphasizing so-called “resistance skills” current programs assume that most young people try alcohol or other drugs for the first time because of direct pressure from their peers. To adults this is an appealing and seemingly self-evident explanation for drug initiation, even among those who should know better. Yet, spontaneous imitation of what others do is a fundamental principle of human behavior and is a core principle in modern social learning theory. When a behavior is perceived to be normal and engaged in by admired or even envied peers, human beings copy willingly. Imitating what others do is arguably the single most distinguishing characteristic of the primate species. It reaches its apogee among humans. Most young people who try alcohol or marijuana do not need to be “pressured.”

“The peer pressure scene in DARE is stupid. DARE made it seem like you had to give into the peer pressure by taking one puff to get your friends off your back.”  (University student)

”My friends offered marijuana because of courtesy…because they felt obligated since we were friends. They never teased me for not smoking.”
(University student)

It is hardly surprising that a recent report by the National Research Council concluded that there is limited evidence supporting the effectiveness of current prevention programs including social influence programs and that there have been serious design and measurement flaws in research ostensibly supporting these programs.[7]

Exaggerating harms and ignoring personal experience that contradicts approved prevention messages promotes cynicism among young people. Honesty in prevention is actually the best policy, because it does not alienate young people who have their own sources of information about alcohol and other drugs. Research suggesting that current approaches to prevention are associated with increased use by some groups supports this conclusion.[8]^,[9]

Exaggerating dangers and demonizing behaviors that are engaged in by large number of youth and adults is a dangerous business. The US experience has been that increasing public fears about drugs yields enhanced funding for ineffective interventions and more punitive law enforcement.[10] For example, the California legislature is currently considering a law that would criminalize smoking by teenagers. This is another example of the larger context in which US prevention programs have evolved.

What, then, do we propose as an alternative?

First, substance use and with it prevention education should be viewed as a public health rather than law enforcement responsibility so that harm reduction can become a legitimate strategy. Significant changes in the objectives, process, and content of prevention education could then be undertaken.

Second, assistance for problematic users who need help would replace expulsion from school and confinement in jails, prisons, and boot camps.

Third, there would be significant expansion in the criteria by which prevention is evaluated. Current programs are assessed almost entirely on whether there is a decline in overall prevalence defined as is the percentage of a population reporting use of a substance at least once in a given time period. Overall prevalence alone is a flawed measure because it fails to distinguish between moderate versus heavy and problematic use.  Experience suggests that declines in prevalence are likely to reflect a drop in the number of one-time or occasional users rather than in problem users.[11] Since most of the damage resulting from use occurs for the latter, reduction in total prevalence does little to reduce real harm.

Fourth, given the normalization of substance use in the youth population and its consequent persistence, failing to inform about safety is both callous and irresponsible. Rather than giving permission, harm reduction prevention messages would be seen by young people as evidence that adults actually care about their welfare, instead of being obsessed with restricting their fun and their right to make their own choices about personal experience.

Finally, and probably most important, effective prevention education must change the relationship between adults who do prevention and the young people who are its target. Currently, the dominant approach in my country is strictly top-down. This patronizing relationship is another reason why prevention accomplishes little or nothing.  Adults hold assumptions about how to influence young people that do not work when applied to intensely personal choices such as whether to get high or have sex. There are many ways in which this leads down blind alleys. One of them is represented in the endless search for a curriculum that will convince kids not to drink or use, not to have sex, or not to smoke.

The idea of a “curriculum” as a package of information and learning activities administered by an adult is not the solution. Given normalization in the youth culture of both substance use and active sexuality, information, especially one-sided and often inaccurate information supporting abstinence, will never persuade the majority of young people to avoid these activities. Yet adults continue to search for a better curriculum. Why do they persist in this after decades of failure? It is because they confuse academic learning with learning about living.

Most adults have a sense of how academic subjects are taught, since virtually every adult in our society has been to school. Because of this fixed idea about one kind of learning, strategies are ignored that could promote positive personal development and wise choices in life outside of the classroom. But such strategies do exist, and there are people who know how to use them. Better to say that there are adults who know how to establish relationships of deep trust and mutual respect with young people. Many of these adults work in the field of prevention, but in my country they work quietly and avoid public attention to the way in which they do their work.

The key to developmental learning is the relationship between adults and young people rather than the content of a curriculum package.  The right kind of relationship involves trust—learners know that the teacher cares about them and is always honest with them. It involves respect—the teacher acknowledges the intelligence, personal experience, and active contributions of the learners. It involves flexibility—the learners have an equal opportunity to set the agenda and the teacher recognizes the importance of the “teachable moment,” the time when learners want to know something. Finally, It involves responsibility—learners as well as teachers are responsible for making the experience worthwhile.

Putting relationship and process first does not mean that substantive content is neglected. Relationship and process are the keys to learning when that learning is about choosing a healthy and productive way of living.  But, above all, these are choices that we all, young and old, make for ourselves. In a democratic society there will never be a magic bullet that can insure that people will make the decisions that others believe they ought to make. Only a theocratic police state with total control over its inhabitants could accomplish this goal, and that kind of “solution” is simply not worth it.