Risk Factors for Substance Use among High School Students: Implications for Prevention HEATHER J. WALTER, M.D., M.P.H., ROGER D. VAUGHAN, M.S.,

AND

ALWYN T. CaHALL, M.D.

Abstract. To identify salient risk factors for drug use that could be targeted for modification in prevention programs, a survey was administered to a sample of 1,091 urban and suburban 10th grade students. Substantial proportions of students reported alcohol and cigarette use in the past year, and around 10% reported heavy use of these substances. In general, the measured risk factors most strongly associated with the use of alcohol, cigarettes, and marijuana were those derived from the socialization model of substance use; however, certain factors derived from the stress/strain and disaffiliation models also were related to increased drug use risk. J. Am. Acad. Child Adolesc. Psychiatry, 1991,30,4:556-562. Key Words: substance use prevention, adolescents.

The use and abuse of licit and illicit drugs continue to pose both immediate and long-term threats to the life and health of today's youth. The use of alcohol and illicit drugs is a contributory factor in the majority of violent deaths (i.e., from accidents, homicides, and suicides) among teenagers and young adults (Blum, 1987). The long-term use of cigarettes is said to account for one-third to one-half of all deaths from both lung cancer and coronary heart disease, and prolonged alcohol abuse is implicated in a substantial proportion of all deaths from cancer and liver disease (Ravenholt, 1984). The extensive, sustained use of illicit drugs may compromise psychosocial adjustment as well as produce untoward physical effects (Kandel et al., 1986). The primary risk period for the initiation of use of these substances is the teenage years (Kandel and Logan, 1984). It has been suggested that youths who have not experimented with cigarettes, alcohol, or illicit drugs by age 21 are unlikely to do so thereafter (Kandel and Logan, 1984). Accordingly, over the past few decades, a substantial effort has been directed toward the development, implementation, and evaluation of drug use prevention programs targeted at adolescents (Battjes, 1985). A greater understanding of the determinants of substance use in target populations is an important precursor to the development of effective prevention programs. Although a large body of research over the past several decades, both Accepted January 22, 1991. Dr. Walter is Assistant Professor ofClinical Psychiatry, Department of Psychiatry, and Dr. Cohall is Assistant Clinical Professor of Pediatrics, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York. Mr. Vaughan is Research Scientist at the New York State Psychiatric Institute, New York, New York. This research was supported by NIMH/NIDA Grant Number 5-P50MH43520, HeatherJ. Walter, MD., M.P.H., Principal Investigator, AIDS Prevention for Adolescents in School, Anke A. Ehrhardt, Ph.D., Principal Investigator, HIV Center for Clinical and Behavioral Studies. The authors wish to thank Richard Neugebauer, Ph.D., Janet B. W. Williams, D.S. W., Deborah Fish Ragin, Ph.D., Stephanie Kasen, Ph.D., and Iris Tropp, M.A. for manuscript review. Reprint requests to Dr. Walter, New York State Psychiatric Institute, Box 29,722 W. 168th Street, New York, New York 10032. 0890-8567/9113OO4-0556$03.00/0© 1991 by the American Academy of Child and Adolescent Psychiatry.

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cross-sectional and longitudinal, has identified numerous correlates and predictors of drug use (Kandel, 1982), much of this work has been descriptive. Recently, however, investigations in this area have become increasingly sophisticated, resulting in the generation of a number of theories that attempt to account parsimoniously for various aspects of drug-using behavior. Most of these theories can be organized into three primary models of substance use: socialization, stress/strain, and disaffiliation. The socialization model posits that young people initiate drug use because the norms, values, and beliefs of their primary reference group sanction such behavior. The stress/strain model suggests that young people use and abuse drugs in an attempt to cope with internal and external distress. The disaffiliation model hypothesizes that drug use is generated by a lack of ties to conventional social groups, including school and family. Although none of these models is sufficiently complex to explain fully the biopsychosocial phenomena of drug use and abuse, the models, nonetheless, have heuristic value for the planning of prevention programs. To date, most prevention research has adopted the socialization perspective, an emphasis seemingly supported by a recent comparative analysis demonstrating the superior explanatory power of the socialization model compared with the stress/strain and disaffiliation models of substance use (White et al., 1986). Other investigations, however, have suggested that the presence of factors derived from any of these models increases the risk for substance use among adolescents, and thereby warrants preventive intervention (Bry et al., 1982; Newcomb et aI., 1986b). To identify salient risk factors for drug use that could be targeted for modification in prevention programs, a substance use survey was administered in the spring of 1989 to a sample of urban and suburban 10th grade students. The goals of the survey analyses reported herein were threefold: first, to describe the prevalence of substance use; second, to investigate the associations between factors derived from the theoretical models identified above and the most widely used substances; and third, to assess whether the observed risk factor/behavior associations varied according to gender or area of residence. J.Am.Acad. Child Adolesc. Psychiatry, 30:4, July 1991

RISK FACTORS FOR SUBSTANCE USE AMONG STUDENTS TABLE

Urban sample Study schools Borough total Suburban sample Study schools County total

I. Demographic Characteristics of Study Schools

White %

Black %

Hispanic %

Other %

Enrollment

18.6 12.0

45.9 43.3

29.7 35.6

5.8 9.0

6,557 36,761

80.4 82.9

11.8 9.8

3.4 4.4

4.4 2.9

2,940 14,730

Method Subjects

Tenth grade students in selected urban and suburban schools were chosen as the two eligible study populations. The eligible urban sample comprised 10th graders in three of the 14 public academic high schools in a New York City borough. The eligible suburban sample comprised 10th graders in three of the 10 public academic high schools in Rockland County, New York. Schools were selected on the basis of their willingness to participate in the survey and their racial/ethnic similarity to the larger populations from which they were drawn (Table 1). Students attending the urban schools were predominantly from working and welfare class families; students attending the suburban schools were predominantly from middle-class families. Parental consent was required for students' participation in the survey; the participation rates were 94% in the suburban schools and 52% in the urban schools. In both the urban and suburban samples, the mean age of participants was 15.3 years (range, 13-18 years). In the urban sample, 35.0% of participants were male; in the suburban sample, 52.0% were male. The age and gender distributions of the participating samples were similar to those of the eligible samples. The boards of education did not permit the inclusion of racial/ ethnic data in the survey; consequently, the racial/ethnic composition of the participating samples is unknown. Measurements

The data reported herein are drawn from a large battery of survey items designed to assess the need for AIDS and substance use prevention among students in the two target populations. Because the goal of this planning survey was to obtain as much information as possible from many different domains, a large number of items was created and subsequently divided into several different survey forms. The forms were distributed randomly to students within classrooms (matrix design) by research staff in one class period during regular school hours. Survey completion was anonymous. All participating students (N = 1,091) completed items pertaining to lifetime and past year substance use. Separate random subsamples of these same students completed additional items pertaining to the socialization model (norms) (N = 167), the socialization model (values and beliefs) (N = 181), the stress/strain model (N = 171), and the disaffiliation model (N = 165) of substance use. J. Am. Acad. Child Adolesc. Psychiatry, 30:4, July 1991

Substance Use Behavior

Students were asked to complete 24 items about lifetime and past year use and age of initiation of the use of beer, wine, liquor, cigarettes, marijuana, cocaine, crack, and intravenous (IV) heroin. They also were asked to complete one item about the amount of alcohol consumed on a single occasion and two items about riding as a passenger in a car with a driver who was drunk on alcohol or "high" on drugs. Socialization Model (Norms)

Students were asked to complete six items assessing how many of their four closest friends used alcohol, cigarettes, marijuana, cocaine, crack, and IV heroin in the past year. They also were asked in six items to estimate the proportions of students in their grade involved in past year use of these drugs. Socialization Model (Values and Beliefs)

Students were asked to complete 12 items about whether their friends and parents think that they should use alcohol, cigarettes, marijuana, cocaine, crack, and IV heroin and six items about whether they personally think that people their age should use these substances (values). Students also were asked to complete six items assessing how sure they were that they could refuse offers to use these drugs if their friends were pressuring them to do so (beliefs about refusal selfefficacy). Finally, students were asked to complete 12 items assessing the degree of risk associated with occasional and frequent use of these substances (beliefs about risk). Stress/Strain Model

Students were asked to complete 21 items about the occurrence of stressful life circumstances, including familial disruption, parental discord, economic hardship, and crime. This scale was adapted from that developed by Coddington (1972) and was found to have moderate internal consistency (alpha coefficient 0.64). Students also were asked to complete 14 items pertaining to perceived stress. This scale was adapted from Cohen et al. (1983) and had high internal consistency (alpha coefficient 0.83). Finally, students were asked to complete the anxiety and depression subscales of the psychiatric symptom index of Ilfeld (1978). Internal consistency of the anxiety subscale was 0.82 and of the depression subscale, 0.84.

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WALTER ET AL. TABLE

2. Proportions of Students (in Percent) Reporting Past Year Substance Use (N = 1,091)

Heavy Useb

Experimental Use" Beer Wine Liquor Cigarettes Marijuana Cocaine Crack IV Heroin

Males

Females

Total

Males

Females

Total

52.9 53.3 45.6 19.0 13.0 1.6 0.3 0.0

51.8 61.9 45.2 22.4 13.0 2.3 0.8 0.0

52.3 58.3 45.5 20.9 13.1 2.1 0.6 0.0

13.6 5.4 3.5 6.8 1.9

5.6 1.4 2.3 16.7 1.4 0.0 0.0 0.0

9.0 3.2 2.9 12.5 1.6 0.5 0.5 0.0

1.1 1.1

0.0

"Reported use a few times in the year or a few times per month. bReported use a few times per week or more.

Disaffiliation Model Students were asked to complete 26 items pertaining to seven categories of parental support: communication, conflict, support, discipline, supervision, expectations, and synergy. The results of factor analysis suggested a single dimension of general parental support, and the internal consistency of the entire scale was 0.89. Students also were asked to complete four items pertaining to past year academic problems, including poor grades, absences, failures, and suspensions.

Statistical Analysis To evaluate the relations between substance use and the clusters of theoretical model variables unique to each subsample, multivariate odds ratios (O'R) and associated 95% confidence intervals were calculated using stepwise logistic regression. In these analyses, the variables for substance use were coded "0" for no use in the past year and "1" for any use in the past year. All regression models included the following as covariates: age (per year), gender (male vs. female), and area of residence (urban vs. suburban). For those theoretical model variables shown to be associated with substance use, interaction terms (with gender and with area) also were entered into each subsample model. For the first subsample, substance use was regressed on the socialization model (norms) variables. These variables were dummy coded to reflect any substance use by one or more of the respondent's close friends and by half or more of the respondent's same-grade peers. For the second subsample, substance use was regressed on the socialization model (values and beliefs) variables. These variables were dummy coded to reflect friends' and parents' sanction of the respondent's use of substances, the respondent's personal sanction of substance use among people his/her age, the respondent's belief that he/she would be unable to refuse offers to use substances, and the respondent's belief that occasional and frequent substance use is not risky. For the third subsample, substance use was regressed on the stress/strain model variables. These variables were dummy coded to reflect the top versus the bottom two tertiles of the stressful life circumstances scale, the top versus the bottom half of the perceived stress scale, and the top 15% versus the bottom 85% of the anxiety and depression symptom subscales. 558

Likewise, for the fourth subsample , substance use was regressed on the disaffiliation model variables. These variables were dummy coded to reflect the bottom versus the top two tertiles of the parent support scale, and any versus none of the four academic problems.

Results Substance Use Behaviors Seventy-six percent of students (72% of males and 79% of females) reported having more than a sip or taste of alcohol more than two or three times in their lifetime. The modal age of initiation of beer and wine use was 11 years, and of hard liquor use, 14 years. Nearly two-thirds of students reported using beer and wine in the past year, and half reported using liquor (Table 2). Most of this use was experimental; however, nearly 10% of students reported heavy use (a few times per week or more) of beer in the past year. One-third of the students, irrespective of gender, reported that they had drunk more than five glasses of alcohol on a single occasion, and one-quarter of the students of both genders reported being a passenger in a car in which the driver was drunk. Forty percent of students (33% of males, 45% of females) reported use of cigarettes more than two or three times in their lifetime. The modal age of initiation of cigarette use was 11 years. One-third of students reported smoking cigarettes in the past year: over 10% reported heavy use. Twelve percent of students (equal proportions of males and females) reported use of marijuana more than two or three times in their lifetime; the modal age of initiation of use was 15 years. Reported marijuana use in the past year was confined largely to experimentation. Thirteen percent of students (11 % of males, 15% of females) reported being a passenger in a car in which the driver was "high." Students reported very little lifetime or past year use of cocaine or crack, and no lifetime or past year use of IV heroin.

Socialization Model (Norms) Approximately three-quarters, two-thirds, and one-third of students reported alcohol, cigarette, and marijuana use, respectively, by at least one close friend (Table 3). The same proportions of students, respectively, estimated that half or more of their same-grade peers used these drugs. l.Am.Acad. Child Adolesc. Psychiatry, 30:4, luly 1991

RISK FACTORS FOR SUBSTANCE USE AMONG STUDENTS

TABLE 3. Proportions of Students (in Percent) Reporting Friend and Peer Past Year Substance Use (N Alcohol One to four close friends use Half or more of students in grade use

Cigarettes

= 167) Marijuana

Males

Females

Total

Males

Females

Total

Males

Females

Total

74.3 81.4

73.2 77.3

73.1 79.0

56.5 50.0

58.8 78.4

57.9 66.4

37.1 24.3

34.0 36.1

35.4 31.1

TABLE 4. Proportions of Students (in Percent) Endorsing Selected Values and Beliefs Pertaining to Substance Use (N

People my age should use Parents think I should use Friends think I should use Not sure could refuse offers to use Occasional use not risky Frequent use not risky

= 181)

Marijuana

Cigarettes

Alcohol Males

Females

Total

Males

Females

Total

Males

Females

Total

16.9 12.0 30.5 56.1 45.0 12.4

14.3 2.0 22.4 48.0 49.5 4.2

15.5 2.8 26.1 51.7 47.5 7.9

7.2 2.4 12.2 32.9 32.1 3.7

10.2 1.0 15.3 31.6 44.3 3.1

8.8 1.7 13.9 32.2 38.8 3.4

9.6 3.6 13.4 34.1 21.0 7.4

6.1 0.0 10.2 17.5 23.7 6.2

7.7 1.7 11.7 25.1 22.5 6.7

Socialization Model (Values and Beliefs) Although less than 3% of students thought that their parents sanctioned the use of alcohol, cigarettes, and marijuana, one-tenth to one-fifth personally sanctioned, and one-tenth to over one-quarter thought that their friends sanctioned, the use of these drugs (Table 4). One-quarter to one-half of students were not sure that they could refuse offers to use alcohol, cigarettes, and marijuana, and the same proportions of students believed that the occasional use of these substances does not pose a health threat. Three to 8% of students believed that the frequent use of these substances is not risky \ Stress/Strain Model The mean number of stressful life circumstances was 5.0 (4.3 for males and 5.4 for females), with a range of 0 to 14 (possible range, 0 to 21). The mean score on the perceived stress scale was 41.3 (38.5 for males, 43.6 for females), with a range of 16 to 64 (possible range, 14 to 70). The anxiety symptoms subscale mean score was 8.6 (7.3 for males, 9.6 for females), with a range of 0 to 29 (possible range, 0 to 33). The mean score on the depression symptoms subscale was 9.1 (6.9 for males and 10.9 for females), with a range of 0 to 24 (possible range, 0 to 27). Disaffiliation Model The mean score on the parental support scale was 78.7 (77.4 for males, 79.5 for females) with a range of 39 to 103 (possible range, 26 to 104). Twenty-seven percent of students (21 % of males and 32% offemales) reported having five or more unexcused absences from school in the past year. Fourteen percent of students (11 % of males and 17% of females) reported having grades of Cs and Ds or below, and 53% of students (43% of males and 59% of females) reported failing one or more subjects. Five percent of students (6% of males and 4% of females) reported being suspended from school one or more times. Correlates of Substance Use

Of the socialization model (norms) variables assessed, J.Am.Acad. Child Adolesc.Psychiatry, 30:4, July 1991

friends' use of drugs in the past year was significantly correlated with past year substance use (Table 5). Students having any friends who used alcohol, cigarettes, and marijuana were six to 76 times more likely to have used these substances than were students having no friends who used these drugs. Estimations of past year drug use by peers were not associated with use of these substances in the past year. Of the socialization model (values and beliefs) variables measured, friends' sanction of drug use, beliefs about refusal self-efficacy, and beliefs about the risk of occasional use were significantly associated with substance use in the past year. Students reporting friends' sanction of alcohol, cigarette, and marijuana use were six to 14 times more likely to have used these substances than were students reporting friends' proscription of drug use. Students reporting uncertainty about their ability to refuse offers to use cigarettes were nine times more likely to have smoked cigarettes, and students reporting a belief that occasional use of cigarettes and marijuana was not risky were three to four times more likely to have used these substances than were students not endorsing these beliefs. Beliefs about the riskiness of frequent use of alcohol, cigarettes, and marijuana and personal and parental sanction of the use of these drugs were not significantly associated with past year substance use. Of the stress/strain model variables assessed, stressful life circumstances and symptoms of anxiety and depression were significantly correlated with substance use in the past year. Students scoring in the top tertile for the occurrence of stressful life circumstances were four times more likely to have used marijuana than were students scoring in the bottom two tertiles. Students scoring in the top 15% of the distribution of anxiety scores were four times more likely to have used alcohol, and students scoring in the top 15% of the distribution of depression scores were six times more likely to have smoked cigarettes than were students scoring in the bottom 85% of these distributions. Perceived stress was not significantly correlated with past year substance use. Of the disaffiliation model variables assessed, only parent support was found to be significantly associated with past

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WALTER ET AL. TABLE

5. Multivariate Odds Ratios (O'R)n and 95% Confidence Intervals (in Parentheses) for Past Year Substance Use b Given Modeled Constructs

Socialization model (norms) (N = 167) Any friends YS. no friends use Socialization model (Yalues, beliefs) (N = 181) Friends think I should YS. should not use Not sure vs. sure could refuse offers to use Occasional use not risky YS. risky Stress/strain model (N = 171) Stressful life circumstances (top YS. bottom tertiles) Anxiety (top 15% YS. bottom 85%) Depression (top 15% YS. bottom 85%) Disaffiliation model (N = 165) Parental support (bottom YS. top tertiles)

Alcohol

Cigarettes

Marijuana

5.9(2.0,17.5)

13.6(5.1,35.8)

75.6(19.8, 274.0)

5.8(1.3, 26.5)

5.9(1.5,23.6) 9.0(3.4, 23.8) 3.9(1.6, 9.6)

13.5(4.1, 43.1) 3.1(1.1, 9.6)

3.7(2.1,6.9) 4.1(2.3,7.3) 5.6(3.5, 8.9)

5.3(2.7, 10.4)

4.6(2.6,8.3)

"Adjusted for age (per year), gender (male YS. female), and area of residence (urban YS. suburban). bAny use YS. no use in past year.

year substance use. Students scoring in the bottom tertile of the distribution of parent support scores were five times more likely to have used alcohol and cigarettes than were students scoring in the top two tertiles. Academic problems were not significantly associated with past year substance use. Although there was some evidence that more female than male students reported past year cigarette use, and more suburban than urban students reported past year alcohol use, the analyses failed to reveal consistent main effects of age, gender, or area of residence on past year substance use. Similarly, although there was some evidence that the associations between friends' use and personal use of cigarettes and between symptoms of anxiety and alcohol use were stronger for females than for males, the analyses failed to demonstrate consistently that the theoretically derived factors operate on the drug use behaviors differentially for males or females or for students from urban or suburban settings. Discussion The principal finding of these analyses is that substantial proportions of this sample of urban and suburban 10th grade students reported alcohol and cigarette use in the past year, and around 10% reported heavy use of these substances. Most reported marijuana use was experimental, and few or no students reported past year use of cocaine, crack, or IV heroin. In gev.eral, the factors most strongly associated with the use of alcohol, cigarettes, and marijuana were those derived from the socialization model of substance use; however, certain factors derived from the stress/strain and disaffiliation models also were related to increased drug use risk. Before considering the implications of these findings, some methodological issues are addressed. First, the external validity of the findings may be compromised by the incomplete participation of students in the survey. Most 560

nonparticipation was a result of absenteeism (averaging nearly 30% per day in the urban schools); the remainder was a result of the failure of parents to grant consent for survey participation. Unfortunately, data (other than age and gender) comparing participants with nonparticipants are not available; consequently, the findings should be generalized beyond the participant population only with caution. Second, because of the self-report nature of the survey, the veracity of students' responses may be questioned. However, the anonymous nature of survey completion was stressed to participants. In addition, there was high agreement (98 %) of responses to similarly worded items dispersed throughout the survey. The validity of responses also is strengthened by the similarity of the prevalence rates reported in this study to those reported in other studies (Robinson et al., 1987). Finally, recent evidence has demonstrated the cross-sectional reliability and longitudinal stability of self-reports of drug use (Barnea et al., 1987) as well as the validity of such data based upon multitrait-multimethod analyses of independent ratings (Stacy et al., 1985). Because of the cross-sectional nature of this investigation, causal relations between substance use and the factors derived from the theoretical models are not to be inferred. The associations presented in this analysis are intended to be suggestive and await confirmation in longitudinal studies. As a final methodological point, it would be of interest to compare the explanatory power of the three theoretical models in a combined regression analysis; however, the matrix design of the survey precludes such an analysis. The purpose of this survey administration was to identify salient risk factors associated with substance use that could be targeted in prevention programs. Future surveys will be designed to test the relative explanatory contribution of the three theoretical models and will be structured accordingly. In the midst of heightened concern in recent years about what has been called an epidemic of cocaine and crack use among teenagers and young adults (Washton, 1986), the J.Am.Acad. Child Adolesc.Psychiatry, 30:4, July 1991

RISK FACTORS FOR SUBSTANCE USE AMONG STUDENTS

use of alcohol and cigarettes by today's adolescents is in danger of being overlooked. Although the use of most substances by teenagers appears to have declined over the past decade (Johnston et aI., 1988), cigarette smoking continues to increase, particularly among adolescent girls (Committee on Adolescence, 1987a). The finding that fewer than onethird of smokers are successful in quitting once the habit has been established (Kabat and Wynder, 1987) makes even the occasional use of this substance of particular concern. The observation from this study that a nontrivial proportion of 10th grade students drink alcohol heavily and frequently suggests that these teenagers are at risk for the adverse consequences of indiscriminant use. Of particular concern is the proportion of students in this study who reported having been a passenger in a car in which the driver was drunk: alcohol has been implicated as a contributing factor in the majority of fatal automobile accidents among teenagers (Committee on Adolescence, 1987b). The first generation of prevention programs targeted at the use of these substances as well as at marijuana use was based on the fear arousal model of prevention (Goodstadt, 1980). These programs emphasized the dire consequences of even experimental substance use and during the decade of the 1960s were largely ineffective. Nonetheless, the findings from this study about the importance of beliefs pertaining to the riskiness of even occasional use of cigarettes and marijuana as well as a similar finding reported from a study conducted among younger students (Mittelmark et ai. , 1987) suggests that communicating messages about the adverse health consequences of these behaviors may still have some merit, particularly in early adolescence. Recognizing the limitations of the didactic approach to substance use prevention, the second generation of prevention programs began to address social factors hypothesized to influence drug use (the socialization model). This strategy was thought to be particularly appropriate for youths in middle adolescence, among whom peer influence is thought to play an important role in the adoption of new drug use behaviors (Glynn, 1981). The findings from this study confirm the important association of certain social factors, namely, friend's use of substances, friends' sanction of substance use, and beliefs about refusal self-efficacy with the use of alcohol, cigarettes, and marijuana, underscoring the need to address these factors in drug use prevention programs. Recently, the results from two well-designed programs based on the socialization model of prevention have been reported (Ellickson and Bell, 1990; Pentz et aI., 1989). Both of these programs reported declines in the initiation of experimental use of the target substances; however, both programs were less successful in preventing problem drug use, or in reducing levels of use among those previously initiated. There are several possible explanations for the equivocal success of these programs. One explanation might be that the socialization model is based upon a limited view of the social influence process among adolescents. This model asserts that the strongest inducement to initiate substance use is pressure from peers; accordingly, the prevention strategy focuses on modeling, practicing, and reinforcing the I.Am.Acad. Child Adolesc.Psychiatry, 30:4,July 1991

skills necessary to successfully resist these pressures (Botvin et aI., 1985). Thus, this approach assumes that peer influence consists largely of coercive pressure, resulting in slavish conformity to group demands, and thereby ignores the social consensus that tends to evolve in peer groups and the resultant self-imposed pressure to conform to these norms. More effective prevention programs based upon the social. ization model may require a broader conceptualization of the social influence process (Gladis et aI., 1990, submitted manuscript). Another explanation could be that prevention programs based on the socialization model fail to address other important risk factors for adolescent drug use. Indeed, the analyses reported herein demonstrate robust associations between certain factors derived from the stress/strain and disaffiliation models of substance use (namely, stressful life circumstances, symptoms of anxiety and depression, and poor parental support) and the use of alcohol, cigarettes, and marijuana. The correlations between symptoms of anxiety and alcohol use and between symptoms of depression and cigarette use are consistent with those reported by other investigators (Anda et aI., 1990; Kushner, 1990) and are congruent with the "self-medication" hypothesis (Khantzian, 1985). Thus, the need for further inquiry into the comorbidity of these disorders among adolescents is underscored (Bukstein et aI., 1989). Associations between stressful life circumstances, poor parental support and substance use also have been reported previously (Brown, 1989; Climent et aI., 1989; Dishion et aI., 1988; Newcomb and Harlow, 1986a; Schweitzer and Lawton, 1989), although, as is the case for the relations between psychological symptoms and substance use, the directions of the associations have not been clarified and require further investigation. Nonetheless, the accumulated weight of evidence regarding the etiology and prevention of substance use among teenagers supports the notion of a two-tiered intervention strategy. The first tier would target the prevention of drug experimentation among the general population of adolescents by educating them about the health risks conveyed by substance use, and training them in the social skills required to successfully resist friends' offers to experiment with drugs. The second tier would target the prevention of drug abuse among troubled adolescents by providing appropriate pharmacological, psychotherapeutic, social, and remedial intervention for the presenting psychological and social problems. Supporting this suggestion is Tobler's metanalysis of 143 drug use prevention programs conducted between 1972 and 1984 (Tobler, 1986). She found that programs based upon the socialization model of substance use reduced the experimental use of drugs by teenagers but had less impact on drug abuse. Those at risk for abusing drugs were most favorably influenced by so-called "alternatives" programs, such as those providing job training, mentoring partnerships, community and leisure activities, remedial education, and medical and psychiatric counseling and treatment. Because the great majority of children and adolescents in the United States are in attendance at school, schools are a logical vehicle for the delivery of substance use prevention 561

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programs. Although schools have proven to be a workable site for the implementation of prevention programs comprising drug education and refusal skills training (Ellickson and Bell, 1990; Pentz et al., 1989; Walter et al., 1989), less is known about the effectiveness with which school personnel can screen students for psychosocial problems and refer them to an appropriate site for "second tier" intervention. Thus, the development, implementation, and evaluation of accurate, efficient, and confidential school-based mental health screening and referral mechanisms is urgently needed. In conclusion, substance use and abuse, particularly of cigarettes and alcohol, continue to pose major threats to the well-being of today's youth. Although the results from recently reported prevention studies have been encouraging (Ellickson and Bell, 1990; Pentz et al., 1989, Walter et al., 1989), the findings from this and other investigations (Shedler and Block, 1990) suggest that a new generation of broader prevention approaches focused on helping teenagers to cope more adaptively with internal and external distress should become a research priority. Practitioners providing treatment to socially and psychologically troubled teenagers should be alert to the possibility that these youths are at risk for substance use and abuse, and appropriate preventive intervention should become a standard part of their clinical repertoire.

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