Alcohol misuse amongst young people is common and the burden of disease, social costs, and disability associated with this use is considerable
[1–4]. The peak of this disability occurs in those aged 15–24 years and corresponds with the typical age of initiation to alcohol and other drug use
. The high prevalence of use amongst adolescents is of particular concern given that early initiation to substance use is a risk factor for the development of substance use disorders, co‐morbid mental health problems, juvenile offending, impaired educational performance and early school drop‐out, all of which negatively impact on both current functioning and future life options
To reduce the occurrence and cost of such problems, prevention is essential and needs to be initiated early before harmful patterns of alcohol and other drug use are established and begin to cause disability
[9, 10]. Although an array of school-based prevention programs exist
[11–16], the majority show minimal effects in reducing alcohol use and related harms
[17–20], and some have even reported iatrogenic effects
[21, 22]. The most common factor which impedes on effectiveness is implementation failure
[23–25]. Given that school‐based prevention is the primary means by which alcohol and other drug education is delivered, it is essential to focus on increasing program efficacy.
There are two common approaches to school-based drug education; ‘universal’ and ‘selective’
. The selective approach involves delivering programs which target specific populations, such as individuals at greatest risk for developing substance use problems. On the other hand, the universal approach aims to deliver interventions to all students regardless of their level of risk for drug use, and focus largely on teaching normative education and drug resistance skills
. Ideally, preventive interventions should aim to delay onset in both adolescents with low-risk profiles who may be influenced to take up alcohol and other drugs due to peer influence and social conformity, and adolescents with high-risk profiles whose underlying vulnerability to psychopathology can lead to substance misuse. Yet, there appear to be no models of well implemented programs that do this. The current cluster randomised controlled trial (RCT) addresses this gap by developing and evaluating an integrated approach to preventing alcohol misuse and related harms in adolescents by combining the efficacious ‘universal’ Climate Schools and ‘selective’ Preventure programs.
The universal ‘Climate Schools’ program
The universal Climate Schools program aims to reduce the use of the most commonly used licit and illicit drugs in most developed countries: alcohol and cannabis
[2, 4]. The Climate Schools program is based on the effective harm-minimisation approach to prevention
[28–32] and uses cartoon storylines to engage and maintain student interest and involvement over time. The program is facilitated by the internet which guarantees complete and consistent delivery whilst ensuring high implementation fidelity. The program is designed to fit within the school health curriculum and be implemented to students 13–14 years old before significant exposure to alcohol and other drug use occurs. The Climate Schools program consists of twelve 40-minute lessons; the first six lessons focus specifically on alcohol and are delivered approximately six month prior to the remaining six lessons which focus on both alcohol and cannabis.
The first part of each lesson is completed individually over the internet where students navigate through cartoon storylines which impart information about the short- and long-term effects of alcohol and cannabis, normative alcohol and cannabis use, drug refusal and harm-minimisation skills, and tips on staying safe and first aid. Students are provided with confidential login details to access the Climate Schools website. The second part of each lesson is a group or class activity delivered by the teacher which reinforces the information in the cartoons and allows interactive communication between students. Teachers are provided with a manual containing the activities, implementation guidelines, links to the education syllabus and teacher and student summaries for each lesson.
The efficacy of the Climate Schools program has been established using a cluster RCT in 10 schools in Sydney, Australia (n = 764)
[31–33]. Results of the trial demonstrated that compared to the control group, students in the intervention group showed significant improvements in alcohol and cannabis knowledge at the end of the course and at six and twelve months following the intervention. In terms of behaviour change, the intervention group showed a reduction in frequency of cannabis use at the six-month follow-up, a reduction in average weekly alcohol consumption at the six and twelve month follow-ups, and a reduction in frequency of drinking to excess twelve months following the intervention. In addition, program evaluation showed that students and teachers rated the program as an acceptable and enjoyable means of delivering drug education in schools. Specifically, 100% of teachers who implemented this program in their classroom rated it as superior to other drug prevention programs, and over 90% of students reported information delivered in this format was easy to learn and would like more school subjects to be taught through this method.
Despite these positive results, the effectiveness of the Climate Schools program is somewhat limited. Firstly, the Climate Schools program is intended only to reduce the use of alcohol and cannabis and not other drugs. As the prevalence of illicit drug use other than cannabis is relatively low amongst adolescents, it has been suggested that such drugs may be better addressed using selective rather than universal prevention programs
. Secondly, although the Climate Schools program had significant effects on reducing alcohol and cannabis use, the effect sizes were modest (<0.38)
, as is expected with universal programs
[12, 16]. In addition, analyses of the efficacy of Climate Schools in high-risk students only (i.e., youth already using substances or youth with substance using peers), found the effects to be smaller than those high-risk students experience as a result of participating in ‘selective’ interventions
[36, 37]. This could be attributed to the fact that most universal preventive interventions address substance use through a social influence perspective and do not take into account the many other risk factors involved in developing substance use disorders such as underlying vulnerabilities due to individual and genetic factors
. This suggests that high-risk students may benefit from additional ‘selective’ prevention which is specifically tailored to their needs and risk factors. Selective programs offer the benefit of being able to focus on the role of other risk factors for substance use such as psychopathology and personality. Such programs have often been overlooked due to their practical limitations as not only is it difficult to initially identify those individuals at greatest risk, but finding suitable, cost-effective ways to screen and deliver interventions can also be challenging
. The selective personality-targeted Preventure program overcomes these obstacles.
The selective ‘Preventure’ program
The school-based Preventure program is a brief manualised personality-targeted substance use preventive intervention for high-risk adolescents aged 13–15 years. Preventure is the first and only selective school-based program that has been shown to curb excessive alcohol and illicit drug use in Canada and the United Kingdom (UK)
[37, 39–41]. Unlike universal programs delivered to a whole population, this selective personality-targeted approach addresses four personality risk-factors for early-onset substance misuse and other risky behaviours: Sensation Seeking, Impulsivity, Anxiety Sensitivity and Negative Thinking
. The Preventure program is also consistent with new models which conceptualise substance use as being driven by personality traits such as impulsivity and disinhibition
The Preventure program involves two 90-minute group sessions, specific to the four personality types, which are carried out by a trained facilitator and co-facilitator. The interventions are conducted using manuals which incorporate psycho-educational and cognitive behavioural components, and include real life scenarios shared by high-risk youth in specifically-organised focus groups. In the first session, participants are guided in a goal setting exercise, designed to enhance motivation to change behaviour. Psycho-educational strategies are used to teach participants about their target personality trait and associated problematic coping behaviours like avoidance, interpersonal dependence, aggression, risky behaviours and substance misuse. They are then introduced to the cognitive behavioural model and guided in breaking down personal experience according to the physical, cognitive and behavioural components of an emotional response. A novel component to this intervention approach is the fact that all exercises discuss thoughts, emotions and behaviours in a personality-specific way, e.g. identifying situational triggers and cognitive distortions related to Sensation Seeking specifically. In the second session, participants are encouraged to identify and challenge personality-specific cognitive distortions that lead to problematic behaviours.
The efficacy of the Preventure program has been demonstrated in a number of RCTs in Canada and the UK
[36, 37, 40, 41, 44]. Results from these trials revealed that Preventure successfully stemmed the growth in drinking and binge drinking in high-risk youth at six- and twelve-months following the intervention
, and more recent analysis has revealed the onset and escalation of drug misuse was prevented over a two-year period
. In addition, Preventure has been shown to reduce emotional and behavioural problems specific to each of the personality profiles
. This is of particular importance given that comorbidity between substance use disorders and ill mental health is substantial and leads to worse outcomes
. Finally, a recent effectiveness cluster RCT showed that a standardised training model which trained teachers to deliver the program in schools resulted in treatment effects that are comparable to those reported for the previous trial involving more controlled treatment delivery conditions