(introduction...)

This Chapter gives more detail about some national drug abuse prevention policies and strategies in order to propose a practical overview in some European countries during the last decade and to offer a few illustrations of how drug abuse prevention theory or philosophy can be translated into practical prevention, and into educational programmes for different target groups. The focus will be on some aspects, such as:

- background information on national drug policy;
- types of educational or prevention programmes;
- short description of some programmes;
- review of evaluation studies.

There are, of course, many types of prevention programmes being carried out in these countries. The aim is not to offer an extensive overview, but rather to give an idea of how the main programmes, targeted on segments of the national population, fit (or do not fit) into the policy framework of a country.

Mass media programmes, school drug prevention programmes, training programmes for health professionals, and community prevention programmes have been selected from The United Kingdom, The Netherlands, Sweden and Germany.

United Kingdom

· Drug policy. Drug policy in the UK has undergone considerable change over the last 20 years. It used to be internationally regarded as one using treatment and opiate prescription, rather than law enforcement to control and prevent drug problems. According to Dorn (25), education, once considered almost synonymous with prevention, is now seen as a supporting system. By the late 1980s, drug prevention was effectively defined as an enforcement problem first, and a medical, social and educational problem second. The main objective now is to attack the drug problem on five fronts:

- reduce supplies from abroad;
- render enforcement even more effective;
- maintain effective deterrents and tight domestic controls;
- develop prevention and education;
- improve treatment and rehabilitation.

25) Dorn. N. British Policy on Prevention. In: Ghodse, H. et.al. Drug Misuse and Dependence. Parthenon, Lancs. 1990

The first three policy objectives deal with supply, and the last two with prevention, treatment/rehabilitation and demand reduction. An Advisory Council on the Misuse of Drug established by the British Government in 1984 recommended that preventive measures be developed according to two basic criteria:

- reduce the risk of an individual engaging in drug misuse;
- reduce the harm associated with drug misuse.

Several prevention programmes have since been carried out.

Mass Media Campaign. In February 1985, the British government commissioned a London advertising agency to develop a wide-ranging and striking anti-heroin campaign, targeted at all youngsters aged 13-20 '28), especially those running a high risk of using heroin (an estimated 15% of all youngsters). The campaign "Heroin screws you up", consisted of two TV commercials broadcast regularly on Channel 4 Television. One commercial shows a boy who proudly announces that he controls his heroin use, but slowly deteriorates. The other shows a girl who, despite her efforts with make-up, looks worse and worse. Full-page advertisements in nineteen different fashion, music and girls' magazines brought the message "Heroin screws you up" to the attention of the younger generations.

28) Irving. A. The Role of Advertising in the Prevention of Heroin Misuse: the UK experience. In: Proceedings of 15th ICAA Institute on the Prevention and Treatment of Drug Dependence. Amsterdam/Noordwikherhout. 1986

A special campaign for parents, educators and intermediaries was also developed, with especially written brochures on drugs "How to act when your child uses drugs". Three different advertisements published in some weeklies and monthlies drew attention to the heroin problem and the brochures.

The goal of the first campaign was to get across the negative short-term physical and social effects of heroin use in a penetrating way. The second campaign also demonstrated through TV commercials, posters and adverts, how youngsters can turn down an offer of drugs without losing face. During recent years this anti-drug campaign has increasingly become modified into an HIV/AIDS prevention (Anti-Injecting) campaign addressed to drug users and, on a broader level, all those concerned by drugs, to meet the policy objective of reducing the harm caused by drug misuse.

The Anti-Injecting campaign "Shooting up once can screw you up. Forever" used the different media of television, posters, teenage newspapers and radio annoucements and which focused on the risk of contamination through shared use of syringes to communicate the general idea that the syringe is a deadly weapon "Screw up your blood, your liver, your life"

- even though individual use of a syringe is never discussed. The inherent risk is amplified by the advertising slogan which reduces time to a simple equation: Once = Forever.

· School drug prevention. The UK has built up a long tradition of school drug education programmes, including low-level scare tactics, factual person-focused health promotion and mixed approaches. Most programmes and packages have been developed by Health Education Authorities or by agencies like ISDD, TACADE '29). There is, as argued in the Chapter V, no overwhelming evidence available to help in decisions as to what would be the most effective drug prevention approach in the school context. Probably this is the main reason for distributing a variety of drug education programmes and packages in primary and secondary schools, such as the two very different programmes, "Drug Wise Drug Education for Students, 14-19" developed jointly Health Education Council, TACADE and ISDD, '30 and the "High Profile Youth Work Curriculum about Drugs", developed and distributed by ISDD (31). The "Drug Wise" programme is a broad, factual person/skills focused prevention programme, including many educational methods (lecturing, discussion, peer support, materials etc.). The "High Profile Curriculum" is a rather traditional, cognitive based educational programme that fits into most subjects of the curriculum, whatever the type and level of education or professional training. Dorn illustrates this approach in the following table:

29) Free to Choose: an approach to drug education. TACADE, Salford. IRK. 1984
30) Drug Wise Drug Education for Students, 14-19. ISDD, London. 1986
31) See Note. 19

DRUG ISSUES IN EDUCATION CURRICULA
In subject	Drug Related Matter includes
Mathematics	Calculating spread of HIV, drug surveys
English	Drugs in literature
Biological sciences	Central nervous system and effects of drugs

The UK also pays much attention to training teachers and school counselors how to educate their pupils and students and how to deal with young people with drug problems. Since 1986 several drug education video programmes and packages are available for a variety of educational settings.

· Training programmes for health professionals. Most of the drug prevention programmes described so far deal mainly with primary prevention. Health professionals are often confronted with substance abuse problems at an early phase, in hospitals, or during primary care and crisis intervention. Many are not familiar with coping and intervening with drug problems, scant attention having been paid to this aspect during their medical training. There are several attempts to fill this gap, one of the best known being the post-graduate "Diploma Course in Addiction Behaviour", developed and taught by the Addiction Unit of the Maudsley Hospital in London (32). This very intensive, one-year training course is addressed to physicians, psychiatric nurses, psychologists and other health professionals confronted with early addiction problems in their work. It is interesting to note the high international participation in this training course, with professionals from Africa and Asia who return to their countries and train their colleagues in education and intervention with drug misusers. An international example of the "teaching the teachers" training model.

32) Glass. I. B. Diploma Course in Addiction Behaviour. paper presented for WHO Consultation Meeting "Substance Abuse Education for Health Professionals". Vienna. 1987

· Community prevention projects. So far as this author is aware, there are no striking examples of community drug prevention projects directed at primary or secondary prevention levels. What we do have, however, are examples of projects that try to reach local drug users in big towns and cities. In Manchester, for instance, a harm reduction comic called "Smack in the Eye" has been distributed to drug users (33). It uses popular cartoons to get messages across about safe drug use and safe sexual behaviour. In Brighton, a harm minimization project using local radio and telephone lines to warn young people about the dangers of mixing sedatives, including solvents, produced wrapping paper with printed messages about drugs 34).

33) See Note. 27: p. 143
34) Dorn. N. Can Local Drug Prevention Sizzle? Druglink. 1990

· Evaluation of drug prevention in the United Kingdom. No general evaluation data is available to determine the effects of all preventive measures, either on supply reduction, or on demand reduction, to decide whether the British drug policy is a successful one. And it is virtually the same for the prevention and education programmes described above where no quantitative data is available to indicate success or failure. However, there is evidence that the British mass media campaign was successful to some extent, research findings indicating that negative attitudes of youngsters towards the use of heroin had increased by 10% after the campaign '35).

'35) Heroin Misuse Campaign Evaluation. Report of findings stages I-III. Research Bureau Limited. London. 1986

The Netherlands

· Drug policy. The global objective of Dutch drug policy over the last 15 years has been the "normalisation" of drug abuse problems, which means treating drug users as far as possible as "normal" citizens, to whom "normal" demands are made and to whom "normal" chances for living should be offered and who are considered to be responsible people, subject to the same rules as the rest of society. There should be no prosecution of drug users because they use "illegal" drugs but, on the other hand, drug users who commit crimes will have to face the consequences of their acts. This does not mean that the Dutch do not carry out any law enforcement or implement a control policy. The penalties for trafficking in heroin and cocaine, for example, have been increased from 4 years to 12 years imprisonment. New laws exist to trace, freeze and confiscate assets acquired from the proceeds of drug related crimes.

Today there is general consensus among Dutch prevention officials on the main features and principles of drug prevention which has to be developed on a broad base, not simply at the level of publicity campaigns and information. It is generally accepted that drug education should begin in primary schools, at the age of 10, with alcohol and tobacco education. These educational efforts should be repeated, and include cannabis education during the first years of secondary school, where young people are in a critical phase of their psychological development, exposed to peer pressure and media influences. In higher secondary schools, alcohol, tobacco and cannabis education should be repeated, and include other drugs.

Besides primary prevention programmes, there is now a movement towards secondary prevention programmes. This means that prevention officers are now faced with problems such as, how to contact high risk groups, how to motivate them for education and information, how to communicate with minority groups, with school drop outs etc. Those groups often have no institutional relations, and cannot be contacted through community organisations. Therefore, there is a need to develop local and regional networks of drug prevention specialists, cooperating with community institutions (schools, youth clubs, childcare centres, local police etc.) to create appropriate educational and communication techniques which will permit contact with populations at risk.

· Mass media campaigns. Mass media, especially media campaigns against drug abuse, have played a minor role in Dutch prevention compared to those for alcohol and tobacco prevention 36). The most striking example has been the "What everybody ought to know about drugs" carnpaign, carried out in the eighties, the main goal of which was to educate parents and educators about drugs and drug abuse. The campaign designers assumed that the social environment of experimenting drug users is usually badly informed and mostly reacts wrongly to drug abuse. The campaign was aimed at inciting parents to talk more openly with their children about drugs, and before it started, interviews were conducted with parents to determine the tonality and style of the campaign. It transpired that parents were not motivated by a campaign suggesting that their children could be involved in drug abuse and it was therefore decided to design a low-key communication campaign avoiding pictures of needles, bad-looking youngsters etc. 37).

36) Buisman. W. R. Mass Media and Drug Abuse Prevention in the Netherlands. paper presented at the 1st International Drug Abuse Prevention Research Symposium. Lexington. K.Y. USAOctober 20-23 1991

37) See Note. 5

There were two phases to the campaign. Striking headlines were slightly emotionally charged ("Fear is a bad advisor, let's talk about drugs"). The written press drew its readers' attention to the availability of receiving a free booklet on drugs containing objective, factual information, written in an easy, but serious style in order to eliminate fear and myths. The booklet also included two examples of discussions between parents and children to illustrate appropriate communication. Since the start of the campaign, more than 500.000 copies of the booklet have been distributed. In line with the main principle of the "What everybody ought to know about drugs" campaign, to educate the social circle of drug users, a few years later a series of six television and radio programmes was broadcast on Dutch National Educational Television (40). Part of the series has been published in a small education handbook for parents and educators.

40) Van Amerongen, R. Cinderella's Portrait: some observations on Dutch Drug Prevention Policy. Paper presented at the French-Dutch Drug Prevention Symposium. Paris, France. 1986

More recently, a Cocaine Prevention Campaign was initiated by the Jellinek Treatment and Prevention Centre in Amsterdam. The main aim of this campaign was to change the attitudes of local youngsters heavily involved in disco-dancing towards cocaine-experimentation. In the first stage of the programme, a special campaign was directed towards correcting the general belief of many youngsters that cocaine is a safe drug when used carefully. Large and striking posters and information booklets were mailed to discotheques, coffee shops, trendy youth bars and youth-centres. The slogan of the campaign was "Coke, the white hammer" (copying a popular pro-milk drinking campaign "Milk, the white motor"). The second stage of this campaign tried to change the belief that cocaine use increases a youngster's status with his peer group ("Cocaine, the illusion of being strong"). In both stages of the campaign, much attention was generated in the mass media, with free publicity on television, radio, newspapers and magazines.

Three video clips were produced for risk groups frequenting youth centres, coffee shops and youth care institutions. Although no large-scale evaluation was conducted, the use of cocaine in Amsterdam decreased from 1.6% in 1987 to 1.3% in 1990.

· School, community and other prevention programmes. By far the greater part of drug education activities are planned and carried out by trained drug education specialists working in nearly all the large and medium-sized towns and local communities. Their main task is to train and advise key-persons or intermediaries who work with young-people-risk groups, ethnic minority groups, youth clubs, young people in care, young prisoners and, of course students and pupils in schools. The Dutch drug education system applies the "teaching the teachers" model, both in primary and secondary prevention, but in practice, courses are provided for a broad category of intermediaries in school, youth work police, prison, childcare settings. These courses last several days, and the current policy is to include drug education and drug intervention training for all these different intermediaries, who are also offered educational and audio-visual materials for use in their own prevention activities.

One important area of drug prevention is, of course, school drug prevention. To some extent a similar development can be observed as in the UK In the beginning there was strong emphasis on factual drug education "Give them the naked facts on drugs". Later the focus changed and was directed towards a person-oriented, value clarification based approach. In the late eighties the peer resistance and skills development approaches were adopted. The latter are still popular, but there is a tendency to offer the education market whatever they most appreciate. The main criterion is still that only qualitative materials are marketed to schools. However, this does not mean that teachers can only choose between types of materials. There are also large-scale training projects for teachers, both at primary and secondary school levels, which are developed nationally, but carried out locally, adjusted to the specific demands of local schools.

Among many other initiatives and drug education programmes, we should mention a specific "theatre drug education" project, called "Kick-seekers" which is aimed at secondary school children, aged 14-18, who are presumed to be at risk of becoming involved in drug use. Based on the assumption that many young people are looking for kicks, often to prevent feelings of depression, disappointment and disapproval, the young actors depict real-life situations and tell of their own search for friendship and acceptance in connection to drinking, smoking and sniffing. After watching the play, all schools having participated in the project were invited to join a chat show, in which the actors discuss and share their experiences and opinions with the public.

· Training programmes for health professionals. During the early eighties, much attention in drug prevention was paid to health professionals, especially physicians, several training courses on drug problems being offered both in undergraduate and post-graduate medical training (41). In most Dutch medical schools, courses in substance-abuse problems are taught in the second or third year. Attention is paid to knowledge and attitudes of medical students, their own use of drugs, including alcohol, aspects of early intervention and detection. In the training for general family physicians, a module of substance abuse has been integrated into the curriculum. Similar courses are being developed for the vocational training of nursing staff and social workers.

41) Lange. W. M. Alcohol Consumption and Alcohol-related Problems in the Netherlands Paper presented at the Who Working Group on the Role of Physicians in Alcohol Abuse Prevention. Oslo, 26-29 August 1986

· Evaluation of drug prevention in the Netherlands. As with the general international situation, it is difficult to determine the results and effects of the Dutch drug prevention programmes. However, there has been some evaluation. For example, an assessment of the "What everybody ought to know about drugs" campaign indicated that 50% of the respondents reported that they had become more interested in the problem of drug use, about 75% had developed better attitudes towards open communication on drug use, and another 35% indicated that they had changed their behaviour and discussed drug problems with friends or family members 42). Another study on school drug education indicated that a person-oriented approach is to be preferred to a factual or alarmist approach (De Haes, (43)). Yet another study indicated that educated pupils in primary school used less alcohol and drugs than a control group (Van de Wijngaart, (44)).

42) See Note. 5

43) De Haes. W.F.M. & J.H. Schuurman. Results of an Evaluation Study of Three Drug Education Methods. In: International Journal of Health Education. 1975. 18 (Suppl) pp. 1-16

44) See Note. 36

Sweden

· Drug policy. Sweden has adopted a broad concept of prevention, including drugs, alcohol and tobacco. Three different levels of prevention are conceptualised and included in their prevention policy. Primary prevention is taken to mean general preventive measures (legislation, drug education) for the public as a whole. Secondary prevention aims directly at risk groups and tertiary prevention is used to provide care, treatment and rehabilitation for drug abusers. A central idea behind the Swedish approach to primary prevention is to "vaccinate" young people against starting to use drugs at some later date. According to the Swedish National Board of Health and Welfare, centralised campaigns using large-scale mass media have little or no effect. The main function of campaigns must be to support local activities at the community level. Well organized, with many social and community organizations (an excellent climate for prevention), Sweden has adopted a prevention strategy supported by large segments of the population. Consequently, many different target groups are involved in preventive activities: pre-school children, children and youth in elementary and high schools, young men in military service, students, parents, women, immigrants etc.

· Mass media campaigns. The modest, supporting role of mass media and large scale campaigns in Sweden has already been mentioned. In the early eighties, the Swedish Ministry of Health conducted two national campaigns against alcohol and drugs. "Action mot droger2' (Action against drugs) started as a continuation of an earlier campaign to stop the sale of alcohol to minors (45). "Action mot droger' was aimed mainly at cannabis abuse, trying to stimulate discussion about lifestyles and forces underlying drug abuse. To meet this goal, a snowball strategy was developed in which mass media were the starting point for local activities. This required a strong link between the central coordinating body and the many target groups, which at the regional level, consisted in social advisors to the largest county councils, as well as county school boards. In cities and local communities the link was forged by coordinating the social service, schools, police and sports and cultural organisations. The supportive role of the mass media consisted of two television and radio programmes in which parents discussed their opinions about drug use with young people. Six programmes called "Teenagers need parents" were later broadcast by Swedish radio. The campaign included press conferences, advertisements in newspapers and magazines.

45) Alcohol and Narcotics. Preventive Measures in Sweden. Socialstyrelsen. Stockholm. 1987.

· School and community drug prevention. As a result of the mass media campaigns, a wide variety of instructional materials on drugs and alcohol were developed and distributed through national, regional and local channels. These materials not only dealt with drug information, but were more broadly designed to encourage pupils to face up to feelings of inferiority, insecurity and fear of expressing emotions and values. Different materials were published for elementary and primary schoolchildren and for junior and senior high school students. It was later decided to organise a special campaign on hashish use in cooperation with the National Association for Home and School. Parents of 14 year olds in Sweden were chosen as the target group of this campaign, and a small but striking book called "The Hash Book", was produced and mailed to them (46). To facilitate work with the book a school curriculum was developed and the material sent to key persons in education. To support the campaign, and to improve its effectiveness, the National Association for Home and School arranged a major national conference, followed by local conferences for school class representatives. The idea was that all ninth grade classes should hold discussions with parents and teachers about drugs in general and hash in particular.

46) The Hash Book. Socialstyrelsen. Stockholm. 1987

· Education and training for health professionals. For many years, Sweden has developed research in the field of substance abuse at the major universities. As a result of a curriculum reform in 1983, a two-week training course is now given four times a year at the Karolinska Institute in Stockholm, in which attention is paid to all substances, including psychoactive medicines. For one week medical students are introduced to clinical and ambulatory treatment settings, and meet self-help groups. At the pre-clinical level, introductory information on substance abuse is given during the basic courses on social medicine and medical psychology. Sweden also has specific training programmes for public health professionals (psychologists and social workers) who can participate in certain non-medical parts of training programmes for physicians. Opportunities for education and training in substance abuse problems in Sweden are still increasing.

· Evaluation of drug prevention in Sweden. Unfortunately, no quantitative data is available to show that drug prevention in Sweden is successful. On the other hand, there has been no marked increase in drug consumption during the last decade. Seven hundred thousand (700.000) of the "Hash Book" have been mailed to Swedish families. As in most other European countries there is no strong prevention- evaluation tradition in Sweden, as is the case in the USA.

Germany

· Drug Policy. In Germany it is estimated that the current (hard) drug problem concerns more than 60.000 drug addicts, equivalent to 0,6% of ex-West Germany. Some time ago, a national survey indicated that nearly 25% of young people between 14 and 25 reported having used cannabis once in their life, of whom about 1 million continued to use it. There is no reliable picture of the drug consumption situation in the Eastern part of Germany. The central Government has laid strong emphasis on supply prevention efforts: detection of illegal substances, law enforcement, customs control. The situation in the Bundeslander (Niedersachsen, Bayern, Schleswig-Holstein, Berlin etc.) is different, with more emphasis on demand reduction: education, care and treatment, rehabilitation. The regions (11 + 5 EastGerman) have autonomy to develop their own prevention policies, especially in the area of education, health care and drug prevention. The Federal Government only develops general guidelines and laws.

· Mass media campaigns. The German prevention strategy can best be characterized as a public information and community oriented strategy, which makes little use of high key mass media like television and advertising, with the exception of mass media campaigns to prevent the spread of HIV/AIDS.

Drug abuse prevention is very much integrated in general health promotion and is primarily focused on healthy life styles, not on substances. The prevention of drug abuse is considered as a long-term public health education process involving children, young people, parents and adults, professionals and key-persons. Nevertheless, Germany has a long experience with specific use of television - their Suchtwoche (Addiction Week) '47), when for a whole week (often in Autumn), information and discussion programmes and films focusing on addiction are broadcast. This Addiction week is aimed at raising the awareness of millions of people to substance abuse in their own environment, and programmes offer a lot of information on methods, institutions for treatment and self-help groups. Beside its information function, an important agenda setting effect of the Addiction Week Programs might be expected.

(47) Suchtwoche in Zweites Deutsches Fernsehen. Abhangige, Angehorige. ZDF Press Spezial.

· School and community drug programmes. German drug prevention policy is mainly based on a health education strategy using dissemination of written materials, and, some general objectives have been formulated for specific target groups. For young children in school, it is important to strengthen competence in interpersonal contacts, enabling them to resist counter-healthy influences from media stars and heroes, to enable them to make informed decisions in conflict situations. Positive, recreational activities to strengthen interpersonal relations in peer groups are promoted. For parents, educators, youth leaders and teachers, materials are available containing information and advice on how to communicate with young people. Parents are approached with creative materials, reflecting their own social situations, convincing them that it is their responsibility to speak up on health problems with their children. A well known campaign has been the "Alltag Scenen einer Clique" (Everyday life: scenes from a clique) '48). The brochure used in this campaign analyses everyday situations of young people, illustrating peer group mechanisms, problems like negative feelings and how to express feelings of anxiety, and lack of self-esteem, but also illustrating the importance of having strong positive relationships with friends, parents and school.

48) Buismani W.R. Mass Media Drug Campaigns in Europe. Report for the Council of Europe.Utrecht. 1987

Germany has developed a long tradition of health and drug education in schools. In the Bundeslander (for example, Niedersachsen), training courses are organized in cooperation with some universities to inform and train all secondary school teachers to give lessons on health and substance abuse. It was recently decided that education specialists will be employed in most regions in Germany to support and initiate all kinds of preventive activities in the local communities, including prevention at the workplace, in churches, youth centres, schools, sport and leisure clubs. A national and regional infra-structure to train and educate health professionals in drug abuse prevention is now under development (Institut fur Therapieforschung OFT, Munchen, Hamburg).

· Evaluation of German drug prevention. Germany has a broad concept of prevention, with no strong emphasis on drug education. On the other hand, much attention is paid to health promotion and alternatives to drug use (youth theatre, art projects in Berlin) '49), but insufficient data and information is available to decide whether the German prevention concept is effective in reducing drug abuse.

49) See Note. 26. p. 49