Cracking good prevention

Fences at the top of cliffs are preferable to ambulances at the bottom. We know cannabis can cause harm, so how do we prevent people from using cannabis or at least delay the time they start? Keri Welham tackles the issue of cannabis prevention.

Dr Kevin Sabet is looking for fundamental change.

Sabet has worked in drug policy for 18 years. He’s Director of the Drug Policy Institute at the University of Florida and an assistant professor of psychiatry. Previously, he was an appointee to the Obama and Bush II administrations.

Not so long ago, schools offered occasional classroom lessons about the evils of drugs, delivered at random. Sabet says, while these attempts were commendable and naturally very well meaning, a haphazard collection of high school life skills or PE classes devoted to drug harm just won’t cut it in 2013.

The stakes are too high for such a casual approach when, as Sabet points out, New Zealand research links the early onset of heavy cannabis use to poorer life outcomes.

“Public health experts talk about real consequences on the adolescent brain.”

Sabet wants cannabis prevention efforts to be visible in homes, churches, businesses, sports clubs and, most importantly to his mind, in policy. He wants to see programmes that are able to be tailored to each community’s specific needs. Out with a light sprinkling of classroom lectures; in with communitywide, community-specific, community-led programmes to build resilience and keep young people busy and engaged.

It’s a popular call to arms, echoed by leading researchers and those tasked with rolling out drug prevention strategies.

So how is drug prevention changing in New Zealand and overseas? Why is change necessary? And is any of it working?

Where do we start?

Dr Steve Allsop, Director of Australia’s National Drug Research Institute, says early-onset use must be at the forefront of prevention efforts, alongside heavy use, workplace use, stoned driving and strategies to support mental health.

Early onset of smoking and drinking are risk factors for early cannabis use. As smoking becomes less popular, this flow-on effect may lessen. However, recent evidence has shown that the practice of mixing cannabis with tobacco is introducing some young people to smoking. Those who mix cannabis with tobacco risk developing an addiction to tobacco alongside a dependence on cannabis.

Sabet says the starting point for improved prevention should be a “much more honest” discussion about the harms of cannabis.

“There are multiple negative consequences,” he says.

“Cannabis undoubtedly reduces IQ, affects driving, learning outcomes. Tobacco kills more people, but we shouldn’t downplay [cannabis].”

He says one in six young people develop an addiction to cannabis, and for those people, the drug causes a world of trouble.

“Do you want to take that gamble? It’s not cocaine or heroin. However, it’s still a gamble.”

Why has the anti-smoking campaign been so successful?

Allsop says good prevention engages the whole community and happens in multiple places at once using various avenues to reinforce the core message.

In the case of tobacco, this has translated to regulations around packaging, public health campaigns, price mechanisms, limited availability, school education, good treatment, non-smoking environments, advertising and bans on sports sponsorship.

The anti-tobacco message has been well resourced and visible over several decades.

Ben Birks Ang is a team leader at Auckland residential treatment facility Odyssey House where he runs the facility’s Stand up! and Amplify! programmes. He says some young people have adopted anti-tobacco messaging with such gusto that it has become part of their justification for using other substances. He has heard teenagers make comments such as: “I don’t smoke because it’s so bad for you, so I just do pot instead.”

There is much that cannabis prevention can learn from anti-smoking and anti-drink driving campaigns, as well as from the strategies of alcohol companies. Those trying to dissuade people from smoking cigarettes and drink driving have shown a keen eye for the impact of social pressure, while the alcohol industry is particularly adept at using social media to get its branding and advertising alongside online content popular with young people.

Birks Ang says his clients can name the attributes of the brand image of most alcohol labels, from the big-boozer of one RTD to the feminine soda-pop drinker of another.

To counter this influence, the health and support communities need to be just as agile in the online space.

He says effective advertising needs to follow the lead of the “legend” anti-drink driving campaigns and the “don’t bring your mates” responsible drinking campaign.

Both these campaigns created shorthand for discussing behaviour with friends, which is hard to do at any age – let alone in your teens. The legend ads, in particular, had a positive focus around behaviour to increase social standing.

Sabet says it took 80 years of use, and harm, for tobacco’s adverse effects to finally be understood. He fears that, if cannabis were legalised, there could be a similar 80 years of pain before its harms were fully realised and a backlash took hold.

Allsop says the cannabis prevention effort must get organised and build a plan.

“Let’s get a 20-year plan. That’s what we’ve done with tobacco. A broad range of strategies [and] we endured in our efforts.”

What does good prevention look like?

Senior researcher at the Canadian Centre for Substance Abuse Dr Amy Porath-Waller has devoted her career to research around cannabis use and prevention. She is part of a team that published an analysis of the effectiveness of school-based cannabis prevention programmes in Health Education & Behaviour in October 2010. The evidence revealed school-based programmes did have some impact.

However, the level of success varied with the approach. Programmes consisting of more than 15 sessions or modules, facilitated by someone outside the teaching staff and conducted using an interactive approach yielded strong results.

What worked was age-appropriate skill development, such as older teenagers role-playing how to deal with offers of drugs, and group discussion. For maximum impact, a series of sessions must be implemented as designed, not changed ad hoc or condensed. And the best person to offer school-based education is a health professional trained in drug prevention.

Allsop says a lot of young people understand the risks of cannabis use, but don’t necessarily care. Some campaigners make the mistake of thinking knowledge is enough – they fail because they don’t understand the motivations of their target audience.

He says a campaign aimed at young people would need to appeal to things that matter to them. That might be reputation and status, sporting prowess, sexual success. A Health Canada survey backs this up. What resonated for young people there was the impact on grades, sporting success, mental health and the ability to use their new, hard-earned driver’s licence. Porath-Waller says it’s hard for a 17-year-old to be truly motivated by the thought of a death by lung cancer in 30 or 40 years.

“Drug education should equip young people to live in a drug-taking world and offer skills and strategies so they can protect themselves from other people’s drug use.

“Children have a right to information. They live in a world where, even if they don’t use drugs, lots of other people might.”

Part of the education process is to make young people aware that the majority of people don’t use drugs. Often, in an environment where drugs are not discussed at all, young people can end up overestimating their peers’ drug use, Allsop says.

Some research has shown that parental influence plays a significant role in drug use in early adolescence. Parents should not underestimate their influence: the Health Canada survey found 87 percent of young people thought their parents would be a credible source of information about illegal drugs.

Allsop says parents should offer a safe and loving home, clear expectations, an interest in the risk profile of their child’s friends and open dialogue on topics such as how to care for your friends if drugs are around and what to do if drugs are brought out at a party.

Another key plank of prevention is effective treatment.

“It reduces the overall number of people in the community who use,” Allsop says.

“This reduces the visibility of cannabis use and potentially access to the drug.”

He also believes there is an argument for a more inclusive approach to dealing with broken rules in school. He respects a principal’s right to implement a consequence for a student who brings drugs to school, but he would like to see “responses that don’t simply disengage those most in need of connection to an education system and the community”.

Sabet says great prevention means offering young people alternatives. In the States, this might be midnight basketball; in New Zealand, it might be a regular touch rugby tournament.

While strategies might differ between demographics and addiction is generally a more ingrained problem in poorer communities, Sabet says bored young people with access to disposable income can quickly turn to drug use.

What works in New Zealand?

Birks Ang says young people who dabble in cannabis and other drugs are doing exactly what teenagers are designed to do – test boundaries and define themselves. They need to feel they’re developing social skills and are coping with difficult social situations.

Drug taking lets them believe they are making progress in some of these areas, but it usually means they are not developing the necessary skills at all. Good prevention means putting the safety nets in place to support young people if they stumble.

A young person using cannabis is less likely to develop a problematic habit if they have the stability of a strong network of trusted adults, a safe community and alternative opportunities for socialising, such as sport.

Birks Ang’s job takes him across wider Auckland to deliver programmes into secondary schools. In some schools, where there is a culture of asking for help, his teams work at a visible level and are able to achieve early intervention with young people before habits have taken hold.

In other schools, the service keeps a low profile and works with those whose drug use is now causing them grief.

“What we’ve noticed is there are a lot of young people that are using.”

Birks Ang says Mangere is one community in which he’s noted marked change in recent years. Local schools have become a model of the “wrap-around” strategy, where various groups complement each other’s work to produce a swift and effective response.

He believes New Zealand is closer than ever to cracking good prevention.

One effective strategy in preventing early-onset drug use is to consider the peer group above that which you’re concerned about, he says. Young people are deeply swayed by the behaviour and attitudes of those a year above them.

They also need to know they don’t need to have the most dysfunctional life, or the heaviest cannabis habit, to benefit from cutting back. Effective campaigns consider young people at various points on the drug-use continuum.

What doesn’t work? Scare tactics.

Birks Ang points to the American movement Scared Straight!, where inmates took emerging juvenile offenders behind bars and frightened the bejeezus out of them.

He says research shows the programme was ineffective; a claim backed by recent Canadian research suggesting young people do not respond to shock tactics.

Now for the good news: cannabis use is dropping.

The Health and Wellbeing of New Zealand Secondary School Students in 2012 report, known as Youth’12, surveyed 8,500 teenage New Zealanders. It found that, between 2001 and 2012, the percentage of teenagers who had tried cannabis fell from 38.2 percent to 23 percent.

Something has changed over the past 11 years. The move away from total reliance on those early classroom lessons may be reaping rewards. Birks Ang says there’s logic in coordination of effort – pulling together various public health campaigns, movements, services and policies to develop a “healthy young people” strategy. This could address a host of risk factors for poor life outcomes, and the figures for early-onset cannabis use could continue to fall alongside those for other risky behaviours such as smoking and drink driving.

Australia’s National Drug Strategy Household Survey has also shown a substantial drop in cannabis use. Between 1998 and 2010, there was a reduction of more than 30 percent in the number of people who reported using cannabis in the past year.

Allsop believes young people are now better informed, there has been increased investment in education, there have been improvements in treatment, targeted campaigns against driving on drugs have been particularly effective and he wonders if media commentary regarding some of the risks of cannabis use has also had an impact.

Sabet says building on these recent developments in drug prevention is essential. Parents, educators, health workers and policy makers need to understand that modern best practice involves a consistent message reinforced in multiple environments. This change is evidently under way – he is keen for it to gain even greater momentum.

“We have to change the paradigm about prevention.”

Porath-Waller says it’s gratifying to see cannabis use rates quickly decreasing in Canada. In 2008, 11.4 percent of people reported using cannabis in the past year. By 2011, that figure had fallen to 9.1 percent. In young people (those aged 15–24), those figures were 32.7 percent for 2008 and 21.6 percent for 2011.

But this is no time to ease off, she says.

“Just because we’ve seen some declines, it doesn’t mean we can be complacent. We need to be in for the long haul.”

Which cannabis prevention measures do young people think would work?

In mid-September, the Canadian Centre on Substance Abuse (CCSA) released the findings of in-depth interviews with 76 people aged 15–24.

Dr Amy Porath-Waller says the participants in What Canadian Youth Think about Cannabis believed “everyone smokes weed”. Not using cannabis was abnormal.

Most did not consider cannabis a drug, arguing that it was naturally grown, safe and non-addictive. They said it reduced violent tendencies and did not change the user’s perception of reality. They believed cannabis was “much safer” than alcohol and tobacco.

The youth surveyed believed cannabis was capable of helping people focus, relax, sleep and be less violent. Some believed it purified the body and cured cancer.

Participants believed driving stoned was not as dangerous as driving drunk, largely because cannabis focused the mind on the task of driving.

They suggested providing more fact-based information at an earlier age, providing more content relating specifically to cannabis (and not all drugs) and using approaches that were aimed at reducing the harms of using cannabis rather than focusing on abstinence.

They thought their peers might be persuaded away from cannabis by health risks, poor academic performance and negative impacts on family relationships.

Participants also suggested those who delivered prevention messages should have an ability to connect with youth as well as first-hand experience with the drug.

Youth cannabis use in New Zealand by the numbers

• 8,500 Kiwi teenagers were surveyed in 2012 for comparison against surveys in 2001 and 2007
• 38.2% had tried cannabis in 2001. By 2012 this had fallen to 23%
• 12.8% of 2012 respondents currently used cannabis, of whom 21.4% used before or during school.
• 8.3% in 2012 used cannabis alone.
• 33.5% tried to cut down
• 9.9% of kiwi teens believed it was okay for people their age to use cannabis in 2012
• 10% said the same of cigarettes.