In doing this review, I discovered rather quickly that there was little in the research journals about substance abuse prevention in human service fields other than in education and the schools. Most of the work involving prevention activities in the other areas covered in this review was focused on potential activities and early, almost anecdotal initiatives. In addition, much of what was included in this review was not primary prevention, but rather secondary prevention and treatment, extrapolating to primary prevention.
   
    However, there are signs of change in each of the areas reviewed. In addition, several significant documents that will be available in the near future should be considered. They are:

The Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice, will be revising its ADelinquency Prevention Works@ publication by December 31, 1996.

The U.S. Department of Housing and Urban Development will be starting an evaluation of its Drug Elimination programs in late 1996.

The U.S. Department of Education is completing a 5-year study of some matched pairs of schools, comparing more and less comprehensive programs. This is due to be completed by early 1997.

The Georgetown Child Development Center, under contract to the Substance Abuse and Mental Health Administration, U.S. Department of Health and Human Services (DHHS), is conducting a 5-year study of health care reform and the impact on children with problems. The Center=s 1995 baseline did not include substance abuse, but it will be included in the next survey. A report on this project should be available in the summer of 1997, looking at 13 states already involved in managed care. The following year it will report on all 50 states.

Constance Weisner and others at the Alcohol Research Group, Oakland, California, have two studies looking at substance abuse treatment in other settings. One is a study of clients in public, private, and health maintenance organization settings. The other is a probability sample of health and human service providers focusing on their perceptions of alcohol and drug problems in their caseloads and community and what they personally do with such cases in their daily work.

The Administration on Children and Families, DHHS, has two programs that may produce some information over time. They are a AShared Family Care@ program in which the mother has substance abuse problems and the AEmergency Services Grants@ to prevent child abuse caused by substance abuse.

The data included in the paper suggest that both the welfare program and the area of child abuse and neglect would be good areas for substance abuse prevention, since there is a fairly significant incidence and prevalence of substance abuse among program beneficiaries. However, no studies on substance abuse prevention were available in either area.

Introduction

   Substance abuse has become a national problem that affects virtually every institution in our country. Moreover, a clear connection is emerging between tobacco, alcohol, and other drug use and other human service systems that both affect and are affected by substance use and abuse. These systems offer major opportunities for enhanced prevention efforts. Primary among those systems are schools and education, health, criminal justice, workplace, and public housing.
    Much of the current prevention research is based on the concept of risk factors that influence the use of alcohol, tobacco, and other drugs (ATOD). Many of these risk factors can be greatly reduced through resiliency and protective factors fostered through ATOD prevention programs (Hawkins, Catalano, & associates, 1992). In addition, based on a variety of research and applied sources, we have mounting evidence that prevention efforts are not successful if implemented in isolation, and it is unlikely that we can point to a single prevention intervention as the cause of reduced substance abuse. These several systems must work together in a comprehensive, complementary effort if we, as a nation, are to be successful in preventing substance abuse.
    Most of the research on substance abuse prevention has focused on various individual prevention approaches and their impact on selected, specific population groups. Less research has focused on the institutional policies, organizational structures, or interrelationships with other relevant organizations and institutions. Only in more recent years has there been a major focus on comprehensive, community-wide prevention that encompasses prevention strategies within each of the human service systems, as well as the interaction among them. With that focus, evaluations of community coalitions and community-wide efforts are only just beginning to yield results.
    Understandably, however, much of the attention to substance abuse prevention is secondary in other human service organizations and is more a contextual factor than a central focus. For example, most of the prevention literature regarding drunk driving focuses on just thatCpreventing people from driving when they are drunk or drugged. It is only of secondary interest if they get drunk in the first place. Within the workplace, the focus is on employee performance on the job and reducing or alleviating problems that may affect performance. General employee wellness programs have gained in popularity and have the resultant benefit of improving the health of the working population overall. However, the impetus for such wellness programs was to reduce employee health costs, absenteeism, and accidents, rather than to prevent employee use of substances.
    Historically, by far the great majority of prevention efforts and research has focused on school-based programs. Over the years, much of this research has focused on the particular curricula used in the schools and the evolution from information-based to affective and, more recently, social influence programs. There has been little attention to the role of school authorities, policies, and enforcement of those policies. Moreover, there have been frequent criticisms of school-based programs and questions regarding their effectiveness. The more recent community prevention research suggests that the ineffectiveness of school-based programs may lie in the dosage, the level of booster sessions, the fidelity of the intervention, the model (Bell, Ellickson, & Harrison, 1993; Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995; Ellickson, 1993, 1995; Ellickson, Bell, & McGuigan, 1993), or possibly the failure to look at comprehensive, community-wide prevention programs of which the school-based curriculum is but one component (Funkhouser, Goplerud, & Bass, 1992; Gerstein & Greene, 1993; Hansen, 1992; Kumpfer, 1990).
    As comprehensive, multifaceted, community-wide approaches have grown, so has the understanding of and commitment to substance abuse prevention within many different human service systems. Most of these systems have begun to accept the legitimate role of substance abuse treatment but have not yet defined their role in substance abuse prevention. As a result, there has been little research reflective of existing substance abuse prevention programs within most of these other human service systems. The predominance of the literature focuses on the limited efforts that are underway and offers encouragement and suggestions as to future opportunities for these systems to expand their role into the arena of substance abuse prevention.

Costs, Incidence, and Prevalence of Substance Abuse

    A variety of studies have been done about the costs of substance abuse. The Rice, Kelman, Miller, and Dunmeyer (1990) study of the costs to society examined a variety of direct and indirect costs associated with substance abuse and determined the cost to be $114 billion in 1985. The Center on Addiction and Substance Abuse (CASA) (1995) study of a variety of federal entitlement programs, including Medicaid, Medicare, Social Security Disability Insurance, veterans= health, other federal health entitlement programs, and welfare, found that in fiscal 1995, substance abuse and addiction were expected to account for $77.6 billion of these entitlements. This represents nearly 20% of the $430 billion that the federal government spent on these programs. Lastly, one study by the Office of Management and Budget estimated the drug abuse costs to the United States at $300 billion a year, including government antidrug programs and the costs of crime, health care, accidents, and lost productivity (Falco, 1993).
   

    There are other studies addressing the costs of substance abuse to specific arenas; these studies are included later in this paper in the discussions of schools, health, criminal justice, workplace, and public housing. Examples of some of the costs to these systems follow:

Costs to victims of drug-involved crime (excluding the value of pain, suffering, and lost quality of life) are approximately $23.9 billion a year, including $3.5 billion for medical and mental health care; $8.2 billion for property damage and loss; $2.2 billion for police response, victim services, and other public programs; and $11 billion in lost future earnings (Center for Substance Abuse Prevention [CSAP], 1996c).

Costs of alcohol-involved crime (excluding the value of pain, suffering, and lost quality of life) are estimated at $31 billion, including $2.5 billion in medical care and over $28.5 billion in future earnings, property damage and loss, public services, and insurance costs (CSAP, 1996b).

Substance abuse-related care accounted for 20% of total Medicaid general hospital days in 1991, or 5.3 million days of care. Of this, only 1.2 million days, or almost 23%, were used for direct treatment of substance abuse (Fox, Merrill, Han-hua, & Califano, 1995).

Costs to the workplace resulting from alcohol and other drug (AOD) abuse are estimated at over $100 billion annually (U.S. Department of Labor [DOL], 1996a).

    Financial cost is not the only measure of the effect of substance abuse. There are a variety of consequences of substance abuse that affect many other human service systems. They include:

Alcoholism causes 500 million lost workdays each year, and AOD-related problems are one of the four top reasons for the rise in workplace violence (DOL, 1996a).

Substance abuse has become a dominant characteristic in the caseloads of child welfare agencies. The incidence of maltreatment among children in alcohol abusing families was 3.6 times higher than for children in families without alcohol abuse. The proportion of alcohol abusing-adults in families of maltreated children who also abused illicit drugs was 39% (NCAN, 1993).

Of maltreated children with substance-abusing perpetrators, 65% are maltreated while the perpetrator is under the influence of alcohol or other drugs (National Center on Child Abuse and Neglect [NCAN], 1993).

In a study of youth with runaway, throwaway, and homeless experiences, 31% of those in shelters and 45% of those in the street reported substance use by a family member in the 30 days before the youth left home, suggesting that familial substance use is associated with poor family functioning (Family and Youth Services Bureau, 1995).

    Substance abusers show up in large numbers not only among the disadvantaged populations, but in the workforce and among our youth in schools..

The 1995 Monitoring the Future Survey shows 12-month marijuana use is rising and now includes 15.8% of 8th graders, 28.7% of 10th graders, and 34.7% of 12th graders (U.S. Department of Health and Human Services [DHHS], 1995).

Seventy-one percent of illegal drug users are employed; 60% are with companies that have 500 or fewer employees (DOL, 1996a).

In a 1989 study by the U.S. Postal Service of workers who tested positive for drugs in pre-employment tests, but were hired anyway, nearly 70% were discharged involuntarily in less than 22 years; almost 60% were more likely to be heavy users of leave time; and by the 33rd month those testing positive were absent about 66% more often than those who had tested negative (DOL, 1996c).

Approximately 4.9% of female AFDC recipients are estimated to have significant functional impairment related to AOD abuse, and another 10.6% are estimated to be somewhat impaired by AOD abuse problems (Office of the Assistant Secretary for Planning and Evaluation and National Institute on Drug Abuse, 1994b)

In the Aid to Families with Dependent Children (AFDC), Medicaid, and Food Stamp programs, a DHHS study of 1991 program participation of persons 15 years of age and older found that 16.4% of Medicaid recipients, 19.5% of food stamp recipients, and 21.6% of AFDC recipients had used illicit drugs in the past year; 9.4% of Medicaid, 10.1% of food stamps, and 10.5% of AFDC recipients had used illicit drugs in the past month (Office of the Assistant Secretary for Planning and Evaluation and National Institute on Drug Abuse, 1994a).

In 1991, 5% of the 62,000 juveniles confined in juvenile detention and correctional facilities were there because of drug-related offenses (excluding drug distribution and alcohol-related offenses), and 66% of them had AOD dependency (Office of Juvenile Justice and Delinquency Prevention [OJJDP], 1994).

    Although there have been many studies on the incidence, prevalence, and, to a lesser extent, costs of substance abuse to other human service systems, there have been few studies about the prevention and treatment service patterns outside the substance abuse system itself. A major study has been conducted by the Alcohol Research Group, Berkeley, California, looking at alcohol- and drug-related problems in the health and social service agency populations (Tam, Schmidt, & Weisner, 1996; Weisner & Schmidt, 1993, 1994, 1995). The focus was on early intervention and treatment; however, it has implications for prevention. Noting that the research indicated that many individuals with substance abuse problems never come into contact with specialized treatment professionals, the authors looked not only at the alcohol, mental health, and drug treatment systems, but also at hospital emergency rooms, primary health clinics, criminal justice and welfare systems, and the general population. From their study, the authors concluded that health and social service agencies provide significant opportunities for prevention, screening, and referral of individuals with alcohol and drug problems. They suggested that general medical settings, where there was a lower frequency and severity of substance abuse problems, should focus prevention and education activities on alcohol, marijuana, minor tranquilizers, and combinations of these drugs, since these were the substances most commonly used by their populations They also concluded that perhaps more such screening and referral should be done in the criminal justice, welfare, and mental health settings where the preponderance of individuals with substance abuse problems is represented. They found the criminal justice and welfare systems bore a major portion of the substance abuse loadC67.5% and 18% respectively of the weekly drug-user population (Weisner & Schmidt, 1994). Lastly, Tam and associates (1996) also identified problem drinkers as needing perhaps somewhat different approaches to alcohol problems in the jail and welfare systems, with an emphasis on early intervention and the problematic social consequences of mild or moderate drinking, rather than on treating alcohol dependence.
    There are sufficient studies showing the enormous costs to human service systems outside the substance abuse prevention and treatment system to warrant greater attention to prevention within the context of those systems. The following discussion describes additional cost, incidence, and prevalence studies, as well as substance abuse prevention efforts underway within several major human service systems.

Substance Abuse Prevention: Approaches in Schools, Health, Criminal Justice, Workplace, and Public Housing

Schools

    The school system traditionally has been the primary venue for substance abuse prevention efforts. Although the evaluations of school-based prevention programs have shown mixed results and cost-effectiveness studies are few, there have been sufficient studies to refine school-based programs and make them more effective. Falco (1993) pointed out that two of the most promising school programsCLife Skills Training (LST) and Students Taught Awareness and Resistance (STAR)Care quite cost-effective. They cost about $15-25 per pupil and reduced new smoking and marijuana use by half and drinking by one-third.
    Much of the literature on substance abuse prevention in the schools focuses on particular models of drug education and prevention; limited attention has been given to school policies and organizational approaches. Schools have been the focal point for substance abuse prevention programs largely because they provide a captive audience encompassing nearly everyone in the appropriate age range for prevention (Ellickson, 1995). School-based prevention programs have evolved from the early information-based programs, where imparting factual information about drugs and drug use was the focus; to affective programs, which concentrated on the broader issues of personal development, including decision making, values clarification, and stress management; to the current social influence model, which focuses on resistance skills training, comprehensive programs, and broader interpersonal and social skills training. The first two approachesCinformation-based and affective programsCgenerally have been judged as ineffective. Since the late 1970s, considerable attention has been focused on the social influence model, which is grounded in psychological theories of human behavior (Botvin, 1995; Ellickson, 1995; Gorman, 1995; Hansen, 1990, 1992; Tobler, 1993).
    The social influence model has its basis in work done by Richard Evans and his colleagues who put forth the concept of Apsychological inoculation@ to prevent adolescents from smoking cigarettes (Botvin, 1995; Ellickson, 1995). This model has been the focus of prevention research for nearly 20 years, although there have been substantial questions about the effectiveness of the interventions used, leading to their continual refinement. For example, Gorman (1995) reviewed a variety of studies on resistance skills programs associated with the social influence model and judged them to be ineffective, although he did not find them to be detrimental. He concluded that these approaches were too limited; the prevention field should expand its view of prevention beyond the schools. Reviews of the literature by Hansen (1992, 1993), Botvin (1995), and Ellickson (1995) found mixed, but generally positive, results from the studies done of social influence programs.
    In separate discussions, Ellickson (1995) and Botvin (1995) discussed the history of the social influence model in some detail. Ellickson included detailed descriptions of work done at the University of California, The Rand Corporation, Cornell University Medical College, and the University of MichiganCwork that spanned 15 years. The focus of most studies that have documented the effectiveness of the social influence model has been on smoking prevention; for the most part, the studies have shown the potential of reducing drug use by 30-50% after the initial intervention. Of the few studies done on other substances, the magnitude of reported reductions generally has been similar to that found for smoking (Botvin, 1995). Both Ellickson and Botvin highlighted the principal problem with these programs as the decay in the effects over time, suggesting the need for booster sessions and ongoing intervention. Botvin noted that in studies of his Life Skills Training, those students receiving booster sessions showed reductions in substance use as high as 87%. Many researchers have begun to look at the broader-based prevention approaches that emphasize teaching generic personal self-management and social skills to provide students with the types of skills that will have broad application; the approaches differ from resistance skills training that is designed to teach students information and skills related specifically to substance abuse (Botvin, 1995).
    A number of studies conducted to examine the social influence model more closely have begun to identify some of the key variables to success of these programs. Botvin and associates (1995) conducted an evaluation of the long-term efficacy of a school-based approach. They concluded that a school-based intervention, conducted by regular classroom teachers, can produce reduction in tobacco, alcohol, and marijuana use that lasts until the end of high school and that prevention programs can affect more serious levels of drug use. They offered four possible reasons for the decay in other, previously studied, promising prevention approaches: (a) dosageCmany programs offer 6-8 sessions, whereas their program offered 15 in the first year; (b) there were no or an inadequate number of booster sessions; (c) implementation fidelity was not taken into account; and (d) the intervention models themselves may have been deficient in some way. They ended their discussion with the caution that this study involved predominantly white, middle-class students. There needs to be further study to see if similar results would occur among inner-city, minority youth.
    Several studies also examined the characteristics of successful school-based prevention programs, all of which noted the tendency for successful programs to include social influence approaches (Hansen, 1992, 1993; Rohrbach, Graham, & Hansen, 1993). Hansen (1992) did an extensive review of school-based substance abuse prevention curricula used from 1980 to 1990. He found that the encouraging strategies for prevention fall largely in the comprehensive and social influence domains (2 of 12 domains he identified), although because both of these approaches embody many different strategies, it was not possible to determine which component was more key or whether or not its effectiveness resulted from the additive combination of program components. He further cautioned that, although these two approaches were most consistently effective, there are many intervening variables (e.g., training and background of teachers, fidelity of presentation, and target population) that affect the successful implementation of these programs.
    Rohrback and associates (1993) reinforced the need for improved strategies for implementation of prevention programs to increase their level of success. They specifically looked at the program implementation issues of (a) teacher adoption, implementation, and maintenance; (b) teacher characteristics associated with implementation; (c) the relationship between the integrity of the program delivery and program outcomes; and (d) the effectiveness of teacher training and school principal involvement in increasing implementation. They concluded that school systems should (a) recruit and train teachers or other providers who are skilled in the use of nondidactic methods, and who are enthusiastic and committed to teaching psychosocial-based programs; (b) implement policies to permit teachers sufficient time to carry out the programs; (c) engage the principal in the process; (d) establish and enforce substance abuse policies; and, (e) like Botvin and associates, ensure the integrity of program delivery. Lastly, in another report looking at school-based alcohol prevention programs, Hansen (1993) argued that school-based prevention programs must identify the risk factors associated with alcohol use and address those that can be modified through some type of education. He cited several studies suggesting that training dealing with peer pressure and changing perceived peer-group norms may be effective in curbing alcohol use.
    Reports emanating from work done by The Rand Corporation=s Project ALERT reinforce the necessity of booster sessions for prevention programs (Bell et al., 1993; Ellickson, 1993, 1995; Ellickson & Bell, 1990; Ellickson et al., 1993). The authors examined a junior high program using the social influence model and its long-term effects. They found the program had strong effects in the first year, but the effects could not be sustained into the high school years; once the prevention program lessons stopped, the program=s impact on drug use stopped. They further found the program could curb both cigarette and marijuana use, and it appeared to work equally in schools with both high and low proportion minority populations and high- and low-risk adolescents.
    One popular school-based drug prevention program is the Drug Abuse Resistance Education (DARE) program; it has been adopted by approximately 50% of the school districts nationwide. There have been a number of evaluations of the program, and the results have largely been unencouraging (Ellickson, 1995; Ennett, Ringwalt, & Flewelling, 1993; Ennett, Tobler, Ringwalt, & Flewelling, 1994; Tobler, 1993). The 1994 meta-analysis reported by Ennett and associates concluded that DARE=s effect on drug use, relative to whatever other drug education, if any, was offered in the control schools, was slight and not statistically significant, except for tobacco use. They noted that there may be a variety of reasons for their findings, such as the traditional teaching style used in DARE (more like the didactic information and affective models of prevention) as opposed to interactive teaching, the inability of law enforcement officers (despite extensive training) to lead the curriculum, and the young age of the children targeted by the curriculum. Although they cautioned that there are limits to any school-based curriculum changing adolescent drug use, they concluded their discussion by expressing some concern that DARE, with its limited influence on adolescent drug use, may be taking the place of other, more beneficial drug curricula. Three of the four authors involved in this meta-analysis suggested that perhaps the program itself might need to be entirely redeveloped using prevention experts outside the DARE organization (Ennett et al., 1993).
    Countering the criticisms of DARE, Dunn (1993) argued that DARE is effective and is a means of bridging the gap between law enforcement and the schools. He found DARE was making a difference by providing essential information to young people, reinforcing self-esteem, providing a positive experience with law enforcement as a friend, helping law enforcement view itself as part of the social service system, helping police officers better understand how and why children behave the way they do on the streets, and delivering a strong Ano use@ message.
    Some studies have looked at substance abuse in a somewhat broader context than the immediate school curricula. One such study examined the effect of extracurricular participation on student alcohol and drug use in secondary schools (Cooley, Nelson, & Thompson, 1992). This study examined student participation in athletics, student government and clubs, and music and drama programs compared to nonparticipation in such activities. The results of the study suggested that extracurricular participation was a factor in reducing student experimentation and use of alcohol, tobacco, and other drugs.
    Gilchrist (1990) examined community-based prevention in the context of AIDS and intravenous drug use and offered an alternative approach whereby the school is but one component of a multicomponent community-wide effort. He concluded that three primary strategies should be employed: (a) universal, where classrooms in all schools disseminate information to all students; (b) selective, where special efforts are made in particular schools where the risk of AIDS is greatest to provide more intensive programming; and (c) indicated populations, where there is already behavior associated with HIV transmission, and the schools are then only peripherally useful sites.
    The environmental approach to prevention was the topic of a study done by Ross, Einhaus, Hohenemser, Greene, and Gold (1995). They looked at the school health policies related to tobacco, alcohol, illicit drugs, and violence at both the state and school district levels. They found widespread state and school district policies prohibiting the use of AOD (90.2% of states and 96.7% of districts), and 63.7% of the districts had drug-free school zones. At the school level, over 97% of the schools had policies prohibiting tobacco and AOD use. Although 82.0% of the states and 71.6% of the districts supported AOD prevention, the consequences of use were limited largely to notification of parents/guardians and school administrators. Participation in an education or counseling program resulted only 50.1% of the time in middle/junior high schools and only 42.9% of the time in senior high schools. Lastly, they found that although there might be school policies, enforcement was limited; first-time offenders usually did not participate in an education or counseling program. These results were corroborated by Rohrback and associates (1993), who found that school policies are significant in implementation; if school districts do not develop and enforce policies mandating prevention program implementation, long-term maintenance is unlikely.
    The U.S. Department of Education (DOE) provides guidance to schools that reflects the studies cited. First, it has included some guidelines on substance abuse policies in its Web page (ERIC Clearinghouse on Educational Management, 1993). This guidance suggested the following: school systems should establish a policy that links punishment for substance use/abuse to corrective action as well as intervention and prevention; student assistance programs should make nonpunitive help available to students and staff who request it, including nonusers affected by friends= or family members= substance abuse; specific prevention curricula might be authorized by the school district; and drug awareness and prevention training should be mandated for all staff.
    In addition, DOE, in concert with its regional centers, has a recognition program for schools implementing exemplary substance abuse prevention programs. The results are printed in several publications, two of which were reviewed for this paper (Buford & Davis, 1995; Voorhees & Burke, 1995). Another document, Success Stories =94: A Guide to Safe, Disciplined & Drug-Free Schools (DOE, 1994), focused on schools= implementation of Goal 6 of the National Education Goals to be reached by the year 2000 and highlighted five examples of successful drug-free school programs. The annual recognition program listings have provided descriptions of up to 100 different school programs each year. Some of the successful programs have included (a) involving local businesses, clubs, and organizations to contribute time and money to assisting students who could not otherwise participate in after-school activities (e.g., dance, art, music, athletics, and field trips); (b) establishing a Saturday program for at-risk students in grades 6-9, which enables them to discuss peer pressure and other issues and to bond with other children before they enter high school; (c) providing life-skills training to students who are suspended to help them develop self-confidence and decision-making skills; (d) operating a summer jobs program during the hours when drug dealing activity is at its highest and using kids in such roles as tutors and office helpers; (e) promoting community service; and (f) training parents.
    Goal 6 of the National Education Goals is that by the year 2000, every school in America will be free of drugs and violence and will offer a safe, disciplined environment conducive to learning. The objectives include (a) every school will implement a policy on use, possession, and distribution of tobacco, alcohol, and other drugs; (b) parents, businesses, and community organizations will work together to ensure a safe school environment; and (c) every school will have a comprehensive drug prevention education program. The Guide outlines six key components for schools to undertake in ensuring safe and drug-free schools. They are (a) recognizing, assessing, and monitoring drug and safety problems; (b) setting, implementing, and enforcing policy; (c) developing and implementing a drug education and prevention program; (d) educating and training staff; (e) promoting parent involvement and providing parent education and training; and (f) interacting and networking with community groups and agencies. DOE further notes that it is important for schools to implement drug education prevention programs in the early school grades and that they should be integrated into class experiences routinely and continued throughout the students= education.
    There are several limitations to the studies and programs reviewed. First, most of these programs have been tested in white, middle-class communities; study is necessary to see how effective the programs would be if applied in other communities. Second, program evaluation has been limited, and there is difficulty separating the effects of any given intervention from other efforts underway in the school and community. Third, as yet there has been no published evaluation of the Drug Free Schools and Communities/Safe and Drug Free Schools programs, a substantial source of funding for school-based prevention programs over the last 8 years. However, a 5-year study comparing more and less comprehensive school programs is nearing completion, and the report should be issued in early 1997.
    Prevention programs in schools are centered around the social influence model. Studies have shown that this model can be effective, provided it has a broader focus than substance abuse resistance skills training. In addition, the studies have shown the need for long-term prevention efforts with booster sessions up through high school. Several factors can affect the successful implementation of prevention programs in the schools, including the fidelity of the program, teacher training and enthusiasm, and support from the school administration. Programs also need to be tailored to address the population being targeted. School policies and enforcement of these policies are significant factors in setting the norms for schools. Lastly, programs should be comprehensive and coordinated with the community.

Health Care

    The Center on Addiction and Substance Abuse (CASA, 1995) conducted an extensive study of the costs of substance abuse to federal entitlement programs. The Center found that health care and disability costs alone were $66.4 billion. In that study, the costs to the Medicaid program resulting from substance abuse were enormousCan estimated $4 billion on substance abuse-related hospital care, which, in 1994, accounted for almost $8 billion in Medicaid expenditures (Fox et al., 1995). The authors believed their cost estimates were low because they used average per diem costs, when research indicated that people with substance abuse problems often require greater intensity of services. Lastly, the authors concluded that substance abuse-related illness costs could potentially be averted by a greater investment in prevention, early intervention, and treatment.     Another study, completed by the Kaiser Commission on the Future of Medicaid (Feder, Rowland, Holahan, Salganicoff, & Heslam, 1993), confirmed the great and increasing costs of substance abuse to the Medicaid program. It found that the rise of drug use, especially in poor and urban areas, resulted not only in issues with respect to substance abuse treatment, but also with respect to the related problems of street violence and drug-involved mothers and infants. It further noted the growing problem of HIV disease among low-income intravenous (IV) drug-using populations as a particular problem. As states have focused on developing and expanding programs to address these problems, Medicaid has become one of the primary payers of these services for low-income populationsC not only for the mothers but also for the infants born to them. In 1991, Medicaid paid for approximately 40% of the total amount spent on care for persons with AIDS, representing the single largest source of coverage for this group.
    Although there is clear evidence that substance abuse has a major cost impact on the Medicaid program, there is little evidence that the program supports substance abuse prevention programs. The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service is frequently cited as an area where the Medicaid program could engage in primary care by targeting developmental delays and many mental health and substance abuse services that are nonclinical (Substance Abuse Mental Health Services Administration [SAMHSA], 1996). However, no studies documenting substance abuse prevention in the EPSDT program were available. Recently, the President=s Commission on Model state Drug Laws (1993) targeted the EPSDT program for expansion to include early intervention and treatment programs for children.
    CASA (1995) found that the 1995 projected costs to the Medicare program from substance abuse were $18.2 billion. In a study of the effects of drug abuse on Medicare patients with cardiovascular disorders, Ingster and Cartwright (1995) found that their results examining prescription and other drugs were consistent with previous studies supporting the association of cocaine with cardiovascular abnormalities for a variety of cardiovascular conditions. They found that of the patient records they reviewed, patients whose substance abuse was indicated used nearly 330,000 more hospital days a year, amounting to nearly $175 million in annual costs to the Medicare program. Lastly, they noted that this estimate likely was conservative since the number of patients with substance abuse problems was severely underestimated.
    There is widespread acceptance of the importance of identification and screening for substance abuse problems, and primary care providers offer an excellent opportunity for both these tasks. However, there are few studies where the primary health care system has played a major role in substance abuse prevention beyond tobacco cessation programs. One program, the Group Health Cooperative of Puget Sound, has a 20-year history of developing and providing clinical preventive services. Their primary care system includes an extensive screening tool that asks both mental health and substance abuse questions (Thompson, Taplin, McAfee, Mandelson, & Smith, 1995). Although Thompson and associates= substance abuse discussion focused on decreasing tobacco use, they made a strong argument for greater preventive efforts in the health care system and for the need to address risk behaviors and risk behavior change in their patients. Another part of the Puget Sound program included a detailed approach to alcoholism detection, working with community resources (del Toro, Larsen, & Carter, 1994). Again focusing on secondary prevention, the authors concluded that placing a team to address these problems in a primary health care facility was advantageous to both the patient and the medical team.
    A key impetus for the integration of substance abuse prevention into the primary health care arena is the increasing incidence of HIV/AIDS. Although injecting drug use is a clear source of HIV transmission and a rising risk factor among youth, it still represents less than 20% of the HIV infection cases among adolescents. Rotheram-Borus, Mahler, and Rosario (1995) found the primary risk of infection for adolescents= use of alcohol and other drugs is the result of the disinhibiting effects of these substancesCa growing concern as we see the gradual rise in youth substance use. Therefore, HIV prevention must address the impact of alcohol and other drugs on sexual activity in adolescents. They laid out three approaches to HIV prevention, based on the level of sexual activity and substance use experience, ranging from eliminating drug use and/or eliminating needle sharing for IV drug users to reducing the frequency of substance abuse in situations where there was a risk for unprotected sex and to maintaining prevention strategies that reduced sexual risk for others while under the influence of alcohol and other drugs.
    Prenatal transmission of the AIDS virus and the increasing number of drug-exposed infants have resulted in major attention to overall prenatal substance abuse services and services for pregnant women and women of childbearing age. Again, many of these services are focused on secondary prevention and treatment for the woman, yet there is recognition of the need for primary prevention services as well. Ewing and Foran (1993) maintained that incorporating substance abuse prevention activities into routine prenatal care was important and should include the following: providing education on AOD use on pregnancy and the fetus and the nature of AOD dependence, screening for AOD use and dependence, and offering intervention when risk for AOD problems is suspected. They believed that a focused AOD interview, including assessment, education, motivational counseling, and referral, if needed, should be incorporated into every program. Similarly, in reviewing several successful community-based prevention programs, Soman (1993) found that the Women=s Alcohol and Drug Education Project, operating in a number of community or campus-based women=s centers around the country, included AOD education, information, referral and intervention services, support groups, and advocacy. In her review, Soman found that although the programs reviewed employed a variety of prevention strategies, two prominent components were public education and training of professionals (including physicians, nurses, social workers, dieticians, alcohol counselors, outreach workers, and other clinical staff) and community members.
    Key to the success of any incorporation of primary and secondary substance abuse prevention services into the health care field is the training and attitude of primary health care providers (Ewing & Foran, 1993; Soman, 1993; Stimmel, 1995; Ungerleider, Siegel, & Virshup, 1995). One critical article (Stimmel, 1995) examining physicians= ability to address substance abuse problems noted the lack of concern with physician ignorance regarding substance abuse, given that IV drug use is a major risk factor for contracting HIV. Stimmel discussed the history of medical educationCfrom the classroom through residencyCand the changing attitudes of physicians over their lifetimes. Very little has been offered in medical schools regarding any aspect of substance abuse. Moreover, although there was continuing medical education in substance abuse, only a small number of practicing physicians were targeted. Stimmel suggested several reasons for physicians= reluctance to become involved with substance abuse, including inadequate training; negative attitudes toward AOD abusers as angry, unkempt, deceptive individuals; inadequate time and compensation for AOD services, especially prevention; and the progression of cynicism evident as students progress through their medical education experience.
    In examining a broader group of health care providers (including health care professionals, health insurers, physician organizations, pharmaceutical companies, direct service providers) and medical education, Ungerleider and associates (1995) identified primarily the same barriers as Stimmel, but they also identified some encouraging signs of improvement. For example, at the federal level, they noted the power of the Surgeon General to affect preventive strategies (citing Koop and tobacco) and the (albeit limited) support from the National Institutes of Health for research and medical school curricula. They noted physician organizations were developing education programs, the public was beginning to work against industry advertising, and studies have demonstrated that prevention and treatment are cost-effective for health insurers. Lastly, they noted that educators have been moving slowly toward ATOD programs in medical school curricula. However, they concluded that much remains to be done, including increasing federal and state attention to prevention and treatment, improving physician ability to recognize early signs of abuse, ensuring health insurers provide better support for preventive measures, offering greater support to parents and families, and upgrading substance abuse education in medical schools.
    There is growing interest in integrating substance abuse prevention into managed care. Several statesCmost notably Kansas, Michigan, Ohio, Oregon, and WashingtonChave begun efforts to include substance abuse prevention into their programs. To date, only Kansas and Oregon have taken administrative action toward that inclusion. Kansas is currently letting contracts to develop and monitor funds for a statewide continuum of prevention centers and treatment providers for the express purpose of facilitating the union of substance abuse prevention and managed care (Kansas Alcohol and Drug Abuse Services, 1996). Similarly, the state of Oregon has required that prevention services be part of its managed care contracts (Jeff Kushner, personal communication).
    At the federal level, the Centers for Disease Control and Prevention (1995) recently provided recommendations for fostering the incorporation of prevention practices into managed care. Although the focus was on tobacco, the document provided a good discussion of the relationship between managed care and prevention, listing assumptions, opportunities, and barriers, most of which were applicable to the broader substance abuse prevention field. They included the development of prevention effectiveness measures, program guidelines, models for Medicaid agencies, and information systems. SAMHSA has developed guidelines for managed care organizations (MCOs), is working closely with the Health Care Financing Administration in reviewing Medicaid waivers relative to managed care, and is monitoring the development of behavioral health managed care (SAMHSA, 1996).
    The guidelines developed by CSAP/SAMHSA (CSAP, 1995) for MCOs, as well as similar guidelines developed by the National Committee for Quality Assurance (1996), covered a host of areas in which MCOs could better address substance abuse prevention problems and both organizational and program aspects of implementation. These guidelines included conducting a risk needs assessment, affirming substance abuse problem prevention as integral to its program, having a coordinator/coordinating team responsible for all aspects of ATOD prevention, keeping both staff and members regularly updated on available ATOD prevention services, training staff and allowing them time to implement prevention services, ensuring follow-up and hospital liaison, involving the community, and including evaluation and documentation. The guidelines provided a full list of prevention activities that the MCO might undertake, such as information and education programs, health risk appraisals, screenings and follow-up for ATOD problems, counter advertising, school health education, server training, employee assistance programs (EAPs) for corporate clients, Student Assistance Programs (SAPs) for schools, and participation in post-traumatic event debriefings (e.g., disaster debriefings) within workplaces, schools, and communities.
    Although neither the general primary care system nor the managed care system has actively embraced AOD prevention services as part of its mandate, there is a growing body of literature that urges it to do so and that addresses the benefits. However, much of that literature focuses almost exclusively on secondary prevention; primary prevention is less well understood, beyond providing information materials and occasional awareness workshops. One of the great difficulties in convincing managed care organizations to take on a full range of substance abuse prevention is the lack of cost-benefit data. Given that MCOs are profit-making entities and part of a medical system expecting concrete methods and outcomes, preventionists must expand documentation and evaluation of prevention activities to give credence to those programs in MCOs (Tolnai, 1996). CSAP has attempted to address this problem with respect to secondary and tertiary prevention. The Center has developed cost-benefit estimates for proven services (CSAP, 1996a) and has recommended that managed health care include early identification of heavy users of alcohol or other drugs through simple screening questionnaires, much like those used by Group Health of Puget Sound; provide brief intervention services to reduce drinking and drug use by heavy, nondependent users; and provide specific training for health care workers in early identification and brief intervention techniques.
    In summary, although there is strong evidence of the major costs of health care due to substance abuse, the general health care delivery system has not actively embraced primary, or even secondary, prevention. Generally, primary care providers have referred substance abusers to specialty treatment facilities. However, there is growing evidence that the primary health care system can be (and has been in some cases) a major partner in preventing substance abuse by providing education, screening, and brief interventions, in addition to the more accepted role of referral to treatment. With HIV/AIDS and drug-exposed infants, there is a growing urgency that the primary health care system take this more active role. However, as has been shown in numerous studies, a number of developmental steps are necessary, beginning with inclusion of substance abuse prevention into the medical school curriculum.

Criminal Justice

    Studies about alcohol and other drugs and crime have shown significant disagreement about the causal relationship of drug use and crime, although the interrelationship between the two has been repeatedly confirmed. There has been considerable evidence that delinquency and drug use have the same underlying causes; OJJDP publications summarizing risk factors for both substance (defined as alcohol and other drugs) abuse and delinquency noted that they are identical in all but one caseCthe availability of firearms was an added risk factor for delinquency (OJJDP, 1995a). In a report on juveniles in correctional facilities, although not specifically citing them as risk factors, 15 behaviors/problems were most common among juveniles in custody. Of those 15, family problems ranked the highest at nearly 80% of juveniles in custody, closely followed by drug and alcohol abuse at approximately 65% of juveniles in custody (OJJDP, 1994).
    Deschenes and Greenwood (1994) reported that there was contradictory evidence about the magnitude and the temporal ordering of the relationship. The studies they reviewed all supported the contention that the seriousness and frequency of drug use by offenders was one of the best predictors of the seriousness and frequency of offending. Similarly, Goldstein (1993) found that, although there were frequent claims of the relationship of drugs and crime/violence, there were no valid and reliable sources of data to describe the true nature of that relationship. In discussing the relationship of drugs and violence, he identified three distinct ways they are relatedCpsychopharmacological (as a result of ingesting substances), economic-compulsively (to finance drug use), and systemically (related to the drug trade). Huizinga, Loeber, and Thornberry (1995b) found that delinquency and drug use were related to each other, with drug use stimulating delinquency more than the reverse; delinquent youth were more likely Ato be arrested, to engage in precocious sexual behavior, to have reading problems, to exhibit oppositional and acting-out behaviors, to join gangs, and to own guns.@ In addition, findings from studies of violence have spawned much research into the link between alcohol use and violenceCthe great number of violent acts that have alcohol present and intoxicated persons involved and the relatively high proportion of persons implicated in violent events (victims as well as perpetrators) who have a history of heavy drinking and/or drinking problems (Wiley & Weisner, 1995).
    Several studies conducted by the Alcohol Research Group examined the relationship of alcohol consumption and drinking problems relative to criminal behavior, victims, and arrests (Greenfield & Weisner, 1995; Greenfield et al., 1996; Wiley & Weisner, 1995). These studies confirmed the relationship between alcohol consumption, problem drinking, and crime. Greenfield and Weisner found that there was an association between arrests and convictions (whether or not they were alcohol-specific offenses) and a history of alcohol problems. They cautioned that they have not demonstrated that alcohol/drug consumption facilitates criminal behavior, only that there remains a predictive relationship between them. Wiley and Weisner found that arrestees charged with violent crimes showed significantly higher rates of drinking specifically related to the events of the arrest; they did not find a similar relationship to the 12-month drinking patterns of arrestees. Greenfield and associates determined that it is important to examine not only the volume of consumption, but also the frequency of drunkenness when considering the relationship of criminal victimization and alcohol use.
    In the context of juvenile delinquency prevention, OJJDP has funded numerous projects and research efforts to look at the causes and correlates of juvenile delinquency and to identify better strategies to prevent delinquency. Although focused on preventing juvenile delinquency, the OJJDP programs incorporated program elements that largely mirror the accepted elements of substance abuse prevention programs (Huizinga, Loeber, & Thornberry, 1995a, 1995b; OJJDP, 1995a; Weingart, Hartmann, & Osborne, 1994). The four general characteristics of delinquency prevention and treatment programs were as follows: (a) programs need to start early in life; (b) behaviors follow a set of behavioral pathways that progress from less serious to more serious; (c) intervention programs need to be comprehensive and deal with the multiple, co-occurring problem behaviors of the serious delinquents; and (d) programs must address the multiple and interlocking causes associated with delinquency. Lastly, OJJDP cautioned that intervention programs must be designed for the long termCfor years.
    The OJJDP studies in three communitiesCDenver, Pittsburgh, and RochesterCshowed that rates of drug use were quite high among youth involved in delinquent behavior, with alcohol being the Adrug of choice,@ and marijuana and other drugs being of concern as well (Huizinga et al., 1995b). In these studies, they found that the prevalence of violence among the drug-using groups was more than double the prevalence of violence in the nonusing group. They further noted that drug users (including alcohol, marijuana, and other drugs) accounted for 72% of violent males and 73% of violent females; violent drug users constituted only 9% of males, but accounted for 74% of all violent acts committed by males. Drug use was also a risk factor for future violence among males; males who had prior year drug use had a higher rate of violence than those who did not. As in the previously discussed studies, the authors noted that none of their findings indicated that drug use was a direct cause of violence.
    The research reported that attachment and social integration with successfully socialized individuals and groups provided a buffer against delinquency and drug use. Huizinga and associates (1995a, 1995b) proposed several areas for intervention, noting that they were not all within the purview of the juvenile justice system but that the juvenile justice system frequently can be a major actor. The following are their suggestions for juvenile justice system involvement: (a) improving parenting skills and providing support services that empower parents to monitor and supervise their children; (b) attempting to ensure that youth in Atreatment for delinquency@ return to more effective and caring homes; (c) examining ways in which schools could be prepared to provide help for parents seeking help for the delinquent behavior of their children; (d) providing prevention and potential treatment referral services; and (e) developing programs that integrate delinquency-prone youth into generally prosocial groups, accompanied by substantial adult involvement.
    Finally, OJJDP reported that programs implemented by many of the communities engaged in antidrug activities have included an extensive array of drug prevention programs directed primarily toward youth, including drug education, employment, counseling, and recreation. In some of its programs specifically targeted to preventing juvenile delinquency, it has included programs such as life skills building, parent training, conflict resolution, development of school resources to prevent school failure and dropout, family counseling, and alternative activities.
    Throughout much of the juvenile justice/criminal justice literature there were references to risk factors, such as those included in the substance abuse prevention and education literature. For many years OJJDP has used the Hawkins/Catalano Risk and Protective Factors model for its research grant program. This model was cited in each of the OJJDP documents reviewed for this paper. As noted earlier, using this model, all but one of the risk factors were identical for substance abuse and juvenile delinquency. Moreover, the programmatic responses for both were largely the same. OJJDP reported delinquency prevention programs that use approaches common to substance abuse prevention such as peer mediation, peer counseling, conflict resolution, parent training, mentoring, after-school recreation, youth service, and community mobilization (OJJDP, 1995b). Using this same model, CSAP has developed a training session, Working with Criminal Justice (CSAP, 1996e), which reinforces the close linkages between the issues facing the criminal justice and substance abuse systems. This training was designed to assist prevention professionals to become more conversant in the field of criminal justice and to develop strategies to work more closely with that system.
    In summary, the primary connection for substance abuse prevention to the criminal justice system is through the juvenile delinquency prevention programs. As noted above, these programs were founded on the same principles of risk identification and protective factors, and they tended to engage in similar program activities (e.g., parent training, peer counseling, youth service, mentoring). Moreover, the interrelationship of the two youth problem behaviors was clearly shownCan interrelationship that is so intertwined, it is difficult to determine the causal relationship.

Workplace

    Several studies have been conducted about substance abuse in the workplace. Most of these have identified a significant negative impact of substance abuse on attendance and accidents, although findings on other performance or earnings factors have been less clear. In examining the costs of substance abuse in the workplace, French, Zarkin, Hartwell, and Bray (1995) reported on the prevalence and consequences of substance use at five worksites, finding that the AOD consequences in the workplace were poor performance, absenteeism, and accidents. Claims analyses for several companies by Samuelson (1994) further reinforced the costs of substance abuse at the worksite. He determined that the top three health-related areas in terms of economic impact on the workplace were mental health (including substance abuse), smoking, and hypertension.
    In an earlier review of the effects of alcohol and drug use in the workplace, French (1993) looked at the effects on both earnings and workplace behavior. He concluded that one cannot generalize the relationship between substance use and earnings for all workers, but that illicit drug use consistently appeared as a statistically significant predictor of absenteeism; for workplace behaviors, the results were mixed. French concluded that although a wide variety of undesirable workplace effects have been linked with substance use, few definitive conclusions can be drawn regarding the direct effect of substance use on such workplace measures as lower productivity, job satisfaction, and accidents. Partially corroborating these conclusions in a review of several studies of work-related outcome measures, the Institute of Medicine (IOM) (Normand, Lempert, & O=Brien, 1994) found that several studies suggested that an effective worksite wellness program can show a positive cost-benefit ratio by reducing absenteeism and employee benefit claims. However, the IOM cautioned that there are few evaluation studies of EAPs and that there is no such thing as a Ageneric@ EAP.
    Roman and Blum (1995) provided a good overview of the approaches to substance use/abuse in the workplace. The two predominant types of approaches have been drug screening programs and EAPs. As workplace approaches to substance abuse emerged, they initially focused on prohibition. Worksite prohibition has become an institutionalized policy in the United States, although there are no precise measures of its effectiveness. Since the mid-1980s, the focus has been to establish a Adrug-free workplace,@ usually involving drug screening. Initially, drug testing was considered the solution, but subsequently the focus has been more on the marriage of drug screening and EAPsCproviding assistance to substance-using employees. EAPs emerged from the industrial alcoholism programs and have had as their goals the treatment and rehabilitation of employees with personal problems that affect their work. Because of the reduction in positive drug screens in workplace drug testing, some characterized both drug screening and EAPs as secondary prevention with primary prevention being the prohibition strategy.
    DOL encourages employers to establish workplace substance abuse programs (DOL, 1991, 1996a, 1996b). The program development consists of the following five steps: writing a substance abuse policy, training supervisors, educating employees, providing employee assistance, and testing for drugs and alcohol. Educating employees includes information about the dangers of alcohol and other drugs and the potential impact they have on individuals and families; job safety, productivity, and quality; health care costs; the consequences for violation of the policy; a description of the employee assistance program and/or substance abuse testing; and ways to obtain help, if needed. DOL indicates that drug and alcohol testing by itself is not a substance abuse program but can be a useful tool in a comprehensive program.
    To assist employers, DOL also has a program called the AWorking Partners Initiative,@ which is designed to deliver helpful information to small businesses in a variety of areas, including solutions to substance abuse problems. As part of this program, DOL electronically provides fact sheets on manufacturing, construction, general services, hospitality, retail, and wholesale businesses on the World Wide Web that include descriptions of successful substance abuse prevention programs. However, in reviewing these fact sheets, they focus almost exclusively on strong drug-free workplace policies; pre-employment and post-employment drug testing; and referral to counseling, treatment, and rehabilitation, usually administered through an EAP (DOL, 1996a, 1996b, 1996c). These programs offer an opportunity to intervene in the early stages of substance use to avoid greater problems in the future, but they do not include prevention.
    Although drug testing is widely accepted as a component of workplace programs, the IOM (Normand, 1994; Normand et al., 1994) found that the preventive effects of drug testing have never been adequately demonstrated nor is there conclusive scientific evidence that drug testing widely discourages drug use or encourages rehabilitation. The authors further indicated that employers need to be clear about the objectives for drug testing (e.g., preventing accidents, saving health costs, improving performance, promoting a drug-free society) before they can measure the effectiveness of the programs they implement.
    The focus of most workplace substance abuse programs is on preventing the negative consequences of substance abuse. However, there is a growing trend to broaden the approach to workplace substance abuse prevention and the potential of a positive impact on working people, their families, and the community (Ashery, 1993; Backer & O=Hara, 1991; Cook, Back, & Trudeau, 1996; Yandrick, 1994). Cook and associates (1996) noted a growing appreciation for mainstream substance abuse prevention within the context of workplace wellness programs. Some of this activity dates back to the mid-1980s, but the approach is getting more attention with a greater focus on the interrelationship of health practices and substance abuse. Risk behavior management is also becoming a greater focus within the context of wellness and human resource management. The influence of environmental risk factors on substance useCthe Aculture@ of the workplace with respect to the acceptability of substance useCis increasingly included in this approach.
    Cook and associates (1996) described two programs designed to improve health-related attitudes and behavior and reduce substance abuse aimed at the individual within the workplace, based on a social learning model. The chief elements consisted of (a) a focus on raising worker awareness, motivation, and knowledge about health and AOD use; and (b) the belief that as healthful behaviors provide rewards and as the social environment provides support for such behaviors, employees will avoid substance abuse. Prevention strategies should be implemented at all three levelsCthe community, the workplace, and the individual employeeCfor successful change in substance abuse practices.
    EAPs are considered the most likely location for worksite substance abuse prevention programs. EAPs affect a large number of employees; a 1991 national employee survey found that more than half of American workers have some EAP coverage (Roman & Blum, 1994). However, their use to date has been limited to instances of impaired job performance, peer or self-motivated requests for addressing an employee=s substance problem, or self-motivated requests for assistance in dealing with a substance-using family member (Roman & Blum, 1995). Macdonald and Wells (1993) noted that often employers do not recognize or acknowledge the value of health promotion and prevention programs and, where EAPs were established, employees often are unaware of the resources available to them through their company=s EAP.
    Several large-scale, multiyear studies conducted by Roman and Blum (1994) examined EAPs, their role in the workplace, and their potential. They found that EAPs were mainstreamed and that substance abuse problems were intermingled with other problems. They also found considerable secondary prevention activity in the companies they studied, with 78% of the EAP caseload being in the low dependence category (Blum & Roman, 1995), 63% of them having some form of a drug-free workplace program, and 55% reporting some prevention activities (Roman & Blum, 1994). They did not, however, provide details on those prevention programs. Although EAPs have focused largely on treatment and rehabilitation, mature EAPs and those in communities that have other AOD prevention activities dealt less often with late-stage substance abuse problems (Blum & Roman, 1995). Examples of preventive and early intervention activities in which EAPs were involved included the following: helping to ensure job retention by those who may abuse substances but are not yet severely dependent or addicted; extending services to family members; assisting employees and their families in resolving problems that might lead to substance use/abuse; offering services to parents; developing drug-free workplace policies; providing brief interventions; distributing educational materials on substance abuse, mental disorders, and their prevention; educating supervisors and union representatives about the management of AOD and mental health problems; and helping to transform workplace cultures into ones that discourage excessive drinking and support recovery.
    Similarly, Macdonald and Wells (1993) found that the most frequent prevention programs cited were health promotion, fitness, stress management, weight/nutritional counseling, smoking cessation, and financial planning. Although not necessarily addressing substance abuse directly, these programs addressed many of the risk factors for substance abuse; raising the level of understanding for, and appreciation of, a healthy lifestyle; and reducing the acceptability of substance use/abuse. Stoltzfus and Benson (1994) described a program implemented at 3M that included supervisory training, all-employee workshops, and a peer-helper program. Their results suggested that such a worksite prevention program can reduce alcohol consumption, improve employee and supervisor prevention skills, motivate employees to share prevention responsibility, and reduce the negative impact of substance abuse on work.
    A variety of programs that extend beyond the workplace have shown promise. The AI=m Smart,@ program in New York State (Yenawine, 1994) was a community-focused, risk-management program designed to combat substance abuse. This program provided liquor-server training, guidance on social-hosting practices, worksite training on rules for smart drinkers, and transportation alternatives to those who may be impaired and unable to drive, and it assisted employers in developing sound substance abuse policies. Kline and Snow (1994) reported promising results from a stress reduction intervention for mothers employed in secretarial positions. The intervention focused on both worksite- and family-related risk and protective factors; they found greater results in improving the worksite than the family situations.
    Foote and associates (1994), reporting on the early results of a 4-year study, suggested that an EAP could define its role more broadly to facilitate a support network for clients in need of treatment, which would include family members, friends, co-workers, and others. As part of their study, they found that long-term client follow-up and family involvement with the EAP appeared to be effective secondary prevention strategies by identifying problems not immediately presented by a client, which may include alcohol, family, or marital problems. Although they suspected this approach also could prove to be an effective primary prevention strategy, they have no evidence to support that conclusion as yet. Another study, seeking to reduce family risk (Felner et al., 1994), found that parent training programs in the workplace can create enduring impacts. They found that organizational context was especially important to the program=s success (i.e., employees were given regular lunch/meal breaks, and attendance was supported by supervisors). Similar to the findings for school prevention programs, parents who received higher dosage levels of the program exhibited enduring changes in risk and protective factors as measured in terms of parent/child interaction, parenting stresses, and substance abuse knowledge/attitudes.
    Lastly, Colan and Schneider (1994) and Colan, Mague, Cohen, and Schneider (1994) reported on a project where worksites became the source of family-focused primary prevention by implementing a program for latch-key children and their parents. Seminars were sponsored by the employer covering the multiple issues of safety, decision making, and substance abuse pressures associated with leaving a child at home alone. They were offered after hours, with both child care and dinner provided. Early reports from this experiment indicated that the parents in the program experienced greater comfort with self-care, talked more with their children about self-care, and had a greater sense of self-efficacy. Their children reported an improved family environment, a greater sense of self-efficacy, and less general anxiety.
    Much of the workplace substance abuse literature with respect to prevention consists of suggestions on how prevention might be included, rather than what exists today (Ashery, 1993; Backer & O=Hara, 1991; Shain, 1994; Vicary, 1994a, 1994b). Other literature has promoted extension of prevention programs beyond education and information to changing attitudes, behaviors, and beliefs to change the work environment with respect to substance use/abuse (Backer & O=Hara, 1991; Shain, 1994; Vicary, 1994a, 1994b). Vicary (1994a, 1994b) promoted the concept of a broad comprehensive approach to substance abuse prevention within the workplace. She proposed not only information and education but also social and life skills training, positive alternatives, policies and programs that set norms and standards, and community mobilization programs and activities. Vicary proposed a comprehensive model that addressed several audiencesCindividuals, families, peers, school, work, and community members. She emphasized the importance of the worksite as a partner in prevention programming and cited a number of possible workplace-related prevention activities, such as alcohol-free social activities, AIDS-awareness programs, flexible employee policies such as adoption leave, flex-time employee courses in communications or life skills training, parenting programs, wellness programs, and community services such as sponsoring sporting events or academic and other youth awards.
    In summary, workplace approaches to substance abuse prevention have rested largely in the arena of drug testing and EAPs (Blum & Roman, 1995; Normand et al., 1994). EAPs generally have limited their attention to employees who are experiencing substance abuse problems themselves or within their families. There is general support for both drug testing and EAPs, but there is also substantial ambivalence about the proper role of the workplace in dealing with substance abuse problems (Roman & Blum, 1995). Regardless, there is growing attention to the expansion of workplace prevention efforts within the contexts of wellness programs and comprehensive, community-wide prevention efforts. Many wellness and health promotion programs have focused on reducing individual risk factors (e.g., smoking, obesity, hypertension) that are often associated with AOD use. These programs are quite varied, ranging from a smoking policy to occasional health education classes, comprehensive interventions including health risk screening, and organization-level activities designed to provide an environment supportive of health (Normand et al., 1994).
    Finally, in reviewing workplace studies, one must note that there were few evaluations of these programs, and those that exist generally were done on comprehensive programs, making it difficult to assess the effectiveness of any given component with respect to a specific risk factor. Lastly, there were no studies demonstrating persistent, long-term effects (Normand et al., 1994). Although there was little to report on substance abuse prevention programs that currently exist, there was evidence that more programs are being developed.

Public Housing

    Recent data by the U.S. Department of Housing and Urban Development (HUD) indicate that although public housing communities represent less than 5-10% of a local population, they have twice the share of that locality=s substance abuse problems (Cocke, 1996). The problem greatly increased in the late 1980s, and the response was to enact the Public Housing Drug Elimination Program (PHDEP). This program provided grants for which public housing authorities across the country could compete. The program increased greatly over the yearsCfrom $8.2 million in FY 1989 to $260 million in FY 1995. HUD currently is instituting efforts to assist housing authorities in identifying and administering effective drug prevention programs and in developing and measuring performance outcomes relative to safety and drug prevention.
    The PHDEP grants permit a wide range of uses for the funds, including prevention, intervention, and treatment of substance abuse. In FY 1995, under this program, housing authorities spent 35% of their funds for substance abuse prevention activities, with another 7% for intervention (Cocke, 1996). Although there has not been a recent national evaluation of the PHDEP grants, HUD conducted an evaluation of the program between July 1991 and July 1993 (HUD, 1994b). This study gathered data on local public housing programs, looking at the following five major strategy areas: law enforcement/security, physical improvements, drug prevention, drug treatment, and Resident Management Corporation/Resident Council programs.
    The results of the study showed a significant focus on substance abuse prevention programs, with 38% of the funds dedicated to prevention. The most commonly implemented activities in all five strategy areas were drug education, youth sports and recreation, and youth education and tutoring. Seventy-five percent of the programs included some prevention as part of their total program, with 22% focusing on prevention-oriented programs. Over time, the grantees began to shift their resources toward prevention, with more than a third of the grantees who were initially focused on security shifting to mixed or prevention programs in their second grants (HUD, 1994b). The evaluation found that drug prevention activities targeting youth, rather than adults, tended to be most effective and had substantial resident involvement. Lastly, the authors arrived at somewhat contradictory findings. Grantees cited security as the single most effective activity, followed by prevention; however, the drug prevention and treatment activities were most frequently perceived to be the least effective (the authors noted that this may be attributable to the short time frame for the study).
    The HUD evaluation studied 617 grantees and examined 15 sites closely (HUD, 1994a). Of the 15, only 4 were considered to be Asuccessful PHDEP programs,@ 6 were considered mixed or moderately successful, and 5 were considered unsuccessful. Of the four programs consistently considered successful by HUD, each program had some previous history of prevention activity. Most of the 15 sites were determined to have an effective balance between law enforcement/ security and drug prevention/intervention, although the programs encountered more difficulty in implementing prevention/intervention components. Resident participation was somewhat uneven in all activities but was generally better in children=s activities. The authors concluded that the prevention/intervention activities were central to the PHDEP grants and should be included even though they were difficult and time-consuming to implement. Lastly, they noted that a key issue for implementation of the programs was persistent outreach to residents regarding activities and services.
    In addition to the programs described in the evaluation along with private partners, the Boys and Girls Clubs of America (HUD, undated b), Ozulu and Goldman (1994), and HUD (undated a) released several documents describing successful substance abuse prevention programs in public housing communities. Examples of the most successful programs described were as follows: teen leadership strategies on how to help themselves and their friends cope with the social problems that often lead to drug abuse, tutorial programs, female adolescent support groups, athletic teams, parent support groups, school bonding programs focused on middle and high school students, art classes for children, performing arts, SMART Moves, and AJust Say No@ clubs. In addition, in a guide for public housing authorities on law enforcement strategies to eliminate drugs in public housing, HUD suggested a variety of demand reduction strategies (HUD, 1994c). Along with promoting drug-free lifestyles, these strategies included establishing DARE programs in schools that serve public housing communities; providing education and drug reduction programs; promoting tutorial and dropout prevention programs within the local schools; establishing scholarships, work-study programs, and parent training and support; supplying computer games; and offering home-study programs and college role models.
    Two private organizations that have reported substance abuse demonstration projects in public housing communities are the Boys and Girls Clubs of America (BGCs) and AJust Say No@ International. The Boys and Girls Clubs have programs in many housing communities, some of which use the SMART (Self-Management and Resistance Training) Moves program demonstrated in an Office for Substance Abuse Prevention (OSAP, now CSAP) High Risk Youth Grant (HUD, undated b). SMART Moves focuses on high-risk preteens and adolescents, is community oriented, and aims to educate parents and the community, as well as adolescents. Evaluating the OSAP program, Schinke, Orlandi, and Cole (1992) came to the following conclusions: (a) BGCs appeared to be associated with an overall reduction in substance abuse, drug trafficking, and other drug-related criminal activity; and (b) BGCs appeared to have improved the physical quality of life in the housing community, boosting the morale of the residents. Although there was not a significant difference between housing developments with BGCs and those with BGCs with the SMART Moves program, Schinke and associates speculated that this result could be because those with BGCs alone had been in operation longer.
   AJust Say No@ clubs exist in many public housing communities. AJust Say No@ International reported on a program in eight public housing authorities beginning in October 1990. The first-year report of the program (Simmons, Stratman, D=Onofrio, & Moskowitz, undated) found that the clubs, using teen leaders, engaged in a variety of recreational, educational, community outreach, and community service activities and provided a positive antidrug support system for young people to learn leadership and decision-making skills.
    One prevention strategy jointly implemented by CSAP and HUD was described by Van Houten, Hailman, Yanssaneh, and Bowen (1996). They reported on 10 Prevention in Housing Communities Training Institutes that consisted of team training of public housing authority staff, residents, and representatives of other key social institutions for the purpose of creating their own solutions to the substance abuse environment they live in. The evaluators found that the training provided participants greater motivation, enthusiasm, and a sense of newly acquired skills and knowledge but that the effects diminished upon the participants= return home. More intensive preinstitute training and postinstitute technical assistance and follow-up were suggested to improve the outcome of the institutes.
    The principles of substance abuse prevention most commonly employed in public housing communities consisted of the following: inclusion of residents in the planning and implementation of the program, use of mentors/role models, substance abuse education, resistance skills training, alternative activities, and environmental approaches.