ࡱ> Oh+'0   8D ` l x <Developing a national programme: what's in the mix and why/eveBlaine Stothardlai Normal.dothBlaine Stothard5aiMicrosoft Word 8.0a@vA@iR@j@ !՜.+,D՜.+,< hp  Dell Computer Corporationch` <Developing a national programme: what's in the mix and why/ Title(H9  _PID_GUID _PID_HLINKS_AdHocDeveloping a national programme: what's in the mix and why/ practice, professionalism, prescription. Blaine Stothard. January 2005. Introduction Governments are increasingly raising the profile of responses to illegal drug use within society; and increasingly adopting prescriptive responses. This political agenda has been gaining pace in the past three decades, with a range of factors - international treaties and conventions, awareness of the global trade in illegal drugs, the growth of the use of cocaine, the emergence of stimulants and the associated dance and club culture - contributing to the urgency. Accompanying this 'big-picture' development has been a parallel, at least in Europe, return to some basic thinking on responses. At an international level, institutions and governments have tended to focus on supply reduction, using criminal justice and sometimes military responses in an attempt to reduce or prevent the production and supply, and therefore the availability and use of illegal drugs. At a national level, governments are increasingly looking at a dual approach: supply reduction and demand reduction. In the UK and other countries this has meant increased attention to and resourcing of treatment and care services. Accompanying this change has been the tacit or overt adoption of harm reduction approaches; and attempts to reduce demand through education and prevention programmes, although there has been continuing opposition and hostility from some sources. The strategic assumption that accompanies this change in emphasis is that drug education programmes, predominantly in schools, but also in the youth justice field, will have a drug prevention outcome. In turn that would lead to future demand reduction, with decreases in the extent of illegal drug trafficking and reductions in domestic demand for treatment and care programmes. An additional benefit is the saving to health budgets. This view is based, in part, on the chronological linkage between the expansion of school-based sex education in the past twenty years and the consistent decline in teenage pregnancy rates over the same period in the UK (Social Exclusion Unit 1999; UNICEF 2001.) The core to this politically attractive view, which emerged in the mid-1990s, is the role of schools as drug prevention agencies. It is this process of trying to use schools to educate young people not to use drugs with which this chapter is concerned. In particular the chapter looks at recent drug education policy and practice developments in the UK, with a national bias to England. Given the UK's top or near top position in the European league in terms of young peoples illegal drug use, alcohol use and early uptake of smoking (Hibell et al 2000) and the similarity of the policy making process in western democracies, both the urgency and the outcomes are likely to be of interest to other countries. There are questions to be raised about the impact on substance use and misuse of: education and prevention in-puts; emotional support and literacy; consumerism and spending choices; the internal distribution of wealth. However, it is only the first of these, which is currently on the 'official' political agenda in the UK. Education or Prevention The terms 'education' and 'prevention' need further definition. Drug prevention is a set of interventions intended to prevent drug use. Prevention may be primary stopping use before it has started or delaying the age of first use; secondary stopping use which has started; or tertiary reducing the extent and frequency of existing use, and possibly diverting users to less damaging substances and forms of use (harm reduction). Drug prevention is against drug use. Drug education is a set of interventions intended to inform an audience about the facts, contexts and consequences related to drugs and their use. It includes the transmission of facts and information; discussion of this information; opportunities to reflect on attitudes to the information gained and the behaviours involved. Drug education is about drug and substance use. (Cohen 1996; Gossop 2000) Often seen as synonymous, education and prevention are clearly distinct, although education in-puts can contribute to prevention outcomes. The tendency of politicians to synonymise the terms can lead to unrealistic expectations being made of school (and other) drug education programmes. It is pertinent here to point out that the 1995 government guidance to schools in England was entitled Drug Prevention in Schools (Department for Education 1995). It is also important to be aware that education and prevention programmes are not restricted to young (in this context, school age) people. One of the successes of UK public health campaigning has been the reduction in the incidence of drink-driving; and the change in social attitudes towards drink-driving. Largely achieved through long-term TV, radio and printed media campaigns, the results have taken twenty-five to thirty years to emerge; and are reinforced regularly. No short-term, once-and-for-all approach here, but a constant, repeated, long-term, behaviour and norm focussed process. This represents a process which may have lessons for school-based work that government is not yet willing to acknowledge - long-term inputs are needed for each age-group and generational cohort of school pupils. A reliance on 'one-off' in-puts (even if the 'one off' is a five-year cohort) is not adequate to influence normative assumptions or behaviour. The UK Context Forms of drug education has been provided in many, but not all, schools in the UK for decades. The earliest provision was based on local awareness by, primarily, teachers and youth workers of young people's behaviour. These interventions tended to concentrate on tobacco, alcohol and volatile substance (i.e. solvents) abuse (VSA). Some of the teaching materials produced in the 1970s and 1980s remain valid and methodologically relevant today. The drugs involved remain of concern to many of those who provide services to young people in 2004. In addition cannabis has had a constant presence and continues to be the most widely used illegal drug in the UK. The 1970s saw official acknowledgement of an 'at-risk' group of adolescents, alienated and absent from schooling and formal society. This group was seen as able to benefit from programmes and projects aimed at raising basic educational standards and encouraging entry into further education and the labour market. These 'intermediate treatment' programmes (intermediate in that they attempted to intervene in 'at risk' young people's lives before they came into conflict with the criminal justice system) taught us much about adolescent drug use. This occurred in the decade after illegal drug use extended into all social classes in the UK. Not only were the hallucinogens, associated with the 1960s, being used, but also stimulants and depressants associated with mods and rockers and, a decade later, punk. Added to this mix was increased over-prescription of tranquilisers by doctors. This escalation of drug use in the UK is often referred to as democratisation, because use was no longer confined to particular social groups. By the time of the intermediate treatment programmes, much substance use for those without the connections or cash was volatile substance abuse. This side-stepped illegal drug use and illustrates some of the socio-economic (or to use a term currently out of official favour: class) factors which determine patterns of drug using behaviour. The increased availability, use and acceptability of cannabis in these decades did not spread to all population groups, in part because of cost and in part because of the reluctance of some young people to use an illegal drug. Starting in the late 1980s, the UK has seen a rise in the use of newly-available and fashionable stimulants, initially ecstasy and amphetamines. Although having by far the highest public and media profile, ecstasy was an also-ran to amphetamines until the late 1990s, when it became the second most used illegal drug in the UK after cannabis (Aust and Condon 2003). Most recently, its use has become less fashionable and it has fallen out of favour. From the late 1990s there has been a rise in the availability and use of powder (as opposed to crack) cocaine. The increase in powder cocaine use is, in the main, a recreational use. The use of crack cocaine remains predominantly an addiction affecting the socio-economically disadvantaged. The latest Home Office (i.e. ministry of the interior) statistics (Aust and Smith 2003; Condon and Smith 2003; Aust and Condon 2003) suggest that this rise has peaked, and that there has been a reduction of stimulant drug use. Although not included in these statistics, which cover only illegal drugs, this apparent reduction in illegal drug use has coincided with an increase in alcohol consumption. Many in the media and also in education concentrate their attentions on illegal drugs. However, education ministry (currently known as the Department for Education and Skills (DfES), the name changes on a regular basis) documentation and guidance refer to 'drug' education as covering all substances, which may be used by or available to young people and which can present a health risk. This group encompasses medicines, tobacco, alcohol and solvents, in addition to illegal drugs. This clarity and depth of thinking about the content of school drug education programmes has not, however, extended to the consideration of effectiveness or outcomes. An attempt to rectify this omission may explain in part the more recent (2000 on) focus by government on 'evidence based practice' and 'what works' approaches. The early drug education programs provided as a response to immediate and local needs were far from universal, and activity prompted by local professional observation and concern has not always been sustainable. Indeed, it has been a feature of UK education that with the increasing intervention of central government in school practice since the mid-1980s, much practitioner-originated (i.e. bottom-up) service provision, including drug education, has been excluded to make way for practice and provision demanded by government. This has included a highly prescriptive national curriculum, whose earliest versions made little or no provision for young people's social and emotional needs. In broader education terms, this reflects a transfer of power over the school curriculum from teachers and other practitioners to politicians and government. (Lawton 1980.) Perhaps predictably, this particular wheel continues to turn, and drug education is again on the school agenda. Attitudes towards young people differ markedly between government departments. The Department of Health has consistently adopted a more realistic and pragmatic approach to young people's health related behaviours than the Department for Education, although closer inter-Departmental collaboration is beginning to reduce the attitudinal differences. (These attitudinal differences between health and education ministries appear to be an international characteristic). Department of Health-led guidance on child protection (The Stationery Office, 1999) refers to children (defined in English law as an individual who has not yet reached his or her eighteenth birthday) as citizens entitled to the protection of the law. Draft curriculum guidance published by the Qualifications and Curriculum Authority the same year referred to school pupils as being 'future citizens', a term omitted from the final guidance. This contrasts markedly with 1990 instructions provided to educationalists writing government guidance on health education to accompany the first version of the national curriculum. These instructions indicated that the term 'empowerment' was not to be used in the guidance. A 1993 report by the influential Advisory Council on the Misuse of Drugs examined the role of schools in drug prevention strategies and recommended a strengthening of work in schools. The report acknowledged that outcomes of school drug education were difficult to assess and that attitudinal changes do not necessarily result in changes in behaviour. It acknowledged the probable long-term, as opposed to immediate, benefits of information and skills based programmes; and reinforced the view that school drug education should encompass medicines, volatile substances, alcohol and tobacco. The report referred to the welfare of pupils; and acknowledged the difficulties of drug agencies working with under-16 year olds. It also recommended that a future national strategy for drug education should include work in initial teacher training. This was a recognition that school approaches to drug issues should include both curricular and pastoral dimensions. Young people themselves have much to say about drug education - amongst many other topics. One increasingly heard comment is that the very existence of programmes of school drug education implicitly assumes that all young people are actual or potential illegal drug users; and that this assumption creates antipathy to such programmes - an interesting example of governmental normative assumption. As young people are beginning to ask, why concentrate on trying to prevent a behaviour (the use of illegal drugs) that the majority of young people aren't involved in? More broadly, much research into young people's health concerns indicates that top of young people's lists of health-related concerns are relationships and bullying (Healey, 2004). UK education legislation and practice continues, nevertheless, to regard the 'customers' of education as being adults - parents and carers, not young people themselves. This is despite the introduction in 2000 of the new subject of 'Citizenship' into the school curriculum. This specifically emphasized young people's involvement and participation, which has itself now been included in law (Education Act 2002) Inhalants A further ACMD report (Advisory Council on the Misuse of Drugs, 1995) indicated concern at the high level of teenage deaths associated with volatile substance abuse (VSA.) The expression of this concern was a useful reminder of the prevalence and harm caused by VSA, with all the associated public health implications. Still acting as the 'cheap' substitute for illegal drugs in many neighbourhoods, volatile substances were recognised as easily available and causing high rates of death and physiological harm. The report accepted the difficulties in following a supply reduction strategy because of the legitimate uses of volatile substances. Accordingly it recommended a demand reduction emphasis, including school programmes. Volatile substance abuse has been of concern to practitioners working with young people long before the official recognition afforded by the ACMD report. Statistics collected and published by St. George's Hospital School of Medicine from 1971 indicate that this has been a major and constant medical and public health for some time (Field-Smith et al 2004.) Practitioners and the ACMD were united in seeing VSA as distinct from other forms of substance use because of its high mortality rates and easy availability. They also recommended clear 'don't do it - it's dangerous' messages to young people. ACMD emphasised the need for a variety of tailored messages to suit the audiences, and the inappropriateness of any harm reduction approach - 'safer sniffing' messages were and are almost universally accepted as inappropriate to VSA. ACMD also identified a need for more epidemiological research into VSA - and other forms of substance misuse - by young people. The recognition of how prevalent VSA had become led to responses by government ministries and agencies in the early 1990s, which coincided with a reduction in deaths attributable to VSA from a peak of 152 in 1990 to average of 65 70 a year in the a late 1990s. This reduction was achieved by a combination of localised advertising/public health campaigning; and laws restricting the sale of volatile substances. This appeared to be an effective and successful example of a supply reduction approach, supported by some demand reduction components, although a causal relationship between government action and changes in the pattern of VSA has not been conclusively established. Moves to reduce the size of containers, and hence remove potentially fatal dosages from retail sale, have not yet been adopted by manufacturers or government in the UK, which continues to favour the voluntary regulatory approach set out in the 1993 ACMD report (Advisory Council on the Misuse of Drugs 1993). The National Strategies Attempts to ensure that drug education is provided by schools have developed through various stages. It might be considered that each new stage has been an attempt to fill the gaps, correct the failings and maintain the sense of urgency of the previous stage. These stages effectively began in the UK in 1995, when the UK's first national drugs strategy, Tackling Drugs Together was published. This strategy included the target of improving cooperation and communication between government ministries (or departments as they are currently known), which had previously been reluctant to cede or share responsibilities (and budgets) with one another (The Stationery Office 1995). The aims announced in this document included "reduce the acceptability and availability of drugs to young people" (p. vii), which was to be achieved by ensuring "that schools offer effective programmes of drug education" (p. 2). Further: "an effective programme of drug education in schools can be an important step in helping young people to resist drugs" p. 15); and: "the Government places a very strong emphasis on preventing young people from misusing drugs in the first place" (p. 16). This national aim was described in more detail in a 1995 Department for Education Circular, Drug Prevention and Schools, which represented the education ministry's contribution to the national strategy (Department for Education 1995). The status of a Circular in the UK is that of recommendation or expectation. This guidance recommended that all state schools, primary, secondary and special, put in place: a set of responses to drug related incidents; an age-appropriate programme of drug education; and a nominated member of staff to act as the school's drug education coordinator. As a subject, drug education was not made a separate statutory requirement for schools. This remains the case today. The Circular defined 'drugs' as alcohol, tobacco, medicines and solvents as well as illegal drugs. Here, then, was the first indication by central government that it expected schools to provide comprehensive programmes of drug education for all pupils. While a Circular clarifies government wishes and expectations; it does not have statutory or legal force. Pragmatically, however, the Circular's recommendations are reinforced by the inclusion in school inspection handbooks of a requirement for commentary on school drug education policies and programmes. These handbooks have decisive power and influence in prioritising schools' activities and provision. (Office for Standards in Education 2003.) Complementing the Circular, the Department for Education published additional guidance on a drug education curriculum (School Curriculum and Assessment Authority 1995.) Although still based on an expectation that information leads to behaviour change, this guidance rejected simple "slogans or vivid and frightening images" (p 2) as ineffective and, possibly, counter productive. The document was based on the then current version of the national curriculum and recognised training only on an 'in-service' basis, not as part of initial professional training for teachers. Written by practitioners, the document was closely over-seen by civil servants who exercised final control over content. Importantly, the additional drug education role placed on the education and youth services was accompanied by additional funding for teacher, school manager and youth worker training. Central government funding for school drug education advisers had first been introduced in 1986. From 1990 to 1993 this funding was extended to cover health education advisers, a reflection of governmental concerns around drug misuse and HIV/AIDS. When the funding was withdrawn in 1993 - coinciding with a government public health white paper (Her Majesty's Stationery Office 1992) which emphasised prevention approaches - the number of health education advisers in post fell as Local Education Authorities (LEAs) were either unwilling or unable to replace central government funding locally. One activity funded from 1995 was that of 'innovative' drug education programmes and interventions. Ministry reports said much about the activities, but little about the outcomes, which was contrary to ACMD recommendations and represented one of many lost opportunities to evaluate drug education outcomes. Central government funding for LEA-based school drug advisers was re-established in 2001, but again was time limited to three years. LEAs and professional bodies predict that, as before, many of these posts will disappear at the end of the funding cycle. This will coincide with increased service demands associated with the publication of revised drug education guidance for schools. Ministers dismiss these concerns and pass the responsibility for the continuation of the posts to LEAs. In the mid-1990s, the assumption by government was clearly that young people were actual or potential users of illegal drugs and other substances. Many schools became over-concerned with responses to drug related incidents and produced school procedures, which were largely disciplinary and punitive, not educational or supportive. Taken to its logical conclusion, this approach - frequently presented as the 'zero tolerance' approach - has been analysed in an Australian article which indicates its contradictions and consequences, and its implicit adoption of an abstinence curriculum model. (Munro G and Midford R 2001.) It has taken nearly a decade for official recognition that parents' and carers' substance use has negative effects on young people's health, well-being and educational achievement. (Advisory Council on the Misuse of Drugs 2003.) There has been a consistent lack of reference to this aspect of the effects of substance use on young people in official UK guidance, in spite of representations made to government agencies during consultation processes and other opportunities (e.g. Drug Education Forum evidence to UKADCU 1998). The existence and impact on young people of this aspect of substance use has finally been given formal acknowledgement in revised guidance for schools (Department for Education and Skills, 2004). Reports published by the school inspections organisation, OFSTED, give a picture of school responses to the expectations of the Department for Education with regard to drug education (Office for Standards in Education, 1997; Office for Standards in Education, 2000). The reports estimated that in 2000, nationally, 75% of primary schools (40% in 1997, 61% in 1998) and 93% of secondary schools (70% in 1997, 86% in 1998.) had policies on drug education. Slightly more secondary schools had policies on responses to drug related incidents (95% in 2000) than had policies on the provision of drug education. In 2002, OFSTED reported that drug education lessons in schools were generally 'adequate' but 'less than good' in 60% of lessons (Office for Standards in Education, 2002.) School policies varied, from the 'zero tolerance' to the responsive and creative. Although prescription has clearly led to the writing of policies, it has not also led to universally high-quality policies or practice. While these figures indicate widespread provision of drug education the quality of teaching and the understanding and confidence of teachers varied. The impact of training courses was not evident in the overall picture of quality of teaching and lessons. This is not to discount the many examples of good practice, well-planned lessons and school - and LEA - programmes. The effectiveness of this education is also poorly understood as both OFSTED reports commented on the poor overall quality of monitoring and evaluation of drug education provision by schools. In addition, pupil awareness suggests that the education provided has had low impact. The Schools Health Education Unit at Exeter University, which conducts annual surveys of tens of thousands of pupils, found that 32% of 15 year olds could not remember any drug education lessons during their own schooling (Schools Health Education Unit, 2003). School provision demonstrated a range of approaches. One-off in-puts were often provided by police officers, in spite of police reservations about taking on this role. There was much creative and well-informed drug education observed by OFSTED that was responsive to pupil needs and involved them in planning and evaluation. There was also much poor practice. Shock-horror messages continued to be used by some schools and there was frequent adoption of 'zero-tolerance' responses to drug related incidents. Some headteachers continue to regard OFSTED reports on their schools which contain no reference to the school's drug education programme or policy as an expression of approval of their practice. Guidance produced by the education ministry in 1998 (Department for Education and Employment 1998) concentrated on making available to schools information about good practice in drug education by describing methodological approaches and programmes. It recommended programmes of drug education which formed part of a wider personal social and health education curriculum. In these, attitudes and skills are 'taught' along with knowledge and information. This document referred to and gave examples of good practice in drug education and acknowledged that drug education can delay the age of first use of drugs - a significant advance on the prevention focus of the 1995 Circular. The document detailed expectations of LEA interventions and support, including the involvement of other agencies, in response to young people's substance use - a progression from the curriculum-only approach. Mention was made of "family alcoholism or use of drugs" (p 29), although this realism was not expanded on or reinforced in supplementary guidance published the following year (The Standing Conference on Drug Abuse, 1999). The role given to LEAs was a politically significant change, following the succession of Acts of Parliament (laws) in the 1980s and 1990s, which transferred powers, responsibilities and funding from LEAs to headteachers and school governing bodies. The guidance references emphasised in the previous paragraph can be seen as a response to the reluctance or refusal of some headteachers to follow central government guidance on cross agency working; and their insistence on using permanent school exclusion as the principal response to drug related incidents in schools, without consultation with other relevant agencies. This tension continued into the new century, with the amendment and re-writing, at the insistence of headteachers and their representative organizations, of a further Circular designed to reduce the numbers of young people socially alienated or labelled by permanent school exclusion (Department for Education and Employment, 1999). Government Interventions. Following the 1997 election of Prime Minister Tony Blair's government, a national Anti-Drugs Co-ordination Unit (UKADCU) was set up to continue the inter-ministerial work and strategy first announced in 1995. Based on the US-style 'drugs tsar' the co-ordinator published a revised national strategy in 1998. In keeping with the language associated with Blair's 'New' Labour government, this revised strategy was entitled Tackling Drugs to Build a Better Britain (The Stationery Office, 1998). The revised strategy included targets and recommendations for schools and LEAs (see above.) In contrast to the 1995 Circular, these emphasised drug education, not prevention; and school and LEA responsibilities for supporting pupils affected by drug and substance use and misuse. UKADCU began to examine school-based drug education and prevention interventions and programmes. This interest did not extend to the commissioning of longitudinal research into the impact of UK drug education on young people's substance using behaviours, although UKADCU staff, including the 'drugs tsar' and his deputy frequently acknowledged the lack of reliable research evidence. The work and research findings of the Home Office based Drug Prevention Teams, set up in 1992, informed much of the UKADCU's recommendations. Drug Prevention Teams were reorganised and expanded into a Drugs Prevention Advisory Service (DPAS), which was part of the Home Office Drug Strategy Directorate. This had regional offices and locally-based Drug Action Teams covering the whole of England and Wales. With the growing influence and involvement of government, terminology began to change. Previous references to 'good practice' were replaced by references to 'best practice,' in spite of the concerns expressed in education circles at the increasingly prescriptive and inflexible nature of the education initiatives regularly introduced by DfES. While the term 'good practice' acknowledges the variety of approaches, which could be adopted to achieve a certain outcome recognising local skills and situations, 'best practice' implies a 'one size fits all' response. Unfortunately this was reinforced in the adoption of the title 'Blueprint' for a Home Office-led schools drug education programme announced in 2002. Education initiatives and strategies described as 'pilots' were often quickly expanded or promoted into national status before any opportunity to examine the results and effectiveness of the pilots. In many cases it seemed that 'intentions' became 'outcomes' - 'will this work?' became 'this will work'. There was a shift from open enquiry into closed instruction (prescription.) At the same time as such pilots were being described as 'successful' and therefore worthy of expansion, government and ministers began to adopt the terminology of 'evidence based practice.' The associated claim was that only practices and programmes for which there was an evidence base for effectiveness would be recommended to schools and supported by government, financially or by research. This was a strange undertaking given that it implied that there was an satisfactory 'evidence base.' The intentions of this rhetoric are clear and well-intentioned. However, adoption of the slogan has not advanced practice in translating research results and other knowledge into professional practice. The body of social science and paedagogical evidence and knowledge accumulated over the past fifty years is not fully recognised and findings are often dismissed because they do not support what governments and ministers say ought to work - beware the ministerial intervention which invokes "common sense" as sufficient reason for introducing new or changed practices. This claim of only using approaches for which there was an evidence base did not prevent ministers - as distinct from ministries - from advocating 'shock-horror' approaches. Nor did it inhibit two separate proposals to send into all schools, videos based on the deaths of two young people from drug use: one from a heroin overdose; the other after taking ecstasy. The two videos in question remain controversial, both methodologically and because of the doubts that have been raised about the actual causes of death of the two individuals whose stories are told. Ministers did not, in the event, give their official support to the distribution of these videos. In February 2004 the Prime Minister, in an interview with a Sunday newspaper (News of the World 2004), encouraged the use of random drugs testing in schools, citing unspecified US evidence in support of his view. This was at variance with advice on testing contained in Department for Education and Skills guidance (Department for Education and Skills, 2004) launched the following week. There has been a relaxation of inter-ministry co-operation from 2001 onwards, coinciding with the arrival of the previous education minister at the Home Office; and marked by the effective and quiet sacking of the UK Anti-Drugs Co-ordinator and his deputy. The Home Office has begun to re-assert its role as the 'lead' ministry on illegal drugs. This has raised concerns about the advances made by the health and education sectors in securing greater emphasis for care and treatment. Associated with this are fears that education and prevention responses may be discounted and again absorbed into criminal justice and supply reduction responses. These fears have not so far been realised in practice. However, the government contribution to national debate on illegal drugs is increasingly in the hands of the Home Office; and increasingly asserts links between illegal drug use and criminality, which are not universally accepted and not conclusively established. (Pudney 2002; Bean 2002). This probably reflects political concentration on short-term interventions and results as part of an electoral cycle, rather than a considered and well-founded - indeed, evidence-based approach. A focus on drug related crime also diverts attention from more deep-rooted social, cultural and economic causes of substance misuse, not least the pursuit of a free-market economy, which maintains or deepens unequal distribution of internal wealth. Blueprint The new assertiveness at the Home Office - we would call it turf wars on the other side of the legal fence - has, among other things, lead to the adoption of the Home Office sponsored Blueprint research project. Blueprint was announced in the government's Updated Drug Strategy (Home Office 2002), where it is described as having "been developed after a review of materials from 'what works' programmes in the United States (e.g. Life Skills Training and Project STAR.) " (p 76). There are questions here about the choice of the US models - most publicly that of Project STAR - for the Blueprint project. The principal question is that of universality and transferability. It is highly debatable whether US and UK social, cultural and demographic conditions are sufficiently similar for programmes developed in the one to be relevant and transferable to the other. In addition, the US programmes, which are claimed to be successful - specifically, Life Skills Training (LST) and Project STAR - are increasingly being shown not to be as successful as claimed. They may not even be deemed 'successful' at all if 'success' is defined as reducing or preventing substance use amongst young people. This in turn raises the question: is this really 'evidence-based practice?' There appears to be a confusion here of intention and outcome (the naturalistic fallacy: the confusion of 'is' and 'ought') because of the pressure from politicians who want the chosen programme to work. It does appear that the Blueprint project has come to accept some of the comments made about its origins and apparent rationale. Blueprint managers are now down-playing or denying the originally announced links to Project STAR and LST. Although not openly acknowledged, it would appear that the re-think has been prompted by two important UK commentaries on these US programmes. The Scottish Executive commissioned a review of LST which concluded that the programme had little impact on substance using behaviour; and that it would not be appropriate to adopt it as a national programme in Scottish schools (Coggans et al 2002). An article in the UK journal Drug and Alcohol Findings reached similar conclusions about Project STAR. (Ashton 2003.) Clear and open acknowledgement by Blueprint staff of influences on and changes to thinking and programme design would be a helpful contribution to professional debate about drug education options in the UK. The current emphasis being made by Blueprint managers is that the programme is a research programme, and that its results, when known (the full results are expected in 2007), will be available to inform future drug education practice in the UK. Materials are currently being written and training programmes arranged for participating schools. The research programme now involves 23 schools in 4 local education authorities, with 6 'control' schools. As described to drug educators the programme being developed will emphasise resistance skills and normative assumptions; and builds on the theory of risk and protection factors. The evaluation will include, but not be restricted to, behaviour changes. It is clear that the Blueprint programme will review and evaluate itself, not other programmes or approaches. This approach seems likely to exclude consideration of the basic assumption made by such programmes that curriculum approaches to drug education - and hence prevention - can succeed. US evaluation evidence produced by researchers independent of the programmes being evaluated suggest ever more strongly that curriculum based programmes alone do not affect substance using behaviour (Ashton, 2003; Dusenbury and Falco 1995; Stothard and Ashton, 2000; Tobler and Stratton 1997). One response to such findings is to discard whole-population curriculum-based approaches as ineffective in changing behaviour. Another is to persist in the conviction that whole-population curriculum-based approaches can and will change behaviour, if only the content is 'right' - the 'magic bullet' or 'holy grail' approach. It remains to be seen what Blueprint will be able to tell UK health and drug education practitioners about effective approaches and the characteristics of successful drug education interventions that they don't already know. It will be of particular interest to see if the account of 'success characteristics' which constitute the 1998 DfEE Circular is confirmed, modified or in anyway disproved or discredited by Blueprint outcomes. In retrospect, that Circular may prove to have been the single most useful piece of guidance for schools, with findings not dissimilar to those from De Haess (1987) review of effective drug education programmes. More recently, however, the ministerial urge to prescribe has again taken over the agenda. There are indications that Blueprint can incorporate a more contextual approach to school drug education. Recent presentations by Blueprint staff have included references to parental involvement in the school-based drug education programme; and to risk and protection factors. How far the first will be implemented in practice is yet to be shown. How far the second reflects a significant shift in analytical thinking, as opposed to lip-service inclusion of a promising approach, is similarly unclear. In essence, however, Blueprint is another curriculum-based approach. Research and Evidence There has been a marked lack of UK evidence about the impact of drug education and prevention programmes on behaviour - largely because little research has been undertaken. In addition, most research illustrates only the short-term impact of such programmes, typically confirming that there is knowledge gain and attitude change; and that the materials used are attractive and relevant to both teachers and young people. In their meta-analysis, White and Pitts (1997) found only one piece of UK research, which could be regarded as methodologically sound in its assessment of the impact of drug education on behaviour. Their conclusions were that the effectiveness of school drug education in preventing illegal drug use has not been established, in spite of claims by some US and UK programme managers. Dorn and Murji (1992) are sceptical of the outcomes of drug education and the reliability of research: "..each new wave of prevention tends to attract rather positive evaluations in its early yearswith more balanced appraisals taking some time to be published" (p. 4). The authors refer in agreement to the 1989 study by Coggans and colleagues on outcomes: "These researchers found that there was no evidence that drug education of any kind reduced either illegal or legal drug use (p. 17)". Dorn and Murji question the over-reliance on programmes aimed at young (under 16 - i.e. school age) people, suggesting that the focus on initiation of use and reduction of use may be misplaced. While acknowledging that 'drug education' can have broader educational benefits they cautiously conclude that "It seems fair to float the suggestion that no method can halt the rite de passage from never-used to once-used" (p. 38). Not surprisingly, and not alone, they argue for more research. These findings were re-stated in Coggans and Watson (1995) on methodological as well as effectiveness grounds. This review saw little evidence of school-based drug education preventing substance use and commented on the continuing adherence to information-based approaches. The authors suggest that there is "a mismatch between drug education interventions and relevant social psychological models, particularly in relation to the issues of peer pressure and self-esteem deficits" (p. 212). They summarise their conclusions: "there are many shortcomings in drug education interventions. Problems include inappropriate definitions and expectations, as well as a lack of suitable targeting" (p. 220). Similar conclusions have been reached, although on a different basis, as a result of the longitudinal research programme carried out in NW England by Parker and colleagues (1995). Practitioners' knowledge and other research (de Haes 1987) tell us that the ethos and atmosphere of the school and communication and relationships between teachers and pupils are more effective than a curriculum-based programme. The innovative programmes of drug education funded by the UK education ministry in 1995 - 96 were intended to extend the repertoire and awareness of practitioners. A range of programmes and initiatives was funded on a one-off basis. What evaluation there was (Department for Education and Employment, 1997) was of programmes, not outcomes - another of many missed UK opportunities to look at programme outcome rather than programme appeal. Typical of the response was that of one primary school headteacher who commented after a multi-agency in-put at his school: "I'm sure everyone had a lot of fun, but I don't think there was much learning about the world of drugs." There was extensive implementation of drug education in the mid-1990s, much of it directly resulting from Government funding, but little worth-while evaluation of what it achieved. Health educators have long established some principles and bases for their work. Included in these are four theoretical models of the teaching of health education: the medical model, which involves a teaching programme based on the presentation of facts and information for consideration by the individual student, aimed at prevention, persuasion and behaviour change. It assumes that information on its own leads to behaviour change. the educational model, which involves giving knowledge and information which are discussed by students and aims at helping them to make rational choices and decisions about their own behaviour, and to understand and use the process and tool of decision making. the pastoral model, which concentrates more on the process of learning and the use of materials and information, emphasises personal development and autonomy, and aims at promoting self-esteem and the development of coping strategies. the radical model, which uses a structured developmental teaching programme emphasising interactive group working, aiming to achieve political and social change through co-operative problem solving. These models are advanced as 'pure' definitions, with a recognition and expectation that practitioners will mix and adapt aspects of the four models to best suit their needs, skills and constraints - i.e. 'good practice.'  There is no extensive evidence base relevant to UK drug prevention policies and practice. The expectation that drug education prevents the development of damaging forms of drug use does not yet rest on a firm UK-derived evidence base. The 'evidence base' being advanced by UK politicians is, at present, dominated by the US zero tolerance and abstinence agendas. In contrast, UK government guidance for the education and youth services emphasises responses which fit the government's social inclusion strategies. There is an inherent clash of ideologies in these two approaches, which is likely to result in inconsistencies in implementation and confusion amongst practitioners about both provision and expected outcomes. The approach of the Scottish Executive has been an illuminating contrast to that of the Home Office and the Department for Education and Skills in England. The English approach could be caricatured as: 'here's a model of drug education - make it work here.' The Scottish approach has been a more cautious, one of: 'here's an interesting idea and approach - let's see if it does what it says it does - if it does, let's consider introducing it here.' The adoption by government of US models of drug education and prevention pre-supposes that they work. Many commentators have questioned this assumption (Ashton, 2003; Coggans et al, 2002; Dusenbury and Falco, 1995; Stothard and Ashton, 2000; Tobler and Stratton, 1997.). The US still has the highest rates of illegal use by young people in the developed world (Hibell, 2000). It is valid to question whether it is appropriate to adopt US programmes, and analysis of drug use, in the UK. In particular, the 'ethnic' analysis of drug use is very different in the US and the UK. 'Visible' statistics (e.g. arrest figures, imprisonment) in the US suggest high levels of illicit drug involvement - use and trafficking - associated with the black population. UK statistics suggest that black and white drug involvement are similar, with slightly higher levels amongst the indigenous white population than the black population; and far lower rates amongst the Asian population. (Aust and Smith, 2003). This once again raises questions about the validity of transferring US 'experience' or 'evidence' into the UK and other countries. The demographic and cultural contexts are dissimilar, inequalities of wealth greater in the US than in the UK - and far greater in the US than in much of mainland Europe. The review of responses to young people's substance misuse needs commissioned by government in 2001 commented on the UK research base: "There has been relatively minimal research, apart from epidemiology, in England on this issue [young people's substance use and misuse]. The experience from the US may usefully point to issues, areas, aspects of work but it cannot substitute [for UK research]" (Gilvarry et al 2001, p. 116.). Conclusions It is relevant to ask: Are we genuinely looking at evidence based practice in UK government approaches to drug education (and other health and social issues), or is there political imposition taking place? This question and experience fits with the increasingly centralist approaches to education and other public services of recent UK governments, such that some commentators have begun to refer to "policy-based evidence." Many drug education programmes on offer continue to focus on one of the models of health education, namely the 'medical' model, in the stubborn expectation that some knowledge will act to counter and over-come all existing and accumulated social, cultural and psychological influences on young people. A reliance on the cognitive alone cannot outweigh socio-economic, cultural and psychological factors and influences on behaviour. This is a doomed or dishonest attempt to transform the individual without transforming the society in which s/he lives. Perhaps the beneficial results of drug education programmes in school have not been widely recognised because they do not confirm the intended outcomes - delay, reduction or prevention of substance use - that (in the main) governments have hoped for. Failure to achieve these outcomes seems to result in government insistence in finding 'the right and perfect' curriculum-based approach; and to dismiss or fail to recognise unintended benefits. One rare piece of UK longitudinal research suggests that school drug education should concentrate on providing information and discussion opportunities, and perhaps confirming the decisions of those young people, who have decided that their futures do not include illegal substance use (Parker et al. 1995.). This contrasts with the more traditional aim of drug education programs which is to persuade young people not to use drugs. Parker's research has been conducted in N W England and represents a pragmatic response to the 'normalisation' of illegal drug use by young people in the UK in the 1990s. However, it is unlikely to gain political acceptance. Finally, the broader social context in which drug use takes place needs to be acknowledged. The major root cause of substance misuse - socio-economic inequality - seems to be discounted or unrecognised by government. This may be because reappraising economic policies and their social consequences represents a huge challenge (see e.g. Wilkinson, 2000). While health and education ministries fund drug education and prevention programmes and ministers warn of the dangers of illegal drug use, economic policies continue to promote free-market approaches, which lead to the extension of economic inequality. This inequality is a major contributory cause of social ill-health, including substance misuse and crime. These two problems need to be recognized as symptoms of economic disparity and injustice, not causes of each other. One famed piece of US advice might well be heeded here: 'it's the economy, stupid. References. Advisory Council on the Misuse of Drugs, 1993, Drug Education in Schools: the need for new impetus, London. Advisory Council on the Misuse of Drugs, 1995, Volatile Substance Abuse, London. Advisory Council on the Misuse of Drugs, 2003, Hidden Harm, London. Ashton, M. 2003, 'The American STAR comes to England', Drug and Alcohol Findings, Issue 8, Spring 2003, pp. 21 - 26. Aust, R and Condon, J. 2003, Geographical Variations in Drug Use: Key Findings from the 2001/2 British Crime Survey, Home Office, London. Aust, R and Smith N. 2003, Ethnicity and Drug Use: Key Findings from the 2001/2 British Crime Survey, Home Office, London. Bean, P. 2002, Drugs and crime, Willan Publishing, Cullompton. Coggans, N and Watson, J. 1995, Drug education: approaches, effectiveness and delivery, Drugs Education Prevention and Policy, vol. 2 no. 3, pp. 211 - 224. Coggans et al. 1989, National Evaluation of Drug Education in Scotland, University of Strathclyde. Coggans et. al, 2002, The Life Skills Training drug education programme: a review of research, Scottish Executive, Edinburgh. Cohen, J. 1995, Drug education: politics, propaganda and censorship, International Journal of Drug Policy, vol. 7 no. 3, pp. 153 - 157. Condon, J and Smith N. 2003, Prevalence of Drug Use: Key Findings from the 2002/3 British Crime Survey, Home Office, London. De Haes, W. 1987, Looking for effective drug education programmes: Fifteen years exploration of the effects of different drug education programmes, Health Education Research: Theory and Practice, vol. 2, no. 4, pp. 433 - 438. Department for Education, 1995, Circular 4/95: Drug Prevention and Schools, London. Department for Education and Employment, 1997, Innovation in drug education, London. Department for Education and Employment, 1998, Protecting our Children, London. Department for Education and Employment, 1999, Circular 10/99: Social Inclusion: Pupil Support, London. Department for Education and Skills, 2004, Drugs: Guidance for schools, London. Dorn, N. and Murji, K. 1992, Drug prevention: a review of the English language literature, Institute for the Study of Drug Dependence, London. Dusenbury, L and Falco, M. 1995, Eleven Components of Effective Drug Abuse Prevention Curricula, Journal of School Health, vol. 65 no. 10, pp. 420 - 425. Ewles, L and Simnett, I, 1992, Promoting health - a practical guide, Scutari Press, London. Field-Smith, M. E. et al., 2004, Trends in Death Associated with Abuse of Volatile Substance 1971 - 2002, St. George's Hospital Medical School, London. Gilvarry, E. et al, 2001, The Substance of Young Needs, Health Advisory Service, London. Gossop, M. 2000, Living with drugs, Ashgate, Aldershot. Healey, K, 2004, Linking Children's Health and Education: progress and challenges in London, King's Fund, London. Her Majesty's Stationery Office, 1992, The health of the nation, London Hibell, B., Andersson, B., Ahlstrom, S., Balakireva, O., Bjarnason, T., Kokkevi, A., and Morgan, M. 2000, The 1999 ESPAD Report Alcohol and Other Drug Use Among Students in 30 European Countries, The Swedish Council for Information on Alcohol and Other Drugs and Co-operation Group to Combat Drug Abuse and Illicit Trafficking in Drugs (Pompidou Group), Stockholm. Home Office, 2002, Updated Drug Strategy 2002, London. Lawton, D. 1980, The politics of the school curriculum, Routledge and Kegan Paul, London. Munro, G and Midford, R, 2001, 'Zero tolerance' and drug education in Australian schools, Drug and Alcohol Review, 20, pp. 105 - 109 National Curriculum Council, 1990, Curriculum Guidance Five: Health Education, York News of the World, 2004, 22nd February 22 2004, Available at  HYPERLINK "http://www.newsoftheworld.co.uk" www.newsoftheworld.co.uk (accessed 23 February, 2004). Office for Standards in Education, 1997, Drug Education in Schools, London. Office for Standards in Education, 2000, Drug Education in Schools: An Update, London. Office for Standards in Education, 2003, Handbook for inspecting nursery and primary schools, London. Office for Standards in Education, 2003, Handbook for inspecting secondary schools, London. Office for Standards in Education, 2003, Handbook for inspecting special schools and pupil referral units, London. Parker H et. al., 1995, Drugs Futures: Changing patterns of drug use amongst English youth: Research Monograph Seven, Institute for the Study of Drug Dependence, London. Pudney, S. 2002, The road to ruin? Sequences of initiation into drug use and offending by young people in Britain, Home Office, London. Ryder, J and Campbell, L. 1988, Balancing acts in personal social and health education, Routledge, London. School Curriculum and Assessment Authority/Department for Education, 1995, Drug Education: Curriculum Guidance for Schools, London. Schools Health Education Unit Exeter University, 2003, Education and Health, vol. 21, no. 3, p. 56. Social Exclusion Unit, 1999, Teenage Pregnancy, London. Stothard, B and Ashton, M. 2000, Education's Uncertain Saviour, Drug and Alcohol Findings, Issue 3, Summer 2000, pp. 4 - 20. The Standing Conference on Drug Abuse, 1999, The Right Responses, London. The Stationery Office, 1995, Tackling Drugs Together, London. The Stationery Office, 1998, Tackling Drugs to Build a Better Britain, London. The Stationery Office, 1999, Working Together to Safeguard Children, London. The Stationery Office, 2002, Education Act 2002, London Tobler, N S and Stratton, H H, 1997, Effectiveness of school-based drug prevention programmes: A meta-analysis of the research, Journal of Primary Prevention, vol. 18, no. 1, pp. 71 - 128. United Nations Children's Fund (UNICEF), 2001, A league table of teenage births in rich nations, Florence. White, D and Pitts, M. 1997, Health promotion for young people for the prevention of substance misuse, Health Education Authority, London. Wilkinson, R. 2000, Mind the gap: hierarchies, health and human evolution, Weidenfeld and Nicolson, London. Summary. The concern of governments to reduce the extent of illegal drug use is shared in the UK. Demand reduction approaches are being specifically aimed at young people in school settings, perhaps using the apparent success of school sex education in changing attitudes and behaviour as a model. There is a lack of clarity around the role expected of schools, education or prevention, reflecting an unwillingness to distinguish between the two. Drug education - including alcohol, tobacco and volatile substances - has long been provided in some schools where the need has been recognised. There has been a growth in the extent and a change in the nature of drug use in the UK since the 1970s. Democratisation and normalisation are terms being used to describe these trends. There is a constancy in the use of alcohol, tobacco, cannabis and volatile substances by young people. The government's focus is on illegal drugs. Education ministry definitions and documentation also refer to alcohol, tobacco, medicines and volatile substances. The increased centralisation of policy making includes drug education, with successive volumes of policy and curriculum guidance issued by government to schools. Advisory reports and research commentaries continue to call for research into both the epidemiology of young people's substance use; and the effectiveness of drug education interventions. There has been a failure on the part of government to act on these recommendations. There is an increased reliance by government on both US research and US programmes. UK researchers question the effectiveness of these mainly curriculum-based programmes and the transferability of research conclusions to the UK because of the differing cultural, social and demographic contexts of the US and the UK. There is a variation in the nature and quality of school responses, with supportive and punitive approaches both evident. Practice is often at variance with intention. Government analysis of influences on drug use continues to ignore or down-play socio-economic contexts. Blaine Stothard. January 4. 2005.  It needs to be acknowledged that harm reduction approaches can be regarded in at least two ways. For some, it is a fall-back position for reducing damage caused by substance misuse when supply and demand reduction approaches have failed. For others, who do not accept either the legitimacy or the efficacy of supply and demand reduction, it is a primary and pragmatic response to substance misuse.  Youth Offender Teams are the current equivalent of the intermediate treatment programmes.  Authors conversations with working-party members  Author's own conversations with young people in school and other settings, 1998 - 2004.  In the UK, state schools are those for which the government provides funding, including some faith based schools. Independent schools, sometimes misleadingly referred to as 'public' schools, are those which charge a fee for the education they provide. Primary schools cater for children aged 5 to 11 years old, and increasingly for 3 and 4 year olds. Secondary schools cater for 11 to 16 year olds (the age limit for compulsory schooling) with much additional provision for the 16 - 18 age range (sixth forms). Special schools provide education for some children with special learning needs, both physical and intellectual.  Author's personal experience - also applies to 'zero-tolerance' approaches.  Presentation by Ruth Joyce, Blueprint manager, to Drug Education Practitioners Forum, London, July 1 2003.  Some writers use the term 'risk and protective'. The two terms are used synonymously. They are to be distinguished from 'risk and resilience' which appear to put the responsibility for substance use (and other behaviours) on the individual rather than to adopt the systemic/contextual view explicit in 'risk and protection.'  Conversation between headteacher and author, 1996.  For further discussion of these models see e.g. Ewles and Simnett 1992; and Ryder and Campbell 1988.  Professor Gerry Stimson, Imperial College, London: Personal communication. 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