School Effects on Young People’s Drug Use: A Systematic Review of Intervention and Observational Studies

Article Outline

• Abstract
• Methods
  • Search strategy
  • Selection of studies
    • Intervention studies
    • Observational studies
  • Data extraction and data analysis
• Results
  • Description of studies
    • Intervention studies
    • Observational studies
  • Results of intervention studies
    • Effects on young people’s drug use
    • Effects on other outcomes
  • Results of observational studies
    • School-level associations
    • Individual-level associations
• Discussion
  • Limitations of studies
  • Limitations of the review
• Conclusion
  • Implications
• Acknowledgments
• References
• Copyright

Abstract 

Purpose

This systematic review examined the hypothesis that school institutional factors influence young people’s use of drugs. We aimed to (1) identify the effect of school-level changes on drug use and (2) explore the possible mechanisms by which school-level influences on individual drug use might occur.

Methods

Systematic review. Experimental/quasi-experimental studies of “whole-school” drug prevention interventions and longitudinal observational studies on the association between school-level and individual-level school-related exposures and drug use were included. Experimental studies were included because they are the most reliable available source of evidence about causation. Observational studies of school-level and individual-level school-related exposures were included with the aim of providing evidence about a wider range of possible school-level effects and how school-level influences might be mediated by individual-level factors.

Results

Experimental studies suggested that changes to the school social environment that increase student participation, improve relationships and promote a positive school ethos may be associated with reduced drug use. School-level and individual-level observational studies consistently reported that disengagement and poor teacher–student relationships were associated with drug use and other risky health behaviors.

Conclusions

There is evidence of school effects on young people’s drug use. Interventions that promote a positive school ethos and reduce student disaffection may be an effective complement to drug prevention interventions addressing individual knowledge, skills, and peer norms. Such approaches should now be piloted in a wider range of settings. Further research is also needed to explore mechanisms by which schools may influence young people’s drug use.

Keywords: Substance misuse, Prevention, Adolescents, Schools, Systematic review

Use of illegal drugs and volatile substances (henceforth termed “drug use”) is common among young people in developed countries, such as the United States and the United Kingdom [1], [2], [3], [4]. As well as presenting direct health risks, drug use is associated with accidental injury, self-harm, suicide, and other “problem” behaviors, such as alcohol misuse, unprotected sex, and antisocial behavior [5], [6], [7], [8], [9]. Drug use at an early age is also associated with future use of particularly harmful drugs, such as heroin or cocaine [10], [11], [12]. In turn, dependence on these drugs is associated with high rates of morbidity and mortality, social disadvantage, and crime [13], [14]. It is because of these health and social problems that reducing teenage drug use is a priority.

Schools are generally regarded as a promising site for drugs prevention [15], [16]. Drug education is commonly provided in schools in countries such as the United States and the United Kingdom [17]. The aim is usually to improve individuals’ knowledge, develop refusal and negotiation skills, and modify peer norms. Although systematic reviews report that such interventions can have positive effects on drug use, these are small, inconsistent, and generally not sustained [18], [19]. Recent evidence of “school effects” on health outcomes has prompted considerable interest in “whole-school” drug prevention interventions that go further than these individual-focused, classroom-based interventions, and make changes to a school’s overall organization, and its policies, working practices, culture, and environment (generic and/or drug-focused) to promote young people’s health, including in relation to substance use [20], [21], [22], [23]. The theory is that young people’s actions are partly shaped by the wider social environment, an important aspect of which is their school [21], [23], [24], [25].

Despite this interest, research evidence about the effects of school factors on drug use has not been systematically reviewed. This systematic review examined the hypothesis that school institutional factors influence young people’s use of drugs. We aimed to (1) identify the effect of school-level changes on drug use and (2) explore the possible mechanisms by which school-level influences on individual drug use might occur. Two types of studies were examined: experimental/quasi-experimental studies of the effects of “whole-school” drug prevention interventions on drug use outcomes; and longitudinal observational studies of school-related exposures on drug use outcomes. The latter comprised both research on the effects of school-level exposures on drug use as well as research on associations between individuals’ behaviors and attitudes toward school and their drug use.

Experimental and quasi-experimental intervention studies were included, not so much to identify “what works,” but because these are the most reliable available source of evidence about causation. Observational studies that examined school-level effects over time were also included because, although these are more vulnerable to bias and confounding, we felt that they may nonetheless provide evidence about a wider range of school-related exposures, many of which might not have been studied using experimental designs. Longitudinal observational studies examining the effects of individual-level measures of school-related attitudes and behaviors on drug use were also reviewed, not to draw conclusions about school-level effects, but because they might provide evidence about the possible mechanisms by which school-level effects bring about individual health–behavior outcomes. Cross-sectional studies were not included because they cannot provide evidence about temporality and therefore causation.

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Methods 

Search strategy 

Keywords, titles, and abstracts in major commercial bibliographic databases (Social Science Citation Index, PubMed, Embase, PsycINFO, ERIC) and specialist registers (Cochrane Library, C2-SPECTR, EPPI-Centre Bibliomap, Drugscope DATA) were searched in March 2006 using appropriate free-text and thesaurus terms relating to drug use (e.g., substance misuse or drug prevention or risk taking) and schools (e.g., secondary school or high school or health promoting school). The bibliographies of included studies were also searched and authors contacted and asked to identify additional reports. To minimize publication bias, key investigators were contacted to identify any “gray literature” missed by these searches, and to identify forthcoming publications currently in press.

Selection of studies 

Different criteria for inclusion and quality assessment were used to screen different study types. There were no restrictions according to language or publication date. The inclusion and quality assessment criteria are described below. All studies that met the inclusion criteria were quality assessed by two independent reviewers.

Intervention studies were eligible for inclusion if they:

To be considered of “high quality,” studies were required to minimize problems arising from confounding and bias. Age, sex, and socioeconomic status (SES) were considered to be the major potential confounders [1], [3], [26], [27]. To minimize confounding, a study had either to allocate schools to intervention/comparison arms randomly, restrict or match the intervention and comparison groups according to the major potential confounders, or adjust for major potential confounders in the analysis. To avoid selection bias, attrition rates should not have differed significantly by treatment groups according to age, sex, or SES.

Observational studies were eligible for inclusion if they:

To be considered of “high quality,” studies were required to minimize problems arising from confounding via adjustment or restriction; age, sex, and SES were again considered to be the major potential confounders. Observational studies were not quality assessed according to any differential attrition rates because observational studies rarely report attrition by exposure category.

Data extraction and data analysis 

A standardized framework was used by two independent reviewers to assess the quality of included studies and to extract data from “high-quality” studies. There was no disagreement between these reviewers, although on two occasions a third reviewer was consulted where the methods and/or findings reported were unclear. Data were extracted for the latest period of follow-up reported. In the case of both intervention and observational studies, neither the outcomes related to drug use nor the interventions and exposures themselves were sufficiently homogenous to undertake statistical meta-analysis, and therefore, the findings are synthesized narratively. In addition to outcomes related to the primary outcome of interest (drug use), data were also extracted about smoking, drinking, and other “problem behaviors” (e.g., truancy) because these behaviors “cluster” together [8]. Effect sizes and indicators of statistical significance or confidence intervals are given where these were reported.

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Results 

Description of studies 

A total of 7290 records were screened against the inclusion criteria for each review. Full reports of 226 were retrieved and screened for possible inclusion.

Four studies met the inclusion criteria; they were all published since 2002 [28], [29], [30], [31]. Two of the studies were carried out in the United States [29], [31]. The remaining two studies were carried out in The Netherlands and Australia [28], [30]. All four studies were deemed to be of high quality when judged against the quality-assessment criteria outlined above: three studies randomly allocated schools to an intervention or comparison group [29], [30], [31]; one study matched intervention and control schools according to sociodemographic factors, reported no significant baseline differences in terms of age or gender, and adjusted for prior health behaviors [28]. Loss at follow-up ranged between 10% and 49%, but did not differ significantly by allocation condition according to main potential confounders in these studies. All the studies evaluated multicomponent interventions that included school-level and individual-focused components (Table 1, Table 2).

Table 1. Summaries of interventions studied

Table 2. Summaries of high-quality intervention studies: study design, sample, and intervention effects

Although all the interventions made changes to the “whole” school, their focus differed markedly. Three interventions—the “Gatehouse” project, “Aban Aya” youth project, and “D.A.R.E. plus”—involved school action teams addressing overall school organization and ethos alongside individual curriculum elements focused on health education or social/emotional development. The Aban Aya and Gatehouse projects also provided teacher training to promote a positive school environment. Unlike these studies, the Dutch Healthy School and Drugs project did not aim to make substantial changes to school ethos, and instead implemented new school rules focusing on smoking, drinking, and drug use, and introduced new school committees to coordinate drug prevention and provision for drug screening and interventions for individuals found to be using drugs.

Eighteen studies met the inclusion criteria; they were published between 1985 and 2006 [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49]. All but two of these studies were carried out in the United States: one was carried out in Scotland [47], and one in Sweden [32]. Only 9 of these 18 studies were deemed to be of high quality when judged against the quality-assessment criteria outlined above (Table 3). The other studies did not adjust for, or restrict by, students’ SES [32], [33], [34], [36], [37], [42], [43], [45], [49]. Only two high-quality studies reported associations between school-level exposures and young people’s drug use [38], [47]. Seven high-quality studies reported associations between individual-level school-related exposures and drug use [37], [39], [40], [41], [44], [46], [48].

Table 3. Characteristics and findings of high-quality observational studies

Results of intervention studies 

The Aban Aya study reported that, 4 years after the start of the intervention, there was a 34% reduction in the rate of increase of a combined measure of alcohol, tobacco, and cannabis use for boys in the intervention group compared to the comparison group. Boys at D.A.R.E. plus schools reported a significantly lower rate of “growth” in the use of drugs other than cannabis, and intentions to use these drugs, compared to the comparison group, after 2 years of the intervention. These interventions had no significant effect on girls’ drug use. Three years after the start of the Gatehouse project, fewer young people in the intervention group than the control group reported having used cannabis in the last 6 months. There was a 3.1% risk difference between the intervention and comparison group, a nonsignificant association. Although the Dutch Healthy School and Drugs project had a significant positive effect on young people’s health-related knowledge, it had no effect on the number of the students who had used cannabis at the end of the intervention; of those students who had used cannabis, cannabis appeared to be used more frequently among students at intervention schools compared to control schools.

Three studies reported rates of smoking and drinking separately from young people’s drug use. All three suggested that the interventions had a protective effect for these outcomes. At the end of the D.A.R.E. plus intervention, boys reported fewer occasions when they had drank alcohol in the last month and the last year, and were less likely to be current smokers. Evaluation of the Gatehouse project showed nonsignificant but consistent 3% to 5% protective risk differences, such as for students drinking alcohol in the last month, smoking in the last month, smoking regularly, and their friends’ substance use. The Dutch Healthy School and Drugs project found that students in the intervention were drinking less alcohol than the control group and smoking less.

Three studies reported outcomes relating to school conduct and education. The Aban Aya study found that intervention reduced violent acts, bullying, and truancy, and school suspension for boys. The D.A.R.E. plus intervention had borderline-significant effects on reducing violence at school among boys. The Gatehouse project had no significant impact on measures of bullying, school relationships, and students’ depressive symptoms. The Dutch Healthy School and Drugs project did not aim to influence school relationships.

Results of observational studies 

The West of Scotland study followed students from the end of primary school (age 11) into secondary school, and measured health behaviors at ages 13 and 15 [47]. It found that the number of students who had used drugs, regularly drank alcohol and smoked were significantly lower in some secondary schools than others, and these large variations remained after adjusting for potential confounding arising from students’ health behaviors prior to entry to secondary school, individual, and family sociodemographic factors, parental behavior, disposable income and religion, as well as neighborhood using postal district data. The adjusted odds ratio (OR) for the difference in outcomes between a school at the bottom 2.5th centile and the top 97.5th centile were 2.8 for drug use, 3.4 for drinking, and 2.9 for smoking at age 15 (p < .001), which suggests that there are important school-level effects on substance use.

The authors attempt to explain these apparent school effects via analyses of schools’ aggregate levels of students’ perceptions and attitudes. After adjustment for confounding, the study found significant associations between school-level rates of drug use at ages 13 and 15 and the number of students in a school reporting disengagement (based on questions on how much they liked school, felt safe, and part of their school) as well as poor teacher–student relationships. These factors were also associated with regular drinking and smoking at age 13 and 15 (adjusted OR 1.19–1.55; p < .001). This study also found that students’ involvement at school was associated with lower rates of drug use, drinking, and smoking, although these associations were no longer significant after adjusting for school disengagement and teacher–student relationships. The authors also report that schools that were perceived by the aggregate of pupils to be worse in terms of the school environment, pupil involvement, pupil engagement, and teacher–pupil relations had poorer health outcomes, in terms of the numbers of students smoking at 13 (OR 1.14; p < .05). A second set of analyses involving researcher-derived measures found that larger schools with a poorer ethos—based on a priori ratings of the school organization and pupil behavior—were associated with high rates of student drug use at age 13 (OR 1.13; p < .05) but not at age 15.

The only other high-quality study of school-level associations reported no association between school uniform policies and drug use, drinking, smoking, absenteeism, or students’ behavior at school [38].

The U.S. National Longitudinal Study of Adolescent Health [46] found that high-school students aged 15 who reported that they were treated fairly by their teachers and felt that their teachers cared about them were significantly less likely to have tried cannabis 1 year later or started smoking cannabis regularly (more than four times a month) 1 year later. Teacher support was also protective against getting drunk more than 2 or 3 times in the last month (relative risk [RR] 0.86; p < .001), having smoked on at least 20 days in the last month (RR 0.84; p < .001) and not using a condom when having sex for the first time (RR 0.91; p < .05). These associations all remained significant after adjustment for students’ sociodemographic characteristics: age, gender, ethnicity, family structure, and household income. This study also found that school disengagement predicted cannabis use; however, this effect was no longer significant after adjusting for students’ reports of teacher support.

Using data from the Seattle Social Development Study, O’Donnell and colleagues [37] reported that boys considered to be at “high risk” of drug use aged 12–13, based on teachers’ reports of their “aggressive” behavior, and who were rated as having low “bonding” to school using a 22-item scale, which assessed commitment and attachment to school, educational expectations, and teachers support, were significantly more likely to be using cannabis, drinking alcohol, and smoking when followed up a year later, even after adjustment for age, gender, and social background. A U.S. study of white and Hispanic high-school students, found that those doing well at school and getting on well with teachers at age 13 were less likely to be using drugs in early adulthood [39].

One study of U.S. high-school students did not find a clear association between school disengagement and subsequent higher rates of drug use: Bryant and colleagues [44] reported that, although greater increases in cannabis use during adolescence were predicted by feeling “left out” or lonely at school and a composite measure of “school misbehavior” based on student reports of suspensions, detentions, being to sent to see senior staff and truanting, student reports of not being interested at school and not enjoying school were not associated with increased cannabis use between ages 14 and 20. However, the authors acknowledge that these measures may not have fully reflected young people’s attitudes to school. Parental involvement in young people’s schooling did not predict drug use.

Two studies of U.S. high-school students examined the association between students’ participation in extracurricular activities at school and subsequent drug use [40], [48]. One reported that students who participated in more extracurricular activities at high school were significantly less likely to have used cannabis and other drugs in the last year at age 17–18, and that involvement in extracurricular activities was also associated with more positive attitudes about school (p < .01) [48]. The other found that, after adjusting for prior health behaviors, age, sex, SES, and educational attainment, extracurricular involvement was not associated with drug use [40]. However, this study did find that involvement in extracurricular activities was associated with young people’s attitudes to school and their relationships with adults at school and school sports were associated with “liking school” (p < .05).

A study of school students in California indicated that attending a greater number of schools by age 15 had a borderline-significant association with later “hard” drug use—defined as having used illegal drugs other than cannabis—at age 17–18 after adjusting for age, gender, prior drug use, parental income, and education [41].

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Discussion 

Intervention studies provide some evidence that there is a causal association between, on the one hand, modifying the school environment to increase student participation, improve relationships, promote a positive school ethos, and address disaffection and truancy and, on the other hand, reduce student drug use and other risk behaviors, especially for boys. The lack of effects reported for girls may have been because of a lack of power, because these outcomes are rarer among girls. Students’ early experiences of secondary/high school appear to be particularly influential: the Aban Aya and D.A.R.E. plus interventions appeared to have the most substantial effects on drug use, and this may in part have reflected their targeting younger pupils. The results of the Gatehouse trial did not attain statistical significance. This may have been because the intervention was delivered when students were aged 13/14 and already disaffected and disillusioned with school. This possibility receives support from the findings from a follow-up study conducted 4 years after the trial, which found that there was a statistically significant protective effect for subsequent cohorts of new students at Gatehouse schools compared to schools in the control group for a composite measure of health risk behaviors (OR 0.71; confidence interval [CI] 0.52–0.97) [50]. In contrast, the Dutch Healthy School and Drugs project, which focused more narrowly on policies and practices concerning drug use and its prevention, did not appear to reduce students’ drug use.

Only one high-quality observational study focused on school-level exposures relating to ethos, as well as to aggregate pupil reports on the school environment, involvement, engagement, and teacher–pupil relations. This study suggested that poor ethos and negative aggregate pupil reports were associated with higher rates of drug use after adjustment for the main potential confounders.

A larger number of longitudinal observational studies focusing on student-level exposures relating to school were identified, and these studies overwhelmingly found that disengagement from school and poor teacher–student relations were associated with subsequent drug use and other risky health behaviors after adjustment for students’ demographic characteristics, SES, and prior drug use. At least one additional study has been published since this review was completed, which provides further evidence that “low school connectedness” during early secondary school predicts substance use 2–4 years later [51]. There was also evidence that truancy, suspension from school, and frequent changes of school were associated with higher rates of drug use. These individual-level observational studies in isolation cannot provide evidence about school-level causal effects on student drug use, but alongside the school-level intervention and observational studies they do add weight to the idea that young people’s experiences at school might exert some influence on their drug use. These studies are particularly useful in providing some indications of possible causal processes. For example, a number of studies suggested that participation in extracurricular activities and other forms of involvement might facilitate school “bonding” and engagement, which in turn is a protective factor against drug use [40], [46], [47], [48]. One study also suggested students’ reports of school disengagement might lie on a causal pathway between teacher support and risky health behaviors [46]. Based on the studies included in this review a plausible explanation regarding the process through which schools may influence drug use is that at schools that are not inclusive and where there are few opportunities to be involved and participate in extracurricular activities, students may not feel part of their school or receive the support they need, and in turn, may become dissatisfied with, and disengaged from, school and more likely to use drugs.

Limitations of studies 

Only a limited number of intervention studies were identified. These programs varied widely in their scope, and they all, to some extent, combined components that addressed the whole school with individual-focused curriculum components such as social development or health education. It is therefore difficult to know whether effects on drug use that are reported are the result of the former or the latter components. Inconsistencies in the measures used also make it impossible to establish whether overall whole-school interventions have smaller or greater effects on drug use than those reported for more conventional drug-prevention education intervention as reported in recent systematic reviews [18], [19]. However, D.A.R.E. Plus [29], which did include the whole-school components alongside curriculum components, was found to have a greater effect on drug use than was the original D.A.R.E. intervention, which lacked the whole-school elements, suggesting that whole-school modification may be causally linked to rates of drug use. Nonetheless in the absence of further studies to confirm whether whole-school elements are indeed an “active ingredient,” we must be cautious in our conclusions about causal relations between whole-school modifications and rates of student drug use.

Although the observational studies we identified as of high quality did adjust for major potential confounders, these may still have been subject to unmeasured confounding. For example, confounding may have occurred because of aspects of young people’s background, which were not measured and controlled for, such as parenting styles or unmeasured baseline non-health risk behaviors. With respect to the observational studies of student-level exposures, although such individual-level factors as school disengagement may be affected by school-level characteristics, they may also reflect non-school factors, such as problems at home.

Limitations of the review 

As in all reviews, we were reliant on authors’ descriptions of the interventions or exposures under study and their findings. Where possible, authors were contacted to provide additional information, but measures of effect sizes were reported inconsistently across studies, and in some cases the effect sizes were not reported. In such cases, we relied on p-values to indicate the statistical significance of association. However, it is important to note that in some cases multiple tests of significance within papers may have resulted in some apparent associations having arisen because of chance. Furthermore, these reviews were dominated by studies carried out in the United States, and these findings may not be generalizable to other settings. However, the findings of two high-quality studies, one experimental and one observational, and which were not carried out in the United States, were broadly consistent with the overall pattern of results [30], [47].

Despite the inclusion of observational studies, our review can only provide some crude indications of causal processes, and it is certainly not clear how these school-related factors interact and influence young people’s actions, or how these school effects differ across different groups of young people. This is probably an inevitable limitation given the difficulty of examining extended, complex chains and cycles of causation merely via quantitative research with its attendant problems of statistical power and measurement error. Furthermore, in isolation from reports of lived experience, these ideas are depersonalized. For example, students who are disengaged from school are not an homogenous group. Individual factors, such as students’ gender, ethnicity, and social disadvantage, as well as even more personal factors, unlikely ever to be captured by quantitative data, may well influence these processes.

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Conclusion 

This paper fills an important research gap by systematically reviewing high-quality quantitative studies examining school effects on young people’s drug use as well as those examining how individuals’ drug use relates to their experiences of, and attitudes to, school. The studies reviewed offer reasonably consistent evidence in favor of school effects on rates of drug use among students as well as other outcomes. Intervention studies suggest that action to improve ethos and support student engagement can have positive effects in reducing drug use. Observational studies also suggest that positive ethos and overall levels of strong school relationships and engagement are associated with lower rates of drug use, and that, at the individual level, negative behaviors and attitudes relating to school are also associated with drug use.

Implications 

Taken together, this evidence suggests that improving school ethos to combat disaffection should be viewed as a promising complement to current curriculum-based interventions to prevent drug use, particularly school-wide interventions that target young people as they enter secondary schools. These studies suggest that interventions should now be developed that help schools to improve their ethos to reduce disaffection and consequent problems within the domains of health and education. Potential ways of doing this are through school action groups that review and revise policies and practices impacting on ethos and inclusion [29], [30], [31], conducting in situ reviews of school needs [30], and through training for teachers in interactive teaching and developing better relationships with students [30], [31]. Such interventions should be piloted across a wider range of settings and rigorously evaluated to explore their effects before being more widely implemented.

This review also highlights the limitations of research conducted to date, and supports the findings of other reviews that conclude that further research is needed to examine school-effects on health outcomes [52], [53]. Research is also needed to isolate the specific effects of whole-school elements and to explore further whether intervention effects are generalizable between settings. Such studies must employ cluster randomized controlled trials to minimize problems of bias and confounding in estimating effects, and employ integral process evaluations to describe what aspects of school organization were addressed. Research is also needed to examine students’ perspectives on the mechanisms through which experiences at school interact with other sociostructural and biographical factors to influence decisions regarding drug use.

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Acknowledgments 

Adam Fletcher is supported by a studentship from the U.K. Medical Research Council. Chris Bonell is supported by core funding from the London School of Hygiene and Tropical Medicine. James Hargreaves is supported by a Postdoctoral Fellowship from the U.K. Economic and Social Research Council and Medical Research Council. We would like to thank the many authors who responded with more information about their studies.

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