The NARCONON™ drug education curriculum for high school students: A non-randomized, controlled prevention trial

The purpose of this study was to evaluate the capacity of the Narconon drug education program to produce a long-term impact on students' drug use behaviors in a universal (all student) classroom setting. To a large degree, baseline survey responses were similar to drug use patterns seen in large national surveys. After controlling for pretest levels of use, at six months after receiving the drug prevention curriculum students in the drug education group had lower levels of current drug use than students in the comparison group. Significant reductions were observed for alcohol, tobacco, and marijuana – important categories of drug abuse for this population – as well as certain categories of "hard drugs" including controlled prescription drugs, cocaine, and ecstasy. The results in Table 4 show a clear and reliable tendency among every category tested for the drug education program to produce reductions in drug use behavior.

This is encouraging in light of the evaluation being designed to provide a "real world" test of the Narconon program under the normal conditions of operating a classroom based intervention. Inherent barriers to administering the program and evaluation while schools were in session, including assessing its effectiveness with self-report questionnaires, leads to modest measurable differences between the drug education groups and the control groups with relatively large error terms.

The use of the CSAT survey methodology does not make quantifying the reductions in drug use possible and that was not an aim of this evaluation. Importantly, by testing a universal audience, rather than selecting groups of high risk students, the mathematical differences between student responses in each category remained modest due to the majority of students indicating no drug use at baseline.

The CSAP questions testing the hypothesis that changes in attitudes and beliefs would be modified by the drug education program, argue for a mediating effect on substance use. Interestingly, the questions aimed at discerning whether new knowledge was obtained and retained over time, although indicating an overall pre-existing acquaintance with the data, nonetheless categorically produced the most statistically significant changes.

Primarily an education strategy (Center for Substance Abuse Treatment classification [14]), the Narconon program includes approaches that align with key prevention theories. Throughout the curriculum, persuasive communication is emphasized as the means to impart each component [15]. Competency enhancement is accomplished through student interaction [16] and after-school personal inspection of media and other environmental influences aimed at addressing social influences. Science based information is presented, and students complete exercises aimed at developing their ability to assess the correctness of messages presented as information from a variety of sources.

Originally researched on cigarette use by Evans and colleagues in 1976, social influence theory was one of the first strategies to produce an impact on drug use behavior. This theory posits that alcohol and other drug use among young people is primarily a social behavior strongly influenced by social motives, a complex and reciprocal interaction between both personal and environmental factors including both overt and covert pressure from friends and others to conform to what is depicted as the group norm. A major departure from previous approaches to tobacco, alcohol, and other drug abuse prevention; Evans work emphasized increasing awareness of the various social pressures promoting drug use, including media influences [17, 18].

One well-popularized aspect of today's social influences model is the focus on social resistance skills training. However, programs based primarily on resistance training have shown mixed results [19, 20]. While this is not a focus of the Narconon program, students who received the curriculum were more likely to say they could now resist pressures to use drugs compared with those who did not receive this program. Interestingly, both groups answered similarly about their ability to resist pressures in the past.

Instead of directly practicing resistance skills, the Narconon drug education curriculum provides an opportunity for youth to inspect a myriad of positive, negative and often conflicting messages regarding drugs and their abuse, messages that often include incorrect and conflicting information about drugs and their effects. Program developers believe that prevention effectiveness is currently compromised by the pervasiveness of conflicting messages, including popular prevention approaches that do not communicate a consistent message.

Attempts to promote abstinence contrast with other messages heard in and out of school. For example, the notion that "everyone will experiment" has lead to various, sometimes controversial, practices aimed at reducing harm [21]. Goodstadt argues that dichotomies such as "licit" versus "illicit" drugs, or simply "good" versus "bad" drugs, result in ambiguities and problems [22]. Petosa adds that legal definitions designating certain recreational drug as "licit" for adults but "illicit" for adolescents may encourage young people to use those drugs to demonstrate their transition to adulthood [23]. The current prevalence of media advertising for prescription medications sends another powerful message [24], one complicated by the fact that commonly prescribed medications are too often used in ways substantially inconsistent with diagnostic guidelines [25, 26].

Although students may "know" a certain datum about drugs, conflicting messages such as these may cause that datum to be minimized or rejected entirely unless placed in correct context or inspected relative to other information. To address this, the program teaches about the often subtle pro-drug advertising and other environmental messages aimed at increasing tobacco, alcohol and other drug consumption; contrasting these pro-drug messages with true scientific facts about drug effects on the body, mind, emotions, and enjoyment.

Program facilitators purposefully encourage students to arrive at their own conclusions regarding the data presented based on each student's own observation of the topic under discussion. Facilitators do not tell students what to think, rather, they teach students how to observe.

Another environmental influence addressed by the Narconon program includes more accurate awareness of family and peer drug use patterns. The program includes modules to review and discuss personal observations and provide opportunity for youth to work out what are correct and pro-survival norms.

Media, family, peer and other environmental influences become the subject of competency enhancement activities included in the Narconon curriculum. Competency to observe is applied during after-school practicals and becomes subject of the subsequent group discussion. These take home assignments and classroom activities are also aimed at developing broader personal and social skills with peers, family and community members. Research supports the use of activities that improve interpersonal relations, self esteem, communication, and other skills as directly applicable to substance use as well as many other adolescent problems. Such activities appear to generally enhance program effects [27, 28].

With respect to the importance of knowledge, while many early prevention programs gave individuals accurate facts about the harmful effects of alcohol and other drugs, theorizing that those individuals would reduce or avoid drug use because it was in their own best interest to do so, studies of this generic information-only or awareness model have led to one of the very few universally agreed-upon facts in the prevention field: That is, for the vast majority of individuals, simple awareness through passive receipt of health information is not enough to lead them to alter their present behavior or reduce their present or future use of drugs [29, 30].

According to Botvin and Botvin [12, 16]., inclusion of information remains a necessary component of substance abuse education, although information alone is not sufficient to reduce or prevent use. Evans stresses the importance of attention and comprehension of the contents of the message [15]. Narconon program developers posit that true information correctly communicated can lead to changed behavior by changing the perceived value or social acceptance of that information.

Since inception, Narconon prevention training materials have emphasized correct communication of information and interaction with the communicator. Facilitator training aligns with the five component communication persuasion model described by McGuire [31]. According to this theory, to be effective an educator must get and hold the listeners' attention, must be understandable (comprehension), must elicit acceptance on the part of the person exposed to the message (yielding), the acceptance must be retained over time (retention), and thereby be translated into action in appropriate situations. Testing the ability to choose a correct answer only begins to answer the question of the perceived value and usefulness of that information. To that end, the incorporation of persuasive communication into facilitator training and multi-media program components is suggestive. In theory, the communication of science-based information regarding the nature and effects of drugs can assist students in developing judgment and awareness, but only to the extent that the message sent is very real to youths and delivered in a way that students respect and can appreciate. Measurements of student satisfaction that include affective reactions (e.g. enjoyment, content value) should be further explored as they may reveal important shifts in perceptions about the information itself that would not be detected in simple "true/false" questions.

This theory is supported by a previous evaluation of 1045 post-program student surveys, published in 1995, with findings that the Narconon program format was engaging and appreciated by youths [32]. Participants also reported heightened perceptions of risk – including a shift in attitude among the borderline group of students who held the view that they might use drugs in the future. Eighty six percent of the students in this category stated that the session they had attended changed their mind; most stating that they were now more concerned about the effects of drugs or that they had not realized that drugs were so damaging.

In addition to analyzing elements of content and implementation, a recent synthesis of characteristics common to exemplary prevention programs by Winters, et al. [33] raises the issue of management structure and sustainability. Narconon International's corporate and regional offices provide centralized management and assistance to ensure that local prevention offices receive meaningful attention and support. In addition to the questionnaire used in this study, Narconon program staff continued to collect their own feedback evaluations for ongoing quality management. Staff interaction with teachers and community members helped the schools further reinforce the prevention messages.

The report by Winters, et al. [33] points out the broad lack of programs aimed at high school years and, interestingly, the need for multiple sessions in future years to reinforce the message. The Narconon high school curriculum helps fill this need. Existing materials for younger ages should also be developed into an age appropriate curriculum to provide a continuum of educational resources. As the program further develops its training materials for professional facilitators it may consider also making them appropriate for peer leader groups who may particularly benefit through improved communication skills. The program should also develop appropriate universal booster sessions and provide educator consultation.

Project findings may have policy implications regarding both setting goals and objectives for prevention programs as well as evaluating their success. For example, the Safe and Drug-Free Schools and Communities act of 1994 includes "slow recently increasing rates of alcohol and drug use among school-aged children by 2000" among the six performance indicators chosen for assessing program accomplishments. It also expects prevention to "realize continuous improvement in the percentage of students reporting negative attitudes toward drug and alcohol use between now and 2002". Further, this act is subject to requirements of the Government Performance and Results Act of 1993 (GPRA) in requiring local and state education agencies to monitor program effectiveness, for which the CSAT instrument is a recommended tool sanctioned by the National Institute on Drug Abuse (NIDA), and the Substance Abuse and Mental health Services Administration (SAMHSA). Unfortunately, the instrument is unable to quantify change in drug use and does not assess completely the factors that might lead to such a change, factors that may include change in knowledge and the perceived value of that knowledge.

As current youth drug use levels remain high, it is clear that much more remains to be learned regarding effective drug abuse prevention. What works best; what goals additional to reduction in youth drug use – if achieved – constitute an effective program; how to measure achievement and the extent to which a school-based implementation strategy can counter other influences remains under discussion.

As an intensive, eight-module, educational curriculum, the Narconon program has thorough grounding in theory and substance abuse etiology, incorporating several important and historically successful prevention components. This supports the prediction that participants in this classroom-based program would change their behavior regarding drugs of abuse. Further, the Narconon network provides a strong organizational structure to foster sustainable and high fidelity program implementation.

In this evaluation, the Narconon drug education curriculum produced reliable reductions in drug use a full six months after completion of the drug education program and in every category of drug use tested. A third of these questions – those assessing the drugs most commonly used by youths; alcohol, tobacco and marijuana as well as "hard drugs" – showed statistically significant reductions in use. The reductions achieved with both amphetamines and non-prescription use of amphetamines are important given recent increases in availability and initiation of these drugs. The reliability of the reductions measured in drug abuse behavior provide the most relevant support for the Narconon drug education curriculum.

The program's ability to produce reductions in drug use behavior appears to be through correcting prevalent but false messages while empowering youth to observe, draw their own conclusions, and potentially also improves interpersonal skills contributing to the development of appropriate group norms. These changes may result in shifts in perception of risk and corrected attitudes as individuals and as a group. However, the mechanisms of action for this program should be further explored using sensitive instruments and analyses designed to test this hypothesis. Although the CSAP questionnaire underwent an extensive development process, isolating effective components of drug prevention programs may require a more robust methodology, particularly in light of the theory constructs of this program.

The Narconon drug education curriculum for high school grades shows clearly positive results and sends an important and powerful message promoting abstinence. Given the significant reductions in drug use behavior, the scientific content and social influence theory underlying the program materials and their implementation, and the strong, centralized management by Narconon International, this program is very promising and fills a vital need in substance abuse prevention.