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JOHN ECKENRODE: I'm John Eckenrode. I'm Director the Family Life Development Center. And I really welcome you here today on behalf of the Center to the annual John Doris Lecture. And it's really my distinct pleasure and honor to introduce our speaker to you today, Dr. Gilbert Botvin. He's standing very close to me, so that he can pick up the mic here. But we are friends, too.
DR. GILBERT BOTVIN: I didn't want anyone to get the wrong idea. I didn't want to get too close.
JOHN ECKENRODE: Let me tell you a little bit about Gil before I turned the mic over to him. He is a fellow member of the Cornell faculty in the city, being professor of psychology in the departments of both public health, but also in psychiatry at the Weill Medical College. He also directs the Institute for Prevention and Research there.
He received his PhD from Columbia with training in both developmental psychology and clinical psychology. He's an internationally known expert for his pioneering work in the field of substance abuse prevention. He's been a prolific author, authored over 250 articles and chapters, and has been the recipient of numerous federal grants to support his work, too many for me to document this morning-- this afternoon.
Among his many awards, I'll just mention one. In 1995, he was awarded a prestigious MERIT Award from the National Institute on Drug Abuse. And for those of you who know MERIT awards, these are only given to the most productive of the federally funded researchers in the NIH. So it's a distinct honor.
He has contributed to many scholarly areas. But he's perhaps most widely known for his work on prevention efforts in school based settings, having developed the LifeSkills Training program, which was tested and found to be effective in multiple randomized clinical trials, which I'm sure he'll talk some about today. Often, as we know, evidence based programs do not extend beyond the research and development phase with developers not really being able to establish a effective dissemination infrastructure after those efficacy trials.
In contrast, Dr. Botvin, has excelled in that regard as well. He is Founder and President of National Health Promotion Associates, which markets the LifeSkills program, which is now perhaps the most widely used drug abuse prevention programs used in schools today. His recent and NIDA-funded research on models of affected diffusion of evidence based programs also involves some of our colleagues here at Cornell. Bill Trochim has worked with Gil as well as Don Tobias in Extension. So it's been a lot of fun working with him and having our colleagues work with him.
Let me say that Gil has also contributed widely to the field of prevention research generally. He's the past President of the Society for Prevention Research. And he was also the inaugural editor of what has now become a very influential journal, Prevention Science. And he's also served as a consultant on several federal agencies and members and has been a member of many influential committees and panels.
I just want to take a minute to say why this is a particularly opportune time to have Gil visit with us and talk about his work. As some of you may know, over the coming months, the Family Life Development Center is going to be emerging with the Bronfenbrenner Better Life Course Center to be a new center called the Bronfenbrenner Center for Translational Research. More to come on that, they'll be announcements and events and so forth in the coming months.
Translational research involves many approaches, multiple approaches, to the utilization of research knowledge for the development of innovative programs and practices to benefit children, youth, and adults. But also, it involves practices to improve the translation of practice based wisdom to back to the research process. It's kind of a circular process.
This actually characterizes much of the work of the two centers over the years. But we'll be seeking now to add some new and innovative programs and approaches to our efforts. And we also anticipate that this new center will embody a new vision or an updated vision of the College's outreach efforts generally.
Our center will indeed compliment the work that's going on in the city in the biomedical and clinical areas with the clinical and translational science centers. So we look forward to working with folks in the city at the medical college as well. So with that background, I mean Dr. Botvin's work is very much in keeping with the mission of our new center.
So we're thrilled to have him here today. And I'd like to have you all join me in welcoming Gil to Cornell, up to the upstate part of the campus, and to the College. Thanks for coming.
[APPLAUSE]
DR. GILBERT BOTVIN: John, thank you very much for that kind introduction. It's great to be here up in Ithaca. I've been back and forth a fair amount over the past year. I've got a daughter who's a senior here at Cornell, a nutrition science major.
I couldn't quite influence her to do exactly what would I do in prevention, but nutrition is close enough. So I'm thrilled with that. It's great to be here.
What I'm going to be doing today is talking about the work that we've done at Weill Medical College in the Department of Public Health, the division that I run, which is the Division of Prevention and Health Behavior. I'm going to talk about the work that we've done in the area of tobacco, alcohol and drug abuse prevention, the extent to which that work has broadened to include other health compromising behaviors. I'm going to summarize some of the work that we've done over the last 30 years now-- it's been nearly 30 years-- and then talk about how that kind of experimental work leads quite naturally to work in translational research and the kinds of things that John and his group up here are interested in and the group at the medical center, the Translational Research Center at Weill Cornell, are interested in the area of biomedical research.
Let me say a word or two about how I ended up going down this path in life. Like many things in life, there is a fair amount of serendipity involved in getting to where I am today. You all know what serendipity is, by the way?
That's when you're looking for a needle in a haystack and instead you find the winning ticket to the New York Lottery. Or better, maybe you find a free ticket to the Harvard, Cornell hockey game. I know the last time I was up here, they were in short supply.
So I ended up down this path coming out of Columbia and not knowing exactly what I wanted to do, but having an interest both in clinical and in developmental psychology. And it turns out I ended up getting a job at a place called the American Health Foundation, which was started by Ernst Wynder. Ernst Wynder a very interesting guy.
He spent about 25 years at Memorial Sloan Kettering and is one of the first people credited with finding the link between cigarette smoking and lung cancer. He started an institution called the American Health Foundation. And I end up working there right out of graduate school, still wet behind the ears with a freshly minted PhD, and began to work in what came to be the area of health promotion and disease prevention.
It goes by many different names now. It's called preventive medicine, behavioral medicine, and so forth. But when I first arrived on the scene at the American Health Foundation having little experience in this area, I was told by Dr. Wynder, listen, I want to give you a job that everybody else before you has failed at. I want you to develop an effective smoking prevention program.
Now, here I am fresh out of graduate school, my very first job. And you can imagine what I thought. I thought, oh, my heavens, I better look for another job. I'm in deep trouble.
And so I looked at the literature. And sure enough, it was a disaster. Almost everything before had been unsuccessful. So I did what I was trained to do in graduate school. I began to look more broadly at the literature to look at the extent to which we knew something about the etiology of cigarette smoking.
And there was very little literature available at that time. But there were certain leads in the literature which eventually led me to a conceptualization of the problem which eventuated in developing the intervention that John mentioned, LifeSkills Training program. So I'm going to talk about our work with the LifeSkills Training program and talk about in general advances that have been made in prevention science over the last 20 or 30 years.
I say 30 years. I know you all saying to yourself, 30 years? How is it possible? This guy looks so young. He couldn't have been doing this for 30 years. I started at an early age.
This is, by the way, a picture of our Department of Public Health. Our chairman is right here in the middle. There's a picture of me on the end there with my colleague and collaborator Ken Griffin on the side.
The kind of work that we are currently doing in our division and within the Institute, it focuses in its broadest possible way on health promotion and disease prevention. But over the years, necessarily our emphasis has been somewhat narrower. And it stems from my early days at the American Health Foundation and the charge that Ernst Wynder gave me to develop an effective smoking prevention program.
So my initial focus was on cigarette smoking and smoking prevention. And then over the years, it broadened to include alcohol and drug use. So in our group we've been interested over the years in the epidemiology and the etiology of substances behavior, adolescent substance use behavior, and developing effective intervention approaches.
We also have worked ongoing in the area of violence and delinquency prevention. Ken Griffin is doing work in HIV risk behavior. Jennifer Epstein has been doing work in suicide prevention. And also recently with internet use and health risk behaviors, she just had a paper accepted to Addictive Behaviors looking at internet use and alcohol use among adolescents.
And then, of course, we're doing work most recently in the exciting new area of translational research. Let me start out by framing the issue of prevention. What do we mean by prevention? Prevention over the years has had two conceptualizations. The traditional classification or system that was used to describe prevention was primary, secondary, and tertiary prevention.
So in that framework, what we do is primary prevention, focusing on a population before a problem has developed. So, trying to deal with the area of cigarette smoking with kids at a point where most kids have not begun to smoke cigarettes. And then also in about 1994, there was a recognition that that conceptualisation of prevention was perhaps not as clear as it could be, particularly because there was overlap between the tertiary prevention, for example, and treatment. And it became rather murky as to what was treatment and what was prevention.
So the Institute of Medicine developed this classification of the continuum of care where over on the left side, there is universal, selective and indicated prevention. And that's defined by the populations that are targeted. Universal prevention approaches target the general population. So for example, a school based universal prevention program would target all the kids in the school.
A selective intervention targets a subset of the population who are considered to be at high risk. Indicated programs are for those individuals who already are at high risk or exhibiting some indicators of a particular disorder or problem. So the world that we inhabit, the neighborhood that we live in, is really pretty much down here. Although, we've begun doing some work in these other areas.
As I started to say at the outset when I was talking about Ernst Wynder and my early days at the American Health Foundation and the focus on cigarette smoking, of the various forms of substance use that we're interested in, cigarette smoking is extremely important for many reasons. Most obviously, from a public health perspective, cigarette smoking is important. Because it is the number one premature cause of death and disability in the United States today with well over 400,000 deaths occurring each and every year.
Worldwide, the problem is even bigger. Over a billion people smoke cigarettes. We know right now that it seems to be falling in high income countries, which has generally been the pattern in the United States going from the 1950s where roughly half of the population smoked in the United States to the present day where only about 20% of the population smokes.
But it's also been rising in low and middle income countries throughout the world. Overall, as I said, in the US over 400,000 deaths occur annually that are attributable to cigarette smoking. Worldwide, it's estimated that cigarette smoking kills 5 million annually.
And it's projected to increase by the year 2030 to between eight 8 and 10 million people. So this is a huge problem. So that's one of the reasons that we're very interested in cigarette smoking.
It's also important to know that cigarette smoking occurs in the beginning of the developmental progression of substance use, tobacco and alcohol use. This slide shows past 30 day use among 12th graders from what used to be called the High School Senior survey. It's now called Monitoring the Future, because they now collect data from 8th and 10th graders as well as 12th graders.
But you can see this overall pattern which just shows data from the 1990s until 2009. But generally, cigarette smoking peaked during this time frame around 1996, '97 and has dropped alcohol abuse. That is, instances of being drunk has stayed fairly elevated.
Marijuana use has risen, plateaued, and then seems to be converging, as you can see in this slide, with cigarette smoking. And then other forms of illicit drug use are substantially below that in terms of their prevalence rates. So it's clear from a public health point of view, again, that tobacco and alcohol are two huge problems in terms of mortality and morbidity.
And also, as I indicated, that they are part of a developmental progression that typically starts in kids usually during the pre-adolescent years with alcohol and/or tobacco, and then moving on to marijuana, which is usually the first illicit substance used, and then on to other illicit substances. But the use of other illicit substances, again, is dramatically lower than at the top three. Now doing part of the progression, an interesting thing occurs with respect to inhalant use.
Inhalant use peaks around the ninth grade, and then drops off. So it defies this pattern where typically people start at one level with one substance and the prevalence rate in society goes up until it plateaus and reaches the level of the prevalence rate in the adult population. Inhalant use, it has a very different pattern where it rises quickly, and then drops at the ninth grade. So inhalant use isn't something that we have particularly focused on for a variety of reasons. And it's not on this slide.
Let me say a word about the prevention research process. I borrowed this from Rick Price at the University of Michigan a number of years ago. And it's very similar to the NIH model of prevention research or research in general. As applied to prevention, research typically starts with an effort to understand the etiology of the problem, in this case, understanding the risk and protective factors.
Once you've identified risk and protective factors, to identify a subset that are potentially modifiable, and then to develop interventions, pilot test those interventions. And then once they've been found to be acceptable to the population, they've found to be feasible. They've been found to be potentially efficacious, then to move forward with larger scale randomized trials.
But after that, down here is where things get interesting where there's a focus on diffusion research, i.e. translational research. Now, what's happened with the area of prevention is we've actually cycled through this several times, particularly the first three of these from the top left of the top right to the bottom right down here to diffusion research, with different populations. But as we continue to do research, we will continue doing research in all of these areas.
But there's a great deal of interest of course in translational research. The kind of research agenda that we developed early on at Weill Cornell Medical College first started by trying to understand the causes of tobacco, alcohol, and illicit drug use, trying to develop effective interventions, trying to demonstrate, if possible, that some interventions work. Because, remember, I said at the outset that the literature was really just littered with failures, studies demonstrating that most prevention efforts didn't work. Most prevention approaches used in schools were ineffective.
And so the field was at a crisis about 25 or so years ago where essentially it was widely recognized that nothing worked. So it was a real question about whether we could develop an intervention that would be effective and we could demonstrate that in a well-designed and well-executed study.
Then once you could demonstrate that, the question would be well if you have effects, initial effects, short term effects, how long do the effects? Do you produce durable effects or not? Then related to this at that point in time, cigarette smoking was seen to be a separate problem from alcohol and illicit drug use.
And it wasn't until maybe 5 or 10 years after that, I would say in the mid-'80s that there was a recognition that this was part of a larger syndrome of behaviors and that tobacco, alcohol, and illicit drug use did really belong together and had many common etiologic factors. And the developmental progression, in fact, meshed together. And therefore, it made sense in developing interventions not to develop, as had been done in the past, separate interventions for each one of these in the form typically of smoking or tobacco education, but instead to develop integrated approaches that might have the potential of impacting on all of these.
The next issue that we were interested in thinking about and testing is do the effects generalize to other kinds of health behaviors? Or, if you slightly modify the intervention, could you have an impact on other health risk behaviors? Next, we are interested in the extent to which it might work with a variety of populations.
These studies were initially conducted with predominately white middle class populations. Subsequently, there was a focus on testing the effectiveness of these interventions on inner city minority youth. Once you've demonstrated that prevention approach works or any kind of intervention works and you've demonstrated it works with more than one population, of course, the next interesting question from a theoretical point of view is, well, why does it work? What are the mediating mechanisms? What's the theory underlying this?
And then finally, can you effectively disseminate these programs, move them from the world of research into the real world and ultimately have an impact on public health? In those early days, the approaches that were taken to attempt to prevent cigarette smoking focused initially on providing health information. Most of those programs that were knowledge-based made the assumption, essentially, that kids who smoked cigarettes just didn't know any better.
They didn't have the information. They didn't have the facts. And if you would provide them with sufficient factual information, they would make a logical and well-informed and well-reasoned decision not to smoke cigarettes.
Well, it turns out that that's not the case and that there are many other factors that play a role in promoting behaviors like cigarette smoking. So it's not too surprising that health information alone was not effective. And it's also the case that most studies found that by the time the kids reached the seventh grade, they're more than 90%, in fact close to 98%, of all the kids were fully cognisant of the fact that cigarette smoking was dangerous for their health.
Now, one of the things that occurred to me that I encountered-- let me put it that way-- earlier in my career when I was at the American Health Foundation that helped me to understand how unimportant health information was as a single intervention strategy was when I met a person at the American Health Foundation who was an epidemiologist there and who probably knew more about the adverse health consequences of cigarette smoking than anybody else in the country. She was a colleague of Dr. Ernst Wynder, wrote many articles with him.
But I was shocked to find out one day when I walked outside that she was smoking a cigarette. She was a cigarette smoker. And I talked to her. And I said, why are you smoking cigarettes?
You know that this is not good for your health. And she said, you know, that's really true. I know it's not good for my health.
But I have developed this habit. I've become a cigarette smoker over the years. And I've found it extremely difficult to quit. And she continued to smoke cigarettes in the face of all the evidence that smoking was hazardous to her health.
The use of scare tactics, fear arousal approaches, have been commonly used in the case of cigarette smoking showing people blackened lungs or, as is often the case before proms-- in fact, this time of year is to show kids the aftermath of what happens when you drink and drive. These things are dramatic. They'll capture your attention. But here, again, there is little empirical evidence that those kinds of approaches are effective.
The two most promising approaches going back to the early '80s fell into these categories. First, one that focus on social influences recognizing that most kids who smoke cigarettes and, indeed, most kids who use other substances it turns out have friends who engage in these same behaviors. And so starting with the work of Richard Evans a number of years ago, he was the first one to find that you could develop a preventive intervention that was effective in preventing cigarette smoking by targeting the social influences that were posited to play a role in the smoking onset process.
And the first study, that first success, stimulated a floodgate of research around the United States. It also stimulated a lot of funding from NIH for this kind of research, funding that helped to move the field of smoking prevention along. And along with it, moved the field of alcohol and drug abuse prevention as well.
Another approach is the competence enhancement approach, one that incorporates many aspects of the social influence approach, but also emphasizes the development of positive social and personal self-management skills-- in a word, youth development-- but putting together a prevention approach that in a very structured way was designed to promote individual competence skills. This provides the general components, the major components of the social influence approach, which included at that point in time psychological inoculation, included something called normative education, which really means trying to correct the misperception that most people smoke and trying to correct the norms, if you will, in a school or a local environment.
Something called public commitment, where the researchers would have kids come up to the front of the room and make a public commitment not to smoke, so would go on the record. I'm not going to be a cigarette smoker. And then teaching them a set of resistance skills or refusal skills, skills that they could use, for example, to resist offers to smoke cigarettes. What Nancy Reagan in famously, or infamously, called "just say no."
That was based on some reasonably good science at the time showing that you could teach resistance skills or refusal skills to kids. But, of course, in prevention you need to do much more than simply teach kids to just say no. Now, these kinds of approaches when tested and applied across the board to tobacco, alcohol, marijuana showed initial reductions in the range of 20% to 40% or 45% with most studies falling in the range of 30% to 45% with effects lasting typically only about 18 months or two years.
There are one or two studies showing that effects lasting for as long as five years. The strongest effects have been demonstrated using peer leaders, for example, work done by Cheryl Perry and her colleagues at the University of Minnesota at that point in time. There's some evidence, although it's limited, with minority youth.
And there are a number of important researchers who have been working this area, Evans, the first one I mentioned, Phyllis Ellickson at RAND, David Murray who is now at Ohio State, Maryann Pentz, and Cheryl Perry. Now, a competence enhancement approach has been used and tested by several researchers. And several programs use that approach.
Let me just sort of pick one at random just out of the blue, talk about the LifeSkills Training program, a good exemplar of the competence enhancement approach. The general strategy here, it really embodies three major components, the drug resistance component which also focuses on normative education, a personal self-management component, and a general social skills training component. This is a general conceptualization or model, for those of you who look like models, that shows how the LifeSkills training program is designed to have an impact on personal competence skills, social skills, and domain specific skills that relate to utilizing resistance or refusal skills to resist pressures to smoke, drink, and use drugs.
The drug resistance component, folks, is on trying to increase awareness of the influences to use drugs. It focuses on teaching kids, as I mentioned, anti-drug use norms or correcting the misperception that everybody's doing it and teaching a set of general refusal or resistance skills. The self-management component teachers general problem solving and decision making skills in a fairly straightforward and simplified way, teaching kids a personal behavior change technology, a set of skills they can use to tackle problems. If they are interested in becoming a better student or better athlete, they learn how to set a goal, break it down into a series of smaller short-term goals, reinforce themselves for their successes, and move towards achieving each goal sequentially step by step through successive approximation.
And then, teaching kids general stress and anxiety management skills, also, as I indicated, general social skills, communication skills greetings and brief social exchanges which are particularly important for kids when they want to meet new people as they move from one school to another, they move into a new school, they go from elementary school to middle school, or from junior high school to high school, conversational skills, complementing skills, and assertive skills. Now, the general structure of the LifeSkills Training program as it interfaces with the school environment is laid out in this slide.
For middle schools, the focus would be on sixth, seventh, and eighth grade where the first year of intervention would occur in the sixth grade and with booster interventions in the seventh and eighth grade. In junior high, where most of our early research took place, the focus initially was on the seventh grade with booster sessions in the eighth and ninth grade. As the program is currently constituted, it consists of 15 class periods in the first year, 10 in the second year, and 5 class periods in the third year.
We and others testing this approach or similar approaches have tested its effectiveness with different kinds of program providers, regular school based health educators, prevention specialists, peer leaders, and regular classroom teachers. The most practical program provider for a program like this is either a health educator or a regular teacher who has an interest in prevention and either teaching the program alone or in combination with peer leaders. Peer leader programs are effective, as Cheryl Perry and her group has demonstrated.
But they're difficult to sustain. And they take a lot of adult effort and supervision to sustain them. But they can be utilized in a way that's effective.
In this kind of prevention approach, it's not just important to have the right kind of content in the intervention, so domain specific material that relates to the problem of interests, tobacco, alcohol, or illicit drug use as well as generic skills training, but also the way in which you implement the program, the way in which the program is taught. It needs to use interactive teaching skills that can facilitate class discussion or that relate to skills training and providing reinforcement for learning those skills and opportunities that are structured by the teacher, both with respect to in-class practice and out-of-class practice via behavioral homework assignments. Now, in our group at Weill Cornell, we've conducted well over 30 studies published in peer reviewed journals demonstrating the short-term effect of this kind of prevention program in our early work, intermediate, and longer-term effects.
We've demonstrated it's effectiveness in studies with white suburban middle class kids with white inner city kids with minority inner city kids with separate studies focusing on African-American youth and on Hispanic youth, as well as studies that really involve, as is typically the case in New York City, multiply ethnic groupings of kids. So this kind of prevention approach has been tested across the board with various populations. It's been demonstrated to be effective with tobacco, alcohol, and illicit drug use as well as with some other health behaviors. And I'll talk about that in a minute.
And in addition to our research group, there's also been independent replication of this by a few groups. I don't expect you to read this. This just sort of gives you a sense of the databases and the studies that we've conducted. The studies started out with small scale pilot studies back in the early '80s with 200 or 300 kids all the way up to studies involving anywhere from 3,000 to 5,000 kids attending 50 or 56 schools in New York State.
From a methodological point of view, in order to demonstrate the prevention work that preventive interventions were effective, it's important that studies be well-designed and they clear a reasonably high mythological bar. And that typically involves not only conducting randomized trials. But in these kinds of school based studies, you typically have cluster randomization where you're either randomizing whole schools to conditions or classrooms within schools.
Most of our work has really involved randomly assigning entire schools to one condition or another. It's important to collect data in a way that underscores or emphasizes high quality data and that will give you reason to believe that the data are highly valid. We use IDs coded on the questionnaire, so we can track individual students over time.
In some of our studies, we've now tracked kids not only through high school, but we've tracked them after high school into their 20s. And we have one group of kids we're now trying to track in their early 30s. It's important to make sure that you test for pre-test equivalence and demonstrate that you don't have significant pretense differences or that you don't have differential attrition or data loss, and they use analytic approaches that are appropriate for this kind of research.
And often, that means mixed model approaches or approaches that take into account the ICCs or the intracluster correlations as well as other relevant covariates. This is a slide that just shows the kind of form that we use. And we just generically refer to this as a student health survey.
In our earliest research, we demonstrated rather strong effects on tobacco, alcohol, and marijuana in a series of studies in the early '80s, where we were able to demonstrate that we could cut tobacco use or other forms of substance use in half and, in some cases, by as much as 87% when you compare the group receiving the prevention program to the control group. We also found that over time without ongoing intervention there would be an erosion of the prevention effects. And therefore, it was clear that you needed some kind of booster intervention or ongoing intervention.
This slide nicely makes the point with respect to the importance of some kind of booster sessions. And in both of these series of bars, the kids had the prevention program, the LifeSkills Training program in the seventh grade. And then the group in the blue bar had it both in the seventh and the eighth grade, they had two years of intervention compared with the group in the yellow bar that had only one year of intervention and the gray bar which is the controlled condition. So even though we still had significant program effects after a year, the booster sessions not only helped to maintain those effects, but in this case, actually enhanced the prevention effects.
We've, as I mentioned, looked at the longer-term impact of this approach with various populations. And you can see in the series of these bars with weekly smoking in terms of white middle class kids, minority kids, daily smoking in terms of a white sample, and daily smoking in terms of minority youth. And those reductions, you know, range between 20% and 28%.
Now, keep in mind that figure that I gave you at the very outset with over 400,000 deaths each and every year in the United States. If you could scale up a prevention program like this, an intervention of this kind, and implement it across the country and you could produce a 25% reduction which we've been able to demonstrate in a study we published in JAMA following kids until the very end of high school, that means that from a public health perspective you would have the potential of saving 100,000 lives. So this kind of a preventive intervention, from a public health point of view, can have a tremendous population benefit.
But, of course, you have to deal with the many challenges that come from trying to take an intervention like this to scale. These are some additional slides that show prevention effects with multiple substances, polydrug use, narcotic use, hallucinogen use, illicit drug use. This slide shows a study where we looked at binge drinking, kids who drank five or more drinks on one drinking occasion, which is the standard definition for kids.
I know that wouldn't apply here to Cornell probably, right? What would be the appropriate measure? Well, no one wants to volunteer that, a couple of six packs.
So anyway, binge drinking-- where you drink a lot on one occasion which is a pattern that occurs with the kids as they get to the end of high school. And it's certainly characteristic of kids drinking in college, where they're not drinking everyday, but drinking a lot on any particular occasion. This is a study that was done by Dick Spoth and his colleagues at the University of Iowa published in the Archives of Pediatric and Adolescent Medicine that looked at the impact of the LifeSkills Training program alone or in combination with a family prevention approach and, again, showing that it can reduce in this case methamphetamine use by about half.
We've also conducted some research funded by NIDA, the National Institute on Drug Abuse to look at the extent to which this kind of prevention approach might have an impact on violence and delinquency. And this slide, from a study that was published in Prevention Science, shows reductions in various kinds of aggressive behavior, delinquency, and fighting suggesting that this kind of approach might well have potential applicability to a fairly broad range of health compromising behaviors. Another finding that we came upon quite accidentally, when we were trying to track kids, we needed to get access to data from New York State's DMV database.
And in working with New York State, we got the data we needed to track the kids. But we also found that we had their driving convictions in that data that they gave us. And we analyzed that data.
And as it turns out, the intervention also produced a significant reduction in risky driving as was measured in terms of the number of points on someone's driving record, a 25% reduction. And then the study that I mentioned where we followed kids for up to 10 years later in their early 20s, showing that we could reduce tobacco, alcohol, and illicit drug use. So kids who started out in the seventh grade receiving that prevention program, following them up 10 years later in their early 20s. So there are very few studies like this in the literature that demonstrate not only that prevention can work with different substances different behaviors, different populations, but also that it produces effects that are fairly durable.
Now, over time, the effects do decrease. But you still get significant and measurable effects well into their 20s. So by way of summary, we've been able to demonstrate with the LifeSkills Training approach that we can cut substance use in half, that the effects last for up to 10 years. We've produced effects also on inhalants, on narcotics, on meth use, on use of hallucinogens.
We've demonstrated importantly with respect to cigarette smoking that it reduces pack a day cigarette smoking and poly substance use. And as I mentioned, we've demonstrated reductions in violence and delinquency behavior and risky driving. And across the board, we've been able to show that we can have an impact with this kind of prevention program on multiple populations. It's not a program that only works with one population or another.
Steve Ose in Washington State, researchers at Penn State, among others, and I believe also Dick Spoth have also done a cost benefit analysis with a range of prevention programs and found that this kind of prevention approach produces a $25 benefit for every dollar spent. So it's not only effective, but cost effective. OK.
After many, many years of painstakingly designing, executing, these studies and, you know, studiously publishing in the peer review literature, it was clear that although we were having an impact on the state of the science and we were having an impact on policy makers in Washington, we were making headway with Congressional staffers and so forth, in the real world we really were not having an impact on kids. And we were not on track to have the kind of impact from a public health perspective that we hoped to have. Obviously, it's great to develop an effective intervention of any kind. But unless it's used and unless it's used on a large scale, you're not likely to derive a large scale public health benefit.
So the next phase of research for us that we've kind of now blundered into-- it wasn't something we initially wanted to study. But as the intervention began to become well-known, as folks in Washington began to promote it, we began to move out in the field. And we began the process of taking this to scale, but then very quickly, you know, bloodied our noses, found that the world was very different.
The real world is very different than the world in which we conducted these randomized trials. And there's a whole new set of problems that we had to deal with. And, of course, many of these can be dealt with as research issues.
So we are at the point in time where we have now developed evidence based interventions in our field, evidence based tobacco, alcohol, and drug abuse prevention programs. What's happened is that that term has had an impact probably most dramatically on the marketplace and on people who are out marketing educational programs and prevention programs. And so although evidence based programs themselves have been slow to be disseminated and utilized, folks who market prevention programs will pick to appropriate the terms that we were using.
Initially, we called our programs research based programs. And then they were called subsequently science based programs, and then evidence based programs. And what you see is that folks who are marketing programs quickly will utilize these descriptions of what they're doing. So this tells all of us what we mean by evidence based prevention.
Evidence based prevention is very simple. It means programs that have been tested and proven to be effective. They're tested using well-designed randomized control trials that were very carefully executed. Rigorous research methods or well-accepted research methods were utilized.
Appropriate data analysis was used in almost all cases. They've been published in peer reviewed journals. And they have one or more replications.
On a federal level, as an effort to sort of promote the use of evidence based programs, practices, policies, a number of initiatives were developed, one called the Blueprints model that many of you are familiar with. It was funded by the Justice Department's Office of Juvenile Justice and Delinquency Prevention and was led by Dell Elliott at the University of Colorado where they laid out a set of criteria that they used to identify evidence based prevention programs. The National Institute of Drug Abuse weighed in with a set of exemplar programs indicating they're thinking about what constituted an evidence based program.
We now have a registry called NREPP, the National Registry for Effective Programs and Policies that focuses both on the quality of research and readiness for dissemination. That registry is now being widely used and widely disseminated. And there's something called the Coalition for Evidence Based Policy that Jon Baron and his group has put together designed to identify the very top tier, the very best of the best in evidence based prevention program.
David Olds' program is on that list of top tier programs. And I'm happy to say our program, the LifeSkill Training, is also on that list. And, of course, the US Department of Education put together a task force to identify exemplary and model prevention programs that they recommended schools use around the country.
Now, we've made tremendous progress early on in the field in terms of disseminating some of these programs while there was a lot of money from the safe and drug-free schools program within the Department of Education. At its peak, it peaked around just a little over $600 million. And it gradually has declined over time to the point now where it's largely been zeroed out. So there's very little funding available for school based prevention from that source which had been one of the major sources the schools utilized.
So not surprisingly, funding is a critical issue. Stable funding is a critical issue for prevention. But there are other translational challenges that can be addressed with research. One very straightforward challenge that other research groups, even though they had prevention programs that were evidence based programs, they didn't produce standardized materials that were user-friendly, were attractive, and that were competitive with commercial materials that were out there in the marketplace.
So there's the need still for many programs to develop user-friendly materials, attractive, and user-friendly materials. There needs to be more of a prevention infrastructure to support the dissemination of prevention programs to provide technical assistance, to provide effective training. There needs to be research focusing on developing effective training models. And there needs to be work in this overall prevention infrastructure that we need here in the United States to develop the adequate training capacity to support the dissemination of evidence based prevention programs.
And then there are a lot of issues that relate to planning and scheduling and particularly implementation fidelity, which I'll say a few words about right now. John, how are we doing on time?
JOHN ECKENRODE: Well, take another five minutes. We can maybe go over a little bit.
GILBERT BOTVIN: OK. Let me-- thank you. OK. Now one of the biggest challenges that we've confronted in trying to move prevention forward, to disseminate it and take it to scale, refers to implementation fidelity. People have to find fidelity in various ways in terms of exposure, adherence, quality of implementation. It's very similar to what our colleagues in medicine refer to as compliance.
What we began to see as programs were utilized both within the context of randomized trials and even more so when they were implemented in the real world was that there were serious concerns about implementation fidelity. Most groups when they conducted their randomized trials really didn't examine the issue of fidelity. And once they did, I mean, everyone was shocked to see that there was a continuum of implementation fidelity from very low fidelity with some teachers to extremely high fidelity in others.
And when programs were disseminated outside of the context of research studies, overall implementation fidelity was even more questionable and became even more of a concern. And so researchers and policy makers then became extremely concerned about the issue of fidelity. As we began to try to ramp up and disseminate prevention programs, the concern was that we might raise everyone's expectations very high, that we had interventions that worked. But once implemented, in the real world, because of concerns about fidelity, they might not produce the intended results.
So let me say a word or two about fidelity. This slide makes the issue quite clearly I think. The gray bar shows the control group. The yellow bar shows a group that received the LifeSkills Training program, but where there was low fidelity by the teachers implementing the prevention program. And the blue bar shows where it was high fidelity.
And what you see is that, again, you see some evidence of effects with low fidelity. But the there's relatively little difference between the low fidelity group and the control group. Whereas, you get that much stronger effects from the high fidelity group as one might expect.
So in this early research that we did, it not only caused us to be more attentive to the issue of fidelity in our subsequent work, but it also I think helped to alert the rest of the folks in the field that fidelity is something that really needed to be taken quite seriously. And it's something that we needed to pursue as a researchable question, you know, the extent to which we can maximize fidelity. What are the barriers to fidelity? And how do you overcome or surmount those barriers?
These are some of the barriers that folks implementing prevention programs have told us or that we've gleaned from focus groups, a lack of training and support for prevention programs, limited resources, and funding again. Overcrowding in the schools is a big problem. It's hard to implement a prevention program if, you know, the kids are hanging from the rafters or you have three kids at a desk.
Classroom management difficulties in general make it problematic. If a program can't be implemented, because a teacher doesn't have control of the class, obviously, the program won't be implemented with very good fidelity. Often, teachers found that if they didn't pace themselves properly, there was insufficient time. Or, if classroom management difficulties consumed their time, they wouldn't be able to implement the program with sufficient fidelity.
And then, of course, teachers tell us that they're suffering from a burden of multiple competing mandates, many of them increasingly unfunded mandates. In work that Del Elliott has done and in some work that we've done recently, it's clear that there are things that you can do to improve fidelity. Emphasizing the importance fidelity alone, just making it clear in the initial training or in a study that we did recently through just in time emails that were sent out to teachers, you could improve fidelity by reminding them of the importance of fidelity.
Make sure that individuals implementing a prevention program understand the underlying theory of the prevention program. Describe the prevention of approach clearly, so they understand how it should be implemented. Make sure that you have adequate training of the program providers.
As it turns out in the real world, most teachers who implement programs don't go through a structured in-service training for a particular prevention program. And so training is an important issue that relates to fidelity. We and others have found that if you monitor implementation, that monitoring alone can help enhance fidelity.
And, of course, it's important to provide support and technical assistance. But, again, that raises the question, well, what kind of structures do you need for doing all these things, particularly in terms of training, support, and technical assistance? One of the things that we are only, I think, beginning to fully appreciate is that, because there's been the appropriation of many of the terms that we use in the research arena by folks marketing prevention programs in the schools, the school teachers and administrators who have to make decisions about what programs they select don't fully appreciate the difference between a real evidence based prevention program and one that's not evidence based.
The landscape is rather murky out there. And we have to do a better job of articulating the rationale for evidence based prevention, why it's important, why an evidence based prevention program is more important than one that's not evidence based. That's something we have to, I think, think about. And that's an area where more research is needed. Because we're just not doing a very good job there.
There are a number of factors that seem to affect the adoption decisions, issues that relate to the flexibility and feasibility of the preventive intervention, cost, the appeal of the program, and, of course, it's efficacy. There are a number of stakeholders that are often involved in making these decisions. I mean, they're made often in schools by committees.
It's critically important that there be some attention being placed on planning and capacity building before the initial training and definitely before an intervention is mounted in a school. Staff turnover is a big problem. It's often been the case in our randomized trials as well as in other situations that we've been involved in outside of our randomized trials that teachers go through a training.
And a week or two after the training, some of the teachers you've trained get reassigned. And someone else is now assigned to implement that prevention program. And that person now is untrained.
So this is a problem that has to be dealt with. Teachers won't often utilize it. So TA can't be reactive. It has to be proactive. It's got to be feasible. It has to be easy for teachers to use. Otherwise, they won't avail themselves of whatever TA you provide.
And again, on this slide, funding. Funding is critical to sustainability. I'm getting to the end. So where we are as a field in the area of prevention is that we've developed a number of preventive interventions strategies in our particular neck of the woods, tobacco, alcohol, and drug abuse prevention strategies. Other workers have developed strategies that are effective with mental health problems, a whole host of other health compromising behaviors or health related problems.
So we've achieved a great deal of success. And the field of prevention science has really advanced rather dramatically over the last 25 years. But we now have to deal with issues relating to translational research, as I foreshadowed at the outset, what we refer to as Type 2 translational research.
There are others who have talked about many different types of translational research. The one that the Society for Prevention Research uses simply embraces Type 1 and Type 2, research Type 1 being what folks at Weill Cornell are focused on which is from the bench to the bedside and Type 2 being the work that we're interested in, which really involves taking an intervention that's been found to be effective and then disseminating it, promoting the adoption, the effective implementation, and the sustained use in a way that becomes institutionalized over time. So the three major research priorities for the prevention field right now first involves identifying effective strategies and structures for promoting the adoption and use of evidence based interventions or programs.
Secondly, to identify strategies and structures for enhancing implementation quality while trying to maintain some degree of flexibility. Because as Rogers has underscored, we know that without flexibility people will tend to drop programs. So if a program is too rigid, if the demands to implement a program are too strict and too structured, then folks will tend to use programs that appear to be more flexible.
So it's important to develop approaches that promote high implementation quality, while at the same time allowing some degree of flexibility. And finally, to identify structures and strategies for building long-term institutionalization or sustainability. So these are the three broad areas that all of us are now focused on in the prevention field.
And I want to end by just mentioning, as John did, in his introduction a cross-campus project that we're doing with folks here at Cornell, Ithaca. My colleague and I at Weill Cornell are leading the study which is a collaborative systems approach for the diffusion of evidence based prevention. It's a five year study funded by NIDA within NIH.
I'm the principal investigator. Ken is a co-investigator. And then serving as lead investigators at the College of Human Ecology is Bill Trochim and Don Tobias, who is the Executive Director for the Cooperative Extension in New York City. So this is a very interesting study. The overall goal, the overarching ultimate goal is to increase our understanding of how to effectively promote the dissemination, adoption, implementation, and sustained utilization of evidence based drug abuse prevention.
So it has a very lofty goal. We have several specific aims. Two of which relate to collecting data in focus groups and structured interviews that then are subjected to a technique that Bill Trochim and his colleagues use called concept mapping to help us to understand the barriers and how to overcome them or how to possibly overcome the barriers to dissemination, adoption, implementation, and sustainability. And then, to use some of those techniques to develop what we are calling an adaptive approach that can be tested against a standard fidelity focused approach and a randomized trial where we'll look at both the impact on fidelity, catalog the kinds of adaptations that are made by program providers, implementing the program, and also test its impact on student tobacco, alcohol, and illicit drug use as well as on other related student outcomes.
So let me just end by saying that over the last 25 or 30 years we've made tremendous strides in the area of prevention science. We've developed a number of evidence based prevention programs that have been carefully and rigorously tested and generally published in peer reviewed journals and where they've been replicated often, in many cases, multiple times and by more than one group. But there still remains-- notwithstanding the fact that we now have this tool kit available to us of effective prevention approaches. But there's a huge chasm between prevention research and prevention practice.
And then we need to do something to bridge that gap. So there's clearly the need for more T2 translational research. We're at the very beginning of doing work in that area as a field. And it's only by better understanding all of the issues that relate to taking a program to scale and all the challenges that confront you in the course of trying to translate the science into practice that will ultimately be able to promote the use of proven and effective prevention programs.
So I know I probably went over a few minutes. But I want to thank you all very much for coming here today. It's one of those dreary Cornell days. I've been here enough to know that there are some nice days. There are some sunny days that occur once in a while.
But I really want to thank you all for coming. You've been a very attentive audience. And I hope to be back again and hope to be working with John Eckenrode and his colleagues as they move forward with their new translational research center here at Cornell. Thank you very much.
[APPLAUSE]
JOHN ECKENRODE: Some questions? I'm sure Gil's willing to hang around a little bit. And I know that we ran over a little bit. So if you have leave, feel free. But I know we have some very interested consumers of what you had to say.
GILBERT BOTVIN: And here's my email address.
JOHN ECKENRODE: Questions? Thoughts? Yeah. Go ahead.
SPEAKER 1: All right. Do the microphones work? [INAUDIBLE] can you hear me OK?
GILBERT BOTVIN: I can hear you fine.
SPEAKER 1: I feel-- you know, this notion-- and I apologize for giving a little preamble, but I can't think of how to ask my question in any other way. In terms of adoption in evidence based program and the difficulty of getting the tools and the agencies, human service agencies, et cetera, use them-- I mean, I find that in [INAUDIBLE], for example, and elsewhere our major competition isn't doing nothing, it's home grown programs.
GILBERT BOTVIN: Ah, that's a good point. Yes.
SPEAKER 1: But one of the greatest difficulties is people can't observe why the evidence based programs do better than their [INAUDIBLE] than their home grown program. And when I look at agricultural extension of the university, it's much more straightforward. If the new seed it's developing yields a better crop, people make money even in the ensuing year.
And there isn't the same issue around showing the evidence based. It seems to me it's so difficult [INAUDIBLE] a busy agency person who's own program looks as good as anything and people are satisfied. But look 10 years down the pipe for a better outcome So I was wondering, you know, is there a way to use the science of persuasion somehow to convince people that things are better than their current practice? And how we actually do that?
GILBERT BOTVIN: So I think you've put your finger on a big problem and a significant challenge. When I first got into the field, there were very few prevention programs, tobacco, alcohol, and drug abuse prevention programs. Some schools were implementing programs. And some states even had a certain amount of time that was mandated for those subjects.
But over the years, certainly it's been true over the last 10 years, we find ourselves in the position where there are a wealth of programs that are being implemented. And you're exactly right Earlier, the challenge wasn't quite as daunting, because you simply had to develop something, showed that it worked, and then make an effort to disseminate the program.
But now, you have to dislodge a homegrown program first before you can convince someone to use an evidence based program. So that's why, again, we have to do a better job of making the argument and drawing the distinction between evidence based programs and those which aren't evidence based programs. And I think it's a very difficult thing to do, particularly if their homegrown program is something they like, they've implemented that may be less expensive than an evidence based program.
I mean, all of these issues come into play. So it's a big challenge. I mean, one way to deal with it would be if you had a surveillance system in place, if the schools collected data every year on substance use. And they essentially had a report card that graded them on health compromising behaviors. And you had these evidence based programs.
If the programs were implemented properly and effectively, then schools would see that there was a difference. But what happens with most of these homegrown programs is they may have some degree of face validity, or at least they looked like they might have a chance of working. And there isn't any easy way to compare and contrast one with the other.
One has evidence, but they often believe that theirs works. I remember when I first got into the field. You probably have heard similar stories. When you talk to people about whether or not they're implementing a prevention program, they'll say, yes, we've got that covered.
We're doing HIV. We're doing tobacco, alcohol, drug abuse. And then you ask them, does their intervention work? Does their prevention program work?
Well, they won't have data. They won't have evidence. And so what they'll retreat to is their own position saying, well, I know it works. I see it in their eyes. I feel it in my heart.
The kids really like the program. You know, they're really excited. You know, those kinds of things. And that was true 30 years ago. And it's still true today.
I also found something that sort of relates to this whole issue. Whenever I've testified before legislative committees, including testifying before Congress, one of the things that becomes clear if you get up there, and you're on an expert panel, and you're testifying from your expert perspective and there's that person there from the community, and they can talk about how one kid was saved or they think one kid was saved, that just sort of overwhelms everything that the experts say. They're Talking about the evidence somehow doesn't make the point as well as someone just talking in a sort of impassioned emotional way about how effective their program is.
So you're right. We have to dislodge programs that are there. We have to convince people not to use what they're currently using. And it's often the case that the kind of programs people think will work, that they intuitively believe will be effective, are the very ones that have been demonstrated to be ineffective.
But it's hard. So we have to do a better job of making that case. So it's not an easy thing to do. So the very first thing we need to do is to figure out how to do a better job of increasing awareness of the evidence based programs, what they are, and why they're important to implement.
Considerable progress has been made toward developing effective approaches to the prevention of tobacco, alcohol, and illicit drug use. Universal school-based approaches have received considerable attention since schools have traditionally provide a logical locus for reaching a large number of adolescents in a structured setting. The Life Skills Training (LST) approach has been extensively tested and is one of the most widely disseminated evidence-based prevention programs. However, schools have been slow to adopt evidence-based approaches such LST.
Gilbert Botvin, professor of public health and psychiatry at Weill Cornell Medical College, presents an overview of advances in drug abuse prevention, findings from two decades of research testing the LST approach, and a discussion of the many challenges of translating prevention research into practice.
Botvin delivered the College of Human Ecology's John Doris Memorial Lecture on April 6, 2011. The lecture series was established in honor of the founding director of Family Life Development Center.
