Book Reviews 1163

Preventing Drug Abuse: What Do We Know? edited by DEAN R. GERSTEIN and LAWRENCE W. GREEN. National Academy Press, Washington, DC, 1993. 162 pp., U.S., Canada and Mexico $32.95, export $39.75 (cloth).

Drug abuse prevention programs receive substantial fund- ing from public and private sources in the U.S. To direct their prevention research agenda, the National Institute on Drug Abuse engaged a multi-disciplinary team of re- searchers to review the current status and theoretical bases of drug abuse prevention research, explore design and methodology problems, and recommend approaches for future research. After a cogent Executive Summary, the book is divided into three sections, followed by an appendix on other types of prevention efforts in a variety of settings.

The first main section is a review of the problem of illicit drug use in the United States. While recognizing the harms to health and social stability caused by drug dependence, the authors note that public perceptions of the threat of drug abuse vary according to the political and economic priorities of the day. Drug abuse is reviewed in two related frame- works: the individual model, in which drug abuse is ad- dressed as a personal behavioral or health problem; and the environmental or community approach, in which drug use is addressed as a disorder of social groups, including families, neighborhoods, and societies. From the individual perspective, early adolescence is the typical age of onset, beginning with legal substances, and drug use is rarely initiated after age 21. Harmful consequences of drug abuse in the growth and development of young people are noted. In the community model, psychological, social and cultural environments that appear to affect drug abuse are described. Population surveys are cited which document a decline in illicit drug use among young people through the 1980s and early 1990s.

The authors make an important distinction in contrasting the general population, in which drug experimentation is decreasing and consequences of drug use are apparent mainly on an individual level, with that of sub-populations in which drug abuse continues to be an important social problem. When considered by age, youth is clearly the group where prevention efforts are most relevant. When examined by race and social class, conflicting data appear. For example, national surveys show less drug use among black Americans than among whites, but blacks are substantially over-represented in incident reports and criminal justice statistics. The authors conclude that although blacks are less likely than whites to become involved with drugs, those who do are much more likely to suffer disabling consequences. The same conclusion is applied to wealthy and low-income groups. The authors call for tailoring of prevention efforts to such sub-population-based differences.

The second section is a review of the conceptual models on which prevention efforts are based. The discussion includes the risk factors for drug abuse, the mechanisms by which these influences work, and the interventions that can be expected to reduce the probability of drug use. Individ-

ual, developmental, social and community-based elements of drug abuse risk are reviewed in detail, drawing from epidemiology, psychology and sociological studies. Because little consensus exists among experts, this chapter provides a useful integration.

The third section, in which prevention program outcomes are evaluated, may offer readers some surprises. In several metaanalyses of 100 or more studies, comprehensive inter- vention programs were found successful only in increasing students' knowledge about drugs but not in reducing illicit drug use behavior. Programs including peer assistance train- ing had a greater likelihood of behavioral impact, although methodological inconsistencies and short follow-up times made it difficult to judge effect sizes. Several widely-used programs with well-defined content and scientifically sound evaluation designs are individually revieweti. "Life Skills Training' and 'Cognitive-Behavioral' programs had some positive effects on cigarette and other substance use in young adolescents, but larger and longer studies are needed. 'Social Influence" programs, although promising conceptually, gen- erally showed little impact on drug use behavior. In spite of a lack of evidence of effectiveness, social influence-based programs have been applied to huge numbers of school children across the U.S. These curricula appear to improve peer resistance skills but have had little impact on self-re- ported drug use.

Two projects in progress based on developmental models are reviewed; these tightly-controlled and comprehensive programs began 10 or more years ago. Long-term follow-up shows stronger social and self-management skills, but more time is needed to measure effects on drug use behavior. Overall, whole-school reforms rather than isolated class- room-based interventions are the focus of current research. Beyond the classroom, the use of mass media as a route for drug abuse prevention efforts is briefly discussed. In their recommendations for future research, the authors call for stronger study designs, more attention to differences in ethnic and gender-based groups, and studies across the lifespan of drug use, from initiation to cessation and relapse. Meanwhile, the uncertain value of most popular drug use prevention curricula, coupled with the economic and class- room time expenditures required for such large-scale inter- ventions, must be considered as funds are allocated for prevention research.

This book will not serve those seeking a compendium of drug abuse prevention research in the U.S., as studies are by necessity incompletely described. Nor does it include studies from countries where harm-reduction rather than prohibition- ist views of drug use predominate. It is, however, an import- ant critical analysis of American prevention efforts by a federally-sponsored group who ostensibly might have reason to obscure such equivocal findings. Drug abuse prevention researchers, school teachers and administrators will gain from the acute analysis and cautionary message of this report.

School of Nursing MARGARET I-[. KEARNEY Boston College Chestnut Hill, MA 02167-3812, U.S.A.

Morality, Mortality, Vol. 1, by F. M. KAMM. Oxford Univer- sity Press, New York, 1993. 344 pp., U.S. $45.

Successful medical technology provides the ability to inter- vene in otherwise fatal diseases. But as technology advances, dissemination of this technology is limited by scarce re- sources, leading to the need to allocate services. In the United States, explicit rationing has largely been avoided.

The alternative of implicit rationing, however, has engen- dered a distribution of services that appears to be unequal on the basis of race, gender and social class. The growing gap between advancing technology and available resources may force us to confront these inequalities and to determine fair methods of allocating scarce medical services.

F. M. Kamm, in Morality, Mortality, develops a set of ethical principles to guide the allocation of medical