‘Everyone’s not doing it’ message offers hope for prevention
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‘Everyone’s not doing it’ message offers hope for prevention

‘Hot topics’ offer background and analysis on important issues which sometimes generate heated debate. ‘Normative education’ comparing the recipient’s use levels to population norms retains some of its shine as the great hope for school- and college-based prevention, but accumulating data demands a reappraisal.

Science is littered with shining discoveries which became tarnished as accumulating data forced a reappraisal. In substance misuse, ‘normative education’ retains some of its shine, but what seemed the great hope for school- and college-based prevention now seems a tactic of limited application and inconsistent impact. The approach relies on the common (but perhaps at not as common as believed below) overestimation by pupils and students of how many of their peers use substances and how much they use, and/or a similar overestimation of the acceptability of substance use among their peers. Corrective survey data is expected to reduce substance use because it no longer seems ‘normal’ and ‘what everyone my age does’. For more on the thinking and research behind this strategy, see this presentation from John McAlaney of the University of Bradford.

Important recent implementations include the seven-nation EU-Dap European drug education trial and the English Blueprint trial. In the EU-Dap trial of the Unplugged programme, relative to usual lessons none of the measures of whether substances had been used in the past month were significantly reduced by Unplugged lessons which featured normative content. Regular use was reduced only in respect of smoking, and then only fleetingly. Only in respect of drunkenness were there statistically significant and lasting positive impacts, and even these were uncertain given methodological shortcomings. Blueprint’s findings were – if anything – in the ‘wrong’ direction, suggesting the lessons might have slightly encouraged substance use, perhaps partly because pupils often simply did not believe the results of the surveys of their peers they were presented with.

Moving up to university students, a British trial of a web-based intervention based on correcting normative beliefs produced unconvincing results, as had an earlier trial from the same lead author. Both trials suffered substantial drop-out which was somewhat higher among students allocated to the feedback interventions, raising concerns over whether at follow-up assessments there remained a level playing field between them and the control students not offered the intervention. The earlier trial’s finding of a greater reduction among intervention students in the average amount drunk on a single occasion was slight and not matched by overall drinking reductions, and it was unclear how missing data had been accounted for. In the later trial just a third of the students had completed the follow-up assessment which produced the most promising finding, a small extra reduction in the amount drank over the past week among students immediately offered feedback on their drinking versus those who had to wait. This one finding only reached statistical significance after using the available data to predict how much the missing students would have drunk. Other analyses found no significant effect.

So patchy have results been at US colleges that some suspect the drinks industry supports normative campaigns because they divert colleges from imposing restrictions which really would cut consumption. However, there have been notable successes (for example, 1 2) which found not just substance use reductions, but related these to normative beliefs.

Maybe it’s the context that’s wrong

One possibility is that normative approaches falter sometimes because they are embedded in programmes which unrealistically aim to prevent all substance use rather than to reduce harmful consequences (1 2), particularly applicable to alcohol in countries where its use is widespread and accepted, even among teenagers. As in Australia, in Northern Ireland an alcohol harm reduction curriculum which incorporates normative education as an important component curbed the growth in alcohol-related problems in secondary schools and also meant pupils drank less. Also in Australia, another similar curriculum with normative elements retarded age-related growth in alcohol consumption, in drinking in order to get drunk, and in alcohol-related social or health harms.

Perfect for computerised programmes

As a review for NHS Health Scotland observed, normative approaches lend themselves to computerisation and have become the mainstay of web-based interventions for people concerned about their drinking. Typically the site user completes a brief assessment of their drinking. This is then automatically compared with the corresponding sector of the general population and the results fed back to the user, accompanied by computer-generated advice tailored to the information about themselves which had been input by the user. UK-based examples include the Down Your Drink site and the Drugs Meter, which covers illicit drugs as well as alcohol.

These therapeutic applications targeting problem users are addressed by another hot topic, but the same technique can be used as a preventive tool in educational settings and for students in general. Tried in a US university which required new students to undergo alcohol education before moving into student accommodation, the results were promising. Compared to just being assessed, one of the two tested programmes led to significantly fewer adverse alcohol-related consequences, largely because it prevented escalation of drinking after starting college. In contrast, at British universities where alcohol education is not mandatory, trials (1 2) of another web-based normative intervention have produced unconvincing results. In Sweden too, when evaluated across the entire student population at two universities, on no measure did offering normative feedback after online drinking assessments appreciably or significantly improve drinking outcomes.

Why the patchy record?

Part of the reason for the inconsistency in findings seems to be that more distant (eg, “Pupils of my age in this country”) comparators are less influential than closer ones (eg, “My closest friends”). Yet youngsters who drink, smoke or use drugs probably do have friends who do much the same. There is also the risk that cliques which pride themselves on prodigious consumption will feel validated rather than mortified to hear that the ‘typical’ student is more restrained. And many college students under-estimate heavy drinking among their peers; telling them the truth could be counterproductive.

There may also simply be a disconnect between how heavily you think your peers drink and how much you drink. In Welsh universities, how heavily a student believed their friends and the average student drank was unrelated to how much the student themself drank. But a European study which included the UK and covered drug use as well as alcohol, found that student substance use was greater when they attributed relatively high levels of use to other students. The difference might have been due to the uniformly heavy drinking of the Welsh students, every one of whom had (according to UK guidelines) ‘binged’ at least once a week. They still thought their fellow students generally drank more, but were perhaps already at the maximum drinking they could manage, or saw even very heavy ‘weekend’ drinking as normal – which in this context, it was.

One freely available critique has addressed the evidence for whether young people really do generally overestimate the substance use of their peers. If they do not, the foundation for normative education crumbles and with it the rationale for the approach being effective. It judges the phenomenon probably real, but that its prevalence and magnitude and therefore its influence are all much less than some research findings imply. Among the factors casting doubt on these implications are: the tendency of young people to say they drink or use drugs less than they do, creating the false impression that they believe other youngsters use more; methodological limitations meaning the survey results against which normative beliefs are compared may themselves underestimate substance use, and young people may be right in believing their peers use more than the surveys suggest; that youngsters who tend to be seen as ‘friends’ by other youngsters may really drink and use drugs more than youngsters less commonly seen as friends; many youngsters have (unless this is demanded of them by a question set by researchers) no idea how much a typical student drinks or uses drugs, and when asked, the meaning they ascribe to ‘typical’ may not match the researcher’s intention; being asked about their own substance use primes youngsters to exaggerate the use of their peers in order not to appear out of line.

The critic’s conclusions were strongly contested, but she stuck to her guns, and made the further point that few high quality studies have supported normative approaches, perhaps because to the extent that young people do overestimate the substance use of their peers, they do so in respect of groups socially distant from them and least likely to influence their behaviour.

Normative education has not turned out to be a preventive ‘silver bullet’, but neither is it a dud – just more complicated and more limited than at first it seemed. See what you think after running this hot topic search.

Last revised 28 June 2016. First uploaded 01 May 2010

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