2013

Drugs: education, prevention and policy, April 2013; 20(2): 110–119

Copyright � 2013 Informa UK Ltd.

ISSN: 0968-7637 print/1465-3370 online

DOI: 10.3109/09687637.2012.752434

REVIEW ARTICLE

Applying a social determinants of health perspective to earlyadolescent cannabis use – An overview

Elaine Hyshka

Addiction and Mental Health Research Laboratory, School of Public Health, University of Alberta, 3-298Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, Alberta T6G 1C9, Canada

Cannabis is the most widely used illicit drug in theworld. Although the risk of problematic cannabis useis relatively low, the lifetime prevalence of depen-dence is greater than for all other illicit drugs. Assuch, the population burden of problematic cannabisuse warrants attention. Many health and psychoso-cial risks associated with cannabis use are exacer-bated or predicted by initiation of cannabis use inearly adolescence and early adolescent users aremore vulnerable to negative developmental out-comes, longer cannabis use trajectories, earliertransitions to heavier use and dependence. Thissuggests a need for effective prevention interven-tions targeting this age group. Unfortunately, mostprevention efforts focus on individual-level riskfactors and evidence indicates that they are notparticularly effective for deterring use. This over-view outlines a more effective approach for pre-venting cannabis-related harm. Using a socialdeterminants of health perspective, it highlights peernetworks and family structure and quality as themain risk factors associated with early adolescentcannabis use. This article suggests that interventionsthat targeting these determinants can be effective forpreventing cannabis use. It concludes by suggestingcomplementary harm reduction programmes forolder adolescents as a means to further reducecannabis-related harm.

INTRODUCTION

Historically, research into the causes of illicit substanceuse has emphasized the importance of individuallearning and decision-making, and prevention effortshave focused on criminal prohibition of use andprogrammes to provide adolescents with sufficient

information and personal development to discourageuse (Caulkins & Reuter, 2010; Tombourou et al.,2007). However, there is little evidence to support theeffectiveness of either approach for minimizing thehealth and social harms associated with use of illicitsubstances, which continues to be high globally(Degenhardt & Hall, 2012; Room & Reuter, 2012;Strang et al., 2012; Wood, McKinnon, Strang, &Kendall, 2012). Recognition of these failures led tocalls for a shift away from criminal justice approachesto substance use and towards a public health approach,which employs evidence-based interventions to reduceproblematic patterns of use, rather than all use per se.Current alcohol policy frameworks exemplify thepublic health approach by targeting binge drinking,dependence and impaired driving through prevention,treatment and enforcement in an effort to minimizeharm (Fischer, Rehm, & Hall, 2009, p. 101).

Progression towards a public health approach toillegal substance use has been enabled by develop-ments in the fields of social epidemiology, preventionscience and public health and has led to a moresophisticated understanding of substance use and otherrisk behaviours over the past three decades. Riskbehaviours are now recognized as the product ofvarious individual, interpersonal, organizational, com-munity and structural-level determinants (Alexander,2008; Catalano et al., 2012; Green, Richard, & Potivin,1996; McLeroy, Norton, Kegler, Burdine, & Sumaya,2003; Wilkinson & Marmot, 2003) and this has fuelledresearch on the multiple risk and protective factorswhich shape problematic substance use (Catalano et al.,2012; Hawkins, Catalano, & Miller, 1992; Petraitis,Flay, & Miller, 1995). Researchers and policymakersare increasingly applying a social determinants ofhealth approach to substance use, by focusing onreducing the public health burden of use throughinterventions that address multi-level determinants of

Correspondence: E. Hyshka, Addiction and Mental Health Research Laboratory, School of Public Health, University of Alberta, 3-298

Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, Alberta T6G 1C9, Canada. Tel: 001 780-492-6757.

Fax: 780.492.0364. E-mail: elaine.hyshka@ualberta.ca

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problematic use and not just proximate risk factors(Fischer et al., 2009; Galea et al., 2008; Strang et al.,2012).

At the same time, North America, Western Europeand Australia have all witnessed substantial growth incannabis use prevalence, and the development of anincreasingly permissive social context accepting ofrecreational use (Hall, 2009; Hall & Pacula, 2003; terBogt, Schmid, Gabhainn, Fotiou, & Vollebergh, 2006).Cannabis use is concentrated amongst youth and tendsto taper off as individuals age and transition into newsocial roles (Hall & Pacula, 2003; Schulden, Thomson,& Compton, 2009). Although most people who use thedrug do so infrequently and without any major healthor social problems, some progress to harmful usepatterns and dependence (Butters, 2005; Hathaway,Callaghan, Macdonald, & Erickson, 2009; Strike,Urbanoski, & Rush, 2003). In particular, youngpeople who initiate cannabis use in early adolescence(e.g. 10–15) are at increased risk of experiencingcannabis-related harms, including dependence (Ashton,2002; Hall & Pacula, 2003; Hallfors & van Dorn, 2002;Toumbourou & Catalano, 2005). The risk of problem-atic cannabis use is relatively low compared to otherillicit drugs, yet because as many as 125–203 millionpeople worldwide are exposed to cannabis, ‘thelifetime prevalence of dependence is greater than forall other illicit drugs’ (Strike et al., 2003, p. 351;UNODC, 2011). Thus, the population burden ofproblematic cannabis use warrants attention frompublic health researchers and policymakers (Fischeret al., 2009).

Yet cannabis use has been conspicuously exemptedfrom a public health approach, especially in countrieswhere use is very high (Fischer et al., 2009; Room,Fischer, Hall, Lenton, & Reuter, 2010). Moreover,most discussion around mitigating the harms of can-nabis use has focused narrowly on the appropriatenessof legal versus criminal regulatory regimes (Hall, 2007;Room et al., 2010). Although this debate has importantimplications for cannabis-related harm (Strang et al.,2012), it ignores the social determinants of cannabisuse and other preventative interventions. As such, thisarticle explores means for mitigating cannabis-relatedharm beyond criminal law reform. Specifically –because most cannabis use is concentrated amongstyoung people and early adolescents are particularly atrisk of developing problematic patterns of use – itexamines the social determinants of early adolescentcannabis use, and evaluates current prevention inter-ventions for mitigating harms associated with youngpeople’s cannabis use.

CANNABIS USE AND HEALTH

Discussion of cannabis-related harm tends to besimplified into one of two extremes: that cannabisuse is harmless (or at least less harmful than alcohol) orthat it is a source of significant harm (Hall, 2007).

As such a brief review of the evidence regarding theimpacts of cannabis use on health is warranted.

In a recent review of the adverse health effects ofcannabis consumption, Hall (2009) identified severalproblems associated with acute and chronic patterns ofuse. Accidental injury is the acute effect warranting themost public health concern, and cannabis users havehigher rates of injury-related hospitalization than non-users (Gerberich et al., 2003; Hall, 2009). Cannabis isthe most common illicit drug detected in drivers whohave been injured or killed in crashes (Hall, 2009).Indeed, individuals who use cannabis before drivingmay be 2–3 times more likely to be involved in a motorvehicle accident than their sober counterparts(Ramaekers, Berghaus, van Laar, & Drummer, 2004).Chronic cannabis use is also associated with severallong-term negative health outcomes. Regular cannabissmokers report more respiratory problems, includingreduced lung function, chronic bronchitis, infectionsand pneumonia than non-smokers (Ashton, 2002; Hall,2009). Additionally, heavy cannabis use is potentiallylinked to a higher incidence of lung and aerodigestivetract cancers (Hall, 2009).

Cannabis use in adolescence is associated with anumber of other harms. Several studies have demon-strated an association between adolescent cannabis useand psychotic disorders, including a 15-year follow-upof 50,465 Swedish conscripts which showed thatindividuals who tried cannabis before age 18 wereover two times more likely to be diagnosed withschizophrenia than those who had not (Hall, 2009; Hall& Fischer, 2010; Werb, Fischer, & Wood, 2010;Zammit, Allebeck, Andreasson, Lundberg, & Lewis,2002). The risk was increased for those who initiatedand continued cannabis use in early adolescence due toevidence of a ‘dose-response relationship between therisk of schizophrenia and the number of times cannabishad been used by age 18’ (Hall, Degenhardt, & Patton,2008, p. 133). Individuals with a family or personalhistory of psychosis appear to be particularly vulner-able (Hall & Pacula, 2003, p. 99). However, furtherprospective studies are needed to clarify this link (Hall& Pacula, 2003; Werb et al., 2010).

New data from a New Zealand birth cohort suggestthat adolescent onset cannabis users may also experi-ence long-term and permanent declines in neuropsy-chological function (Meier et al., 2012). Additionally,heavier cannabis use in middle adolescence has beenassociated with diagnosis of a personality disorder, andhas been causally linked to major depression aftercontrolling for a number of different risk factors(Toumbourou & Catalano, 2005). Cannabis use inearly adolescence is also associated with reducededucational attainment and is believed to precipitateearly school dropout because the acute cognitiveimpairment associated with use exacerbates pre-exist-ing risk factors for dropping out (Hall, 2009; Macleodet al., 2004; Toumbourou & Catalano, 2005). Early andfrequent cannabis use in adolescence is also positively

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associated with use of other illicit drugs, and thisrelationship is stronger than that for tobacco or alcohol(Hall, 2009). It is currently unknown whether earlyadolescent cannabis use has a causal influence on laterillicit drug use, whether both are the product of anunderlying common liability, or if the associationbetween the two reflects a combination of correlatedand causal processes (Agrawal, Neale, Prescott, &Kendler, 2004). Notably, early onset of cannabis useduring adolescence may also delay the time to cessa-tion of use, potentially increasing exposure to long-term health risks (McGee, Williams, Poulton, &Moffit, 2000). Finally, approximately 10% of usersdevelop cannabis dependence (Ashton, 2002; Hall,2009; Hall & Pacula, 2003; Hathaway et al., 2009), andthis proportion rises to 16% in individuals who initiateuse in early adolescence (Hall & Fischer, 2010). Peopleexperiencing cannabis dependence exhibit cognitiveimpairments, decreased productivity, lowered self-esteem, flat affect, depression, withdrawal and prob-lems in their interpersonal relationships (Hall &Pacula, 2003; Hathaway, Macdonald, & Erickson,2007; Hathaway et al., 2009).

Many health and psychosocial risks associated withcannabis use are exacerbated or predicted by initiationof cannabis use in early adolescence. Users in earlyadolescence are more vulnerable to negative develop-mental outcomes, longer cannabis use trajectories,earlier transitions to heavier use and dependence.Therefore, early adolescent users are more likely toexperience cannabis-related harms (Hall & Pacula,2003; MacLeod et al., 2004; McGee et al., 2000; Tu,Ratner, & Johnson, 2008). This knowledge has led tocalls for evidence-based interventions to prevent can-nabis initiation in early adolescence (Fischer et al.,2009; Hall & Fischer, 2010; Oesterle, Hawkins, Fagan,Abbott, & Catalano, 2010; Patton 2004; Poulin &Nicholson, 2005; Stockwell et al., 2004). The nextsections of this overview illustrate how an understand-ing of the social determinants of early adolescent1

cannabis use can inform the development of effectiveprevention efforts and reduce the incidence of cannabisuse amongst this age group.

SOCIAL DETERMINANTS OF EARLYADOLESCENT CANNABIS USE

Many different risk and protective factors occupyingvarious social-ecological levels likely contribute toearly adolescent cannabis use (Petraitis et al., 1995).Discussing all of them is outside the scope of thisarticle, thus the following review focuses on family andpeer factors which have been identified as the primarydomains of social influence for early adolescents(Bahr, Hoffmann, & Yang, 2005; Lau, Quadrel, &Hartman, 1990; Niv, 2007)

Peer networks are a strong determinant of bothinitiation and current use of cannabis (Bahr et al., 2005;Best et al., 2005; Galea, Nandi, & Vlahov, 2004;

Kosterman, Hawkins, Guo, Catalano, & Abot, 2000;Niv, 2007; Rhodes et al., 2003; van den Bree &Pickworth, 2005). The influence of peers on adolescentsubstance use is generally operationalized throughmeasures of individuals’ affiliations with drug-usingpeer networks but other measures include having peerswho use daily, engaging in risky activities with peersand peer influence (Mason, 2010). Prospective cohortstudies of adolescents in Australia, Germany and theUS demonstrate that peer networks are a strong riskfactor for cannabis initiation (Galea et al., 2004). Interms of early adolescents, van den Bree and Pickworth(2005) report that peer factors were the most importantpredictor of cannabis initiation for adolescents aged11–15. This association was equally strong for pre-dicting progression to regular use, and failure todiscontinue use amongst this group. There is alsoevidence in support of the relationship between peernetworks and current cannabis use by adolescents(Galea et al., 2004; Hall et al., 2008; Poikolainen,2002; Rhodes et al., 2003).

This evidence raises questions regarding the causallink between peer network factors and cannabisinitiation and use. Do adolescents who use cannabisselect friends with similar interests? Or, are adolescentsmore likely to initiate and maintain cannabis usebecause they associate with cannabis-using peers?Research supports both directions, which may reflecta feedback effect in which having a social network withcannabis-using peers promotes initiation, leads toseeking new friendships with other cannabis-usingpeers, and furthers the risk for subsequent use(Coggans & McKellar, 1994; Kandel, 1985; Niv,2007, p. 61; Rhodes et al., 2003).

The most oft-cited theory for explaining the path-way between peer network factors and adolescentsubstance use is the idea of ‘peer pressure’ and the roleof peer networks ‘as a risk factor for drug use is oftenconflated as one of pressurizing or luring individualsinto experimenting with drugs’ (Rhodes et al., 2003,p. 316). This understanding situates responsibility andblame for substance use on adolescent drug users andignores the agency of adolescents to select their ownpeers and choose to use or abstain from drugs (Coggans& Mckellar, 1994; Rhodes et al., 2003). The riskenvironment is one theoretical framework that accountsfor the role of the individual adolescent in his or herown substance use. A risk environment is a social orphysical space where a variety of factors interact toincrease the likelihood of substance-related harm(Rhodes, 2009). Here, peer networks are viewed asless a matter of peer pressure than of peer selection.Adolescents choose which peers to affiliate withbecause of shared interests and values, thus individ-uals’ drug use and health behaviour should be viewedin the context of peer norms and lifestyle (Kandel,1985). Prevention interventions should acknowledgethat cultural resources (and constraints) shape group(and drug use) identities, and view individual drug use

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as a ‘situated product, not so much of pressure, but ofactive lifestyle decisions in keeping with group normswithin social contexts of constraint and opportunity’(Rhodes et al., 2003, p. 316). Thus, preventioninterventions require comprehensive strategies thattarget peer network norms rather than individualadolescents’ beliefs and behaviours (Valente,Gallaher, & Mouttapa, 2004). Those that are primarilydeveloped around the notion that drug use is theproduct of an individual’s susceptibility to peer pres-sure are unlikely to be successful.

Another important social determinant of adolescentsubstance use is family structure and quality. Indeed,the family is the social relationship that has receivedthe most attention in substance use risk factors research(Rhodes et al., 2003, p. 312). Family structure has beenoperationalized in numerous ways, including separa-tion, and/or divorce within an adolescent’s family,single parenthood, etc. Family quality has been oper-ationalized as management practices, parental supervi-sion, familial communication, parenting styles, parent–child relationships, family socio-emotional problems,parental substance use, etc. (Choquet, Hassler, Morin,Falissard, & Chau, 2007; Hall et al., 2008; Hallfors &van Dorn, 2002; Kosterman et al., 2000; Niv, 2007;Oesterle et al., 2010; Rhodes et al., 2003; Spoth,Redmond, & Shin, 2001). Many studies suggest anassociation between family structure and quality andadolescent cannabis initiation and use (Butters, 2002;Chen, Storr, & Anthony, 2005; Galea et al., 2004; Hall& Pacula, 2003; Hall et al., 2008; Hayatbakhsh et al.,2006; Niv, 2007; van den Bree & Pickworth, 2005).For example, Butters’ (2005) analysis of data fromCanadian adolescents finds that for those with dis-rupted family status the probability of initiatingcannabis use was 67% higher than it was for thosefrom intact families. Moreover, she found thatfor ‘every unit increase in the degree of poorfamily relationships, the odds of cannabis useincreased by 16% and the probability of problemcannabis use by 9%’ (Butters, 2005, p. 850). Withregard to early adolescents, Hallfors and van Dorn(2002) report that poor family management, familyconflict and low bonding have all been linked to earlysubstance use.

The above analysis suggests that both familystructure and quality may be important determinantsof early adolescent cannabis use, but is one moreimportant than the other? Though more research isneeded in this area, it appears that family quality maybe more important. Specifically, family managementpractices including a lack of parental monitoring havebeen shown to be a particularly important risk factorfor early adolescent cannabis use (Eitle, 2005;Kosterman et al., 2000; Tang & Orwin, 2009).

The above discussion has highlighted evidence forthe direct impact of peer networks and family structureand quality on early adolescent cannabis use. However,it is likely that both of these determinants also interact

with one another to influence initiation and use(Eitle, 2005; Niv, 2007). Relatively few studies havesystematically assessed the mediating and moderatinginfluences of peer networks and family structure andquality on early adolescent cannabis use, but those thathave suggest that poor family management leads tolower levels of adolescent supervision and increasedopportunities for associating with delinquent peers and/or substance use (Best et al., 2005; Eitle, 2005; Tang &Orwin, 2009).

Socio-economic status (SES) occupies an importantplace in the literature on social determinants of healthand is viewed as a fundamental cause (Frohlich &Potvin, 2008). As such, it is reasonable to questionwhether low SES in an antecedent to negative changesin family structure and quality or affiliation withsubstance-using peers. The current literature on therelationship between SES and adolescent cannabis useis mixed (Hall & Pacula, 2003; Spooner, 2009; Stranget al., 2012; Tu et al., 2008). Hanson and Chen (2007)recently reviewed 25 studies examining the relation-ship between SES and adolescent cannabis use. Sixstudies reported positive associations, between SESand use, whilst four found negative associations, 14studies reported null findings and one reported anonlinear relationship. However, a recent meta-analy-sis of data from 219,517 adolescents (originating fromnine studies) examined the link between SES andcannabis use in early adolescence (10–15). The authorsfound that those with low SES were 22% more likely toengage in cannabis risk behaviours (Lemstra et al.,2010). Additionally, low SES may be associated withtransition from early adolescent use to dependence inlater adolescence (von Sydow, Lieb, Pfister, Hofler, &Wittchen, 2002). This is consistent with broaderliterature on problematic drug use and its roots insocial inequality (Alexander, 2008; Rhodes et al.,2003). The potential added vulnerability of lowSES early adolescents to later cannabis-related harmsuggests a role for development of targeted interven-tions that address structural as well as psychosocialfactors.

The above discussion highlights the importance ofsocial determinants in understanding early adolescentcannabis use. The evidence reviewed suggests thatadolescents may affiliate with drug-using peers andthese networks can facilitate cannabis use throughshared norms, attitudes and behaviours, and familyvariables including a lack of parental monitoringcontribute to early adolescents’ likelihood ofinitiating cannabis use. This vulnerability may beexacerbated by low SES. Thus, a holistic approach toadolescent cannabis use prevention would focus onstrengthening family relationships, during early andmid-childhood, and changing peer network norms,during early adolescence. The following sectionsdiscuss interventions for early adolescent cannabisuse in more detail.

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CURRENT APPROACHES FORPREVENTING EARLY ADOLESCENTCANNABIS USE

Although criminal law reform is not the focus of thisarticle, the vast majority of resources dedicated tocannabis use (and other illegal drugs) focuses onprevention through the enforcement of abstinence(Caulkins & Reuter, 2010; Tombourou et al., 2007).Thus, brief mention of enforcement as a means tomitigate cannabis-related harm is warranted. Ostensiblythe primary aims of cannabis prohibition are to deterindividuals, including adolescents, from using cannabis,and limit supply of cannabis. However, there is a largebody of evidence suggesting that cannabis prohibition iscostly and ineffective at deterring cannabis use orlimiting supply, and produces a number of unintendednegative consequences (MacCoun & Reuter, 2001;Room et al., 2010; Wodak, Reinarman, & Cohen,2002; Wood et al., 2010). The negligible impact ofcriminalization on demand is further supported byinterviews with cannabis users indicating that peernetworks are a far more powerful determinant ofbehaviour than perceptions of the risk of legal sanction(Duff et al., 2011; Lenton, 2005).

In addition to being ineffective at substantiallycurbing cannabis use rates amongst youth and adults, asocial determinants of health perspective suggests thatcannabis prohibition is itself associated with health andsocial costs (Fischer et al., 2009; Hall & Pacula, 2003;Room et al., 2010; Werb et al., 2010). Evidence fromfour decades of research on the impacts of criminal-ization on cannabis users in Canada indicates thatconviction for possession can result in decreasedemployment and travel opportunities and feelings ofstigma (Erickson, 1980; Erickson & Hyshka, 2010).Although little research examines the impacts ofcriminal justice sanctions on adolescent cannabisusers, it is reasonable to speculate that criminal justicesystem involvement has negative outcomes for youngerusers as well (Toumbourou et al., 2007). Moreover,criminalization of cannabis is counterproductive to theextent that it prohibits effective population surveillanceand screening for high risk cannabis-using youth,enables the selective focus of law enforcement onmarginalized youth, and encourages participation inillicit drug markets (Fischer et al., 2009).

When funding is spent on prevention interventionsother than enforcement, it is generally directed towardsuniversal classroom-based programmes that focus onindividual-level behaviour change. Examples of theseprogrammes include life skills training (Botvin,Baker, Dusenberg, Botvin, & Diaz, 1995), the‘Unplugged’ approach (Faggiano et al., 2010) andnormative education (Graham, Collins, Wugalter,Chung, & Hansen, 1991), but the Drug AbuseResistance Education (D.A.R.E., 2012a, 2012b) pro-gramme is probably the most widely implemented,having reached over 36 million children in 49 countries

worldwide. Originally developed in the US, D.A.R.E.targets children in grades 5 (age 10–11) and 6 (age 11–12) to discourage risk behaviours from developing inearly adolescence (DeBeck, Wood, Montaner, & Kerr,2006; Fischer et al., 2009). The programme is theoret-ically grounded in a ‘social skills and social influence’model of drug education, which emphasizes the impor-tance of peer pressure and individuals’ deficits inknowledge or skill to resist peer pressure in determiningadolescent drug use. As such, information about theharms of drug use, psychological inoculation, resistanceskills training (learning to ‘just say no’) and personaland social skills training are all features of the curric-ulum (Rosenbaum & Hanson, 1998, pp. 383–384).

Available evaluations of D.A.R.E. indicate that ithas been ineffective at reducing adolescent substanceuse (Fischer et al., 2009; Gruenewald, 2005; Midford,2009; Rosenbaum & Hanson, 1998; West & O’Neal,2004). In response to mounting evidence of ineffec-tiveness, D.A.R.E. was revamped in 2001 and the newcurriculum has been the subject of a $13 million dollarrandomized controlled trial evaluation (Sloboda et al.,2009). Additional components were added to enhancethe curriculum, including normative education aboutprevalence of substance use, enhanced life skillstraining and a constructivist learning model of instruc-tion. Findings from the ‘new’ D.A.R.E. evaluationindicate that the programme had an iatrogenic impacton student use of alcohol and tobacco, and a minorpositive impact on cannabis use, but only for users atbaseline. The evaluators concluded that unknownexternal factors influenced participants’ substance use(Sloboda et al., 2009). It should be noted that the otherclassroom-based prevention programmes targeting theindividual level, have demonstrated better outcomesthan D.A.R.E., in particular those which are not policeofficer delivered and employ a more interactiveapproach (Strang et al., 2012). However, some haveraised concerns over the methodological quality ofsome of these evaluations, and the potential forpublication bias (Faggiano et al., 2010; Gorman,Conde, & Huber, 2007; Gorman, 2009;McCambridge, 2007).

The failure of D.A.R.E. and its emphasis onindividual-level behaviour suggests the importance ofviewing substance use as a social, rather than individ-ual phenomenon. It also raises the question of whethera didactic individual-level intervention can adequatelyaddress the social context of substance use (Skager,2008; Steiker, 2008; Strang et al., 2012). Indeed,evidence indicates that when classroom-based beha-vioural interventions are interactive and target broadersocial ecological levels, positive short- and long-termsubstance use outcomes are possible. The GoodBehaviour Game is an example of this (Dolan et al.,1993; Kellam et al., 2008; Strang et al., 2012).

A number of other universal prevention interven-tions target substance use and other adolescent healthrisk behaviours at broader levels (Hall et al., 2008;

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Midford, 2009; Spoth et al., 2001; Toumbourou et al.,2007). Examples of these programmes include theGatehouse Project in Australia and the StrengtheningFamilies Program from the US, which target peer andfamily determinants, respectively.

The Gatehouse Project was designed to strengthenpeer networks and a sense of inclusion in schools, andincludes surveys to assess students’ perspectives onpersonal safety, communication with teachers, andparticipation in school life, a staff action team focusedon changing school policies and practices, and schooland individual-level capacity building (Patton, Bond,Butler, & Glover, 2003). After four years, the preva-lence of health risk behaviours including cannabis use,declined by approximately 25% (Patton et al., 2006).

The Strengthening Families Program aimed tobolster family structure and quality as a means toreduce early adolescent substance use. Early adoles-cents and their families were recruited through theirschools and both children and parents received assess-ments followed by tailored interventions (Spoth et al.,2001). Parents received family skills training designedto increase parenting skills, strengthen family bondsand reduce adolescent drug use (Midford, 2009,p. 1689). A controlled pre–post evaluation found a37% reduction in the initiation of cannabis use andreductions in alcohol and tobacco use prevalence(Spoth et al., 2001).

It appears both of the above interventions were ableto positively impact on peer network and family factorsto produce positive outcomes at the population level.Addressing these social determinants necessitated abroader approach, which did not focus on substance useper se yet paradoxically resulted in reduced prevalenceof this risk behaviour. This is consistent with theliterature demonstrating that adolescent risk behavioursshare a number of common social determinants(Catalano et al., 2012; Resnick et al., 1997).Moreover, these studies are congruent with resultsfrom two recent meta-analyses examining preventioninterventions for adolescent substance use, whichconcluded that programmes targeting multi-level deter-minants, may be more effective than those focusingsolely on individual-level attributes (Jackson, Geddes,Haws, & Frank, 2012; Porath-Waller, Beasley &Beirness, 2010). However as both reviews indicate,more and better research is needed to demonstratewhether prevention interventions targeting broadersocial-ecological levels achieve significant reductionsin harmful cannabis and other substance use over thelong term (Gorman et al., 2007; Holder, 2010;Midford, 2009).

PREVENTING HARM AMONGST CURRENTADOLESCENT CANNABIS USERS

Unfortunately, as demonstrated by the prevalence ofD.A.R.E., prevention interventions rarely align withcurrent knowledge (Hall et al., 2008; Midford, 2009).

Moreover, even with widespread implementation of themore promising substance use prevention interven-tions, it is likely that many adolescents will continue toinitiate cannabis use, and use throughout high school(Midford, 2009). Programming is needed to reduce theharms of cannabis use for current users.

Harm reduction represents a promising strategy forpreventing potential negative outcomes associated withadolescent cannabis use (Fischer et al., 2009; Hallet al., 2008; Merkinaite, Grund, & Frimpong, 2010;Poulin & Nicholson, 2005). Harm reduction is apragmatic approach for addressing negative conse-quences of substance use ‘by incorporating severalstrategies that cut across the spectrum from safer use tomanaged use to abstinence’ (Marlatt & Witkiewitz,2010, p. 519). A harm reduction approach to adolescentcannabis use would promote abstinence as a way toavoid all harm, but this message would not be the soleaim of an intervention (Fischer et al., 2009). Harmreduction interventions would also focus on otherstrategies to mitigate harm for current adolescentcannabis users. For example, cannabis-related harmreduction strategies for youth could include educationabout symptoms of cannabis dependence, guidelinesoutlining ‘risky’ use patterns, education on thecannabis-psychosis link, personal safety skill buildingand information about keeping safe in situations whereothers are taking drugs (Fischer et al., 2009, 2011;Midford, 2009; Werb et al., 2010). These strategies aresimilar to tactics currently used by public healthpractitioners to counter harm associated with youthalcohol use (Marlatt & Witkiewitz, 2002).Additionally, practitioners could screen young peopleto identify subpopulations vulnerable to mental illnessand use targeted interventions to further minimize thepopulation burden of cannabis-related harms (Fischeret al., 2009; Toumbourou et al., 2007).

Harm reduction initiatives for adolescents couldtarget a number of different social-ecological levels;however, there is evidence to support the use of school-based programmes that target organizational levelchanges. In one Canadian intervention, Poulin andNicholson (2005) demonstrated significant reductionsin the prevalence of a number of substance use riskbehaviours, including driving whilst under the influ-ence of cannabis amongst high school students, how-ever additional research is needed to outline harmreduction best practices for adolescent cannabis use.

CONCLUSION

The most promising approaches to preventing earlyadolescent cannabis use are grounded in the socialdeterminants of health. This includes interventionswhich take into account the social context of cannabisuse, and address major risk factors such as peernetworks and poor family structure and quality, totarget early adolescent cannabis use at the differentsocial-ecological levels. This overview has focused on

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strengthening current prevention efforts that targetearly adolescent cannabis use; however, a socialdeterminants of health approach has much broaderimplications. As discussed above, adolescent substanceuse and other problem behaviours tend to co-occur andpredictors of these behaviours overlap (Catalano et al.,2012; Catford, 2001). Thus, ‘upstream’ interventionsdesigned to strengthen peer networks and familystructure and quality are likely to have benefitsbeyond reducing early adolescent cannabis use initia-tion. Indeed, health promotion practitioners and pre-vention scientists emphasize that broad interventionswhich target a number of risk factors for adolescentproblem behaviours are more effective and economicalthan the conventional approach of introducing multipleinterventions to narrowly target a single behaviour orset of behaviours (Catalano et al., 2012; Catford, 2001).Thus, policy and decision-makers interested in pre-venting early adolescent cannabis and other substanceuse should consider implementing prevention interven-tions as part of a broader adolescent health agenda andtarget social determinants as a means to improve youngpeople’s overall health and well-being.

ACKNOWLEDGEMENTS

The author thanks her supervisor, T. Cameron Wild, and

the two anonymous reviewers for their valuable com-

mentary on earlier versions of this article.

Declaration of interest: The author reports no conflicts of

interest. The author alone is responsible for the content

and writing of this article.

Elaine Hyshka receives doctoral funding from the

Canadian Institutes of Health Research, Alberta

Innovates: Health Solutions, and the Western Regional

Training Centre for Health Services Research.

NOTE

1. Note that there are no clear age brackets that define adolescence;however generally speaking, early adolescence encompassesindividuals 10–15 years of age. This is the most common definitionin the literature on cannabis use and is thus employed here.

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