CPSTF Finding – Substance Use: Community Interventions involving Coalitions or Partnerships to Prevent Substance Use among Youth

PDF version [PDF – 397 KB].

Return to the Intervention Summary.

Community Preventive Services Task Force Finding and Rationale Statement

Context

Youth substance use is associated with increased risk for behavioral and academic problems, teen pregnancy, sexually transmitted infections, being involved in or experiencing violence, injuries, and mental health symptoms (such as anxiety and depression), among others (U.S. Department of Health and Human Services 2016). Preventing or delaying substance use initiation among youth (defined in this review as adolescents ages 10-17 years and young adults ages 18-24 years) reduces later risk for substance use, substance use disorders, and overdose (U.S. Department of Health and Human Services 2016).

In 2023, substance use was common among U.S. high school students and varied by substance. Approximately one-fourth of students reported current use of alcohol (22%), 17% reported current use of marijuana, and 4% reported prescription opioid misuse (CDC 2024). Substance use trends in the United States have changed in recent years. There have been increases in the availability of illegally-made fentanyl and other synthetic opioids, misuse of prescription drugs, popularity of e-cigarettes and vaping products, and changes in the legal and regulatory landscape for cannabis (Hoots et al. 2023).

Coalitions and partnerships are two organizational approaches to engaging communities in a coordinated substance use prevention effort (SAMHSA 2022, Hutchinson et al. 2021). These initiatives often include 1) engaging community members with needs assessments and prevention planning, 2) building community capacity, 3) selecting and implementing evidence-based practices, and 4) evaluating effectiveness over time (SAMHSA 2022). While community efforts have often focused on alcohol and tobacco prevention, these approaches may provide a framework for application to other substance use prevention priorities including prescription drug misuse, initiation and use of illegal and synthetic opioids, and overdose (SAMHSA 2023, Fishbein et al. 2023, U.S. Department of Health and Human Services 2016, HEALing Communities Study Consortium 2024).

Intervention Definition

Community interventions involving coalitions or partnerships to prevent substance use among youth are multi-component initiatives to prevent substance use by adolescents (ages 10-17 years) or young adults (ages 18-24 years). These efforts must have both a community-based organization and two or more interventions selected and implemented to reduce substance use demand, underage access, or both in the community. Interventions may focus on a specific substance of importance to the community or address risk and protective factors related to substance use in general.

Organization: Initiatives must be directed by a new or existing community-based organization which includes members of the community and may include representatives of community groups, local agencies, and research or implementation partners. Members of the community must be involved in selecting interventions for community implementation and may also be involved in identifying substance use prevention priorities, adapting or modifying interventions for local relevance, and participating in intervention implementation. The two organizational structures included in this review are:

• Community coalitions: Coalitions are an assemblage of relevant community-based organizations, agencies, leaders, and members of the community tasked with identifying and implementing the community prevention initiative.
• Community partnerships: Partnerships are organizations in which research or implementation partners engage with recruited community members, leaders, and organizations on the community initiative. In some partnerships, community members operate as action teams involved in the selection, adaptation, and implementation of community interventions.

The community initiatives examined in this review included support for implementation of the selected interventions. Implementation support included hired and trained members of the community or staffing support from research or implementation partners to coordinate community action. Coalitions and partnerships also received ongoing technical assistance from research and implementation partners in the form of consultations, trainings, program manuals and materials, and model policies.

Interventions: Interventions include two or more programs, activities, and policies selected to address community substance use prevention priorities. Interventions selected for implementation must be research-tested or identified as evidence-based (typically, community members select intervention approaches from a menu of evidence-based program options identified by the research, funding, or implementation partner). Specific interventions, which may differ from community to community, include:

• School-based interventions (e.g., classroom substance use prevention curricula; student assistance services; drug-free activities and events)
• Family-based interventions (e.g., small group trainings for parents on prevention communication and practices; drug-free activities and events for both parents and youth)
• Community-based interventions (e.g., mentorship programs, education and awareness activities, drug-free events)
• Retailer education to reduce sales of alcohol, tobacco, or cannabis to underage youth (e.g., in-person meetings with retailers in the community, compliance checks without citation or fines)
• Enforcement activities directed at underage sales or substance use (e.g., compliance checks with citations or fines; sobriety checkpoints; enhanced law enforcement presence at community events with alcohol service)
• Policy advocacy (e.g., events and activities to support adoption of local substance use prevention ordinances, policies, and local government practices)

Community Preventive Services Task Force Finding

The Community Preventive Services Task Force (CPSTF) recommends community-based interventions involving coalitions or partnerships to prevent substance use among youth based on sufficient evidence of effectiveness in reducing both the initiation of substance use and rates of current use among adolescents and young adults. Interventions implemented in rural and suburban communities were effective in reducing initiation and use of cannabis, tobacco, alcohol (including binge drinking), and illegal substances, however evidence was limited for urban settings. A subset of studies also found reductions in self-reported antisocial behaviors among youth.

Rationale

Basis of Finding

The CPSTF recommendation is based on evidence from a systematic review of 11 studies with 12 study arms (search period January 1990 to May 2023).

The systematic review team evaluated substance use measures reported in the included studies for the following outcome categories:

1. Initiation of use for one or more substances (7 studies)
2. Prevalence, amount, or frequency of use for one or more substances (10 studies)

Studies used a variety of self-reported measures for substance use outcomes primarily collected through school-based surveys of students in study communities or school districts. Initiation of substance use was commonly measured based on self-reported lifetime (ever) use. Substance use was typically measured based on use (any) in the previous 30 days. Measures of change in substance use included longitudinal follow-up of students (typically from middle school through high school) or longitudinal follow-up of schools (e.g., 12th grade students surveyed annually over the duration of the community intervention or study period).

Included studies evaluated a median of 21 communities or school districts (IQI: 10 to 28 communities or districts; 10 studies). Study evaluations included a median of 5921 participants or survey respondents (IQI: 2906 to 28,845 participants; 10 studies) with one state-wide study evaluating 470,795 student surveys collected from six survey waves over 11 years. The median duration of intervention activities was 36 months, with study participants exposed to interventions over 24-47 months (7 studies) and 48 to 72 months (3 studies); one study did not report on intervention duration.

For each outcome category, the review team generated overall effect estimates across substances. Then the review team generated assessments for each substance type (i.e., cannabis, tobacco, alcohol, binge drinking of alcohol, illegal substances, prescription drug misuse, and combined substance measures). As study data permitted, absolute or relative change measures were calculated, and summary effect estimates were generated. For study outcomes that could not be converted into absolute or relative change estimates, study results were summarized and grouped for a narrative assessment.

CPSTF findings are based on both summary effect estimates and narrative assessments for each outcome category and substance type. Evidence showed community interventions led to small but meaningful reductions in both initiation (Table 1) and use (Table 2) when including outcomes for cannabis, tobacco, alcohol, illegal substances, prescription drug misuse, and combined substance measures.

IQI: Interquartile Interval
*Cannabis, tobacco, alcohol (binge drinking not included), illegal substances, combined measures of substance use initiation.

IQI: Interquartile Interval
*Cannabis, tobacco, alcohol (binge drinking not included), combined measures of substance use. No studies provided consolidated measures of use of illegal substances.

---

Subset assessments for specific substances and combined measures are summarized in Table 3. Evidence showed that community interventions led to small, but meaningful (Matthay et al. 2021) reductions in initiation or use of cannabis, tobacco, alcohol including binge drinking, tobacco, and illegal substances.

IQI: Interquartile Interval
*Includes results from one study that also evaluated vaping or use of electronic cigarettes
#Findings from studies that measured self-reported initiation of use of one or more substances selected from a list (for example, “use of one or more illegal drugs such as marijuana, cocaine, amphetamines, methamphetamines, barbiturates, inhalants, opioids, etc.”).

---

CPSTF judged the effect sizes for substance use outcomes (relative reductions of 3%-9%) as meaningful. These determinations were based on evidence that outcomes measured community-level changes in use of substances among all surveyed youth (regardless of actual exposure to interventions), and that effects were sustained over study follow-up periods of two to 14 years. Two studies followed students for 10 to 14 years respectively, from a middle-school intervention period into young adulthood (Kuklinksi et al. 2021, Oesterle et al. 2018; Spoth et al. 2017, Spoth et al. 2022). Both studies found significant effects through 12th grade, and sustained reductions in initiation of substance use through ages 21 and 23 years, although prevalence rates of substance use were not significantly different at follow-up.

Few studies evaluated substances of more recent concern including prescription drug misuse , and vaping or e-cigarette use. Only two studies examined changes in self-reported misuse of prescription drugs (Hawkins 2014, Komro 2017). The first found an increase in prescription drug misuse among intervention participants, though that increase was not significant (Hawkins 2014). The second study found a significant decrease in use among both of its intervention arms compared to the control (Komro 2017). Only one study evaluated intervention impact on self-reported vaping or e-cigarette use and found a favorable, but not statistically significant effect (Hawkins 2014). None of the included studies reported outcomes for recent or concurrent use of more than one substance (i.e., polysubstance use).

Only three studies examined intervention associated changes in morbidity outcomes, and results were inconsistent. All three studies evaluated differences in alcohol-related injuries or hospitalizations. One study from Sweden observed an increase in youth (ages 15-19 years) hospitalized with an alcohol-related diagnosis (Hallgren et al 2013). The second study from Australia found small relative reductions in injury-related hospitalizations, but differences among adolescents were not statistically significant (Toumbourou et al 2019). The third study assessed self-reported alcohol-related injuries among college students in North Carolina (Wolfson et al 2012). Students in intervention schools reported a non-significant increase in directly experiencing injuries, but a significant decrease in causing injuries to others compared to students in comparison colleges.

A subset of studies included in this review also examined intervention effects on improving antisocial behaviors, reducing mental health symptoms (such as anxiety and depression), and improving educational attainment among youth (Table 4). Interventions were effective at reducing self-reported antisocial behaviors related to delinquency and violence overall and when related to alcohol use. There was not enough evidence to support a CPSTF determination on intervention effectiveness in reducing mental health symptoms (2 studies) or improving educational attainment (2 studies).

Applicability and Generalizability Considerations

Intervention Settings

The CPSTF finding is applicable to coalition or partnership directed interventions in community, school, and home settings in the United States. Eight of the 11 included studies were conducted in the United States with findings from this subset indicating effectiveness. Nine studies included rural communities and four studies included suburban communities with these subsets having evidence of effectiveness. One study with favorable effects on substance use outcomes was conducted in the Cherokee Nation (Komro et al 2017). While the two U.S. studies which included urban populations reported favorable effects on substance use outcomes, the overall findings from five studies which included urban communities were mixed. Additional studies are needed to determine the effectiveness of these interventions in urban settings.

Population Characteristics

The CPSTF finding is applicable to interventions targeting adolescents (ages 10-17 years at the time of intervention), and likely applicable to interventions for young adults (ages 18-24 years). Ten of the 11 included studies focused interventions at middle school-level adolescents, with follow-up evidence of effectiveness through high school. The median age of study youth at baseline was 13.5 years (3 studies). Although four studies evaluated community interventions to reduce access to alcohol among adolescents and young adults, only one study specifically focused on young adults (college students) and found mixed effects. Findings are applicable to males and females since interventions were effective across nine studies where the distribution by gender was even. Only two studies compared effectiveness by gender and results were inconsistent.

Reporting on other demographic characteristics was limited across this body of evidence, and most studies evaluated students in rural communities who with predominantly identify as White. Study participants identified as White (median 79.9%; 6 studies), Black or African American (median 6.1%; 2 studies), Hispanic or Latino (20.0%; 3 studies), Asian (3.0%; 2 studies) American Indian (21.5%, 2 studies including 1 study conducted in the Cherokee Nation), or other (9.8%, 5 studies). None of the included studies reported participation rates for youth who identified as a sexual or gender minority. Four studies provided community-level data on free or reduced lunch program participation (range: 31.0% to 57.6%) None of the included studies examined differences in effectiveness for substance use outcomes by race, ethnicity, income, or family characteristics. More complete reporting of demographic characteristics of study communities and participants would help address several important evidence gaps.

Intervention Characteristics

The CPSTF finding is applicable to the organization of community action through both coalitions and partnerships; a focus on either general substance use prevention or narrowed to alcohol prevention; and the use of school-based interventions, family-based interventions, and community prevention activities with interventions maintained for at least two years.

Both coalitions (8 studies) and partnerships (3 studies) were effective organizations for substance use prevention. Evidence of effectiveness came from communities taking a general prevention approach (7 studies) or focusing on alcohol prevention (4 studies). All 11 included studies evaluated communities implementing school-based programs, and 10 also included family-based interventions. Results from the subset of studies that included community interventions (8 studies) were also favorable. The remaining interventions, retailer-directed activities (5 studies), enforcement of underage sales (5 studies) and policy activities (4 studies) were primarily implemented by community coalitions focused on alcohol prevention and results were generally favorable. All included studies evaluated interventions that were implemented for at least two years, and the median intervention duration was 36 months.

Data Quality Issues

There are several important limitations in the studies included in this review. Only four of the included studies randomized communities to intervention and control arms. Although most of the remaining studies attempted to match communities for assignment and comparison, community and demographic characteristics were incompletely reported or identified potentially meaningful differences at baseline. Some comparison communities implemented similar substance use prevention interventions targeting schools, families, and the community. Study youth may have moved into or out of study communities which were often in proximity.

Studies differed in substances and risk behavior outcomes, the measures used to evaluate change, and the reporting of results. These issues limited the review team’s ability to compare study findings, consolidate effect estimates, and calculate summary effect estimates for the outcomes of interest. Almost all outcomes were based on self-reported substance use and other risk behaviors among participating youth, which introduced potential bias in these measures.

Indigenous Knowledge [PDF – 1.1 MB] was not explicitly incorporated within this systematic review. Only one study incorporated elements of Indigenous Knowledge in intervention development and evaluation on tribal lands (Komro et al. 2017).

Potential Benefits

CPSTF postulated that community-based interventions might also reduce substance use among adults. None of the included studies in this review examined substance use outcomes among older adults. No additional benefits were described or evaluated in the broader literature.

Potential Harms

CPSTF did not postulate any potential harms of community interventions involving coalitions or partnerships to prevent substance use among youth. None of the studies included in this review described or evaluated harms of these interventions. No harms were identified in the broader literature.

Considerations for Implementation

The following considerations for implementation are drawn from studies included in the existing evidence review, the broader literature, and expert opinion, as noted below.

Most of the studies included in this review provided training sessions for recruited coalition and partnership members. Training sessions covered a range of topics including but not limited to member roles and process steps, substance use issues, use of data for identifying local prevention priorities, and guidance on evidence-based prevention (Flewelling et al 2005, Eddy et al 2012).

Involvement of community members in decision-making roles may enhance health equity relevance of the community response (Komro et al. 2017). Initiatives should consider cultural relevance of the interventions selected for implementation (Bo et al 2023). Authors of some included studies (Eddy et al. 2012, Jonkman et al. 2015) suggested the need to balance fidelity to evidence-based interventions and cultural responsiveness in community efforts to promote heath equity.

Family-based interventions were implemented by coalitions and partnerships in 10 of the 11 included studies. CPSTF recommends family-based interventions that provide instruction or training to parents and caregivers to enhance substance use preventive skills and practices for children and adolescents.

CPSTF also recommends intervention approaches related to the following:

• Preventing Excessive Alcohol Use
• Reducing Tobacco Use

Several organizations offer implementation guidance for supporting community organizations and for specific interventions to address substance use.

Guidance related to Organization of Interventions

• Brandeis Opioid Resource Connector, a frequently updated selection of community-focused programs on interventions that address the opioid crisis
• State/Tribal Opioid Response Network (SOR/TOR-TA)

Specific Model Resources

• CTC PLUS | The Center for Communities That Care
• How It Works | PROSPER (iastate.edu)

Funding

• Apply for DFC Funding | Overdose Prevention | CDC
• SAMHSA Strategic Prevention Framework – Partnerships for Success for Communities, Local Governments, Universities, Colleges, and Tribes/Tribal Organizations
• SAMHSA Substance Use Prevention, Treatment, and Recovery Services Block Grant (SUBG) program

Guidance Documents

• Engaging Community Coalitions to Decrease Opioid Overdose Deaths Practice Guide 2023 | SAMHSA
• Six Elements of Effective Coalitions Resource Toolkit | Prevention Technology Transfer Center (PTTC) Network
• Implementing Community-Level Policies to Prevent Alcohol Misuse | SAMHSA
• Community Engagement: An Essential Component of an Effective and Equitable Substance Use Prevention System | SAMHSA

The following resources provide technical assistance and guidance for specific intervention options and address issues that may be useful for implementing these interventions for specific communities:

• Blueprints for Healthy Youth Development is a registry of scientifically rigorous and accessible prevention and intervention programs aimed at addressing youth health and behavior issues.

Technical assistance resources to improve implementation and delivery of effective substance abuse prevention interventions:

• Products and Resources | Prevention Technology Transfer Center (PTTC) Network (pttcnetwork.org)
• Strategic Prevention Technical Assistance Center (SPTAC) | SAMHSA
• Prevention Intervention Resource Center – High Intensity Drug Trafficking Areas (hidta.org)
• Evidence-based Prevention and Intervention Support (EPIS) Center (psu.edu)
• Resources Center | Community Anti-Drug Coalitions of America (CADCA)
• Applied Prevention Science International (APSI) | apsintl.org

Technical assistance resources for Tribal communities:

• Tribal Training and Technical Assistance Center | SAMHSA
• Tribal Youth Resource Center – Resource Library

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base.

CPSTF identified the following questions as priorities for research and evaluation:

• How effective are these interventions when implemented in urban communities?
• How effective are interventions when implemented in communities with historically disadvantaged racial and ethnic populations?
• How effective are interventions when implemented in communities with lower household incomes?
• How effective are interventions in reducing development of substance use disorders?
• How effective are interventions in reducing prescription drug misuse?

Remaining questions for research and evaluation identified in this review include the following:

• How effective are interventions in reducing polysubstance use among youth?
• How effective are interventions in reducing vaping initiation and use among youth?
• How effective are interventions when focused on substance use prevention in young adults?
• How effective are interventions in improving mental health outcomes?
• How effective are interventions in improving educational outcomes?
• How does effectiveness differ when evidence-based interventions selected by the coalition or partnership are modified to enhance cultural or community relevance?

References

Bo A, Goings TC, Evans CBR, et al. Culturally sensitive prevention programs for substance use among adolescents of color: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology Review. 2023; 99: 102233.

Centers for Disease Control and Prevention. Youth Risk Behavior Survey Data Summary & Trends Report: 2013–2023. U.S. Department of Health and Human Services; 2024.

Eddy JJ, Gideonsen MD, McClaflin RR, et al. Reducing Alcohol Use in Youth Aged 12-17 Years Using the Strategic Prevention Framework. Journal of Community Psychology. 2012; vol. 40, No. 5, 607–620.

Fishbein DH, Sloboda Z. A National Strategy for Preventing Substance and Opioid Use Disorders Through Evidence-Based Prevention Programming that Fosters Healthy Outcomes in Our Youth. Clinical Child and Family Psychology Review. 2023; 26:1–16.

Flewelling RL, Austin D, Hale K, et al. Implementing Research-based Substance Abuse Prevention in Communities: Effects of a Coalition-based Prevention Initiative in Vermont. Journal of Community Psychology. 2005; vol. 33, no. 3: 333–353.

Hawkins JD, Oesterle S, Brown EC, et al. Youth Problem Behaviors 8 Years After Implementing the Communities That Care Prevention System-A Community-Randomized Trial. JAMA Pediatrics. 2014;168(2):122-129

HEALing Communities Study Consortium. (Samet et. al.) Community-Based Cluster-Randomized Trial to Reduce Opioid Overdose Deaths. New England Journal of Medicine. 2024 Jun 16.

Hutchinson M, Russell BS. Community Coalition Efforts to Prevent Adolescent Substance Use: A Systematic Review. Journal of Drug Education: Substance Abuse Research and Prevention. 2021;50:3–30.

Jonkman H, Aussems C, Steketee M, et al. Prevention of Problem Behaviours among Adolescents: The Impact of the Communities that Care Strategy in the Netherlands (2008–2011). International Journal of Developmental Science. 2015; 9: 37–52.

Komro KA, Livingston MD, Wagenaar AC. Multilevel Prevention Trial of Alcohol Use Among American Indian and White High School Students in the Cherokee Nation. Am J Public Health. 2017;107:453–459.

Kuklinski MR, Oesterle S, Briney JS, Hawkins D. Long-term Impacts and Benefit–cost Analysis of the Communities That Care Prevention System at Age 23, Twelve Years After Baseline. Prev Sci. 2021; 22(4): 452–463.

Matthay EC, Hagan E, Gottlieb LM, et al. Powering population health research: Considerations for plausible and actionable effect sizes. SSM-Population Health. 2021; 14: 100789.

Miech RA, Johnston LD, Patrick ME, et al. Monitoring the Future national survey results on drug use, 1975–2022: Secondary school students. Monitoring the Future Monograph Series. Ann Arbor (MI): Institute for Social Research, University of Michigan, 2023. Available at URL: https://monitoringthefuture.org/wp-content/uploads/2022/12/mtf2022.pdf. Accessed 7/31/23.

Oesterle S, Kuklinski MR, Hawkins JD, et al. Long-Term Effects of the Communities That Care Trial on Substance Use, Antisocial Behavior, and Violence Through Age 21 Years. Am J Public Health. 2018; 108:659–665.

Park-Lee E, Ren C, Cooper M, et al. Tobacco product use among middle and high school students — United States, 2022. MMWR 2022;71:1429–35. Available from URL: http://dx.doi.org/10.15585/mmwr.mm7145a1. Accessed 7/31/23.

Spoth R, Redmond C, Shin C, et al. PROSPER delivery of universal preventive interventions with young adolescents: long-term effects on emerging adult substance misuse and associated risk behaviors. Psychological medicine. 2017 Oct;47(13):2246-59.

Spoth R, Redmond C, Shin C, et al. Applying the PROSPER prevention delivery system with middle schools: Emerging adulthood effects on substance misuse and conduct problem behaviors through 14 years past baseline. Child development. 2022 Jul;93(4):925-40.

Substance Abuse and Mental Health Services Administration (SAMHSA). Community Engagement: An Essential Component of an Effective and Equitable Substance Use Prevention System. SAMHSA Publication No. PEP22-06-01-005. Rockville, MD: National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental Health Services Administration, 2022.

Substance Abuse and Mental Health Services Administration: Engaging Community Coalitions to Decrease Opioid Overdose Deaths Practice Guide. Rockville, MD: National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental Health Services Administration, 2023.

Toumbourou JW, Rowland B, Williams J, et al. Community Intervention to Prevent Adolescent Health Behavior Problems: Evaluation of Communities That Care in Australia. Health Psychology. 2019; vol. 38, no. 6: 536-544.

U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington (DC): HHS, 2016.

Wolfson M, Champion H, McCoy TP, et al. Impact of a Randomized Campus/Community Trial to Prevent High-Risk Drinking Among College Students. Alcoholism: Clinical and Experimental Research. 2012; vol. 36, no. 10: 1767-1778.