Prevention materials can play a key role in the fight against alcohol, tobacco, and other drug problems. A well-executed campaign can foster an environment where dangerous drug-related behavior is widely recognized as unacceptable. An a young person who might otherwise have been inclined to begin using alcohol, tobacco, or other drugs might lose that inclination if he or she is fully informed about the dangers of alcohol, tobacco, and other drug use and addiction. But sometimes prevention materials fail to achieve the desired response because the intended audience either misinterprets or ignores the prevention message. Poorly executed campaigns may even stimulate dangerous drug-related behavior or offend the target audience, thus ensuring that no prevention message will be heard. In order to achieve their goals, developers of prevention materials must do all that they can to ensure that their products are clear, based on solid scientific findings, and relevant to the intended audience.

The Center for Substance Abuse Prevention (CSAP) in the Substance Abuse and Mental Health Services Administration (SAMHSA) has reviewed thousands of products intended to prevent alcohol, tobacco, and other drug abuse and found several unacceptable messages -- messages that are open to misinterpretation, messages that are not adequately supported by scientific research, and messages that fail to address the real concern of, or appeal to, the intended audience.

In order to eliminate the chance for misinterpretation of prevention messages, and to ensure that messages actually reach their intended audiences, CSAP has developed public health principles, and scienfitic and communications guidelines. These principles and guidelines form the basis of CSAP's evaluation of all prevention materials. These principles and guidelines are first and foremost based on the major tenet of "Do no harm." Prevention workers are urged to use these principles and guidelines when screening or developing materials for use in Federal, State, or local prevention programs.

The purpose of this bulletin is to help developers of prevention materials avoid those messages that may do more harm than good. The bulletin focuses on the principles and guidelines with which prevention programmers most often fail to comply.

Make the Message Clear

Prevention materials sometimes contain subtle messages that run counter to the intent of the prevention program. An individual who is inclined to smoke, abuse alcohol, or use other drugs is likely to look for any justification for his or her behavior. That individual may misinterpret a prevention message in order to find that justification. This section provides examples both of mixed messages and of clear messages. The examples of mixed messages are derived -- although not directly quoted -- from materials reviewed by CSAP. Some of these messages may be interpreted to condone what is actually unwise or unsafe behavior. Some of the examples of clear messages may have a familiar ring. These are adapted from national campaigns that have received CSAP approval. Others are also taken from materials submitted by CSAP grantees. These examples are provided to illustrate the clear, positive communication that CSAP is seeking to promote as well as the mixed communication CSAP is seeking to avoid.

Public Health Principle:

Make it clear that illegal and unwise drug use is unhealthy and harmful for all

In an attempt to be "even handed" or "realistic," may prevention materials acknowledge (either directly or indirectly) illegal drug use as a "fact of life." Even though the ultimate intention may be to prevent this kind of behavior, this acknowledgment will be read by some to mean that such drug use is "normal." All prevention materials should take a clear stand against:

• The use of any legally prohibited drug

• The use of a drug for a purpose other than its prescribed use

• The use of any product or substance that can produce a drug-like effect

• The use of any legal drug, including alcohol or tobacco, by individuals legally underage for its use

• The illegal or unwise use of a legal drug.

• "While some people may be able to use a 'soft,' mood-altering drug like marijuana for occasional recreational purposes without any apparent ill effects, no individual can be sure that he or she will not have a negative response to a such drug."

• "Any substance, in and of itself, is neither good nor bad. It is only the improper use, misuse, or abuse of substances that is bad."

Note that these mixed messages imply that some illegal drug use may be "safe" even though they are intended to discourage drug use.

• "It is unlawful to produce, distribute, or purchase cocaine under any circumstances."

• "Even substances that are not prohibited by law can harm your health if they are used improperly."

• "It is not only unhealthy to allow your teenager to smoke cigarettes, but it's also against the law."

Public Health Principle:

Give a clear message that "risk" is associated with using any form or amount of alcohol, tobacco, or other drugs.

Even though alcohol consumption and tobacco use are legal for individuals who are 21 or older, this does not mean that these practices have no adverse consequences. Even small amounts of alcohol, tobacco, and other drugs increase injury or health risks.

• "The alcoholic content of beer and wine is not as high as that of hard liquors like whiskey or vodka."

• "Many people use alcohol in social settings to relax and to celebrate special occasions. There is nothing wrong with social drinking as long as one stays within moderation and does not drive after drinking."

• "The alcohol content of one bottle of beer is the same as that of a martini or a shot of whiskey."

• "Alcohol is a drug. And like any drug, it will affect your judgement and your physical coordination, even when taken in small amounts. Another danger of alcohol is that it can be addicting."

Note that euphemistic terms like "mood-altering drug" or "recreational use" should be replaced with more accurate terms like "mind-altering."

Public Health Principle:

When targeting persons under 21 years of age, pregnant women, recovering alcoholics, or persons taking prescription or nonprescription drugs, give a clear message of no alcohol use.

Many prevention materials aimed at youth stress the importance of learning to make wise decisions. But these materials stop short of giving all the information that would help the teenager make the wise decision of abstinence from alcohol or other drug use. Materials often fail to mention that alcohol consumption by anyone under 21 years of age is illegal. Materials that urge moderation in alcohol use for pregnant women fail to take into account recent research that reveals that even small amounts of alcohol will increase the risk of birth defects.

• "Part of growing up is learning how to make wise decisions. If you choose to drink, drink responsibly. Don't overdo it. And don't drink and drive."

• "You owe it to yourself and your unborn child to be informed about drinking during pregnancy and to avoid excessive or abusive drinking."

These mixed messages do not contain any incorrect information. But they fail to give the clear "no use" message that should be sent to all underage individuals, pregnant women, recovering alcoholics and drug addicts, and individuals using prescription or nonprescription medications.

Furthermore, materials should clearly state that pregnant women should consult their physician before buying any new medication, refilling a prescription, or taking medication on hand for common ailments, such as headaches and colds.

Common over-the-counter drugs that should be avoided by pregnant women without first consulting their physicians include antacids, nasal sprays, nose drops, aspirin, laxatives, and vitamins.

Likewise, commonly prescribed drugs that can be dangerous to the fetus include antibiotics, antihistamines, vaccinations, antimigraines, tranquilizers, antinauseants, sedatives, diuretics, or hormones (e.g., oral contraceptives).

Materials must state clearly that these and other drugs should only be used by pregnant women on the advice of their physicians or other medical practitioners.

• "Part of growing up is learning how to make wise decisions. You should know that if you choose to drink before you are 21, you are breaking the law."

• "The U.S. Surgeon General says that 'the safest choice is not to drink at all during pregnancy or if you are planning pregnancy.'"

Public Health Principle:

Materials targeting youth should not use recovering addicts or alcoholics as role models.

A number of celebrities who have had problems with alcohol or other drugs are eager to use their celebrity status to help others. But the message the celebrity intends to convey may not be the message that teenagers and preteens receive. While the celebrity may be saying, "Don't do it," the youth are hearing, "I did it, and I'm okay now. Taking drugs is part of being famous."

• "I was stupid to do drugs. I almost threw away my whole career. But now that I'm off drugs, I've been able to turn out hit records just like I used to."

• "Taking drugs lessens your chance of succeeding at whatever career you would choose to pursue. Drugs close the doors of opportunity."

An exception may be made for role models who clearly show that they have been negatively affected by the use of alcohol, tobacco, and other drugs, such as someone now visibly disabled or injured as a result of alcohol, tobacco, and other drug use.

Public Health Principle:

Do not unintentionally glamorize or glorify the use of alcohol, tobacco, and other drugs.

In the effort to be informative about drugs, many prevention materials detail the effects the drug has on the user. Even though most prevention materials focus on the negative effects, even a brief description of a drug's positive or euphoric effects might attract a potential user.

• "Alcohol helps many people relax or be more sociable at parties."

• "Jeremy giggled a lot when he smoked marijuana because the drug made him think that everything was funny."

• "Several crack addicts have compared the sensation they derive from the drug to sexual orgasm."

• "Alcohol impairs the drinker's speech, coordination, and judgement."

• "Even more cancer-causing agents are found in marijuana smoke than in tobaco smoke."

• "People who snort cocaine frequently develop nasal problems, including holes in the cartilage separating the nostrils."

Public Health Principle:

Do not include illustrations or dramatizations that could teach people ways to prepare, obtain, or ingest illegal drugs.

Many prevention materials use photographs or illustrations of illegal drugs or drug paraphernalia as graphic fillers. Illustrations of drugs or drug paraphernalia should be used only when they serve a specific purpose (e.g., helping parents to recognize signs of drug use by children.) Materials intended to warn against drugs may inadvertently teach someone how to use drugs. Furthermore, scenes of people injecting drugs, sniffing cocaine, or drinking alcohol may stimulate the behavior. These are best portrayed as implied actions. For example, someone representing a drug user might be shown with his or her back toward the camera so that only a general suggestion of drug use is presented. Prevention materials should avoid representing any details of the procedures of drug use. A powerful craving for cocaine has been found to be very common for all cocaine addicts and can be easily triggered by the sight of this drug and by objects, people, paraphernalia, places, and emotions associated in the addict's mind with this drug.

Public Health Principle:

Do not "blame the victim."

Addiction is an illness. Therefore, materials should focus on preventing and treating the disease and not on berating the individual. When you use negative terms to describe an addict, you may be sending the message that the individual is not worth helping. Do not use insulting terms about the victims of alcohol, tobacco, or other drug abuse. Likewise, do not focus on an individual's shortcomings as a reason for use or addiction. This does not imply that a person should not take responsibility for his or her alcohol, tobacco, and other drug problems, whether related to addiction, dependence, or unwise use. Encourage the person to take responsibility for seeking help if alcohol, tobacco, and other drug problems continue or if dependence is suspected.

• "Only losers take drugs."

• "Stay away from pot heads and dope fiends."

• "Some people start taking drugs as a form of escape because they do not have the courage to face their problems."

• "Be smart. Don't start."

• "If you have problems with alcohol, tobacco, or other drugs, you can get help. But YOU have to take the first step."

Materials that encourage individuals to seek help should include information about organizations or agencies where help is available.

Public Health Principle:

State that abstinence is a viable choice.

In a culture that is conditioned to treat any ailment with a drug, it may not occur to some individuals that they have the option of not taking a drug at all. Be careful to avoid implying that the only solution for a headache is an over-the-counter analgesic or that the only way to celebrate a special event is with an alcohol beverage toast. In fact, prevention materials should strongly recommend alternatives to drug-reliant behaviors. Materials that focus on reducing or limiting the amount of alcohol, tobacco, or other drug taken send a mixed message if they do not include total abstinence as another viable choice.

• "If you want to teach your children to be responsible with alcohol, be a responsible drinker yourself."

• "It's find to relax with a beer at the end of a hard day. But know your limit."

• "In most cases, curing insomnia requires nothing stronger than the sleeping pills you can buy at your local grocery store."

• "If you want to teach your children to be responsible with alcohol, show them that you can abstain from alcohol and still have good time."

• "It's fine to relax with a beer at the end of a hard day. But you don't need a beer to relax."

• "If you have trouble getting to sleep, do not assume that finding the right pill to take is the solution. A change in your nighttime routine might be just as effective."

This last message in no way implies that valid medical attention, including appropriate drugs, should be withheld from anyone for any reason.

Make the Message Accurate

In addiction to being clear, prevention messages must be accurate and based on solid evidence derived from the latest scientific research. Unjustified claims can undermine the credibility of a prevention message. Furthermore, outdated information may fail to contain important findings. For example, as more is learned about Fetal Alcohol Syndrome (FAS), the clearer it becomes that abstinence from alcohol is the wisest course for pregnant women. But in the 1970's, it was common for medical officials to recommend only that women limit their consumption of alcohol. It was even suggested in some materials that as much as two drinks a day was a safe level of alcohol consumption for pregnant women.

Scientific Guideline:

Be sure your message is scientifically significant, based on valid assumptions, accurately referenced, and appropriately used.

If you are working from hypotheses, theories, or models but not from statistically significant, conclusive, and replicated research, be especially careful that your assumptions will not increase drug use and that application will not result in misperception or other harm.

For example, if you are reporting that research has not yet conclusively proven a link between a drug and a suspected health hazard, be very careful not to imply that the drug has been proven harmless. Promoters of some substance (e.g., the tobacco industry) have use a "lack of conclusive scientific evidence" as an argument against restrictions imposed on their products. As the FAS example demonstrates, prevention materials should make it clear that a lack of conclusive evidence is grounds for greater caution rather than for lighter restrictions.

Occasionally, CSAP reviewers find statements that have no apparent scientific base. An example is a course purporting that men required 10 to 12 years to develop the disease of alcoholism while women required half that long and teenagers "only 6 months." These statements may be a misapplication of a sound scientific study, but the reader has no way of discovering the mistake because no source is cited in the course materials. These statements are dangerous not only because of their inaccuracy and their lack of referencing, but also because they may encourage irresponsible use of alcohol. While the statements are clearly intended to demonstrate how easily a teenager may be trapped by alcohol, the statements inappropriately suggest that adults, especially adult men, are relatively immune to the disease for a long period of time. Such a statement clearly violates the tenet of "Do no harm."

If you are presenting information derived from scientific research, be certain that the information is adequately referenced and appropriately applied to the issue at hand. Many prevention materials give relevant information but fail to identify the source of that information. While some readers may be convinced that a statement is true simply because it appears in print, others demand and deserve to know the source of the findings that are being presented. If evidence is derived from sound scientific experiments conducted by respected individuals at reputable institutions, citing the source of the evidence can only help to make the prevention message more convincing.

Make the Message Relevant

Even though your message is clear and accurate, it will serve no purpose if your intended audience ignores the message. In order to reach their targets, prevention messages must be relevant. That is, they must appeal to the values and interests of the audience.

Prevention messages must be cast in a language and at a level of diction that is understood by the audience. However, prevention workers should be careful when attempting to use the dialect or slang that is associated with the target audience. Such attempts may be perceived as inauthentic and condescending. Furthermore, imitations of a group's dialect may reinforce negative stereotypes.

Public Health Principle:

Check for cultural and ethnic biases and sensitivity.

Many of the negative stereotypes associated with minority groups involve perceptions of their alcohol- or other drug-related behaviors. Prevention materials that address alcohol, tobacco, and other drug abuse problems within a specific minority should avoid reinforcing those negative stereotypes. Information about any group's pattern of alcohol, tobacco, or other drug use should be presented objectively -- and based only on scientific and demographic research findings.

Presenting role models from a targeted minority can be an effective means of appealing to that audience. But program developers should avoid limiting their chosen spokespersons to minority athletes and entertainers. Community leaders, teachers, doctors, lawyers, educators, military personnel, writers, parents, and many others can help to demonstrate the variety of opportunities open to minority youth.

Prevention messages must reflect the cultural norms of the audience. It is not enough simply to include images of an ethnic or economic group in the prevention materials. Be sure to reflect the social, economic, and familial norms and symbols of your audience as well as their physical appearance. For example, groups are more important than individuals among some populations; spiritual symbols are important among others. You may also want to reflect such cultural factors as the importance of the extended family, the key role of grandparents, and religion.

Always be extremely careful that you do not inject any of your own biases that could perpetuate a myth or stereotype about a group of people. For example, do not portray everything good with white symbols and everything bad with dark symbols. And don't show only males being arrested for alcohol-impaired driving.

A campaign aimed at any group should communicate that the message sender cares about the well-being of the audience. If a campaign aimed at a specific ethnic group contains negative stereotypes of that group or fails to include any positive symbols of the audience's culture, the audience will receive the mixed message that you are insensitive to their needs. The intention may be to say "We want to help you." But what is being said is "We don't care enough about you to learn anything about your culture."

The best way to ensure that prevention materials will appeal to their intended audience is to involve members of the targeted cultural or ethnic group in the planning and development processes. If your organization does not already include members of the targeted group, people with knowledge of the intended audience should be sought out to provide input at an early stage.

Furthermore, all materials should be pretested before they are widely distributed. Pretesting may include the use of focus groups or individual interviews with representatives of the targeted cultural or ethnic group. Questions asked during pretesting should be designed to reveal whether the audience understands the central message of your product, whether the audience believes the message and the message giver, and whether the audience finds the message personally relevant.

Pretesting may not guarantee the success of a campaign. But it should identify any mistakes that could guarantee its failure. Pretesting can identify the barriers to communication that often keep prevention messages from reaching those who need them most.

Communication Guidelines:

Prevention messages should include appeals that the target audience will perceive as personally relevant.

The producers of prevention messages may strive to keep teens from becoming addicted to drugs or facing other risks, including injuries or health problems. Yet teens who perceive themselves to be immortal may turn off messages that emphasize effects they don't believe they are at risk for. Rather, appeals should be based on something that teens value or consider important, such as peer pressure or looking good and feeling good.

Communication Guideline:

Prevention messages should inform the reader of the seriousness of the problem, persuade the reader of the need for change, and engage the reader with a call for action.

Messages should make the reader aware of the need for change, the need for further information, or the seriousness of alcohol, tobacco, and other drug problems. Materials must not preach but rather find positive appeals that engage and motivate the target audience. And finally, materials must present a desired behavior so the message is not merely negative. Positive actions called for in prevention materials might include seeking treatment, calling a referral number, confronting a drug-using spouse or friend, or joining a parent group.

Communication Guideline:

Do all you can to make your product professional and attractive in appearance. Gear the format (type, size, layout, style) to your target audience.

You do not have to use high-cost techniques to reflect high productions quality. For example, although people generally do pay more attention to materials that use color, black, white materials can be very appealing. Use screens to achieve various shades of gray; box in some copy; use photographs, figures, and bullets.

When developing publications or other products relying on the written word, use white space generously to keep the text from becoming dense and the heading and photo captions to impart essential information. In addiction, use a large typeface for materials that will be read by young children, people with low literacy level, or the elderly.

Audiovisual materials should offer clear and understandable sound and visual quality.

Finally, the style of the product should be appropriate to the audience. For example, teens may find some cartoons "babyish." Some Hispanics may be attracted to fotonovellas. MTV-style videos may appeal to teens and be incomprehensible to their parents.