Intervention Overlap

No single intervention has been demonstrated to reduce the problem of alcohol-impaired driving by more than 17 percent. Therefore, a far more important concern than the best single intervention to implement is the best package of interventions to apply. Understanding how interventions overlap is key to selecting that package.

Interventions that largely address different aspects of the problem are good candidates for combined implementation. For example, if one intervention reduces the risk of drivers below the minimum legal drinking age, while a second reduces the risk of hardcore repeat offenders whose licenses previously were revoked due to impaired driving, implementing both together will yield the full benefits that both have to offer. But if provisional licensing with a midnight curfew for new drivers offers an 11 percent reduction in substance-related crashes in this age group, and zero tolerance for alcohol for drivers below the legal minimum drinking age offers a 40 percent reduction, the two interventions combined may offer only a 46.6 percent reduction (40% + 11%) (100% – 40%) among young drivers.

6.2 Future Directions

Clearly, the ability to conduct cost-outcome analyses of substance abuse prevention efforts has improved. Although this report evaluated a wide range of interventions, it was

challenging because of the difficulties in determining program costs. It was often unclear how many youth would be targeted, and estimates of some costs were not readily available (methamphetamine use, club drug use, and college drinking). These difficulties prevented an accurate analysis of the return on investment in programs targeting those behaviors. In the future, evaluative research priorities may include (1) tracking long-term outcomes beyond a 2-year period, (2) examining the impact of delaying initiation on the seriousness and

consequences of future use, (3) performing replications to refine estimates of effectiveness from youth interventions that presently have been evaluated with only a single randomized

controlled trial, and (4) developing, implementing, and reporting on interventions that drive costs.

7. Conclusion

If effective prevention programs were implemented nationwide, substance abuse initiation would decline for 1.5 million youth and be delayed for 2 years on average. In 2003, an estimated:

8 percent fewer youth ages 13–15 would not have engaged in binge drinking 11.5 percent fewer youth would not have used marijuana

45.8 percent fewer youth would not have used cocaine 10.7 percent fewer youth would not have smoked regularly

The average effective school-based program costs $220 per pupil. It would save an estimated $18 per $1 invested if implemented nationwide. Nationwide school-based effective

programming in 2002 would have had the following fiscal impact:

Saved State and local governments $1.3 billion, including $1.05 billion in educational costs during 2003 and 2004

Reduced social costs of substance-abuse–related medical care, other resources, and lost productivity over a lifetime by an estimated $33.5 billion

Preserved the quality of life over a lifetime valued at $65 billion

These cost-benefit estimates show that effective school-based programs pay for themselves and more. For every dollar spent on these programs, an average of $18 dollars per student would be saved over their lifetime.

Among 10 effective school-based life skills programs, the average return on investment exceeded $15 to 1. That is, every dollar spent on these programs returned an average of $15 dollars per student. The probable costs and cost savings involved in implementing a

composite of these programs for middle school youth ages 12–14 nationwide were estimated. The average program would delay more than a million initiations of alcohol, cocaine,

marijuana, or tobacco use by youth for an average of 2 years. Its cost would be $220 per pupil.29

The out-of-pocket expenses would be repaid by savings to the education system alone in less than 2 years. The program would offer additional savings to State and local governments by reducing spending on Medicaid, police, and other criminal justice services. School-based ___________________________

29_{Added expenses for program materials and teacher training would average $53 per pupil with the value of teacher time} diverted from other instruction accounting for the remaining cost.

programs that offer a particularly large return on investment include All Stars, Family Matters, Keepin’ It Real, Life Skills Training, and Project Northland. Although Project TND and STARS for Families yielded lesser returns than competing NREPP programs, they still yielded $4 in savings per $1 invested.

Programs designed to strengthen families generally cost more than the school-based life skills programs. Several of them also were highly cost-beneficial and offered much larger returns in the aggregate per youth served than the school-based life skills programs. In a program targeting families with low income, intensive home visitation, coupled with preschool enrichment, reduced infant/toddler abuse (Aos et al., 1999; Karoly et al., 1998). As these toddlers reach adolescence and adulthood, visitation programs also can reduce a range of problems including substance abuse and violence. However, the net returns are often realized in the long term (for actual longitudinal cost-benefit results see Karoly, et al., 1998; Schweinhart, et al., 1993).

The proven interventions often cover different aspects of the problem (such as youth drug use initiation, impaired driving, and violence), which make a complementary set of interventions more beneficial. Several interventions are best directed toward different aspects of the problem. If they are massed against the same aspect, the size of that aspect will shrink, and the return on added interventions will decline below the levels shown in this study.

Taken as a whole, the benefits of substance abuse prevention well outweigh the costs of providing that service. Cost-benefit ratios can guide the selection of an optimal intervention package within the available resources. Political feasibility, cultural and demographic differences, and local priorities also must be considered.

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9.

Appendix: Methods

This section explains how published benefit-cost ratios estimates were adjusted for 86 youth development or youth substance abuse prevention programs and related strategies (see Table A1). Program costs for the youth programs occasionally came from the literature, but for this report, they were usually modeled largely from educational statistics and CSAP summaries of costs for training and materials and teacher time requirements (Western Center for the Application of Prevention Technologies [Western CAPT], 2005), or similar summaries from Maryland Blueprints (Maryland Governor’s Office of Crime Control and Prevention [MD GOCCP], 2005). Estimates of program effectiveness were derived from three meta-analyses (Aos et al., 2004; Hansen et al., 2004; Hopkins et al., 2001). Table A2 lists the estimates used and their sources.

All individually targeted substance abuse prevention programs with available estimates of effectiveness in Aos and colleagues’ 2004 study were analyzed, as were the subset from Hansen and associates’ 2004 study. The estimates applied a modified version of the benefits valuation model in Caulkins et al. (2002) as refined by Miller and Hendrie (2005). It further adjusted the model for consistency with the methods used in the existing cost-savings analyses and used effect sizes from the meta-analysis as inputs in place of the estimates of effectiveness in percentages used by Caulkins and colleagues (2002). The remainder of this appendix lists the major assumptions and discusses the cost-benefit estimation processes.

9.1 Assumptions

This report made the following assumptions:

Estimates of effectiveness from Table 4 apply to U.S. youth ages 12–14 (9.483 million).

The impact was reduced by 25 percent to account for reduced intervention effectiveness as one scales up from controlled demonstrations to full field implementation

(Aos et al., 1999; Greenwood et al., 1996; Miller & Levy, 2000).

Youth would not be participating in effective family/community-based prevention programs.

Benefits apply to youth who actually participated in effective school-based substance abuse prevention programs in 2002.

Costs or benefits were determined by estimates from Table 4, and ratios from the 2003 YRBS of (1) current to lifetime users by substance, (2) binge drinkers during the past month to lifetime drinkers, and (3) youth smoking on at least 20 of the past 30 days to lifetime.

Substance abuse costs decline in proportion to delays in initiation as a result of prevention programming.

Total costs equal the monetary costs plus the value of pain, suffering, and loss in quality of life. Estimates are the product of the costs in Table 1 and the percentages in Table 3. Benefits accrue over a multiyear period, and future costs can be converted to present value using a 3 percent discount rate.

Costs from substance abuse among youth decline at the same rate as the number of those who initiate abuse.

Savings from existing school-based programs are included in these estimates. 9.2 Cost Estimation

Program costs include materials costs, training costs, and labor costs to deliver the intervention. Because costs rarely are fully documented, estimating them was the most difficult analytic step. Moreover, some estimates are approximations of the order of magnitude.

Training costs are included to comply with accepted cost-outcome analysis guidelines (Gold et al., 1996; Haddix et al., 2003). Without teacher training, school-based prevention

programming cannot be delivered with fidelity and is unlikely to be fully effective. Many prevention programs will not sell their materials to schools unless their teachers have been trained in the proper use of the materials. Therefore, training costs (including travel to