Summary and recommendations:

1. The purpose of this report is to look at prevention from an environmental perspective and on that basis make recommendations which will continue to contribute and strengthen the many ongoing efforts at drug prevention now being made in this country at a national and local level. It is the individual who is the ultimate agent who does or does not make the personal decision to misuse drugs and their capacity to make sensible and healthy choices will be weakened or supported by the world which surrounds them.

4. When setting up drug prevention policies consideration will often need at the same time to given to the place of alcohol, tobacco and volatile substances in the scheme of things. Drug prevention policies which ignore licit drugs lack credibility.

5. Family, school, work and leisure environments, and peer group influences are part of the environment. So too are cultural beliefs, expectations and attitudes.

8. Cannabis is the drug which has been most used. The total number to have ever taken cannabis is about 7 million.

9. The use of tobacco, alcohol and solvents are predictors of the later use of illicit drugs.

49. When it comes to drug misuse and values we think there is a complexity which must not be overlooked. Some values may appear insulting and unattainable for some people. The aim should be to adopt practices and foster an environment which enables individuals to attain the values which make them a part of society.

50. If society intends to provide young people with an environment which helps them not to take illicit drugs, or to reduce the harms which they do, the climate of awareness and beliefs on alcohol and tobacco must be seen as part of that context.

58. We question whether it is sensible to confine drug prevention messages to the health consequences of taking drugs. We give some examples of other approaches, involving social unacceptability, which might be considered.

91. In accordance with ACMD's report on Police, Drug Misusers and the Community (1994) action against drugs markets should be taken in the wider context of community safety.

93. Any intervention directed at a market will lead to benefits and harms which should as far as possible be foreseen and always evaluated.

94. Not to take action against blatant dealing must have a symbolic importance which should not be disregarded. It suggests a "don't care" attitude which can only affect the climate of beliefs adversely.

105. Deprivation is today in Britain likely often to make a significant causal contribution to the cause, complications and intractability of damaging kinds of drug misuse.

112. We want now and in the future to see deprivation given its full and proper place in all considerations of drug prevention policy, at both local and strategic levels, and not let slip from sight.

118. Drug misuse is a problem with linked personal and social origins. Our contention in this report is that while the individual has personal responsibility for healthy decision making, there is a social responsibility to construct and keep in repair a social, psychological and physical environment surround which supports the individual's capacity to stay away from drug misuse and the harms of drug misuse and helps them pull out of damaging drug misuse.

Chapter 1: aims of the report

1.12 ACMD's prevention approach is concerned with the totality of drugs covered by the Misuse of Drugs Act (and has also embraced volatile substance abuse). When setting up drug prevention policies consideration will often need at the same time to given to the place of alcohol and tobacco in the scheme of things. By way of analogy in its report on drug education in schools ACMD (1993) took the view that health education should embrace use of both licit and illicit substances.

1.13 Prevention should be concerned to relieve the harm done not only to the drug misuser him or herself but to other people besides. Such harm may for instance be done to the family who are bearing the brunt of a young person's behaviour, to the children of adult drug misusers, to the person's sexual partner whom the drug misuser infects with hepatitis or HIV, to the victim of drug-related crime, or to the community at large by damage to comfort and amenities.

1.17 The environment can encourage or oppose drug use partly through greater or lesser physical access to drugs, the presence of drug markets and knowledge of them, the number of dealers and the level of enforcement. In addition, the environment comprises prevalent, normative attitudes towards drugs which make these drugs more or less attractive and acceptable to the individual.

Chapter 2: The nature and extent of illicit drug use in the UK

2.27 In focusing attention upon young people it is important to also look at the use of tobacco, alcohol, and solvents, since early use of these drugs has been shown to predict later use of illicit drugs. A survey of 758 schoolchildren aged between 11 to 16 in Dundee, Scotland, found that just over half (52.6%) had ever smoked.

2.28 In the Dundee study 43.7% of schoolchildren reported having been drunk in the past. Most recently there has been concern over the availability of a number of alcoholic drinks, which in aspects of their marketing, and in some cases their sweet taste, may appeal particularly to young people - these drinks include a variety of white ciders and fruit wines. It has been shown that many of these drinks are being widely consumed by those under 16.

2.29 Over 6% of deaths of 15-16 year olds in 1991 were attributable to solvents.

2.30 Over 40% of 15 and 16 year olds report past experience of having used an illicit drug.

2.45 In 1995 there were a total of 602 deaths attributable to drug dependence.

2.64 Drug use or misuse is not, however, the same as drug dependence. Our best estimate of the extent of drug dependence in England and Wales in 1992 places that figure in the region of three quarters of a million people; our best estimate of the number of people who have ever used cannabis in England and Wales places the figure in the region of 6.5 million people. The difference between these figures gives some indication of the fact that use of an illegal drug does not lead inevitably to drug dependence.

2.67 Is the blanket term "drug misuse" really satisfactory for the policy analysis? ... we would like to see greater investment in studies which determine, partition and quantitatively estimate the relative contributions made to the causes of any type or intensity of drug misuse by, say, environmental factors, personal factors and the drugs supply and availability of drugs.

Chapter 3: Environmental factors and drug misuse

3.6 Access to any substance is a fundamental and necessary requirement of an individual's external environment. Where licit drugs such as alcohol and tobacco are concerned, access can be significantly influenced by such factors as price, taxation, licensing regulations, etc.

3.7 Access to illicit drugs is most likely at the initial stage to be provided by friends. This is well-researched and well-evidenced. In the light of the decisive role of friendship networks in disseminating drugs, it is difficult to conceive of any effective form of conventionally conceived drug enforcement policy to control access at this level - quite simply, how might one be expected to police friendship?

3.10 Drug choices will be influenced as much by fashion as by pharmacology, and fashions can and do change.

3.15 For drug use to continue beyond experimentation, access to the substance must be maintained. Moreover, it must be maintained at an 'effective price', that is not only in terms of monetary price but also in terms of costs such as 'search time' and other potential forms of inconvenience. Raising the effective price (particularly in terms of search time) is potentially one of the most useful ways of erecting barriers between initiation and regular use.

3.16 Another form of non-monetary 'cost' to the individual would be if the form of drug consumption contemplated or undertaken were to be highly socially stigmatised or to be associated with highly stigmatised groups of people or other socially stigmatised experiences.

3.17 A review of environmental influences will necessarily lean in the direction of an emphasis on the role of friendship networks; neighbourhood and family life; the ways in which drugs are found to be compatible or incompatible with daily routines and lifestyle; whether or not an effective means of access to the drug can be maintained or is regarded as desirable; the extent to which drug use is condoned or stigmatised within a person's social circle. And none of this is to contradict the fact that different drugs are in a pharmacological sense different, with differing properties for reward and reinforcement.

3.30 Drinking [alcohol] is a dominant feature of European and North American cultures.

3.34 The emphasis on friendship as 'peer pressure' reflects a major difficulty in so much of the social discourse around drug-related issues - namely the absence of any notion of volition or desire. Health education discourses in particular have often been cleansed of any reference to the possibility that people might use drugs because they find them pleasurable. Reflecting the same tendency to view the drug user as a passive victim of circumstance, there is a constant resort to the use of the term 'pusher' which does not accurately describe the dynamics of consensual drug markets, or to the alleged involvement of foreign and alien influences in drug-dealing networks.

3.40 Low levels of bonding to the conventional social order (i.e. involvement with family and school, and attachment to conventional norms and aspirations) did not in themselves predict either delinquency or drug use. However, where there was both involvement with delinquent peers and a low level of conventional bonding, this was highly predictive - even when controlling for prior involvement in delinquency or drugs.

3.45 High levels of parental monitoring could discourage both boys and girls from beginning to use drugs, help reduce levels of consumption among heavy using boys, and encourage girl experimenters to quit. Once young people had begun to use drugs, however, peer influences seemed more influential than parental behaviour.

3.47 Some North American research has noted an association between modest cannabis and/or cocaine use and increased productivity levels and wages levels.

3.54 Britain first came to experience widespread and serious problems of drug misuse amidst the economic downturn of the early 1980s which devastated the local economies of many industrial working class communities.

3.62 It is commonly assumed that drug misuse causes crime although research has repeatedly demonstrated that a person's involvement in crime often precedes their involvement in drugs.

3.64 The vast research effort on the still disputed drugs-crime connection in the USA, conducted over more than thirty years and including some highly sophisticated methodological work, suggests that questions of causality should be regarded as difficulties and confusions to be lived with rather than resolved.

Chapter 4: Current community-based drug prevention strategies: evidence and review

4.62 The ultimate aim must always be to assess the impact of drugs prevention programmes on drug use.

4.64 While the overall conclusion must therefore be that we know very little for sure, there are nevertheless strong suggestions from the research of the types of approaches that are likely to prove most useful. Given the way that drug use (both legal drug use and perhaps increasingly, illicit drug use) are part of our culture, there has been a growing awareness of the need to tackle drug use in a multi-faceted, community-focused manner.

Chapter 5: Local drug projects and local preventive action

Chapter 6: Drug prevention and the environment of awareness and beliefs

What people and communities believe about drugs is as much part of the environment as is the physical surround. We argue that attitudes to tobacco and alcohol are part of this context of ideas and that DATs should consider the merit of dealing with all substances together. The media as well as intentional health education are among the factors which shape the relevant climate.

6.1 The choices people make about drugs, or anything else, are governed by awareness and beliefs - what they feel about something.

6.2 Our thesis is that how people value themselves, whether they think they can control their destiny, how they think they fit in with society and so on will influence whether they take drugs.

6.4 It is very difficult to say how values of an individual are formed ... but the greater influence probably comes from family and friends and to some extent from the society in which the individual lives.

6.5 We think it is a reasonable expectation on the part of the individual that he or she should not be excluded from being a neighbour, having respect of others and respecting themself - that is, being part of society. Those who feel let down by society and see no means of improving their lot may well feel that society has one set of values for the well off and one for them. They would regard it as insulting if you suggested they should aspire to those general values.

6.6 Some values may appear insulting and unattainable for some people. On the other hand we think that at a general level values remain important as a touchstone of a civilised society. The aim should be to adopt practises and foster an environment which enables individuals to attain the values which make them a part of society.

6.7 It is not society's role to dictate what an individual's beliefs should be but we do believe that the environment of awareness and beliefs should be sufficiently strong to enable an individual to make healthy and informed choices. In this chapter in common with previous ACMD reports we have adopted the word "misuse" to cover harmful and experimental, or occasional use, unless the context makes it plain otherwise rather than adopt the convention of regarding harmful taking as "misuse" and other taking as "use".

6.9 We see awareness and beliefs operating at several levels, or in different layers.

6.10 First there is the layer of what the large society around us believes. Its beliefs are not uniform but contradictory and varied. Some parts want to see drug misusers punished rather than treated while other parts would like to see drugs legalised, arguing that resultant crime would reduce. And there are sections of society which regard their drug taking as use rather than misuse - that is, as a normal and not anti-social activity. Parliament and policy makers' views will be at odds with some part of society's but it will be theirs which at the official level will prevail. Second, there is the layer of neighbourhood. Third, there is the layer of the family. And fourthly, there are the beliefs of individuals themselves.

6.11 This report is only concerned with United Kingdom society, but the United Kingdom is not isolated from the rest of the world and is inevitably influenced in its attitudes and beliefs towards drugs by the international community. This is well illustrated by the United Nations Drugs Conventions which control certain drugs and to which the United Kingdom and many other countries are signatories. It is from these Conventions that the UK laws on drugs derive, and these, of course, set the tone and the embodiment of society's attitude toward drug misuse.

6.12 it is society at large, with policy makers as its agents, who determine how the misuse of drugs should be regarded. There will be conflicts of ideas within society and those ideas are likely to vary with time.

6.13 We believe that there are steps which can be taken to change, to some extent, society's larger "awareness and beliefs" environment in the cause of drug prevention.

6.14 It is sometimes suggested that drug taking in this country is a normalised activity. That as a general proposition is misleading. Nationally among young people (16-29) around 45% have taken a prohibited drug some time in their lives.

6.15 For many young people alcohol, tobacco and illicit drugs inhabit one and the same world rather than constituting separate domains. The possible influence of their illicit drug-taking behaviour which is exerted by the climate of ideas on licit drugs needs therefore to be considered. The majority of people who have used illicit drugs have previously used tobacco and alcohol. Alcohol and cigarette smoking have been found to be the most powerful predictors of marijuana use.

6.20 Alcohol is as much a "dance drug" as ecstasy or amphetamines. Young people live in a society which heavily advertises alcohol and tobacco, and where they are readily and lawfully accessible, and the advertising of 'alcopops' has on occasion seemingly been targeted at young people and has at times veered towards open encouragement of drunkenness. To establish causal connections between use of one type of psychoactive substance and another is notoriously difficult, but our conclusion is that if society intends to provide young people which an environment which helps them not to take illicit drugs (or to abuse volatile substances), or to reduce the harms which they do, the climate of awareness and beliefs on alcohol and tobacco must be seen as part of the context.

6.21 To reduce illicit drug misuse we believe that individuals need to be engaged in the decisions which they take. By this we mean that individuals need to feel there is a purpose to the decisions which they take and that they are realisable. The aim is for society to alter the climate in which those decisions are made so as to make the misuse of drugs less acceptable and thus influence individuals away from them. That climate is more likely to be engendered where people are truly informed, not just of the facts but also the values - valuing themselves, valuing the community and valuing other people. In recent years drinking and driving has become much less acceptable than it was which we see as an interesting parallel in terms of change of attitude with what we are proposing should be the aim of society's attitude toward drug misuse.

6.33 Young people, while being part of larger society, belong to a society of their own. Their attitudes on drugs are quite likely to be at variance with older people's and generally less condemnatory. They are more likely than adults to regard drugs as an accepted part of life even if they do not misuse them themselves.

6.42 Sport is also very much part of young people's existence and there is a ready acceptance of alcohol consumption with some sports and indeed prominent sponsorship of some sports by drinks companies. This very open acceptance of alcohol is part of the wider drugs, alcohol and tobacco context to which we referred in paragraph 6.20. The bodies which are responsible for governing them have anti-drug policies, which cover bot psychoactive drugs and performance enhancing drugs such as anabolic steroids, but reports of drug-taking among sportsmen still appear. Sometimes the offender is sacked and other times he is taken back into the fold on the basis that he will undertake treatment and become abstinent - there is an inconsistency in these two approaches which the young may find difficult to make sense of.

6.44 In short, young people live in a society which acknowledges and accepts drugs to some extent, a state of affairs which arises from environmental factors.

6.54 Continued attempts need to be made with more emphasis being put on distinguishing between non-users, misusers and polydrug users, and even between problematic and non-problematic misusers. Given the links between drug misuse and alcohol consumption, pubs, off-licences, clubs and the like would appear to be obvious locations for targeting.

6.59 The credibility of messages is enormously important if the awareness and beliefs of individuals are going to be influenced. Another aspect of the messages which we should like to mention is the balance to be struck between the desired feelings generated by taking the drug and the undesirable health consequences. For those who misuse the drug in question and know its effects absence of any mention of the desirable effects is likely to reduce the credibility of the whole message.

6.61 We live in a society which makes the production, supply and possession of these substances unlawful on the basis that they cause social problems so why shouldn't the messages also say that drug taking is socially unacceptable as well as unhealthy? Any drug transaction involves illegality and is not subject to the safeguards which apply to most consumer goods and you cannot be sure what you're getting.

6.68 Also significant at the local level is the attitude which is taken toward the use of alcohol. It is part of the spectrum of misused substances.

6.76 Most families, most of the time, will act as bulwarks against drug misuse. They achieve this through the parents adopting an approach which includes listening and responding to their children, acting consistently, defining boundaries and supervising them well. Conversely, harsh and erratic discipline, parental conflict, and lack of parental interest or time, will tend to work the other way.

6.81 The young person today is in a society where the acceptability of the use of drugs and the availability of them has changed markedly in recent years.

Chapter 7: Drug prevention and housing

Chapter 8: Drug markets

The existence within some communities of open, concentrated drug markets may both facilitate dissemination of drugs and become a public nuisance. We believe that it is in the public interest to take planned action against such markets.

8.8 Occasional users may be deterred from use if search costs are high. The "price" paid for any drug includes not just the money which changes hands but also the time taken to find a supplier, the risk of being ripped off, the risk of poor quality drugs and the risk of being caught by the police.

8.13 The ability of drug users to purchase and how much they can purchase of a particular drug will depend on: price; price of substitutes; availability of income; search or other costs.

8.14 Even where the price change is small it may nonetheless have an effect on consumption.

8.18 Any intervention directed at a market should, in assessing the overall outcome, take account of the fact that markets respond to change quickly and sometimes unexpectedly. The intervention will lead to benefits and harms which should as far as possible be foreseen and always evaluated. Complete elimination of an established market is probably an unrealistic aim.

8.19 Intervening at the point of production or some other point of major transaction unfortunately now seems to have little, if any, effect on the drugs market. That is not to say that we think it is useless intervening at these points - such actions are necessary in order to stop the market mushrooming.

8.26 There can be no sympathy for regular dealers primarily motivated by financial gain.

8.29 In deciding what can be done care will need to be taken to ensure that there are no unacceptable consequences.

8.34 In relation to pubs we are aware that the licenced trade has, with assistance fom the police, taken steps to reduce dealing on their premises. Broad approaches in partnership, of the sort which these pub schemes exemplify, seem to us to be the right way to tackle drug dealing in semi-public places.

Chapter 9: Drugs and social deprivation

Deprivation is significantly and causally related to problematic drug misuse.

9.4 The experience of deprivation may have within it a number of constituents such as poverty, inadequate housing, educational disadvantage, and lack of job opportunities. Unemployment and low or relatively low income are often key factors.

9.5 It is important to realise that what we are talking about here is a condition which at the same time will often exist as a potent, corrosive, subjective and personal experience. The mix of feelings are likely to include worthlessness and a sense of failure, powerless and the feeling of not being in control, alienation and apathy and loss of any role as stakeholder, the sense of lacking any hope of a personal way out or up and of there being no better future in sight for one's children.

9.6 There is evidence to show that it is sometimes relative rather than absolute deprivation which is associated with adverse health consequences: people feel bad about themselves when they feel disadvantaged in comparison to others.

9.8 In Britain between 1982 and 1996, there was a rise from 10% to 19% in those whose income was at a level below half the national mean. The poorest fifth of the British population have less spending power than equivalent strata in other major Western countries. Poverty levels in Britain had been decreasing up to the early 1980s, but since then we are the only major Western nation to have experienced a significant increase in poverty.

9.19 At the beginning of the 1990s, cigarette smoking had in this country become a strongly class-related drug behaviour. The less privileged have thus far found it significantly more difficult to give up smoking than have the more privileged sectors. Cigarettes in Britain are moving toward becoming a poverty drug. Alcohol consumption in Britain is greater among the richer than among the poorer segments of society.

9.24 A recent ecological study of cocaine and opiate overdose in New York City over the years 1990-1992 showed that poverty accounted for 69% of the variance in overdose mortality rates.

9.25 Alcohol was undoubtedly in this country the major substance problem for [the 19th] century and there is vivid contemporary testimony as to the appaling social consequences of slum drinking which were embedded in social deprivation of an extent and intensity which is today fortunately long since gone.

9.28 The evidence is persuasive that major drug problems during the 1980s became increasingly associated with social disadvantage.

9.32 Although VSA [volatile substance abuse] is not covered by the Misuse of Drugs Act, ACMD has taken the position that VSA is an integral part of the national drug problem and has published a report which deals specifically with this topic.

9.37 An analysis of persons admitted to hospital for drug-related emergencies ... found a very strong correlation across postcode sectors between rates for drug related and alcohol related admissions (correlation coefficient 0.94 or p less than 0.001).

9.43 Drug use per se probably shows a different relationship with deprivation than VSA related deaths, problematic use which has reached clinical significance or dependence.

9.45 Deprivation relates statistically to types and intensities of drug use which are problematic.

9.47 Deprivation gives rise to personal distress and psychological discomfort of a kind which can result in depressive illness as well as lesser and more amorphous types of mood disturbance. In such circumstances mind-acting drugs (including illicit drugs) can be used as self-medication to relieve distress or as a substitute source of excitement and good feelings.

9.54 What we are suggesting here is fully in accord with more general policies on inequalities in health and with wider health service concern with targeting areas of social need.

9.58 When macro-level social and economic policies significantly fail and social deprivation, structural unemployment and poverty become rife, one of the prices which will have to be paid is the added cost and tragedy of deprivation-related drug misuse.

Chapter 10: The resources available to support community action on prevention

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