Preventing Substance Abuse in American Indian and Alaska Native Youth:
Promising Strategies for Healthier Communities
Elizabeth H. Hawkins
University of Washington
Lillian H. Cummins
Alliant International University
G. Alan Marlatt
University of Washington
Substance abuse has had profoundly devastating effects on the health and well-being of American Indians
and Alaska Natives. A wide variety of intervention methods has been used to prevent or stem the
development of alcohol and drug problems in Indian youth, but there is little empirical research
evaluating these efforts. This article is an overview of the published literature on substance use
prevention among Indian adolescents, providing background epidemiological information, a review of
programs developed specifically for Indian adolescents, and recommendations for the most promising
prevention strategies currently in practice.
Substance abuse, particularly alcohol misuse, is consistently
cited as one of the most critical health concerns facing American
Indian and Alaska Native communities (Beauvais, 1996; French,
2000; Indian Health Service, 1977; King, Beals, Manson, &
Trimble, 1992; Mail, Heurtin-Roberts, Martin, & Howard, 2002;
U.S. Department of Health and Human Services, 2001; Young,
1988). It has had profoundly harmful consequences on both indi-
vidual and societal levels, and it is widely believed that few Indian
families remain unaffected, either directly or indirectly. The his-
torical and political context surrounding alcohol use among Amer-
ican Indians and Alaska Natives is far too complex to address in
the scope of this article (see E. H. Hawkins & Blume, 2002, for a
more in-depth discussion of this topic). Although many commu-
nities have experienced social and cultural devastation that can be
directly attributed to alcohol use, it is essential to note the large
variance in actual rates of alcohol use and related problems expe-
rienced in Indian Country. Alcohol has and continues to be dam-
aging to Native communities, yet there is a sizeable population of
Native Americans who do not drink or who are nonproblem
drinkers (Mail & Johnson, 1993; Myers, Kagawa-Singer, Kuma-
nyika, Lex, & Markides, 1995). Although some degree of alcohol
use is extremely common among American Indian youth, often it
is not the first substance used or the primary drug of choice
(Beauvais, Oetting, Wolf, & Edwards, 1989; Novins, Beals, &
This article is intended as an overview of the published literature
on substance use prevention among American Indian adolescents,
focusing on the most widely used drugs: tobacco, inhalants, alco-
hol, and marijuana. Because research focusing on Native Ameri-
cans has had relatively little representation in mainstream psycho-
logical journals, the field as a whole is largely unaware of many
salient issues. For this reason, this article focuses exclusively on
this underserved and often at-risk population. Information on other
ethnic groups is presented when it is useful for making relevant
comparisons or providing context in terms of the general alcohol
and substance use literature. It may appear that some of the
research focusing on Native populations presented in this review is
outdated or lacks comprehensiveness. However, it is important to
bear in mind that this reflects the current state of the published
research literature, emphasizing the need for more attention and
resources to be directed toward the Native community.
The article is organized into three sections. The first section
provides an introduction to the American Indian/Alaska Native
population and background information on prevalence rates, pat-
terns and consequences of use, and risk and protective factors for
the substances most commonly used by Indian youth. In the second
section, the published prevention outcome research literature
found in the MEDLINE and PsycINFO databases is reviewed, and
Elizabeth H. Hawkins and G. Alan Marlatt, Addictive Behaviors Re-
search Center, Department of Psychology, University of Washington;
Lillian H. Cummins, California School of Professional Psychology, Alliant
Elizabeth H. Hawkins is now also at the One Sky National Resource
Center for American Indian/Alaska Native Substance Abuse Services,
Department of Psychiatry, Oregon Health and Science University, Port-
Preparation of this article was supported in part by the National Institute
on Alcohol Abuse and Alcoholism (NIAAA) Grant 1 R0 1 AA12321-02,
Intervention for Adolescent Indian Drinking, and NIAAA Institutional
Research Training Grant T32AA07455.
We wish to acknowledge our colleagues at the Seattle Indian Health
Board and the Addictive Behaviors Research Center for their support and
encouragement and to thank the participants of the Journeys of the Circle
project for the inspiration and motivation they provided us. This article is
humbly offered in support of Native youth everywhere as they strive to
make healthy lifestyle choices.
Correspondence concerning this article should be addressed to Elizabeth
H. Hawkins, Addictive Behaviors Research Center, Department of Psy-
chology, Box 351525, University of Washington, Seattle, WA 98195-
1525. E-mail: firstname.lastname@example.org
2004, Vol. 130, No. 2, 304–323
Copyright 2004 by the American Psychological Association, Inc.
selected programs that were developed specifically to reduce sub-
stance use among Indian adolescents are described. In the last
section, recommendations are offered for the most promising pre-
vention strategies currently in practice, and a recently developed
substance abuse prevention program for urban Indian adolescents
that incorporates these recommendations is introduced.
Substance Use and Abuse Among American Indian and
Alaska Native Adolescents
Brief Introduction to Native Populations
According to U.S. population estimates, there are 2.5 million
people who report their sole race to be American Indian/Alaska
Native, and 4.1 million people who report being American Indian/
Alaska Native in combination with one or more other races (U.S.
Census Bureau, 2001b). American Indians are an incredibly di-
verse group, currently representing 562 federally recognized tribal
nations and Alaska Native villages and corporations that range in
membership from less than 100 to more than 350,000 (Bureau of
Indian Affairs, 2002). There are additional tribes recognized only
by individual states, and numerous tribes, bands, and American
Indian villages that are not formally recognized by the federal
government for political reasons. Federally recognized Native
American tribes are located in 35 states within 10 distinct cultural
areas. More than 200 tribal languages are currently spoken (Flem-
A common stereotype depicts Native Americans as residing on
remote reservations, well removed from the rest of America. In
reality, the majority (63%) live in urban areas, and only 22% of
Native Americans live on reservations and tribal trust lands (U.S.
Census Bureau, 1993). The American Indian population is a young
one, with a median age of 28.0, 34% being under 18 years old. In
contrast, the median age for the overall U.S. population is 35.3,
with 26% younger than 18 (U.S. Census Bureau, 2001a). About
10,000 American Indian and Alaska Native children today attend
federal boarding schools. First started in the 1870s as a method of
forcibly assimilating Indians into American society, the aim of
boarding schools was to systematically “kill the Indian, save the
man” (Richard Pratt, founder of the first off-reservation boarding
school in 1879, as cited in Kelley, 1999, section 3, para. 1).
Intergenerational historical trauma and grief has been the result.
The mission of federal Indian boarding schools has greatly
changed, and 52 remain open today (44 on reservations and 8 in
Although some similarities and commonalities among Native
American groups do exist, there is significant heterogeneity among
communities and individuals according to tribal-specific factors;
degree of Indian ancestry or blood quantum; residential pattern;
and cultural affiliation, identity, and participation. When consid-
ering the issue of substance use and misuse, it is important to take
into consideration the diversity of American Indians and Alaska
Natives and the implications it has for the development and im-
plementation of prevention efforts.
Although the official terminology as set by the federal govern-
ment’s Office of Management and Budget dictates that this col-
lective group be referred to as American Indian/Alaska Native
(Robbin, 2000), it is common practice to also use the terms
American Indian, Indian, Native American, and Native. Most
generally, these terms are used to identify American Indians and/or
Alaska Natives. In contrast, when Alaska Native is used alone, it
generally refers only to Indians of that region. In this article, these
terms are used interchangeably, but every effort is made to distin-
guish between regional and cultural groups when appropriate. In
working with Indians, community confidentiality is often consid-
ered equal in importance to the protection provided to individuals.
Therefore, in most instances individual tribes and communities are
not specifically referenced, and instead more general terms are
Prevalence of Substance Use
Large-scale national surveys provide comprehensive epidemio-
logical data on alcohol, tobacco, and illicit drug use trends among
youth. However, because of small sample sizes, they often do not
include analyses of substance use patterns for American Indians.
Fortunately, though, much is known about trends in Indian ado-
lescent drug use because of research from three main sources. The
first is school-based surveys conducted by the Tri-Ethnic Center
for Prevention Research at Colorado State University (http://
triethniccenter.colostate.edu). For more than 25 years, these anon-
ymous surveys have been administered annually to a nationally
representative sample of 7th through 12th graders living on or near
reservations. Each year more than 2,000 youth respond to ques-
tions about their drug use, risk and protective factors, violence, and
victimization. The second source of information comes from an
examination of data from the Monitoring the Future (MTF)
project, which has been in existence since 1975 (www
.monitoringthefuture.org). Almost 45,000 adolescents and young
adults from more than 400 schools across the country annually
complete a survey about their substance use and related attitudes
and beliefs. Wallace et al. (2002) analyzed data collected between
1996 and 2000 from approximately 64,000 high school seniors,
thus sufficiently increasing the sample size of Native Americans to
perform analyses of substance use trends. The last source includes
reports that combine multiple years of data from the Substance
Abuse and Mental Health Services Administration’s (SAMHSA)
National Household Survey on Drug Abuse (NHSDA; www
.drugabusestatistics.samhsa.gov). The NHSDA is designed to pro-
vide drug use estimates for all 50 states plus the District of
Columbia over a 5-year sampling period. Every year the NHSDA
is administered as an in-person interview to more than 68,000
people who are representative of the civilian, noninstitutionalized
U.S. population age 12 or older.
Using these three national databases, plus supplementary re-
search where available, prevalence data are reviewed for the sub-
stances most commonly used by American Indian and Alaska
Native youth across the country, namely tobacco, inhalants, alco-
hol, and marijuana.
Tobacco is one of the most frequently used drugs by Native
youth. According to data for 12–17-year-olds from the last avail-
able NHSDA, 27.5% of American Indians/Alaska Natives were
current smokers, compared with 16.0% of Whites, 10.2% of Lati-
nos, 8.4% of Asian Americans, and 6.1% of African Americans
(SAMHSA, Office of Applied Studies, 2002). A study using MTF
PREVENTING SUBSTANCE ABUSE IN INDIAN YOUTH
data (Wallace et al., 2002) reported that among 12th graders, the
30-day prevalence of cigarette smoking for American Indians is
46.1%, as compared to 34.3% for the overall population. Native
American 12th graders also have the highest rate of smoking half
a pack or more of cigarettes a day, at 17.1% versus an overall total
rate of 12.7% (Wallace et al., 2002).
LeMaster, Connell, Mitchell, and Manson (2002) used data from
the Voices of Indian Teens Project to determine the prevalence of
cigarette and smokeless tobacco use among Native adolescents.
Their sample consisted of 2,390 youth ages 13 to 20 attending high
schools in five Indian communities west of the Mississippi. Ap-
proximately 50% of the youth reported having smoked cigarettes,
with 30% smoking “once in a while.” Slightly less than 3% (2.8%)
reported smoking 11 or more cigarettes a week, and only 1.2% said
that they smoked a pack or more a day. The lifetime prevalence of
smokeless tobacco use was 21%, with 3.6% reporting use 4–6
days a week and 6.7% reporting use every day.
Inhalants are commonly among the first substances used by
Indian youth, often preceding the use of alcohol (Beauvais et al.,
1989). Beauvais (1992a) reported that Indian youth living on
reservations had higher lifetime inhalant use rates than did Indian
youth not living on reservations or White youth. Among 8th
graders, 34% of reservation Indians reported lifetime inhalant use,
compared with 20% for nonreservation Indians and 13% for
Whites. The 12th graders surveyed reported lifetime use rates of
20% for reservation Indians, 15% for nonreservation Indians, and
10% for Whites. Reservation Indians in the 8th grade also had the
highest rates of 30-day inhalant use (15%), followed by nonreser-
vation Indians (8%), and Whites (5%). Among 12th graders,
nonreservation Indians had the highest rate (3%), with reservation
Indian and White students using at the same rate (2%).
Native youth living apart from their families in boarding schools
were also found to have extremely high prevalence rates, with 44%
of students reporting that they had used inhalants (Okwumabua &
Duryea, 1987). In contrast, a study conducted with urban Ameri-
can Indian adolescents found that 12.3% of the youth surveyed
reported some lifetime inhalant use (Howard, Walker, Silk Walker,
Cottler, & Compton, 1999).
MTF survey data reviewed by Wallace et al. (2002) revealed
that American Indian 12th graders had the highest past-year prev-
alence rate for inhalant use at 9.4%, as compared with 12th graders
of all other ethnic groups combined at 6.6%. The 30-day preva-
lence rate was also higher than all but one other ethnic group at
4.3%, in contrast to an all-ethnic groups rate of 2.4% (Cuban
Americans were the only group with a higher 30-day prevalence,
Estimates of the prevalence of alcohol use among American
Indian adolescents vary significantly. On the basis of national data
of American Indian students collected from 1975 to 1994, Beau-
vais (1996) reported that 15% of Native youth had consumed
alcohol or used drugs at least once by the age of 12, 62% had been
intoxicated at least once by age 15, and 71% of 7th through 12th
graders had used alcohol during their lifetime. May (1986) re-
ported that approximately one third of Native Americans had tried
alcohol by 11 years of age. This latter rate is substantiated by
another study, which found that 44% of 4th and 5th graders
surveyed in the Pacific Northwest and Oklahoma (mean age ?
10.3 years) had tried alcohol (Moncher, Holden, & Trimble, 1990).
Among American Indian boarding school students, the lifetime
prevalence rate of alcohol use was found to be 93%, with 53% of
these considered to be at risk for serious alcohol abuse (Dinges &
Duong-Tran, 1993). A longitudinal study following urban Amer-
ican Indian adolescents in Seattle showed that at Year 5 (mean
age ? 15.8 years) 41.5% of the youth reported having drunk
alcohol to the point of intoxication (Walker et al., 1996).
Beauvais (1992a) compared drinking rates for reservation Indi-
ans, nonreservation Indians, and White students in the 8th and 12th
grades. Nonreservation Indian 8th graders were more likely to
report lifetime alcohol use (80%) than reservation Indian (70%) or
White (73%) 8th graders. However, lifetime prevalence rates for
12th graders were highly comparable among these three groups.
Reservation Indians in both the 8th and 12th grades were most
likely to report having been drunk in their lifetime (49% of 8th
graders, 87% of 12th graders), followed by nonreservation Indians
(42% and 76%) and Whites (27% and 73%). A similar pattern was
found for the 30-day prevalence of having been drunk, with 8th
and 12th graders on reservations having the highest rate, followed
by nonreservation Indians, and then Whites.
In 1998 the National Institute on Drug Abuse reported slightly
higher rates of alcohol use for American Indian youth as compared
with youth from other ethnic groups. They reported that 93% of
American Indian and 87% of non-American Indian high school
seniors had tried alcohol during their lifetime. The rates for past-
month use were 56% and 51%, respectively. More recently, Wal-
lace et al. (2002) reported a past-year alcohol use prevalence of
76.5% and a 30-day prevalence of 55.1% for American Indian 12th
graders, rates similar to other ethnic groups. In comparison to all
other ethnic groups combined, however, American Indian students
had the highest rate of daily alcohol use (6.1% vs. 3.5%) and were
the group most likely to have consumed five drinks or more in a
row in the previous 2 weeks (37.0% vs. 30.8%).
Marijuana use is also significantly higher among American
Indian and Alaska Native adolescents than other groups. Beauvais
(1996) found that nearly 50% of Indian students in the 7th through
12th grades reported having used marijuana on at least one occa-
sion. In another study (Beauvais, 1992a) he found that of the 8th
graders surveyed, 47% of reservation Indians, 26% of nonreser-
vation Indians, and 13% of Whites reported lifetime marijuana use.
For 8th graders, 30-day prevalence was also highest for reservation
youth (23%), followed by nonreservation (10%) and White youth
(5%). Twelfth-grade adolescents living on reservations had higher
lifetime (77%) and 30-day (33%) rates of use than did nonreser-
vation Indian (58% and 21%) and White students (38% and 13%).
Data from the MTF surveys (Wallace et al., 2002) also show
that American Indian teens had the highest annual (45.3%) and
30-day (29.6%) marijuana prevalence rates as compared with teens
of other ethnic groups. In addition, they were more likely than
teens of other ethnic groups to use on a regular basis. Almost 10%
HAWKINS, CUMMINS, AND MARLATT
of Indian 12th graders said that they use marijuana daily, compared
with 5.4% of the total 12th grade population.
A study using data from the Voices of Indian Teens Project
sampled 9th to 12th graders in seven predominantly American
Indian schools in four western communities. Using a total sample
size of 1,464 youth, Novins and Mitchell (1998) found that 55.7%
of Native teens reported using marijuana at least once during their
lifetime, and 40.0% had used marijuana in the past month. Among
those adolescents who had used marijuana in the past month,
42.5% reported using 1 to 3 times, 27.5% reported using 4 to 10
times, and 30.0% said that they had used 11 or more times.
Epidemiological research indicates a high level of normative
adolescent substance use. However, it suggests that much of this
use is experimental or episodic in nature, with only a small
minority of adolescents qualifying as heavy users. Within the
Native American population, youth tend to initiate substance use at
a younger age, continue use after initial experimentation, and have
higher rates of polysubstance use (Beauvais, 1992a; U.S. Con-
gress, Office of Technology Assessment [OTA], 1990). Substance
initiation in Indian communities typically occurs between the ages
of 10 and 13, with the onset for some individuals beginning as
early as 5 or 6 years of age (Beauvais, 1996; Okwumabua &
The stage, or gateway, theory has been proposed to explain the
progression of adolescent drug involvement (Golub & Johnson,
1994; Kandel & Faust, 1975; Kandel & Yamaguchi, 1993; Kandel,
Yamaguchi, & Chen, 1992; Weinberg, Radhert, Colliver, &
Glantz, 1998). This theory postulates that for most individuals,
initiation of drug use follows a specific sequence: (a) legal sub-
stances, such as tobacco and alcohol; (b) marijuana; (c) other illicit
drugs; (d) cocaine; and (e) crack. However, an adolescent’s use of
substances at one stage does not necessarily mean that he or she
will move on to the next stage. The applicability of stage theory to
American Indian and Alaska Native adolescents has been ques-
tioned. One study found that among American Indian youth (ages
9–15) living in South Carolina, the use of alcohol predicted
subsequent use of tobacco and illicit drugs, similar to what might
be expected given the stage theory (Federman, Costello, Angold,
Farmer, & Erkanli, 1997). However, Novins et al. (2001) found
that among users of both alcohol and marijuana, approximately
35% reported using alcohol first, whereas 35% reported using
marijuana first. Further, these researchers found that 75% of ado-
lescents using substances from three or more classes reported
patterns of use inconsistent with stage theory. They recommend
that a modification which categorizes substances as initiating
(tobacco, alcohol, inhalants, marijuana) or heavy (other illicit
drugs) more accurately and appropriately captures the drug use
trends of Indian youth.
Patterns of Substance Use
According to the Diagnostic and Statistical Manual of Mental
Disorders (American Psychiatric Association, 2000), substance
abuse is characterized by a maladaptive pattern of use leading to
recurrent and significant impairment or distress. For example,
criteria for alcohol abuse include problems at work or school due
to drinking, or repeatedly driving while intoxicated. Substance
dependence is a more severe disorder and is additionally marked
by the development of tolerance or withdrawal symptomatology
(American Psychiatric Association, 2000). Terms such as addic-
tion or alcoholism generally refer to substance dependence
Whereas diagnostic criteria for adults are clearly defined, there
is less standardization for the diagnosis of substance use disorders
in adolescents. To a large extent, this is the result of significant
developmental, physiological, and social differences between adult
and adolescent substance use and misuse. For example, research
indicates that young people drink less frequently than adults but
that they tend to consume larger amounts when they do drink
(Oetting & Beauvais, 1989; White & LaBouvie, 1989). Among
youth, drinking and drug use is more likely to be associated with
“partying.” This pattern decreases the likelihood that substance-
abusing youth will experience tolerance or withdrawal symptoms,
which are necessary criteria for a diagnosis of substance
May (1996) reported that both American Indian youth and
adults frequently consume large amounts of alcohol in a short
period of time, a style often referred to as binge drinking (com-
monly defined as five or more drinks in a row for males and four
or more drinks in a row for females; Wechsler, Lee, Kuo, & Lee,
2000). Beauvais (1992c) has observed two distinct types of drink-
ers among American Indian adolescents. He reported that approx-
imately 20% of American Indian youth in the 7th through 12th
grades begin heavily using alcohol and other drugs at an early age
and continue this use into adulthood. These adolescents are at high
risk for lifelong problems with alcohol abuse and dependence. The
second type of drinker, which is also estimated to account for 20%
of American Indian youth, uses alcohol socially and recreationally.
Drinking for this group is often experimental in nature and highly
dependent on the environment. This pattern is less likely to lead to
It has been noted that in addition to using alcohol and other
drugs at high rates, American Indian and Alaska Native youth
often tend to use in ways different from other adolescent groups.
Numerous studies have examined gender and regional or cultural
differences. However, research findings often contradict one an-
other, highlighting the complexities of making general statements
about this very heterogeneous group.
Within the general adolescent population, boys usually have
higher rates of drug use, particularly higher rates of frequent use,
than do girls. In particular, they tend to have higher rates of heavy
drinking, smokeless tobacco use, and steroid use (Johnston,
O’Malley, & Bachman, 2002). From his research using school-
based surveys, Beauvais (1992c) reported that there does not
appear to be a significant difference in alcohol use rates between
American Indian adolescent boys and girls. Furthermore, it has
been reported that American Indian male and female adolescents
experience drinking problems at equally high rates (Beauvais,
1992c; Cockerham, 1975; Oetting & Beauvais, 1989), and in a
sample of urban Native youth, gender may not have influenced
which youth abused alcohol (Walker, 1992).
PREVENTING SUBSTANCE ABUSE IN INDIAN YOUTH
The NHSDA found no significant gender differences in ciga-
rette smoking rates for American Indians and Alaska Natives, in
contrast to data for other ethnic/racial groups which indicated that
smoking rates were higher for female than male adolescents
(SAMHSA, Office of Applied Studies, 2002). Similarly, LeMaster
et al. (2002) found no gender differences in the rate of cigarette use
but did find a significant difference in the use of smokeless
tobacco between American Indian male and female adolescents
(27% and 15%, respectively).
Inhalant use was roughly equal among boys and girls surveyed
in the Voices of Indian Teens project (May & Del Vecchio, 1997).
However, it was suggested that this might differ on the basis of the
age of the participants sampled. A survey conducted with boarding
school students showed that boys tended to begin experimenting
with inhalants earlier than did girls. The peak period of risk for
inhalant use for boys was between 10 and 11 years of age, whereas
for girls it was between 12 and 13 years (Okwumabua & Duryea,
Novins and Mitchell (1998) reported that although there were no
gender differences at low frequency of marijuana use, defined as
using one to three times in the past month, boys were significantly
more likely to use marijuana at a high frequency, defined as using
11 or more times in the past month (odds ratio ? 2.37, 99%
confidence interval ? 1.52, 3.69). Further, it was found that low
frequency marijuana use among girls was indicative of a more
severe pattern of substance use than was low frequency use among
boys. For both boys and girls, more frequent marijuana use was
associated with the increased use of other illicit drugs as well
(Novins & Mitchell, 1998).
Regional and Tribal Differences
Although tribal differences have been noted in rates of adult
drinking (Levy & Kunitz, 1971; May, 1996; Silk-Walker, Walker,
& Kivlahan, 1988), Indian adolescents appear to use alcohol at
similar levels regardless of tribe (Beauvais, 1998). However, other
factors do appear to affect drinking patterns. Higher levels of
alcohol use have been found among youth who live on reservations
(Beauvais, 1992a), youth who attend boarding schools (Dick,
Manson, & Beals, 1993), and youth who drop out of school
(Beauvais, Chavez, Oetting, Deffenbacher, & Cornell, 1996). Sim-
ilarly, inhalant use seems to be more prevalent among youth living
on reservations or in other rural areas due to the low cost, easy
availability, and the difficulties of obtaining other substances.
A study that compared Alaska Native and American Indian
youth found that Native adolescents living in Alaska were almost
twice as likely to smoke on a daily basis (Blum, Harmon, Harris,
Bergeisen, & Resnick, 1992). SAMHSA’s Office of Applied Stud-
ies (2002) reported a regional difference in cigarette smoking
rates: For other racial/ethnic groups, adolescents living in the
South are more likely to smoke than their peers in the western
United States. This difference is nonexistent among American
Indians, with youth in the southern and western regions of the
United States smoking at approximately the same rate (SAMHSA,
Office of Applied Studies, 2002). On the other hand, a study that
surveyed students in seven predominantly American Indian high
schools west of the Mississippi River found differences in the
prevalence of marijuana use based on tribe; however, tribal mem-
bership stopped being a predictor when other covariates (such as
past month alcohol use and report of having peers that encouraged
alcohol use) were entered into the regression equations (Novins &
Consequences and Correlates of Substance Use
Research shows that although American Indian teens may have
lifetime alcohol use rates similar to non-American Indian teens,
they tend to drink more frequently and to consume alcohol in
larger quantities when they do drink. In addition, they are more
likely to have tried tobacco, inhalants, and marijuana, and to use
these substances on a regular basis. Furthermore, the age at which
American Indian youth initiate substance use tends to be younger
than what is found in other groups. These trends are likely to
significantly impact the development of American Indian adoles-
cents by interfering with the learning of age-appropriate behaviors
and skills (Bentler, 1992). In addition, these trends place them at
increased risk for participating in potentially dangerous behaviors
and for experiencing acute negative consequences of use (May,
1982). Substance-abusing youth have a greater likelihood of suf-
fering social and interpersonal consequences because of their vi-
olation of parental, societal, and legal norms.
Although most teenage substance use is believed to “mature
out” (Kandel & Logan, 1984; Mitchell, Novins, & Holmes, 1999),
early onset of substance use and problem drinking has been linked
to a multitude of negative outcomes. Adolescent alcohol use is
associated with a wide range of high-risk behaviors, such as
driving while drinking (Beauvais, 1992b), delinquency and run-
ning away (U.S. Congress, OTA, 1990; Zitzow, 1990), and un-
protected sexual activity (Rolf, Nansel, Baldwin, Johnson, & Be-
nally, 2002). It is also associated with psychiatric distress,
including concerns such as depression, conduct disorder, and sui-
cide (Dinges & Duong-Tran, 1993; Grossman, Milligan, & Deyo,
1991; Manson, Shore, & Bloom, 1985; May, 1987; Nelson, Mc-
Coy, Stetter, & Vanderwagen, 1992; O’Nell, 1992–1993; U.S.
Congress, OTA, 1990); academic difficulties (Beauvais, 1996;
U.S. Congress, OTA, 1990); and later problems with substance
abuse (J. D. Hawkins et al., 1997; May & Moran, 1995).
Substance misuse is directly implicated in the disproportionately
high morbidity and mortality rates found among American Indian
teens. American Indian youth (ages 15 to 24 years) have an
all-cause mortality rate 2.1 times higher than that of the general
population (196.5 vs. 95.3 per 100,000 population) and 2.3 times
higher than that of Whites, the group with the lowest rate (196.5
vs. 84.3 per 100,000 population; Indian Health Service, Office of
Public Health, Program Statistics Team, 1999). Of the 10 leading
causes of death for American Indian adolescents, at least 3 are
related to heavy use of alcohol: accidents, suicide, and homicide
(Indian Health Service, Office of Public Health, Program Statistics
Team, 1999). In addition, the alcoholism death rate for Native
youth served by Indian Health Services was 11.3 times higher than
the combined all-races rate (Indian Health Service, Office of
Public Health, Program Statistics Team, 1999). This statistic does
not include alcohol-related deaths due to accidents, suicide, or
Research suggests that the etiologic influences of American
Indian adolescent substance use are similar to those found for other
HAWKINS, CUMMINS, AND MARLATT
ethnic groups. Higher levels of alcohol and drug use among
American Indian youth can be attributed to poverty and extremely
poor social conditions that have exposed them to significantly
more risk factors, which may directly or indirectly lead to more
alcohol and drug use (Beauvais & LaBoueff, 1985). Life stress is
a demonstrated risk factor for substance use (Dick et al., 1993;
King et al., 1992; King & Thayer, 1993; LeMaster et al., 2002;
Wills, McNamara, Vaccaro, & Hirky, 1997), and adolescence is a
period of time when stress pertaining to social, physical, cognitive,
and academic growth is enhanced (Dick et al., 1993). As a result,
youth are particularly vulnerable to developing potentially harmful
methods of coping with stressors that arise within themselves, their
immediate environment, or their cultural milieu.
Factors rooted within an individual, such as beliefs and atti-
tudes, tendency to engage in risk behaviors, and psychological
distress, contribute to increased rates of adolescent substance use.
Among American Indian teens, the perception that substance use is
an indicator of adulthood has been suggested as an explanation for
an increased tendency to use (Schinke et al., 1985). Similarly,
positive expectancies of alcohol’s effects were predictive of higher
rates of alcohol problems among urban American Indian teens
(E. H. Hawkins, 2002).
High-risk behaviors and psychological distress potentially serve
as both risk factors for and consequences of substance use. Inhal-
ant users in a sample of urban American Indian youth exhibited
higher rates of lifetime conduct disorder and alcohol dependence,
more aggressive behavior, more sensation seeking, greater nega-
tive emotionality, and lower perceived self-worth than did nonus-
ers (Howard et al., 1999). In another study, distressing life events
of death and loss were linked to increased use of cigarettes and
smokeless tobacco (LeMaster et al., 2002).
Environmental contexts (including community, family, and peer
variables) have great impact on the development of substance use
and misuse among American Indian and Alaska Native adoles-
cents. These sources of primary socialization directly and indi-
rectly communicate social norms and values. The community,
which includes elders, schools, law enforcement, and health agen-
cies, among other institutions, plays a vital role in the transmission
of what is considered acceptable substance use behavior (Oetting
& Donnermeyer, 1998). Youth learn which actions are tolerated or
even sanctioned, as well as the consequences for engaging in
behavior that falls outside the community’s norms.
Likewise, the family conveys powerful messages to youth re-
garding substance use. Adult models of substance abuse (LeMaster
et al., 2002; Weibel-Orlando, 1984) and lack of clear-cut familial
sanctions against substance abuse (Oetting, Beauvais, & Edwards,
1988) are associated with increased rates of use among youth.
Some researchers have noted that drinking within families may be
one way of maintaining a sense of cohesion and solidarity (O’Nell,
1992–1993; Spicer, 1997). Studies have also suggested that a lack
of stability in the home (Garcia-Mason, 1985) and disorientation
within family relationships (Albaugh & Albaugh, 1979) are risk
factors for substance use.
During adolescence, peer influences may be as or more impor-
tant than family variables in the development of substance use
problems. Participation in positive peer clusters is less likely to
lead to deviant behaviors, whereas antisocial peer associations and
pressures can serve as risk factors for substance use (Oetting,
Swaim, Edwards, & Beauvais, 1989).
Cultural epidemiologists have suggested that the stresses of
forced acculturation, urbanization, and cultural disruption have
increased the vulnerability of American Indian youth for develop-
ing psychological problems (Beauvais & LaBoueff, 1985; Kem-
nitzer, 1973; Spindler & Spindler, 1978). Among American Indi-
ans and Alaska Natives there is a historical and generational
trauma that underlies this risk (see Brave Heart & DeBruyn, 1998,
for a comprehensive discussion of historical trauma and grief).
Many Indian communities share similar experiences of warfare
and colonization, coercive methods of assimilation, loss of tradi-
tional land and customs, boarding school educations and abuses,
longstanding struggles to maintain treaty rights, poverty, and high
rates of unemployment and disease. These factors, plus many more
that are tribe or community specific, are often viewed as risk
factors for substance use, as tobacco, alcohol, and other drug use
may offer a method of coping with these stressors.
Specific cultural factors that have been associated with in-
creased substance use include ethnic dislocation (May, 1982; Oet-
ting, Beauvais, & Velarde, 1982; Trimble, Padilla, & Bell-Bolek,
1987), acculturation stress (LaFromboise, 1988), alienation from
the larger culture (Moncher et al., 1990), and an excessive amount
of unstructured time on reservations, during which drinking is
often a response to boredom (E. D. Edwards & Edwards, 1988). In
addition, Whitbeck, Hoyt, McMorris, Chen, and Stubben (2001)
have found perceived discrimination to be a risk factor for alcohol
and drug use. In their study, 49% of fifth–eighth-grade students
from three reservations in the upper Midwest reported experienc-
ing significant discrimination. This was strongly associated with
early onset substance abuse, a relationship that was mediated by
adolescent anger and delinquent behaviors.
Although risk is a widely understood and agreed upon concept,
protection is not, and there has been little consensus on the
definition and operationalization of protective factors (see Jessor,
VandenBos, Vanderryn, Costa, & Turbin, 1995). Some define risk
and protection as opposite ends of a single dimension. A protective
factor, then, is the absence of or a low level of risk. Others argue
that the concept of protection is orthogonal and extends beyond the
mere absence of risk. These scholars contend that a protective
factor is an independent variable that can have a direct effect on
behavior and can also moderate the relationship between a risk
factor and behavior (J. D. Hawkins, Catalano, & Miller, 1992;
Rutter, 1987). Both definitions of protection are represented in the
studies presented here.
Among adolescents in the general population, protective factors
include stable and supportive relationships with parents and proso-
PREVENTING SUBSTANCE ABUSE IN INDIAN YOUTH
cial adults, self-efficacy in social relations, bonding to conven-
tional society, community resources, cultural involvement, partic-
ipation in organized group activities, and involvement in religious
activities (Barrett, Simpson, & Lehman, 1988; Elder, Leaver-
Dunn, Wang, Nagy, & Green, 2000; J. D. Hawkins et al., 1992;
Newcomb & Felix-Ortiz, 1992; Tyler & Lichtenstein, 1997). Com-
paratively little is known about factors that serve to protect Indian
youth against the development of substance use problems. There is
no compelling reason to believe that the factors listed here would
not also be protective for Indian adolescents. Indeed, strong bonds
with the family and school are believed to serve as protective
factors against deviance, whereas peer associations can serve as
sources for either prosocial or deviant norms (Oetting, Donner-
meyer, Trimble, & Beauvais, 1998). In one of the few published
studies of protective factors among American Indian youth, Le-
Master et al. (2002) found that academic orientation served to
lower the risk for cigarette smoking.
Much is unknown about protective factors that are specific to
the cultural and community context of Native Americans. Despite
the strongly held belief in the positive power of Indian cultural
identity and participation, research has yielded conflicting find-
ings. For example, one study demonstrated that inhalant abuse
rates were lower for youth who participated in structured activities
such as traditional tribal activities and ceremonies (Thurman &
Green, 1997). Similarly, Mason (1995) found that a positive cul-
turally oriented self-concept was associated with lower rates of
substance use. However, attendance at cultural events has also
been linked to marijuana and cigarette use (Petoskey, Van Stelle,
& De Jong, 1998), and in one study traditional orientation was
highly correlated with problem behaviors such as getting drunk or
high (Mail, 1997). In a sample of urban Native youth, increased
report of alcohol-related problems was associated with identifica-
tion with the “Indian way of life” (E. H. Hawkins, 2002). Still
other studies have found no relationship between cultural identity
and substance use (Bates, Beauvais, & Trimble, 1997).
There remains strong support for the idea that bicultural com-
petence serves to decrease risk for substance misuse. Bicultural
competence has been defined as the ability to alternate between
one’s ethnic and White identities in response to contextual cultural
cues (LaFromboise, Coleman, & Gerton, 1993). This capability is
widely believed to be instrumental in helping Indian youth suc-
cessfully negotiate potentially harmful situations by increasing
positive coping skills, self-efficacy, and social support, factors that
have been linked to positive outcomes in substance abuse treat-
ment (Annis & Davis, 1991; Marlatt & Gordon, 1985; Rychtarik,
Prue, Rapp, & King, 1992). A similar model is stake theory, which
holds that identifying with, or having a stake in, both Native and
mainstream cultures can serve as a protective factor against sub-
stance abuse (Ferguson, 1976; Honigmann & Honigmann, 1968).
Among many ethnic groups, positive outcomes in issues of
health and adjustment, including addictive behaviors, are associ-
ated with higher levels of bicultural competence (LaFromboise et
al., 1993). For Native adolescents living on reservations or tribal
land, having a bicultural identity has been associated with in-
creased social competencies, personal mastery, self-esteem, and
social support (Moran, Fleming, Somervell, & Manson, 1999).
However, it is clear that further research is needed to clarify the
role culture plays as a source of risk or protection for substance use
problems in this population.
Substance Misuse Prevention
The recognition that substance use among American Indian
youth often begins at an early age has resulted in a growing
emphasis on prevention rather than treatment efforts. Research
detailing epidemiology, etiology, and domains of risk and protec-
tion can provide the basis for developing prevention programs and
identifying intervention targets. These preventive interventions are
designed to reach children early and limit the initiation of sub-
stance use and/or the later development of substance abuse and
An Overview of Prevention Concepts
Prevention services are widely characterized as primary, sec-
ondary, or tertiary (Caplan, 1964). Within the health field, primary
prevention programs are aimed at reducing the incidence of a
particular disorder or risk factor. Secondary prevention programs
target early identification and treatment to reduce the prevalence of
a particular problem. Tertiary prevention programs focus on re-
ducing the severity or impact of an established condition. Because
this framework assumes dichotomous categorization (i.e., present
and absent), using this classification system often makes it difficult
to distinguish between primary and secondary prevention. Instead,
mental health and substance abuse problems tend to be conceptu-
alized as spectrum disorders, with attention focused on the level
and severity of functional impairment rather than the strict pres-
ence or absence of a disorder.
In 1994, the Institute of Medicine proposed a new model that
divides the continuum of care into three categories: prevention,
treatment, and maintenance. The prevention category distinguishes
between three classifications of prevention programs: universal,
selective, and indicated. In a universal program, specific individ-
uals are not singled out for an intervention; rather, all individuals
within a defined area or population are offered the service. Exam-
ples of this include high school health education classes and
anti-smoking media campaigns. Selective prevention targets
groups of individuals considered at higher than average risk be-
cause of the presence of one or more risk factors. A program
designed for children of alcoholics or an after-school mentoring
program for youth experiencing behavioral problems are examples
of selective prevention. Indicated prevention programs are aimed
at specific individuals who have already begun engaging in high-
risk behaviors but who do not meet criteria for a substance use
disorder. Examples of this kind of intervention might include
adolescents screened for problems at school or a physician’s
office, or those mandated to treatment. Selective and indicated
preventions are also often referred to as forms of targeted
Universal and targeted prevention programs both have their
advantages and disadvantages (Offord, 2000). Universal programs
tend to cast a wider net and can, therefore, potentially influence
more people. They also tend to be less stigmatizing, as no one
individual is singled out for attention. However, they are often
expensive, usually have a smaller effect on any one person, and
HAWKINS, CUMMINS, AND MARLATT
may have the greatest effect on those at lowest risk. Targeted
programs have the potential advantage of efficiency, as available
resources are directed only at the high-risk group. In addition, they
tend to be more intensive and may have greater impact on an
individual level. A common difficulty in indicated interventions,
though, is the cost and commitment necessary to screen individuals
to determine risk status. Furthermore, risk factors are usually fairly
weak predictors of future pathology, so screening may not accu-
rately target individuals in the most need. Finding the balance
between sensitivity (the ability to accurately detect those who are
at risk) and specificity (the ability to correctly identify those who
are not at risk) often presents a challenge for clinicians and
Prevention for American Indian Youth
Universal, selective, and indicated substance abuse prevention
programs are all commonly found in American Indian communi-
ties. Distinctions between different types of prevention are often
blurred, however, as commonly the entire community is consid-
ered at risk and is the focus of intervention. Unfortunately, the
majority of prevention efforts in Indian Country have not been
rigorously evaluated for efficacy. In addition, specific details of
these programs often are not published or available in a manner
that allows them to be easily shared with other communities.
Moran and Reaman (2002) provided information on prevention
programs that have not been published in the mainstream litera-
ture. Limited program information can also be found through
SAMHSA’s Center for Substance Abuse Prevention (2003; see
also Western Center for the Application of Prevention Technolo-
gies, 2002). While many of these programs have the potential for
success in combating Indian adolescent substance abuse and for
making valuable contributions to the development of prevention
efforts in other communities, this article focuses on reviewing
those studies that have been evaluated and published in peer-
The principal source of information in this article comes from
searches of the MEDLINE and PsycINFO databases. Information
on qualitative findings has been included where relevant, although
the emphasis here is on presenting quantitative outcome data. The
programs reviewed tend to fall into two categories: those that
target entire communities for change and those that focus their
efforts primarily on individual behavior change.
Several researchers have suggested that programs that target an
entire community rather than specific individuals may be more
effective for the prevention and treatment of substance abuse in
American Indian and Alaska Native adolescents (Beauvais &
LaBoueff, 1985; E. D. Edwards & Edwards, 1988; Gutierres,
Russo, & Urbanski, 1994; LaFromboise, Trimble, & Mohatt, 1990;
Petoskey et al., 1998; Wiebe & Huebert, 1996). A community-
based approach may be preferred for a variety of reasons. Some
authors have described the inclusion of an entire community in the
intervention as consistent with Native values and traditions, which
stress collective decision making in resolving community or tribal
concerns (E. D. Edwards & Edwards, 1988; LaFromboise et al.,
1990). Others have emphasized the role that sociocultural factors
play in the development of drug and alcohol abuse and argued that
a more comprehensive approach is necessary to address risk fac-
tors at familial and community levels (Gutierres et al., 1994). Most
authors agree that whether a curriculum is intended to serve
primarily individuals or larger groups, community support for the
intervention is vital to the success of any treatment or prevention
program (Beauvais & LaBoueff, 1985; E. D. Edwards & Edwards,
1988; LaFromboise et al., 1990; Wiebe & Huebert, 1996).
Community empowerment is one approach that is community
based in its theoretical underpinnings and has been used to develop
substance abuse prevention for Native American youth (Petoskey
et al., 1998; Rowe, 1997). Generally, this method utilizes multiple
strategies to increase knowledge about drugs and alcohol through-
out a community and to change community norms regarding use.
Often the initial step in the community empowerment approach is
the development of a core group composed of community mem-
bers who serve as leaders, role models, and decisionmakers re-
garding the implementation of prevention strategies.
Petoskey et al. (1998) described the Parent, School and Com-
munity Partnership Program, a project that aimed to reduce alco-
hol, tobacco, and other drug (ATOD) use among Native American
youth living on or near three reservations in northern Wisconsin
and Minnesota. A major component of this program was the Red
Cliff Wellness School Curriculum, a culturally focused, skills-
based substance abuse curriculum that was designed to be imple-
mented by classroom teachers in Grades 4 through 12. In addition,
the project involved the following: (a) the training of a small group
of community members to be leaders and facilitators regarding
community health, (b) a community curriculum offered to all
members and designed to increase community involvement and
problem solving around ATOD issues, and (c) teacher training in
the implementation of the school-based curriculum. Outcome vari-
ables such as past-month substance use; attitudes toward use and
perceptions of harmfulness; and attitudes toward school, academic
achievement, absenteeism, and cultural involvement were assessed
prior to curriculum implementation, at the end of the program year,
and at 1-year follow-up. Comparison data were provided by sim-
ilar schools that had agreed to collect data during Years 1 and 2 in
order to receive the curriculum in Year 3. Although past-month
alcohol use increased for both groups at follow-up, the authors
reported a significant two-way interaction of site and time, indi-
cating some slowing in the rise in alcohol use for participants in
the intervention group. At all three data collection points, students
who received the intervention reported lower levels of past-month
marijuana use. Past-month cigarette use increased for both groups
over time; however, this outcome was not a specific target of the
intervention. Although there were no significant differences in
likelihood to accept alcohol from friends between groups, students
from the intervention group were less likely to accept marijuana at
1-year follow-up. Interestingly, these authors also found that in-
creased frequency of attendance at powwows was associated with
increased use of substances. Cultural affiliation has often been
perceived as a protective factor, yet this study found a sex differ-
ence in the relationship between Indian identity and substance use:
Increased Indian identity was associated with decreased use in
girls and increased use in boys.
Rowe (1997) described the Target Community Partnership
Project, an effort that utilized the community empowerment ap-
proach to address substance abuse with a Native American tribe in
PREVENTING SUBSTANCE ABUSE IN INDIAN YOUTH
Washington State. Strategies used in this project included (a)
creating partnerships among community members, professional
services staff, and tribal departments; (b) implementing a process
of ongoing training for the community around ATOD issues; (c)
organizing community-wide alcohol- and drug-free events; (d)
enhancing health, welfare, and youth services for those individuals
with substance abuse or children affected by substance-abusing
parents; and (e) advocating for new tribal policies restricting the
use and abuse of drugs and alcohol. Several types of quantitative
and qualitative outcomes were assessed over the course of approx-
imately 4 years with adult and youth surveys conducted in the first
and last years. Some of these included adult perception of harm
from drugs and alcohol (as measured by an anonymous community
survey), youth perception of harm from alcohol (as measured by a
school survey), number of individuals referred to substance abuse
treatment, number of families receiving services for alcohol and
drug-related parenting problems, community perceptions of im-
provements in drug and alcohol use and drug dealing, community
perception of social changes, tribal staff perception of changes in
community norms, tribal policies related to ATOD, number of
sober adults in the community, current youth alcohol use, current
peer alcohol use, and number of alcohol and drug-related juvenile
and adult arrests. Although the author described many positive
overall changes in the community, including improved social
conditions, a shift in social norms regarding drugs and alcohol, the
creation of new policies and laws around substance use, and
increased collaboration among tribal organizations, no significant
change was found in adults’ perceived harmfulness of ATOD use.
Because the sample of youth surveyed for quantitative data was
likely too small to discern significant change over time, the only
significant outcome was an increase in the number of friends that
youth reported did not expect them to drink. In addition, Rowe
indicated an increase in the number of individuals reportedly
seeking abstinence. Although the numbers of drug- and alcohol-
related arrests, substance-related referrals, and referrals of families
for services all increased, the author suggested that this was an
indication of improved awareness among community members
rather than an indication of rising use.
Dorpat (1994) described a multi-arm prevention program im-
plemented by the Puyallup Tribe of Indians, a tribe that inhabits a
primarily urban reservation located in Tacoma, Washington. Al-
though a description of the program does not indicate that its
format was intentionally based on any particular community-based
theory, the nature of the program’s development and content
appears similar to other community-based interventions reported
here. PRIDE (Positive Reinforcement in Drug Education) was a
prevention program conceived and developed through the guid-
ance of the Puyallup Tribal Council and local school administra-
tion. Its four components included (a) development of students’
cultural identity through both curricular and extracurricular in-
struction and activities in the schools; (b) implementation of a
school-based prevention curriculum dealing with health aware-
ness, drug and alcohol awareness, refusal skills, and life skills; (c)
enforcement of a security policy for reducing in-school drug use
and development of a drug-free environment on school campuses;
and (d) coordinated counseling, referral, and/or case management
services for those students identified as drug users. Although the
author reported that a formal process evaluation supported pro-
gram efficacy, only one postintervention student survey was de-
scribed in terms of outcome evaluation. This survey demonstrated
high rates of expected school completion and positive attitudes
about health among students. The survey also indicated 22% of
high school students reported drinking to get drunk. The author
compared this with a public school survey conducted separately
from the study in which 46% of local high school juniors reported
drinking to get drunk once per month. Although these outcomes
appear positive, efficacy is difficult to establish without baseline or
comparison group data.
In general, it appears that community-based approaches, and
specifically community empowerment, may provide promising
ways of developing culturally relevant substance abuse prevention
programs for Native American adolescents. Further investigation
and outcome data are necessary to better document the efficacy of
community-based interventions and to better understand which
aspects of these programs are most helpful.
The majority of programs that have focused prevention at the
individual level have utilized the approach of adolescent skills-
training interventions. As an extension of social learning theory
(Bandura, 1986), primary socialization theory has been used as a
method to explain American Indian adolescent alcohol use (Oet-
ting & Donnermeyer, 1998). According to this model, socialization
is the process of learning social norms and behaviors and is an
active interaction between the individual and the primary social-
ization sources (namely, the family, school, and peer clusters). The
goal of socialization is the development of the abilities and com-
petencies needed to function successfully within a culture. Drink-
ing among adolescents, then, reflects this process of socialization,
and the norms and expectations of the family, community, and
The link between social–cognitive factors and alcohol problems
is appealing from a prevention perspective because attitudes, be-
liefs, and behavior are subject to modification. Skills training is a
vehicle commonly used for motivating and effecting change in
substance use patterns. As a result, it is perhaps the most widely
researched approach and provides the richest literature on inter-
vention outcomes for the American Indian population.
Skills-training programs are often en-
hanced by using peers as a component of the intervention. Re-
search has shown that peer leaders can be at least as, and some-
times more, effective than adult health educators when working
with adolescent populations (Mellanby, Rees, & Tripp, 2000),
especially in effecting change in attitudes and behaviors (Bangert-
Drowns, 1988; Tobler, 1986).
Theories of social learning (Bandura, 1986), social inoculation
(McGuire, 1964), and social norms (Fishbein & Azjen, 1975)
underlie the rationale for this approach by predicting that individ-
ual behaviors are influenced by the attitudes and behaviors of the
social group to which that individual belongs. More specifically,
these theories hold that people are more likely to take on the
attitudes and behaviors of those members of their social group
whom they perceive as similar to themselves. This may be espe-
cially true during adolescence, a time when individuals may be
more influenced by peer-group norms (Bangert-Drowns, 1988;
Covert & Wangberg, 1992). Researchers have applied these the-
ories to Native American populations specifically by observing
HAWKINS, CUMMINS, AND MARLATT
that drinking patterns among American Indian adolescents can be
both shaped and maintained by peer-group expectations (Carpen-
ter, Lyons, & Miller, 1985; Curley, 1967).
Only one published study thus far has evaluated the usefulness
of incorporating a peer-counseling component into an alcohol
abuse prevention program for American Indian adolescents (Car-
penter et al., 1985). The overall approach of this program was to
teach responsible drinking utilizing self-control training. Thirty
students, from 16 tribes, attending a residential high school were
identified as at risk for problem drinking and were randomly
assigned to one of three interventions: (a) self-monitoring alone,
(b) self-monitoring with peer counseling, or (c) self-monitoring
with peer counseling in addition to an alcohol education class. The
participants represented tribes from across the United States and
had an average age of 16 years (range ? 14–20 years).
Participants were assessed prior to the intervention, postinter-
vention, and at follow-ups of 4 months, 9 months, and 12 months
postintervention. Quantity of weekly drinking, frequency of drink-
ing, and peak blood alcohol concentration in the past 3 months
decreased significantly in all groups over time. However, no
differences between groups were observed, indicating effects were
similar regardless of minimal or full program participation. Car-
penter et al. (1985) concluded that these findings are consistent
with previous research that has “found only modest differences
between extensive self-control training programs and more mini-
mal interventions, as long as the latter have included self-
monitoring and basic self-help guidelines” (p. 307).
programs designed for American Indian and Alaska Native youth
often incorporate a bicultural competence approach in order to
increase relevancy and effectiveness. A critical component of
bicultural competence is learning important coping skills for ne-
gotiating both mainstream and Native cultures. This experience
can be empowering, increasing a sense of self-efficacy and leading
adolescents to be more functional navigators of their often-
A study conducted among American Indian youth living on two
western Washington reservations shows modest support for a
bicultural competence skills intervention for preventing substance
abuse (Schinke et al., 1988). Participants included 137 youth
(mean age ? 11.8 years) who after pretesting were randomly
assigned by reservation site into prevention and control conditions.
Participants in the bicultural competence condition were instructed
in and practiced communication, coping, and discrimination skills
using behavioral and cognitive methods. For example, youth were
introduced to culturally relevant examples of verbal and nonverbal
influences on substance use, were guided in self-instruction and
relaxation techniques to help cope with the pressure of substance
use situations, and were taught techniques to anticipate temptations
and explore healthier alternatives to substance use. Youth in the
control condition received no intervention. Adolescents in the
bicultural competence group showed greater posttest and 6-month
follow-up improvements than those in the control group on mea-
sures of substance-related knowledge, attitudes, and interactive
abilities and on self-reported rates of tobacco, alcohol, and drug
use (Schinke et al., 1988).
Another study involved 1,396 Native youth from 10 reservations
in Idaho, Montana, North Dakota, Oklahoma, and South Dakota
(Schinke, Tepavac, & Cole, 2000). Participants were randomly
assigned by school to one of three experimental conditions. Two of
the three conditions involved 15–50 min weekly sessions focusing
on cognitive–behavioral life skills training. Youth learned
problem-solving, coping, and communication skills for preventing
substance abuse. However, the standard life skills training tech-
niques and content were expanded and adapted to fit the bicultural
world of the Native American adolescents. One of these interven-
tion conditions also included a community involvement compo-
nent, in which multiple community systems worked together to
plan activities to raise awareness of substance abuse prevention.
The third condition consisted of a control group that did not
receive any intervention.
The authors found that except for cigarette use, follow-up rates
of smokeless tobacco, alcohol, and marijuana use were lower for
youth who had received the skills intervention than for those who
were in the control group (Schinke et al., 2000). At the 30-month
follow-up, smokeless tobacco use, defined as seven or more in-
stances of use in the past week, was approximately 7% for the
skills intervention groups and a little less than 11% for the control
group. At the 42-month follow-up, the rates were 10% and 18%,
respectively. Alcohol consumption, defined as four or more drinks
in the week prior to measurement, was also significantly lower at
the 30- and 42-month follow-ups for the two intervention groups
(23% vs. 30% and 16% vs. 19%, respectively). Although the youth
who participated in the skills plus community involvement condi-
tion had lower rates of alcohol use than the control group, their
rates were higher than those youth in the skills-only group. Al-
though these results did not reach statistical significance, this trend
was present at the 18-, 30-, and 42-month follow-ups. At the final
follow-up (42 months), marijuana use rates were significantly
lower for Native American youth who had participated in the skills
intervention (7%) than for those in the control group (15%).
Moran and Reaman (2002) described initial outcomes from the
Seventh Generation project, which involved urban American In-
dian fourth through seventh graders in Denver. This after-school
alcohol prevention program utilized a life skills approach with the
following content areas: correcting misperceptions of alcohol use
norms, enhancing values that conflict with alcohol use, improving
self-esteem, learning structured decision making, increasing re-
fusal skills, and making a personal commitment to sobriety
(Moran, 1998). Local community-based focus groups determined
seven culturally specific core values, which were emphasized
throughout the curriculum. These included harmony, respect, gen-
erosity, courage, wisdom, humility, and honesty. In this way,
cultural relevance of the material was established without the use
of traditional Native activities or artifacts. The intervention con-
sisted of 13 weekly 2-hr sessions with a 5-week booster after 6
months. This quasi-experimental design compared 257 interven-
tion youth with 121 nonintervention youth at pretest, posttest, and
1-year follow-up. The intervention and control groups were not
significantly different at pretest or posttest, except that the inter-
vention youth who completed the 1-year follow-up had signifi-
cantly better decision making and greater Indian identity at pretest
than did control group youth. At 1-year follow-up, the intervention
group also displayed less positive beliefs about alcohol conse-
quences, less depression, greater school bonding, more positive
self-concept, and higher levels of perceived social support. In
addition, a significant difference in reported drinking in the past 30
PREVENTING SUBSTANCE ABUSE IN INDIAN YOUTH
days (5.6% of intervention youth vs. 19.7% of comparison youth)
The prevention programs reviewed here provide strong support
for the use of a skills-training approach in reducing substance
misuse among American Indian and Alaska Native adolescents.
Collectively, the youth who participated in these programs sym-
bolize the diversity found within the greater American Indian
population. Tribes from across the country were represented, as
were both reservation-based and urban youth and those attending
public, tribal, and boarding schools. Further research is needed to
determine the relative contributions made by the various dimen-
sions of a specific program and to identify whether there are
differential outcomes based on participant variables such as gen-
der, age, residential, or cultural differences.
Limitations of Current Approaches
This article reviews prevention programs that have been evalu-
ated and have demonstrated some degree of efficacy in reducing
the prevalence of substance abuse and related consequences. How-
ever, the number of such programs is too few considering the
magnitude of substance use problems experienced by American
Indian and Alaska Native adolescents. It is vital that an evaluation
component be established in the development and implementation
of all prevention efforts. Critical aspects of effective evaluation
include formulating a research design that allows for a comparison
or control group while respecting a community’s expectation of
universal inclusion (Parker-Langley, 2002), recruiting a large
enough sample size to perform more sophisticated statistical anal-
yses, maintaining a follow-up period of suitable duration to ascer-
tain the long-term effects of an intervention, and assessing both
process and outcome variables. Only by doing this can the effec-
tiveness of prevention programs be determined and, thus, re-
sources be directed more competently toward addressing issues of
It has been said before, but it bears repeating: American Indians
and Alaska Natives are an extremely culturally diverse group.
Programs developed for one segment of the Indian population may
not be generalizable to another. This may be due to actual geo-
graphical or cultural differences that render prevention efforts
incompatible between certain groups, or it may reflect a longstand-
ing desire on the part of some communities to assert and maintain
a unique and independent identity. Regardless of reason, programs
developed in one community may not work in or be accepted by
others. Problems of generalizability are often mentioned in limi-
tations sections, but the discussion ends there. Often, there is no
additional dialogue nor recommendations offered regarding how to
adapt interventions for use with other groups. This situation is
extremely unfortunate, as information of this sort would likely
benefit and guide the efforts of other communities struggling with
these same concerns. Given the extensive need for effective sub-
stance abuse prevention among Indian adolescents, researchers
need to address this very important issue.
Of all the programs reviewed here, only one specifically tar-
geted multitribal urban youth (Moran, 1998; Moran & Reaman,
2002). This reflects a critical gap in prevention services and
research. Although approximately two thirds of all American In-
dians and Alaska Natives now live in urban areas (U.S. Census
Bureau, 1993), the vast majority of studies that are reported use a
reservation-based sample. One reason for this may be that indi-
viduals in these communities tend to be easier to identify and are
presumed to be more culturally homogenous. In addition, research-
funding mechanisms often specifically target tribal populations
rather than urban groups. These factors greatly impact the devel-
opment and implementation of prevention programs. However,
substance abuse prevention efforts for Native adolescents are crit-
ically limited by the lack of published accounts of culturally and
developmentally appropriate strength-based urban programs. Ur-
ban youth are likely to have a much different relationship with
their local and tribal community than do rural or reservation-based
youth. In contrast to reservation-based adolescents who are likely
to be more similar, urban youth represent a diverse spectrum of
tribal nations, cultural knowledge, and traditional cultural partici-
pation. As a consequence, prevention research conducted with
reservation samples may not transfer easily to adolescents living in
metropolitan areas. More attention clearly needs to be focused on
this overlooked and poorly understood group.
The body of literature regarding Indian adolescent substance use
and abuse would benefit further from an expansion of current
research efforts. Published studies tend to revolve around preva-
lence data and cross-sectional reports of risk factors. Very few
published studies have explored risk prospectively and longitudi-
nally (e.g., Federman et al., 1997; Walker et al., 1996). In addition,
there are few published accounts of protective factors or avenues
of resiliency for substance abuse problems among American In-
dian youth. Further exploration of these factors is essential to the
development of effective interventions.
Developing prevention programs that are meaningful and rele-
vant for American Indian youth is of critical importance. It is clear
that simply applying adult and majority culture definitions and
conceptualizations of problem drinking to Indian adolescents is
neither appropriate nor useful. Instead, there needs to be a recog-
nition that different developmental trajectories exist, with impor-
tant individual differences in causes, course, and consequences of
substance abuse (Baer, McLean, & Marlatt, 1998). Prevention
programs that are culturally relevant and matched to the unique
needs of Native adolescents are strongly indicated (Bobo, 1986;
LaFromboise & Rowe, 1983; Schinke et al., 1988; Stone, 1981).
One method of assuring that programs are appropriate for their
target population is extensive collaboration with and involvement
of community members. Often this means going beyond the
boundaries of traditional academic research and grant funding. It
requires making a significant commitment of time and resources
toward developing the trust and respect of community members
and learning from them the best methods of designing and imple-
menting a local program. In addition, such involvement entails
providing community members with information, training, and
technical assistance to maintain a program once it has been estab-
lished. Most Indian communities are wary of researchers, and
rightfully so. There has been a long history of “parachute” aca-
demics who “drop in” to a community with prevention program in
hand, collect data, and then leave to move on to other projects. The
time has come to make a long-term commitment to the Native
American population by working with communities to develop and
sustain effective prevention programs.
Although Indian communities are marshalling their resources to
address substance-related harm and to find solutions that work for
their community, these endeavors are not well evaluated or docu-
HAWKINS, CUMMINS, AND MARLATT
mented. Across the country there are innovative programs that are
likely helping to reduce the negative consequences associated with
alcohol and drug use. However, within the scientific literature
there is a paucity of studies that offer both qualitative findings and
quantitative data on efficacy. Nor has there been much discussion
of attempts to culturally adapt prevention programs found to be
effective with mainstream youth or with other segments of the
Indian adolescent population. In general, available research often
lacks the more sophisticated methodologies seen in mainstream
research. To truly ameliorate the problems of alcohol misuse
among Indians, these limitations need to be addressed and new,
more inclusive models advanced.
Prevention Strategies for Healthier Communities
Despite countless efforts to reduce substance abuse in Indian
Country, alcohol- and drug-related problems continue to be the
number one concern of most communities. Indian children and
adolescents are using tobacco, inhalants, alcohol, and marijuana at
disturbing rates. Perhaps more alarming is the age at which they
begin using and the quantity and frequency of their use. The trends
in substance use and misuse discussed earlier reinforce the need
for effective prevention programs to stem the tide of harmful
Promising Prevention Approaches
In reviewing the research literature, several best-practice ap-
proaches for substance abuse prevention among American Indian
and Alaska Native youth emerge. These include principles and
strategies that have demonstrated the potential and promise to help
reduce the severity of problems caused by alcohol and drug use.
They include (a) conceptualizing prevention and behavior change
as part of a continuum, (b) using a stepped-care approach, (c)
utilizing a biculturally focused life skills curriculum, and (d)
establishing community involvement and collaboration throughout
the development and implementation of prevention efforts.
A Continuum of Prevention and Individual Behavior
Recent work in the development of cognitive–behavioral pro-
grams for the prevention and treatment of addictive behaviors has
focused on a continuum of prevention and intervention ap-
proaches. To deter Native youth from experimenting with sub-
stances and to maintain abstinence, universal prevention programs
are appropriate. Once experimentation and initial substance use
has occurred, however, targeted prevention is called for so as to
reduce the risk of harm and the potential for addiction. To prevent
the escalation from alcohol and drug use to alcoholism or drug
addiction, an early intervention approach that targets specific risk
and protective factors is often recommended. For those who have
already developed alcohol or drug dependency, participation in
active treatment interventions and the prevention of relapse be-
come the focus.
Contemporary approaches to individual intervention and treat-
ment in mainstream populations have been greatly influenced by
the stages of change model first described by Prochaska and
DiClemente (1983). The four major stages designated in the model
include precontemplation (no consideration or contemplation of
changing the target behavior), contemplation (characterized by
motivational ambivalence about the prospects of change), action
(the individual commits to a plan of action), and maintenance
(coping with the risk of relapse following successful action). A
primary advantage of this model is that intervention strategies can
be matched to an individual’s particular stage of change (Marlatt,
1992), including motivational enhancement strategies for those in
the precontemplation or contemplation stages (Miller & Rollnick,
2002) and relapse prevention skills (Marlatt & Gordon, 1985) to
enhance the maintenance of change initiated in the action stage.
Clearly, the stages of change model can help address the issue
of how to design prevention along a continuum of need, and it has
important implications for developing promising new approaches
for reducing the prevalence of alcohol problems among Native
youth. In particular, the development of prevention programs may
benefit from conceptualizing a range of behavior change options
and strategies. American Indian and Alaska Native youth partici-
pating in prevention programs will likely already have experi-
mented with alcohol and drugs to some degree but are not yet
experiencing the adverse consequences associated with abuse or
dependency. As such, targeted prevention offers a critical oppor-
tunity to provide an intervention that decreases the likelihood that
their substance use will lead to abuse or dependence. For those
who are unable or unwilling to stop drinking or using drugs
altogether, a harm reduction approach may be helpful (Marlatt,
1998). For Indian communities, a harm reduction prevention
model may be a viable alternative to traditional options because of
its pragmatic emphasis on the acceptance of people at where they
are in the process of substance use, abuse, and recovery (Daisy,
Thomas, & Worley, 1998). Harm reduction attempts to broaden
the availability of prevention and treatment services by lowering
the threshold necessary for entry into such services (Larimer et al.,
1998). Withits emphasison
determination, and learning appropriate ways to cope in the pres-
ence of high-risk environmental conditions, harm reduction has
been reported as a promising model of intervention in a few First
Nation communities in Canada (Landau, 1996).
A Stepped-Care Model
A stepped-care approach is integral in conceptualizing preven-
tion and treatment along a continuum. According to the stepped-
care treatment model (Sobell & Sobell, 1999), one begins with the
first step, usually defined as an initial effort to quit or cut down on
substance use without outside support or treatment. At this point,
little is known about the process of self-initiated change or the
natural history of recovery in the American Indian population,
although a study is currently underway to document this process
among Alaska Natives (Mohatt, Hazel, Allen, & Geist, 1999).
If self-change does not occur or is unsuccessful in terms of
resolving substance problems, the stepped-care approach recom-
mends “stepping up” the intensity of interventions by engaging the
individual in a brief intervention, such as participation in a moti-
vational interviewing session designed to enhance motivation for
change and a commitment to taking action or getting assistance
from others (Miller & Rollnick, 2002). If the brief intervention is
not effective, the stepped-care approach calls for a more intensive
intervention, such as participation in a self-help or professional
PREVENTING SUBSTANCE ABUSE IN INDIAN YOUTH
treatment group. Finally, if the group intervention is not success-
ful, the next step up might include intensive outpatient therapy, or
even the possibility of residential or inpatient treatment as a last
resort. Overall, the stepped-care model provides a series of cost-
effective strategies that can be tailored to the individual’s needs
A stepped-care approach may be useful for designing and im-
plementing prevention efforts with Indian youth. The use of uni-
versal prevention programs, in which everyone in a certain envi-
ronment receives the intervention and high-risk individuals or
groups of individuals are not singled out, is similar to first step
approaches that rely on self-initiated change. Targeted prevention
programs, on the other hand, can provide more customized pre-
vention by first assessing for adolescents’ experiences with sub-
stance use and associated problems when they enter the program.
In doing this sort of evaluation, youth who have already begun to
experience problems with their alcohol and drug use can be iden-
tified and referred for a more intensive intervention or treatment as
needed. In addition, certain guidelines or procedures to monitor the
adolescents’ use throughout the program could help to detect
changes in functioning. If problems begin to occur that suggest a
higher level of intervention is indicated, an individual youth’s level
of care can be stepped up. In this way, a stepped-care model allows
the level and intensity of prevention or intervention to be matched
to the adolescent’s needs.
Bicultural Life Skills Approaches
Research with college student binge drinkers (Baer, Kivlahan,
Blume, McKinght, & Marlatt, 2001; Baer et al., 1992; Kivlahan,
Marlatt, Fromme, Coppel, & Williams, 1990; Marlatt et al., 1998)
provides a foundation for integrating high-risk behaviors as poten-
tial targets for prevention programs, a strategy that may be effi-
cacious for Native adolescents. In these approaches, an attempt is
made to integrate multiple risk behaviors and to develop a
lifestyle-coping skills prevention approach. Adolescents are pro-
vided with education regarding substance use and its effects, and
are taught skills to prevent problems with alcohol, smoking, sub-
stance abuse, high-risk sexual behavior, and eating disorders (in-
cluding risk for obesity and diabetes). As such, the overarching
theme is one stressing health promotion and disease prevention,
with an emphasis on developing skills for lifestyle balance (Mar-
latt, 1985). By addressing healthy lifestyles, a skills-based preven-
tion program provides a good match for adolescent development,
including a focus on growth, personal responsibility, and enhanced
self-efficacy. By avoiding diagnostic labels, lifestyle skills training
programs reduce the stigma and shame associated with seeking
help for substance abuse or dependency. Adolescents are more
likely to be attracted to programs that encourage new learning
about how to cope with the challenges of life. Behavior change is
viewed from this perspective as a “journey of discovery” rather
than a process of “recovery.”
Research has already begun to show the effectiveness of life
skills training programs for both urban and reservation-based
Native American adolescents, as they can potentially be used as a
more developmentally and culturally appropriate prevention
method than other programs (Moran & Reaman, 2002; Schinke et
al., 1988, 2000). The majority of skills-based prevention programs
reviewed here incorporated a bicultural component to make the
program more relevant for Indian youth. The application of bicul-
tural competence to interventions relies on learning and practicing
communication, coping, and discrimination skills (LaFromboise &
Rowe, 1983). It has been suggested that demonstrating the follow-
ing six factors for both Indian and White cultures indicates bicul-
tural competence: knowledge of cultural beliefs and values, posi-
tive group attitudes,bicultural
competency, role repertoires, and groundedness (LaFromboise et
al., 1993). Cognitive and behavioral principles drawn from social
learning theory appear to be an effective mechanism for transmit-
ting bicultural competence skills. The positive outcomes of skills
training programs presented here emphasize that adapting life
skills training curricula to reflect the bicultural world in which
Native youth live and stressing the adoption of bicultural compe-
tencies appear to be promising prevention approaches.
Effective substance abuse prevention in Indian Country requires
the involvement of community members in all stages of program
development and implementation. This includes partnering with
elders, parents, families, schools, juvenile justice, and mental
health, chemical dependency, and medical professionals, as well as
representatives from other relevant tribal and/or urban Indian or-
ganizations. Without a high level of collaboration, prevention
efforts are likely to fail. In most instances, researchers are from
outside the community, and there is an initial amount of distrust
and skepticism expressed toward them. Nevertheless, overcoming
these barriers and establishing good working relationships is es-
sential to develop culturally relevant and sensitive programs.
While researchers and academics might bring with them a certain
degree of scientific knowledge and technical skill, it is important
to remember that community members are the experts on their
community and culture. Their input needs, not only to be solicited,
but also used to direct the project at every stage from initial
planning through implementation and evaluation.
In many communities, a universal prevention approach that
targets the entire community, rather than an individual or group,
may be most appropriate. Involving multiple systems in the effort
to change substance use behavior can be an effective mode of
intervention. For many reasons, this may be especially true in
smaller communities. First, in a smaller community there is likely
to be less individual privacy and confidentiality. Community-wide
interventions can reduce the stigma that might otherwise be asso-
ciated with only targeting high-risk individuals. In addition, social
institutions and agencies may work more closely with one another
than those in larger cities, increasing the likelihood of making and
maintaining systemic changes. Forming community partnerships
when designing this kind of intervention is vital to it being ac-
cepted and successful.
The community readiness model advanced by the Tri-Ethnic
Center for Prevention Research at Colorado State University pro-
vides a useful framework for communities that are seeking ways to
reduce the degree of substance use and related problems among
their youth (R. W. Edwards, Jumper-Thurman, Plested, Oetting, &
Swanson, 2000). A community readiness model can help guide
prevention efforts by assessing how ready a community is to
accept and support a program. The idea of community readiness
emphasizes that unless a community is ready to initiate a preven-
HAWKINS, CUMMINS, AND MARLATT
tion program, it is likely to not happen at all, or to fail. The
Tri-Ethnic Center developed the idea of community readiness into
a comprehensive model that includes methods of measuring readi-
ness, suggestions for interventions appropriate for each level, and
strategies for increasing a community’s level of readiness.
The theory of community readiness is very loosely based on the
stages of change model described previously (Prochaska & Di-
Clemente, 1983). However, because of the added complexities of
dealing with group organizations and processes, a multidimen-
sional nine-stage model was advanced. The nine stages of com-
munity awareness are as follows: no awareness, denial, vague
awareness, preplanning, preparation, initiation, stabilization, con-
firmation/expansion, and professionalization. R. W. Edwards and
colleagues (2000) from the Tri-Ethnic Center offer a method of
assessing a community’s readiness for implementing programs,
using key informants (people who are involved in community
affairs and knowledgeable about the issues at hand, although not
necessarily leaders or decisionmakers). In addition, they present
practical suggestions for ways to increase community readiness at
each stage. As such, this model provides a valuable vehicle to
gauge and increase a community’s readiness and desire for pre-
The Cultural Challenge
Both anthropologists and cross-cultural psychologists have de-
scribed the importance of developing cultural, folk, or emic mod-
els to more accurately represent how certain behaviors, attitudes,
or constructs may be understood within a particular sociocultural
group (Quinn & Holland, 1987; Triandis, 1980). The expectation
is that the application of cultural models to the design of preven-
tion programs will enable them to be more culturally relevant and,
therefore, effective. Many questions remain, though, regarding the
best way to develop and promote a life skills prevention program
for Native adolescents in a culturally appropriate manner.
In their discussion of cross-cultural issues, Moran and Reaman
(2002) discussed the difference between emic and etic approaches
to prevention. Emic approaches are those that are highly specific
and meaningful to members of a particular culture, whereas etic
approaches are based on cross-cultural behavior and models. Many
would argue that given the great diversity of Native American
cultures, emic approaches are necessary for effectively combating
problems of substance abuse. In other words, “one size does not fit
all” when it comes to developing successful prevention programs
for Indian adolescents. Taken to the extreme, however, does this
mean that every individual or group requires its own special
program, or that any one method cannot be used successfully with
The dilemma at hand is whether culturally specific programs
must be developed as a local model or whether a global model can
be developed that has pan-tribal commonalties. This issue becomes
vitally important when developing prevention efforts for urban
Indian youth, as they often represent the full spectrum of tribal
cultures, customs, and identities. In addition, reservation-based
adolescents are exposed increasingly more frequently to the tradi-
tions and beliefs of other tribal nations, as well as to the lifestyles
of mainstream America. It is essential that researchers begin to
critically examine their prevention programs to identify core com-
ponents that may be adapted for use in other communities.
The literature reviewed in this article provides strong support for
one such commonality: Programs that train youth in bicultural
competency appear to be more successful. Adolescents who are
able to demonstrate their ability to function successfully in both
Native and mainstream cultures may be less likely to develop
problems with alcohol or drugs (LaFromboise et al., 1993; Moran
et al., 1999). Although it may not be necessary to develop one’s
identity with both cultures, the capacity to cope with the demands
of life in both Native and mainstream American societies is critical
to successful prevention outcomes. Training in bicultural coping
skills is essential to survival for both urban and reservation-based
Coping skills training has been shown to be effective for both
the prevention of alcohol abuse in adolescents and young adults
(Baer et al., 2001; Dimeff, Baer, Kivlahan, & Marlatt, 1999) and
in the treatment of alcohol dependence (Monti, Colby, & O’Leary,
2001). Because skills training is based on basic behavioral princi-
ples and is evidence-based, it could be considered an etic approach
to prevention. But how can this etic approach be incorporated into
culturally appropriate emic programs, and how can these basic
behavioral strategies be translated or integrated in diverse Indian
communities? By drawing upon the rich resources of Native cul-
tures in terms of myths, stories, legends, songs, and dances, it may
be possible to transfer etic components into emic prevention
Navigating Life’s Challenges: The Canoe Journey
In the Pacific Northwest, a team of researchers from the Uni-
versity of Washington has been working with the Seattle Indian
Health Board to develop a prevention program that addresses these
issues in ways that are culturally congruent with the urban com-
munity and based on empirically validated principles. This project,
named Journeys of the Circle, began with a series of focus groups
with urban Native youth (Mail et al., 2003). These youth described
a cultural experience unique to Northwest Coastal tribes: the
Canoe Family. Throughout the year, youth who belong to the
Canoe Family participate in a wide range of activities designed to
prepare them for annual canoe journeys to visit other tribes both in
British Columbia and the Pacific Northwest. Such activities in-
clude participation in “talking circles” with elders and respected
community members, the construction of large ocean-going canoes
that can carry groups of paddlers from one community to another,
and learning how to navigate the waters of Puget Sound. When
visiting canoes arrive at a particular destination, the event is
celebrated with cultural protocols that include feasting on local
specialties, singing, dancing, and participation in potlatches (gift-
giving ceremonies). The only requirement for involvement in the
Canoe Family is that youth make a commitment to being clean and
sober throughout all activities. Participation in the Canoe Family is
clearly a desirable and prestigious alternative to being involved in
activities associated with drinking and taking drugs.
Using this information, researchers partnered with the Seattle
Indian community to develop a prevention program based on the
principles of the Canoe Family. Community members have been
involved in every aspect of the program’s development and eval-
uation, providing input and feedback through community meet-
ings, focus groups, and an advisory board. The curriculum, entitled
“Canoe Journey, Life’s Journey,” (La Marr & Abab, 2003) was
PREVENTING SUBSTANCE ABUSE IN INDIAN YOUTH
recently pilot tested with urban Native youth who are at risk for
alcohol and drug problems. The program consists of eight lessons
and is administered in small co-ed groups to teens between the
ages of 13 and 19. The course adopts the medicine wheel as a
metaphorical image to organize the Canoe journey itself. The
medicine wheel is divided into quadrants, each representing one of
the four cardinal directions (as on a compass). Two lessons are
devoted to each of these quadrants: north (mental or cognitive
skills), west (emotional coping skills), south (physical skills) and
east (spiritual coping). Group didactics, discussion, role-playing,
and completion of homework assignments are used to train youth
in goal setting, decision making, effective communication, coping
with negative emotions, protecting the physical body, and enhanc-
ing spiritual values.
The overall goal of the course is the same as the Canoe Family:
learning how to cope successfully with various life challenges and
risks, so as to complete the journey safely and to enhance the value
of a clean and sober lifestyle. One advantage of the canoe journey
metaphor is that it emphasizes both the value of personal skills and
the community values of the canoe team as a whole. Each canoeist
must master basic skills ranging from navigation to survival. At the
same time, each individual contributes to the overall success of the
team effort. More than 120 Indian adolescents participated in the
prevention program, and data evaluation is underway. Although it
is too early to report findings, preliminary analyses suggest posi-
tive outcome trends at the 3-month follow-up (Cummins, Burns,
Hawkins, & Marlatt, 2003; Marlatt et al., 2003).
The purpose of this article was to review the field of substance
use prevention for American Indian and Alaska Native adoles-
cents. Epidemiological data indicate that the level of substance use
problems experienced by this population is endemic. Indian youth
are using alcohol and drugs at high frequencies and quantities and
are at great risk for a wide variety of associated negative conse-
quences. The need for effective prevention and treatment services
is paramount. Unfortunately, the majority of interventions cur-
rently underway are not being rigorously evaluated or dissemi-
nated for use in other communities.
On the basis of our review of the published outcome literature,
we offer in this article a set of best-practice approaches to help
guide the development and implementation of prevention pro-
grams for Native American youth. These include conceptualizing
prevention along a continuum, using a stepped-care model to
match interventions to the adolescent’s needs, incorporating bicul-
turally adapted life skills training into programs, and maintaining
extensive community involvement and collaboration in every stage
of the process. These are similar to the strategies for model
prevention programs outlined by the Division of Knowledge De-
velopment and Evaluation at SAMHSA’s Center for Substance
Abuse Prevention (1999). SAMHSA suggests six approaches that
can be used alone or in combination with each other. The first is
information dissemination, which entails increasing knowledge
and altering attitudes by providing information about the nature,
prevalence, and consequences of substance abuse and addiction.
The second strategy is prevention education, or teaching life and
social skills. Third is alternatives, or providing drug-free activities
to meet the developmental needs of youth and decrease their
participation in events where substances are likely to be used. The
fourth strategy is problem identification and referral; this suggests
that prevention programs should have a method of identifying
youth who have already begun experiencing substance-related
problems in order to refer them to more intensive services or
treatment as needed. Fifth is community-based process, or building
interagency coalitions and providing community members and
agencies with training in substance use education and prevention.
The last strategy is an environmental approach, or altering policies
that can reduce risk factors or increase protective factors.
These six strategies are highly consistent with the best-practice
approaches recommended here, as well as with Native American
community values and needs. Contemporary prevention efforts
within Native communities often emphasize a holistic approach to
health and thus resonate with Native American community values
(Vanderwagen, 1999). Programs have begun to incorporate spiri-
tual components with increasing frequency in hopes of instilling
traditional values and a respect for sobriety before young people
begin experiencing substance-related problems (Mail & Johnson,
1993). The development of effective prevention programs requires
an understanding of the strengths and values inherent in Indian
communities. Incorporating these cultural factors into prevention
efforts will enhance the acquisition of culturally relevant coping
skills and, ultimately, lead to a reduction in substance misuse.
The Journeys of the Circle project described earlier was devel-
oped to incorporate these best-practice approaches and strategies
and to address the need for prevention efforts that are both etic and
emic in their approach. Through a partnership with the local
American Indian community, researchers created a prevention
program that incorporates substance abuse education, bicultural
life skills training, and after-school alternative activities. All par-
ticipants were screened for alcohol and drug problems prior to
entering the program and were referred for more intensive services
where indicated. Although developed specifically for urban Amer-
ican Indian youth in Seattle, it may be relevant and useful for tribal
communities as well. The core etic components can be modified
and delivered using relevant emic cultural traditions and meta-
phors. In the Pacific Northwest, the canoe journey symbolism was
a culturally congruent mode of delivering the curriculum. In other
geographic and cultural regions, local stories, myths, and resources
can be used to adapt the course to be more relevant and effective.
Further research will lend information critically necessary to guide
efforts to transfer and adapt the Journeys of the Circle program for
use in other urban and reservation communities.
This review suggests that programs that utilize Indian strengths,
values, and beliefs to promote healthy behavior and reduce the
harm associated with high-risk behaviors, including substance
misuse, are strongly indicated. The discriminating and thoughtful
use of pan-tribal commonalties to adapt approaches found to be
effective in mainstream populations is perhaps the most promising
and cost-effective practice currently available. These programs can
then be customized for implementation in individual community
settings. Such interventions provide the foundation for programs
that are both scientifically validated and culturally sensitive. By
building on the recommendations outlined here and evaluating
their results, the field of psychology can continue advancing the
knowledge base concerning substance use prevention in Indian
communities and thereby more effectively help Indian adolescents
create and maintain healthier lifestyles.
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Received November 7, 2002
Revision received September 2, 2003
Accepted October 3, 2003 ?
PREVENTING SUBSTANCE ABUSE IN INDIAN YOUTH