International Journal of Drug Policy 16 (2005) 403–414

Should harm minimization as an approach to adolescent substance

use be embraced by junior and senior high schools?
Empirical evidence from An integrated school- and community-based
demonstration intervention addressing drug use among adolescents
Christiane Poulin ∗ , Jocelyn Nicholson
Dalhousie University, Canada

Received 3 June 2005; received in revised form 19 October 2005; accepted 1 November 2005

Abstract

The objective of this demonstration project was to determine if school-based harm minimization drug education was potentially acceptable
and effective for junior and senior high school students in Nova Scotia. We conducted a four-year quasi-experimental intervention using
mixed quantitative and qualitative methodologies. The intervention was a co-operative participatory research project with various activities
determined by the participants. The project involved a partnership of four schools, two school boards, two regional addiction services, the
provincial department of health, and a university. The outcomes evaluation was based on a sample of 1117 and 849 students in the intervention
schools, compared with 3755 and 4247 students in the rest of the province, in 1998 and 2002, respectively. The evaluation of acceptability
was based on an analysis of 491 documents generated from 1998 to 2002. The outcomes of effectiveness were specific risks and harmful
consequences associated with substance use. We found that harm minimization was an acceptable approach to drug education targeting the
senior high school population, and there was also some evidence of effectiveness in that age group in that the prevalence of several risks and
negative consequences of substance use decreased significantly in the intervention schools relative to the rest of the province. In junior high
school, harm minimization was found to not be an acceptable approach to drug education. This demonstration project provides evidence that
school-based harm minimization may be acceptable and effective in senior high schools but may not be acceptable in junior high schools.
© 2005 Elsevier B.V. All rights reserved.

Keywords: Harm minimization; Harm reduction; Adolescence; School drug education; Alcohol; Cannabis; Participatory research; Canada

Rationale for a demonstration intervention
From 1991 to 1998, the prevalence of substance use
increased markedly among adolescent students in the Cana-
dian province of Nova Scotia (Poulin & Baker, 1998; Poulin
& Elliott, 1997; Poulin et al., 1999). The annual prevalence of
cannabis use, for example, increased from 17% to 38%. The
increasing trend in substance use underscored the limitation
of primary prevention as a goal of drug education, particu-
∗ Corresponding author. Present address: Department of Community
Health and Epidemiology, Dalhousie University, 5790 University Avenue,
Halifax, Nova Scotia, Canada B3H 1V7. Tel.: +1 902 494 1921;
fax: +1 902 494 1597.
E-mail address: Christiane.Poulin@dal.ca (C. Poulin).
larly as the effectiveness of school-based primary prevention
programs had repeatedly been shown to be equivocal or short-
lived (Brown & Horowitz, 1993; O’Connor & Saunders,
1992; Resnicow & Botvin, 1993; Rundall & Bruvold, 1988;
Tobler, 1986).
These events provided an impetus for Nova Scotia to seek
a new approach to address substance use among mainstream
adolescents still in school. An ad hoc multi-disciplinary
Working Group favored a drug education approach in which
the goals, strategies and outcome measures would capture
the full spectrum of patterns of use and levels of risk among
the different subgroups of the adolescent population, and in
which the achievement of abstinence might be viewed as only
one potential option among a broad range of options. Thus, it
appeared the desired approach might fall under the rubric of

0955-3959/$ – see front matter © 2005 Elsevier B.V. All rights reserved.
doi:10.1016/j.drugpo.2005.11.001
404 C. Poulin, J. Nicholson / International Journal of Drug Policy 16 (2005) 403–414
harm minimization (also called harm reduction) (Duncan,
Nicholson, Clifford, Hawkins, & Petosa, 1994; Erickson,
1997; Marlatt, 1996). According to Erickson (1997), harm
reduction drug education is “education about drugs rather
than against drugs. The goal is to provide accurate and cred-
ible information that will promote responsible behaviour.
This approach acknowledges the appeal of drug use from the
young person’s perspective as well as its potential medical,
social and legal consequences. It is rooted in an appreciation
of adolescent psychosocial development, in which curiosity,
a willingness to experiment and the definition of personal
boundaries come into play.”
While there existed in 1998 examples of harm reduc-
tion strategies targeting adults (e.g. server interventions in
licensed bars), how harm minimization drug education might
apply to adolescents in school was unclear. We therefore per-
formed a systematic review of the literature concerning harm
minimization theory and practice as applicable to adoles-
cents in school. In order to critically appraise published harm
minimization drug education programs, we identified as our
framework the following attributes of harm minimization.
First, the primary purpose of the harm minimization pro-
gram must have been to reduce harmful consequences associ-
ated with drug use (Heather, Wodak, Nadelmann, & O’Hare,
1993). Second, the concept of harm must have been viewed
along a risk continuum (Marlatt, 1996). Third, the stance
taken on the issue of abstinence in respect to an ultimate
least harmful outcome must have been neutral (Single, 1995).
Finally, harmful consequences must have been expressed in
terms of measurable outcomes (Lenton & Midford, 1996).
As of 1998, only three published harm minimization edu-
cation approaches had incorporated enough of the above
attributes to be adapted into an experiment elsewhere. In
the United Kingdom, Cohen and co-workers disseminated a
curriculum to train teachers in harm minimization drug edu-
cation (Clements, Cohen, & Kay, 1996; Cohen, 1997; Cohen
& Kay, 1992; Kay, 1994). The packages aimed to provide
health and education professionals, parents and students with
factual information about drug use, guidelines for program
and policy development, activities, and parent–child discus-
sion and problem solving. Unfortunately, the effectiveness of
the approach had not been evaluated.
In Canada, the Rural and Northern Youth Intervention
Strategy Project developed by the Addictions Foundation
of Manitoba (AFM) was a school drug education program
that incorporated a harm minimization philosophy (Proactive
Information Services Inc., 1994, 1995). Students at high risk
were referred to a special project AFM counselor. Schools
were required to develop comprehensive alcohol and drug
policies that support rather than punish students. The eval-
uation revealed that an early intervention process was fea-
sible, interaction with professionals had increased, and the
addictions counselor played a role that could not realistically
be played by teachers (Proactive Information Services Inc.,
1995). The program was not described in sufficient detail to
allow replication.
In our opinion at the time of our systematic review in 1998,
the best described school-based harm minimization demon-
stration project was a doctoral dissertation hailing from the
United States (Somers, 1995). Somers’ research identified
the psychological theories underpinning the intervention, the
specific harm minimization goals, the methods for evaluating
perceived effectiveness and objective impact, and described
the intervention. The goals of the project were to reduce lev-
els of alcohol use and problems related to alcohol use; to
promote moderate drinking and abstinence as risk minimiza-
tion options; and to evaluate students’ receptiveness to the
approach. The project comprised a needs assessment and a
brief cognitive-behavioural alcohol prevention intervention.
The evaluation revealed a significant decrease in harmful
consequences using explicit criteria, and no change in the
baseline prevalence of abstinence. However, the project was
conducted in only one private school and involved only 50
students. Somers stated that the project was not feasible in
the public school system because of education administra-
tors’ concerns with implementing a non-abstinence-oriented
prevention program. We considered that particular limitation
as critically important as we embarked on our own school-
based harm minimization project.
Thus, our systematic review of the literature in 1998
revealed a dearth of programs for school-based harm min-
imization. We found no peer-reviewed comprehensive harm
minimization program targeting youth in school with both
process and outcome evaluations. We therefore started a
demonstration project entitled An integrated school-and
community-based demonstration intervention addressing
drug use among adolescents (SCIDUA) to determine if
school-based harm minimization drug education might be
acceptable and effective in junior and senior high schools in
Nova Scotia.
Design of our demonstration intervention
Theoretical underpinnings of SCIDUA
We agreed with Somers’(1995) understanding of harm
minimization as “engaging adolescents in a process of self-
management so that they may be capable of anticipating risky
situations, and generating viable, preferred alternatives, that
are suited to the situation at hand and reflect their own con-
sidered goals.” We further agreed with Somers’ invoking of
four psychological theories to support a harm minimization
approach at the individual adolescent level, including: cogni-
tive dissonance (Festinger, 1957) as the rationale for present-
ing factual information to effect more realistic perceptions
about the prevalence and acceptability of alcohol use among
peers; Jessor’s (1993) theory characterizing adolescents as
interactive participants within networks of systems which
together determine risk; social learning theory as adapted to
alcohol education, to address the gap between social context
and classroom instruction (Room, 1994); and, the stages of
 C. Poulin, J. Nicholson / International Journal of Drug Policy 16 (2005) 403–414
change model (Prochaska & DiClemente, 1982) where the
responsibility of goals and action is left with the client.
However, we also understood that for harm minimization
drug education to be viable or even examined in the public
school system in Nova Scotia, we needed to go beyond the-
oretical frameworks that operate at the individual adolescent
level. Importantly, we recognized that the key stakeholders
in drug education in this province had mutually incongruous
spheres of authority and action as concerns drug education, in
the following ways. Firstly, if adolescents are the users, then
they and only they have ultimate control over their own per-
sonal behaviour. However, adolescents in the school setting
do not have the power to influence drug education programs
and policy, i.e. schools do not have to negotiate with students
as to the goals of programs and policies. Secondly, the school
system has been given the task of delivering drug education,
the health system (in particular, addictions services) has a
designated budget to develop drug education, whereas the
community is where adolescent substance use typically takes
place. Finally, in the case of adolescents, alcohol, tobacco
and cannabis use are all illegal in some way. School and
school board administrators were concerned that a goal which
is not explicitly abstinence in a school-based drug educa-
tion program targeting adolescent students could potentially
result in a legal challenge or criminal charges to their institu-
tions or themselves personally. These are serious constraints
when considering the introduction of harm minimization drug
education to adolescents in school. We therefore adopted
community building as our theoretical framework at the com-
munity level in order to “engage with these multiple dimen-
sions of community, recognizing the range of perspectives
and relationships that exist and integrating diverse strategies
and methods of practice. The goal is to build the capacity
of the entire system, and all of its participants, to operate as
community.” (Walter, 1997).
Finally, the need to involve persons from all levels of edu-
cation to allow an exploration of harm minimization in the
public school system, including students, led us to adopt co-
operative participatory research as our basic research method-
ology (Reason, 1994). In co-operative inquiry, persons partic-
ipating in the research are acknowledged as self-determining
and what they do and experience as part of the research must
be determined by them to some significant degree.
Schools participating in the intervention
Comprised primarily of European descendants, the popu-
lation of Nova Scotia is relatively homogeneous. In 2001, the
province of Nova Scotia had a population of about 897,570
persons; about 95% of the population speaks English at home
(Statistics Canada, n.d.). As of 2001, Aboriginals and other
visible minorities made up 1.9% and 3.8% of the population
of Nova Scotia, respectively (Statistics Canada, 2001).
In 1998, all seven school boards in the province were
informed about the possibility of a demonstration project
and were invited to participate. The project organizers were
405
looking to recruit a total of four schools as there was suffi-
cient funding for at most four schools. Two school boards,
and subsequently two schools identified by each of these
boards, expressed a desire to participate in SCIDUA. Two
of these schools were mixed junior–senior (grades 7–12)
high schools located in the major agricultural region of the
province, with one school having a catchment area of numer-
ous small communities in an area of 275 square miles, and
the other being located in a town of 6000 residents. A fur-
ther two schools were middle schools (grades 7–9) located in
Nova Scotia’s capital city. At the start of the project, the urban
schools had enrolments of about 600 and 250 students, and
the rural schools had enrolments of about 400 and 800 stu-
dents. Administrative changes took place in the participating
schools during the four years of fieldwork of SCIDUA. For
example, a total of eight school principals were involved in
SCIDUA during the fieldwork as a result of human resource
decisions not related to SCIDUA made at the school board
level. Changes also took place in the physical plants of the par-
ticipating schools. For example, in 2001, students in grades
9–12 of one of the rural schools were relocated to a new
school. In order to ensure continuity, SCIDUA followed this
cohort of students, the principal and guidance counsellor to
their new school. SCIDUA therefore involved five schools in
the four-year period of field work, but took place in only four
schools at any given time. Our demonstration project thus
involved a partnership of five schools, two school boards,
two regional Addictions Services, the provincial Department
of Health and Dalhousie University.
Project purpose and structure
The primary goal of SCIDUA was to “decrease harm-
ful involvement with and harmful consequences of alcohol,
tobacco, other drugs and gambling” in junior and senior high
school. Gambling was dropped as a focus during the second
year of field work because it was not a priority issue for these
school communities.
From September 1998 to June 1999, we created an orga-
nization and a process to allow us to work as a partner-
ship of institutions. The development phase of our project
required the participation of professionals in positions of rel-
ative power such as school principals and administrators in
addictions services. Their participation was essential given
concerns with implementing a drug education program that
was not specifically abstinence-oriented. In effect, given the
absence of government- or school board-level policy endors-
ing a harm minimization approach to drug education, this
project would not have gained entry into schools had it not
been for the willingness of partners at high policy levels
to allow an exploration of an unproven and controversial
approach. We forged a Memorandum of Understanding stipu-
lating terms of reference for the School Community Steering
Committees, the Regional Project Advisory Committees, the
Provincial Project Review Committee, the project coordina-
tors and the principal investigator.
406 C. Poulin, J. Nicholson / International Journal of Drug Policy 16 (2005) 403–414
The spring 1999 saw the inclusion of members of the
population the intervention purported to address: adoles-
cents themselves. A large part of the energy and activities of
SCIDUA sought to engage adolescents from all parts of the
risk continuum. An Interim process evaluation of SCIDUA
conducted by an External team in the spring of 2001 con-
cluded that there was evidence that (1) marketing strategies
had been thoughtfully applied to attract students, school staff
and parents; (2) that in some schools, recruitment of parents
and teachers had proven to be more difficult than recruit-
ment of students; (3) that parents and community stake-
holders appeared to significantly contribute to the project
development and implementation; and, (4) that some schools
appeared to have more enthusiastic community involvement.
The External team also concluded that the project structure
provided mechanisms that offered philosophical leadership
and resources, as well as project-based leadership in the form
of coordinators, which in turn provided opportunities to the
participants to identify and address issues in their communi-
ties.
School community fieldwork
The fieldwork was initiated by two project coordinators
each of whom was responsible for two schools. The coordina-
tors initiated communication among a variety of individuals
and groups connected to the schools. Student involvement
was treated as a priority. Student representation on the SCSCs
was fairly stable at some schools whereas others needed
annual recruitment. The SCSCs included students, teachers,
the school counselor and a staff member of Addiction Ser-
vices. In addition, some SCSCs invited representatives from
law enforcement, parents, local government and community
groups. This variation in membership reflected the unique
needs and resources of each individual school community.
Coordinators met every two weeks with the committees to
discuss student drug use and to support project activities.
The intervention at the field level was not program-based
and participants were not asked to implement a specific harm
minimization school curriculum. Rather, the approach was
designed to encourage the school and community stakehold-
ers to explore together the issue of student substance use and
then create specific interventions based on what they deemed
to be appropriate for their students. The structure of the
project allowed the coordinator to explain harm minimization
and create opportunities for discussion about harm minimiza-
tion but the participants themselves decided what approaches
they wished to design and implement for their students. Over
the course of the fieldwork, the SCSCs implemented a wide
range of drug education activities such as presentations, pub-
lic service announcements, broad communication of drug
education messages, parent information sessions, teaching
videos, first aid education, teen recreation and leisure oppor-
tunities, building better rapport between adults and teens
through events or community meetings, and fund-raising for
worthy causes. An example of a harm minimization product
that came out of the efforts of one SCSC is “Pot Holes. The
risk of cannabis use and driving”, a video which was later
acclaimed at a provincial workshop of education and health
professionals as providing a clear understanding of harm min-
imization as it might apply to drug education in high school
(T.A.D.A., 2001). Finally we note that, while action-oriented,
the SCSCs identified the opportunity for dialogue between
teens and adults regarding student drug use as in itself an
important intervention.
Evaluation design
Our evaluation design included a quasi-experimental
design with a control group and measurable outcomes in order
to assess effectiveness, and a process evaluation in order to be
able to explicate how and why the outcomes were achieved.
By design, both qualitative and quantitative paradigms and
methods of inquiry were incorporated into this demonstration
project in order to ensure that we would have credible multi-
faceted evidence about harm minimization as an approach to
drug education in the public school system.
Outcomes evaluation of effectiveness
We used a quasi-experimental pre-test/post-test design
with students in the intervention schools completing the same
questionnaire as students in the rest of the province participat-
ing in the Nova Scotia Student Drug Use Survey (NSSDUS).
This province-wide anonymous self-reported drug use sur-
vey calls for a representative sample of students in grades
7, 9, 10 and 12 (Poulin, MacNeil, & Mitic, 1993; Poulin,
Hand, Boudreau, & Santor, 2005; Poulin et al., 1999). A total
of 3755 and 4247 students participated in the NSSDUS in
1998 and 2002, respectively. A total of 1117 in the SCIDUA
intervention schools and in those grades completed the same
questionnaire at the beginning (either 1998 or 1999) of the
field work. The anonymous nature of the survey precluded our
tracking students at the individual level. The cover page of the
2002 questionnaire administered to the students in the inter-
vention schools asked students if they had attended one of the
intervention schools in the previous year. The outcomes eval-
uation was based on the responses of the 849 students who
in 2002 indicated they had attended one of the intervention
schools in the previous year. All surveys were administered
in a four-week period in the spring of the year. The question-
naire comprised 100 questions requesting information about
demographic and social characteristics, substance use and
related behaviours, school rules and help-seeking. Measures
ensuring that the standardized survey is valid, reliable and
minimizes under-reporting are implemented at each iteration
of the survey (Poulin et al., 1993). A detailed description of
the survey is available elsewhere (Poulin et al., 2005).
In the present study, the null hypothesis was that the
change from 1998 to 2002 in prevalence of specific risks
and harmful consequences of use would be the same among
students in the intervention schools as among students in the
rest of the province. Our alternative hypothesis was that the
 C. Poulin, J. Nicholson / International Journal of Drug Policy 16 (2005) 403–414
change from 1998 to 2002 in the prevalence of these risks
and consequences would be more favorable among students
in the intervention schools than among their counterparts in
the rest of Nova Scotia. We used a two-sided test because,
while there was reason to expect that the intervention would
result in a more favorable change in the intervention group
than in the control group, there was also a concern with the
possibility that the intervention would result in a worsening
of the situation.
The main outcomes of interest comprised 8 risks and
harmful consequences of use: heavy episodic drinking (5
or more drinks at a sitting) in the 30 days prior to the
survey; and, in the 12 months prior to the survey, driving
under the influence of alcohol, being a passenger with driver
under influence of a substance, having damaged things when
drinking, alcohol use having caused injury to onself, driv-
ing under the influence of cannabis, having damaged things
when using drugs, and drug use having caused injury to
oneself. We also monitored the use of five substances (any
use of alcohol, cigarettes, cannabis, LSD and non-prescribed
amphetamines or methylphenidate, in the 12 months prior
to the survey) as there was a concern that the intervention
might result in an increase of experimentation with substance
use.
As the study design for the outcomes evaluation entailed
a cross-sectional survey performed at two points in time in
intervention and comparison groups with no tracking of indi-
vidual students, the 1998 and 2002 samples were therefore
analysed as independent samples. We estimated population
and sub-population means and proportions followed by esti-
mations of linear combinations of differences. Regarding the
13 outcomes of interest, we compared (1) the prevalence
of these among the intervention students and their coun-
terparts in the rest of the province at the beginning of the
field work, and, (2) the difference in the change in preva-
lence from the beginning to the end of the field work of the
intervention group relative to their counterparts in the rest of
the province. Due to the nature of our intervention schools,
we performed all statistical techniques on stratified groups
(junior level versus senior level, and junior versus mixed
junior/senior schools). We used a two-sided test with signifi-
cance set at p < 0.05. All estimations and statistical analyses
were performed taking into account the stratified cluster sam-
ple design, using svy commands in Stata 7.0.
Process evaluation of the acceptability of harm
minimization
Reported in the present article is an evaluation of the
acceptability of harm minimization drug education to stu-
dents, parents, teachers, school and school board admin-
istrators. During the four years of field work, about 3000
electronic files of data were collected from approximately
150 informants. All data were catalogued in order to ensure
comprehensiveness and accuracy as to source and chronol-
ogy. Paper data holdings were transformed into electronic
format. We used NUD*IST for data and file manipulation.
407
The quantity and types of data in the four schools reflect
the activities and priorities of the participants and therefore
were not identical across the schools. The variety of data
collection methods, the co-operative participatory research
framework and the length of the field work ensure that the data
used in the present study captured a diversity of opinions of
the persons most closely associated with the public education
system, including students themselves.
The present evaluation was based on documents gener-
ated primarily by the School Community Steering Com-
mittees (SCSCs) or arising from their activities, including
committee minutes, transcripts, reports, funding applications,
video scripts, media releases, presentations, reflections, notes
and survey tools. The minutes and transcripts of Advisory
Committees, and focus groups of selected stakeholders were
included in this analysis. The exit interviews of key infor-
mants at the end of the fieldwork served as confirmatory
information. The present analysis of the acceptability of harm
minimization drug education is thus based on a total of 491
qualitative files collected from 1998 to 2002.
The present qualitative data analysis was confined to data
coded as being relevant to drug education, student substance
use and harm minimization. We first examined the content of
specific participant groups’ statements, philosophies, goals
and activities. Data were coded according to key questions
and themes illuminating how participants conceptualized
harm minimization and to capture reasons for and against
accepting harm minimization. We used a modified grounded
theory approach to identify the basis of the acceptability of
harm minimization drug education to the school community,
through a constant comparative analysis of data from differ-
ent people, from the same individuals at different points in
time, from different events and incidents, within and across
categories (Streubert & Carpenter, 1995). We also performed
a content analysis to obtain a quantitative sense of the extent
to which harm minimization had been discussed explicitly.
Results
Evaluation of acceptability
Our evaluation sought to discern the acceptability of harm
minimization drug education to students, parents, teach-
ers, and school and school board administrators. We found
remarkable consensus within and across participant groups
regarding the sub-groups of the adolescent population for
whom harm minimization education was seen as acceptable
and applicable. In particular, harm minimization was seen
as an acceptable approach for drug education in senior high
school but not in middle school.
Regarding senior high school, we identified several condi-
tions that made harm minimization acceptable as a basis for
drug education. First, participants indicated that harm mini-
mization drug education should be adopted only if harm min-
imization as a philosophy and goal can be clearly understood
408 C. Poulin, J. Nicholson / International Journal of Drug Policy 16 (2005) 403–414
and put into practice by students. The fact that adolescents
take risks was not by itself seen as justifying the adoption
of harm minimization drug education. Senior high school
students and adults recognized that “responsible” use was
possible for older, more mature adolescents. Thus, harm min-
imization was deemed acceptable at the senior grade levels
because most students were likely to have sufficient capacity
to make informed decisions concerning the context of sub-
stance use, decisions that would place themselves or others
at less risk. Second, it was considered important that adoles-
cents should be able to understand that harm minimization
is an approach that supports wiser (less risky) choices, that
non-use is a viable choice and that harm minimization drug
education is not a license to use. Third, senior students indi-
cated that harm minimization, despite not being taught to
them overtly at school, was nonetheless already being imple-
mented by some of their peers.
“If I drink when I am with you, what is the first thing you
make me do? I give you my keys.” (FOCVstudtran1999.10)
Finally, harm minimization was viewed as acceptable
for senior high school students in part because adults were
already tacitly allowing older adolescents to make their own
decisions even if adults did not always condone adolescents’
choices.
“So to me as a parent, . . . It was a gradual loosening
of the ropes or the chains, if you will, allowing them to
learn to make decisions themselves.” (WKSHPVSCSC-
CKtran2000.06.08)
The adult participants in our project stressed that adoles-
cents needed to understand that use is never risk free and that
some negative consequences of use are subtle and become
apparent only years later. As explained by one principal, even
senior high school students may have difficulty appreciating
nuanced boundaries and risks at that stage in life.
“. . . I let them know that . . . I am not talking about or judg-
ing the choices they make but making a strong request that
if they are making the choice to be involved in drug use, it
starts at 3:30 on Friday and ends at 11:00 on Sunday. You
know, make a connection between the value of education
and the impact that drug use does have. And I even encour-
age debate. Like at the grade 11 assembly, we got into a
little bit of a debate with 2 students in particular who feel
comfortable enough to say that marijuana use can in fact
enhance your ability to focus on learning. And I encour-
aged that. Yes, let’s debate that. Trust my experience, and
I’ll tell you categorically that you are wrong. That in fact
it is detrimental. We got into a debate about the difference
between the effects of alcohol and the effects of marijuana.
And they feel quite comfortable in doing that. They know
that they are not going to be judged. They also know that
if I catch them, they are in shit. . . . So I draw the line with
respect to [using or] dealing in the school. They know quite
clearly where I stand there.” (ACVtran20000308)
Senior high school students and adults readily identified
examples of harm minimization that older adolescents were
already applying in their lives. Our content analysis revealed
that 72% of the senior high school Community Steering Com-
mittee (SCSC) meeting-related documents and 49% of their
activity-related documents contained dialogue or direct ref-
erence to a harm minimization approach. An example of an
activity document that clearly espoused a harm minimization
philosophy was a teaching video created by the senior high
school SCSC.
“When we thought about all of the different teens in our
school, we realized that we could no longer just look at pre-
vention. It was really important to help those students who
are using alcohol, tobacco and other drugs to minimize
their risks. Because our school is a rural one, many student
drive or get drives from other teens. [Our SCSC] acknowl-
edged the risks students were taking regarding smoking
pot and driving and thus our video, “Pot Holes” was born.”
(SCSCVCKvidintro).
Regarding middle or junior high school, there was remark-
able consensus as to the inappropriateness and unacceptabil-
ity of harm minimization drug education targeting that level.
The adults participating in this project, as well as senior and
junior high school students, pointed to several reasons for not
endorsing harm minimization as an approach to drug educa-
tion for junior or middle school, including the low prevalence
of substance use among younger students, the wide variability
in the development and maturity level of students in middle
school, and the tendency of younger students to misconstrue
harm minimization as condoning substance use. It was felt
that the appropriate goal for drug education targeting young
students was abstinence, whether or not students were already
engaging in substance use.
“Like in the hallways, you’ll hear the grade 8’s going, ‘Oh
I smoked dope this weekend’ and stuff. And then in the
hallway over there, it’s like ‘Well I got a new Barbie’ or
something.” (FOCVKCAstudtran1999.06).
”Junior high is . . . the age that we get the most problems.
Like I mean that is when it really surfaces. And to tell them
that it is okay to use it but use it safely, that is the wrong
message.” (ACHtran2000.04.25)
The SCSCs in the middle schools did not in fact embrace
harm minimization or implement a harm minimization
approach during SCIDUA. Our content analysis revealed that
only 2% of committee meetings contained direct dialogue
regarding harm minimization and only 4% of documents con-
cerning committee activities mentioned or alluded to harm
minimization. While some discussion of student substance
Table 1
Differences in the change in prevalence of substance use, risk behaviours and harmful consequences from 1998 to 2002, among junior students in grades 7 and 9, in the junior and mixed high schools participating

C. Poulin, J. Nicholson / International Journal of Drug Policy 16 (2005) 403–414

in SCIDUA, relative to the rest of the province of NS
Prevalence (%) at the beginning of field work Prevalence (%) at the end of field work Change in prevalence in SCIDUA schools
minus change in prevalence in rest of NS
Rest of NS Juniors in junior Juniors in mixed Rest of NS Juniors in junior Juniors in mixed Difference in percentages Difference in percentages
(n = 1872) HS (n = 501) HS (n = 244) (n = 2087) HS (n = 320) HS (n = 224) in junior HS in mixed HS
Alcohol use 39.5 38.7 45.5 33.1 33.5 38.4 1.2 −0.8
Cannabis use 26.1 28.3 34.9 23.7 23.5 33.9 −2.3 1.4
Cigarette smoking 28.2 26.7 32.8 15.8 15.8 23.1 1.5 2.6
LSD use 6.7 6.6 14.4* 3.9 3.4 2.7 −0.3 −8.8†
Non-medical use of 7.5 7.8 10.7 9.1 7.1 10.9 −2.3 −1.4
amphetamines or
methylphenidate
Heavy episodic drinking 18.4 15.5 20.5 15.1 13 12.2 0.7 −5
Driving after alcohol use 3.7 2.8 3.3 3.1 3.7 3.2 1.5 0.4
Passenger with driver who 21.4 16.2 23 18.8 19.3 19.7 5.7 −0.7
drank
Damaged things when 9 9 12.7 7.5 6.8 8.1 −0.7 −3.2
drinking
Drinking caused injury to self 9.3 6.6 12.7 6.4 7.4 6.3 3.8 −3.4
Driving after cannabis use 3.7 3.2 4.1 3.1 3.7 3.2 1.1 −0.4
Damaged things when using 4.4 4.6 8.2 4.1 3.7 5.4 −0.5 −2.4
drugs
Drug use caused injury to self 5 4.6 9 3.2 4.3 4.5 1.5 −2.8
* Prevalence significantly greater (p < 0.05) among SCIDUA students than among students in the rest of the province at the beginning of the field work.
† Significant difference (p < 0.05) in the change in prevalence among students in the SCIDUA schools compared with students in the rest of NS, from the beginning to the end of the field work.

409
410 C. Poulin, J. Nicholson / International Journal of Drug Policy 16 (2005) 403–414
Difference in the change in the prevalence of substance use, risk behaviours and harmful consequences from 1998 to 2002, among senior students in grades 10 and 12, in the mixed high schools participating in

‡ Borderline significant difference (0.05 ≤ p < 0.08) in the change in prevalence among students in the SCIDUA schools compared with students in the rest of NS, from the beginning to the end of the field
use occurred at the SCSC meetings, harm minimization was
minus change in prevalence in the rest of NS
Change in prevalence in SCIDUA schools

discussed specifically only when the goals of SCIDUA were

being reviewed by the project coordinator. The middle school
SCSCs viewed drug use itself as a problem and positioned

Significant difference (p < 0.05) in the change in prevalence among students in the SCIDUA schools compared with students in the rest of NS, from the beginning to the end of the field work.
themselves and SCIDUA as an advocacy group promoting
non-use.
Difference in percentages

The extensive cross-talk that took place during SCIDUA

brought to the fore the challenge of determining in which
school grade a transition should be made from abstinence-
based to harm minimization drug education. While there
appeared to be agreement that drug education for students in
−7.2†
−7.0†
−8.0‡

−10.2†

−5.6‡
−3.6‡
0.2
−5.3
−3.2

−3.5

−2.5
−4.8

−2.2
grades 7 and 8 (average age 12.5 and 13.5 years, respectively)
should be based on the goal of abstinence, and that for grades
10–12 (average age 15.5 and 17.5 years, respectively) harm
SCIDUA (n = 305)

minimization was appropriate, the goal of drug education for

Prevalence significantly greater (p < 0.05) among SCIDUA students than among students in the rest of the province at the beginning of the field work.

grade 9 (average age 14.5 years) remained unclear. Infor-

Prevalence (%) at the end of field work

mants indicated that using a harm minimization approach in

a grade 9 classroom would require significant skill and under-
34.9
68.2
53.9

9.1
13.2
35.1
8.8
19.6
13.1
12.6
17.8
3.4
5.8

standing of the teacher.

Finally, our analysis of the qualitative data collected dur-
Rest of NS (n = 2160)

ing the field work clarified the role of guidance counseling

relative to harm minimization. In general, guidance coun-
seling was viewed as a safety net for students experiencing
problems due to substance use. At the junior or middle school
level, how schools could identify users was seen as an essen-
31.2
72.4

7.2
16.9
44.7
10.2
26.8
18.7
17.4
16.9
4.5
5.1

tial component of the school drug control strategy with guid-

51

ance counseling being part of a response aimed at achieving

abstinence. Senior high school counselors indicated that harm
SCIDUA (n = 372)
Prevalence (%) at the beginning of field work

minimization was already part of the work they do and was

considered to be a viable goal of a substance use intervention
for some students.
22.8*

21.5*
47.7
75.3
55.6

16.9
45.9
14.1

15.3
17.5

7.2
7.6
36

Evaluation of effectiveness
Rest of NS (n = 1883)

As the NSSDUS calls for a representative sample of stu-

dents in grades 7, 9, 10 and 12, our evaluations of effective-
ness are based on grades 7 and 9 for junior/middle school
students, and on grades 10 and 12 for senior high school stu-
dents. Tables 1 and 2 show the prevalence of the 13 behaviours
44.1
74.2
49.5

13.6
13.5
47.4
12.1

18.4
17.6

4.7
4.7
33

15

of interest among junior (grades 7 and 9) and senior (grades

10 and 12) students in the intervention schools relative to
Non-medical use of amphetamines or methylphenidate

their counterparts in the rest of the province. Regarding stu-

dents in grades 7 and 9, at the beginning of the field work,
the prevalence of these 13 behaviours among students in the
SCIDUA relative to the rest of the province

intervention junior high schools did not differ significantly

from their counterparts in the rest of the province, whereas
in the mixed junior/senior high schools, the prevalence of
Damaged things when using drugs
Passenger with driver who drank

1 of these behaviours (LSD use) was significantly greater

Damaged things when drinking

Drug use caused injury to self

Drinking caused injury to self

than among their counterparts in the rest of the province

Driving after cannabis use
Driving after alcohol use

(Table 1). By the end of the field work, the prevalence

Heavy episodic drinking

of LSD use had decreased significantly among junior high

Cigarette smoking

school students in the mixed junior/senior high schools com-

pared with their counterparts in the rest of the province.
Cannabis use
Alcohol use
Behaviour

Table 1 also shows that the experiment failed to demonstrate

LSD use
Table 2

a significant decrease in the prevalence of the outcomes of

work.
*
†

interest among students in grades 7 and 9 in the interven-

 C. Poulin, J. Nicholson / International Journal of Drug Policy 16 (2005) 403–414
tion schools compared to their counterparts in the rest of the
province.
Regarding students in grades 10 and 12, at the beginning
of the field work the prevalence of two behaviours (LSD
use and driving after cannabis use) was significantly greater
among students in the intervention schools than among their
counterparts in the rest of the province (Table 2). By the
end of the field work, there was a significant decrease in the
prevalence of LSD use (p = 0.012), the use of amphetamines
or methylphenidate (p = 0.041), and being a passenger with
an alcohol-impaired driver (p = 0.005), as well as border-
line significant decreases in the prevalence of heavy episodic
drinking (p = 0.078), driving under the influence of cannabis
(p = 0.057) and damaging things when under the influence
of a drug (p = 0.060), among students in grades 10 and
12 in the intervention schools compared with their coun-
terparts in the rest of the province. Table 2 also shows
that there was a non-significant tendency of a decreasing
prevalence of all the remaining behaviours except cigarette
smoking, among student in grades 10 and 12 in the interven-
tion schools relative to their counterparts in the rest of the
province.
Discussion
Should the traditional focus, which is the prevention of
drug use itself, be subsumed by a broader harm minimiza-
tion approach? The present demonstration project in Nova
Scotia, Canada, provided evidence that harm minimization
drug education may be acceptable and effective in senior high
school, and may not be acceptable (or feasible) in junior high
school. In particular, among senior high school students, this
demonstration intervention provided evidence of a decrease
in the prevalence of specific risks and negative consequences
of alcohol and cannabis use, and qualitative evidence that
harm minimization was acceptable for and by senior high
students and the school community. In contrast, as pertains
to junior high school students, this project provided evi-
dence that harm minimization was not acceptable and had not
been implemented to any extent, which explains the subse-
quent failure of the experiment to demonstrate improvement
in the prevalence of specific risks and harms of substance
use.
At the inception of our intervention demonstration project
in 1998, there existed little evidence internationally about
the effectiveness of harm minimization as an approach to
substance use by adolescent students. In 2002 and 2004, an
Australian study reported on the results of the School Health
and Alcohol Harm Reduction Project (SHAHRP) (McBride,
Farringdon, Midford, Meuleners, & Phillips, 2004; McBride,
Midford, Farringdon, & Phillips, 2000). SHAHRP was a lon-
gitudinal efficacy study of a harm reduction curriculum, with
14 government secondary schools in the Perth metropolitan
area of Western Australia randomly allocated to intervention
or comparison groups. The goal of SHAHRP was to reduce
411
alcohol-related harm. Students in grade 8 (13 years of age)
were followed until grade 10 (32 months). The intervention
students were found to be significantly less likely to drink
to risk levels, and significantly less likely to experience harm
from their own use of alcohol, from the first to the last follow-
up (McBride et al., 2004).
The Australian experiment provided evidence support-
ing harm reduction goals using a classroom approach. The
designers of SHAHRP argued that curriculum-based class-
room harm minimization approaches are cost-effective and
require less external expertise than do comprehensive pro-
grams, with the latter defined as programs which may include
classroom, policy, environmental, parental and community
components (McBride et al., 2004). Here, it is important
to appreciate the policy context of the Australian exper-
iment. Australia has had a National Drug Strategy based
on harm minimization since 1993 and the Australian States
and Territories all adopted harm minimization as a fea-
ture of drug education (Midford & McBride, 1999). The
policy context of the Australian experiment therefore per-
mitted the testing of a curriculum-based harm reduction
intervention.
The intervention approach for SCIDUA should be under-
stood within the policy context of drug education in Nova
Scotia and Canada. In particular, Canada’s Drug Strategy
(1986), while supportive of harm reduction in principle,
was not ratified by the Canadian provinces (Health Canada,
Office of Alcohol, Drugs, and Dependency Issues, 1998).
In Nova Scotia, addictions largely falls under the aegis of
the provincial Department of Health, including dedicated
resources for setting strategic directions and standards for
drug education from a health perspective. The delivery of
school-based drug education is the responsibility of the pub-
lic education system. Regional school boards are elected
and parents and the general public therefore play an active
role in the development of school board policy. Clearly the
acceptability to parents and community of a new and con-
troversial drug education approach being contemplated for
introduction into public schools is not moot. In 1998 in Nova
Scotia, the lack of provincial government or school board
policy formally supportive of harm minimization for adoles-
cents in school made a standardized curriculum-based harm
minimization intervention impossible. A co-operative par-
ticipatory research approach was viewed as the only ethical
way to engage the school-community in an informed discus-
sion on harm minimization as it might pertain to mainstream
adolescents in public schools. This approach offered a prag-
matic solution to the difficulty of recruiting public schools
for a non-abstinence-oriented prevention project, which had
been an unsurmountable problem for Somers (1995). The
participatory approach also had the potential for “priming
the pump” for the development of innovative school board
policy.
The wide range of drug education activities encompassed
in SCIDUA reflected the understanding of all involved that
adolescent substance use is a complex issue requiring mul-
412 C. Poulin, J. Nicholson / International Journal of Drug Policy 16 (2005) 403–414
tiple, complementary and ongoing interventions, and that no
single specific prevention intervention is likely to be effec-
tive. In that regard, SCIDUA was consistent with American
and Canadian best practices addressing youth substance use
which emphasize collaboration and commitment among mul-
tiple stakeholders (Health Canada, Office of Canada’s Drug
Strategy, 2001; National Adolescent Health Information
Center, 2004). In a real sense, the main intervention in the
present demonstration project was providing teenagers, par-
ents, teachers, school administrators, and addictions profes-
sionals with an ongoing opportunity to communicate mean-
ingfully about substance use. Talk was translated into action;
more importantly, talk was action.
The participatory approach of SCIDUA provided the
means for the school community to identify its own priorities
relative to substances and harms and to initiate action as they
deemed fit. Being a passenger in a vehicle with a substance-
impaired driver and driving under the influence of cannabis
were identified by one of the SCSCs as particular behaviours
they wished to change. That SCSC decided to create a video
about cannabis-impaired driving, and then expended consid-
erable energy determining their mandate relative to impaired
driving, building their relationships with the school adminis-
tration and law enforcement, developing a balanced script and
story-line, and acquiring technical expertise. From a health
promotion perspective, the creative act of producing a video
allowed the school to come together to “own” and address the
issue of impaired driving. From a positivist perspective, the
significant improvements in driving-related behaviors among
senior high school students in that intervention school may
be attributed in part to these activities.
Our demonstration project was clearly an essential first
step given ethical concerns about the relatively uncharted ter-
ritory of harm minimization drug education targeting minors
in the public education system. From the outset, we recog-
nized three limitations in the quantitative arm of the study
arising from its demonstration nature. First, the outcomes
evaluation of the intervention is based on cross-sectional
surveys at two points in time rather than on a longitudinal
design tracking individual students. Tracking individual stu-
dents was deemed not possible because the scope of the study
included cannabis and there were ethical concerns that stu-
dents who engaged in illicit drug use could inadvertently be
identified. Second, the intervention schools were not selected
randomly thus possibly introducing selection bias and limit-
ing our ability to make an inference about our results to the
general junior and senior high school populations. However,
the fact that these schools volunteered for SCIDUA does not
a priori mean the schools were in favour of harm minimiza-
tion. Rather, the schools who volunteered for SCIDUA had an
accepting attitude toward engaging in an intervention which
they could actively shape and which was open to the pos-
sibility of harm minimization. Our comprehensive analysis
shows that the junior high schools participating in SCIDUA
did not in fact accept harm minimization nor implement harm
minimization activities. That is, while all four schools were
interested in innovative approaches to education, the middle
schools were clearly not “early adopters” of harm minimiza-
tion, and the mixed schools were open to harm minimization
drug education pending evidence about its acceptability and
effectiveness. Third, the school and community activities
of SCIDUA were not standardized across the intervention
schools. We chose and were true to a co-operative partic-
ipatory research approach because we recognized that the
question of acceptability trumped the desirability and feasi-
bility of a precise intervention and top-down evaluation. The
promising findings from SDICUA now open the door for an
efficacy study of a standardized school curriculum targeting
senior high school students.
These three aspects of the study design limit the general-
izability of the findings of SCIDUA, but not their value. As a
demonstration project conducted “in the trenches”, SCIDUA
has provided an in-depth understanding of how and why harm
minimization drug education may or may not be acceptable
to real communities, schools and multiple stakeholders. The
acceptability and effectiveness of harm minimization drug
education are contextual for many reasons, including the fact
that the extent of substance use is widely variable in person,
place and time. For example, whereas 12% of students 13
years of age in Western Australia reported using alcohol at
least weekly in the baseline measurement of the SHAHRP
study (McBride et al., 2004), only 3% of Nova Scotia stu-
dents 13 years of age reported that alcohol pattern at baseline
in SCIDUA. Clearly, what works in Western Australia may
or may not be appropriate, feasible or effective in Nova Sco-
tia. Our finding that “one size does not fit all” relative to
the acceptability of harm minimization targeting junior and
senior high school re-enforces the need for a thorough appre-
ciation of the context in which this proposed policy is to
operate.
In summary, harm minimization is increasingly being
advocated as the basis of school-based drug education. In
the United States and Canada, harm minimization for ado-
lescents in school would represent a sea change in health
and education policy. To date, there has been little empiri-
cal evidence as to the acceptability and effectiveness of this
approach to drug education. To our knowledge, SCIDUA is
the first Canadian study on harm minimization drug education
addressing substance use among mainstream adolescents in
school. The present demonstration project showed that harm
minimization may be an acceptable and effective approach to
drug education for senior high school students, but may not
be acceptable for junior high schools students. Our study fills
a gap in the international literature by providing an innova-
tive methodological approach to enquiry as well as empirical
evidence about a controversial social policy targeting youth.
Acknowledgements
This research was supported by the Canadian Institutes
for Health Research (grant 15533), Dalhousie University, the
 C. Poulin, J. Nicholson / International Journal of Drug Policy 16 (2005) 403–414
Nova Scotia Department of Health, Addictions Services in
District Health Authorities 1-2-3 and 9, the Halifax Regional
School Board and the Annapolis Valley Regional School
Board, in Nova Scotia. Dr. Poulin holds a Canada Research
Chair in Population Health and Addictions.
We thank the following persons for their contributions
as members of the SCIDUA Advisory Committees or as
reviewers of this paper: Jim Baker, Jane Bishop, Rick
Bray, Clare Burley, Maxine Clarke, Hubert Devine, Janice
Foote, Janice Graham-Migel, Robert Harris, Catherine Hebb,
Michael Langley, Todd Leader, Everette MacPherson, Eartha
Monard, Betty Nicholson-Smith, Tom Payette, Nancy Pynch-
Worthylake, Jeannette Tobin, Terry Wadden, Gordon Young,
Nataleen Zinck.
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