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  Which psychosocial factors moderate or directly affect substanceuse among inner-city adolescents? Jennifer A. Epstein  ⁎ , Heejung Bang, Gilbert J. Botvin  Institute for Prevention Research, Department of Public Health, Cornell University, Weill Medical College,411 East 69th Street, New York, NY 10021, United States Abstract Past etiology of adolescent substance use research concentrated on the main effects of various risk factors. The purpose of this study was to also longitudinally predict interactions on poly-drug use intensity and future smokingamong inner-city adolescents. A panel sample of baseline, 1-year and 2-year follow-ups (  N  =1459) from the controlgroup of a longitudinal smoking prevention trial participated. We focused on the main effects, as well as, interactioneffectsbetweenpsychosocialprotectivefactorsandvariousriskfactors,includingperceivednormsoffriends,peersandadultstousedrugs.Significanteffectswereidentifiedforintensityofpoly-druguseandfuturesmoking.Theanalysisof the poly-drug use outcome indicated that refusal assertiveness undermined perceived friends' drug use and siblings'smoking, and that low risk-taking undermined perceived friends' drug use. There was a main effect for low psychologicalwellness.The significantinteractionsbetweenperceivedfriends'druguse withrefusal assertivenessanddecision-makingskillswereobservedforfuturesmoking.Moreover,perceivedpeersmokingnorms,siblings'smoking,and high risk-taking also showed significant main effects for increasing future smoking.© 2006 Elsevier Ltd. All rights reserved.  Keywords:  Adolescence; Substance use; Inner-city populations; Psychosocial factors; Peer and friends' norms; Perceived familysmoking Research relevant to adolescent drug use has been shifting from a focus on risk factors to one that alsoincorporates the skills individuals need to meet environmental challenges ( Norman, 1994). Based on a pure risk factor approach, the aim of drug abuse prevention is to eliminate, reduce or mitigate risk factors.A resiliency approach, on the other hand, emphasizes prevention by enhancing behavioural factors that  Addictive Behaviors 32 (2007) 700 – 713 ⁎  Corresponding author. Tel.: +1 212 746 1270; fax: +1 212 746 8390.  E-mail address:  jepstein@mail.med.cornell.edu (J.A. Epstein).0306-4603/$ - see front matter © 2006 Elsevier Ltd. All rights reserved.doi:10.1016/j.addbeh.2006.06.011   protect against vulnerability. Accordingly, such an approach posits that both risk factors and vulnerabilitysignificantly contribute to a model of adolescent drug use and furthermore that resilience moderates theeffects of individual vulnerabilities and environmental hazards. Akers' criminology model of SocialStructure and Social Learning model of crime and deviance posits that social learning is the chief process by which the social structural causes of crime and deviance have an impact on individual behavior  (1998).A criminology study found that variations in the behavioral and cognitive variables specified in the sociallearning process accounted for substantial portions of the variations in adolescent substance use andmediate substantial or in some cases nearly all the effects of gender, SES, age, family structure andcommunity size on these forms of deviance (Lee, Akers, & Borg, 2004).Perceived drug norms and family use play a tremendous role in adolescent drug use. Psychologicalsocial learning theory states that individuals learn new behaviors (including drug use) from observation,modeling and imitation of important others, such as peers and family (Bandura, 1977). Another  psychological theory, the theory of planned behavior describes behavior as being determined byintentions, attitudes, and normative beliefs (Ajzen & Fishbein, 2004). Ethnographic research indicatedthat drinking is useful for manipulating social relationships in many places including the United Statesand is a social act that is part of virtually every social gathering (Myers & Stolberg, 2003). Moreover,according to this same ethnographic review article the ritual importance of drinking is shown by the fact that declining a drink is seen as disrespectful and unfriendly. Ethnography has documented problemdrinking in communities suffering from deprivation, economic and social stagnation and scarce resources(Myers & Stolberg, 2003). This suggests that inner-city adolescents are an important group to study.An ethnographic study of the need to smoke cigarettes found that a major reason that adolescentssmoke is not because they crave or desire nicotine, but rather because of their perceived need to usecigarettes to manage social situations and maintain their social connections (Johnson et al., 2003).Specifically, these youth described requiring cigarettes to function socially (to party, to connect and to fit in).Aside fromthe socialaspectof smoking,adolescents identifiedan empoweringaspect helpingthem togain a sense of identity and independence: they could exert control over others either by sharing or byselectively withholding cigarettes. According to this study, some forms of dependence may exist amongyoung smokers who might be classified as light or irregular smokers. A study conducted by medicalanthropologists regarding nicotine dependence among adolescents found that dependency does not meanthat one smokes all day; cigarettes were used to make them feel better from stress, peak smoking occurredon Friday and Saturday nights at social events or hanging out with friends ( Nichter, Nichter, Thompson,Shiffman, & Moscicki, 2002).Adolescents becomeless reliant on parental influences in making drug usedecisions and turn instead tofriends and peers (Miller, Alberts, Hecht, & Krizek, 2000; Newcomb, 1997). The psychological peer cluster theory also views the peer group as critical in adolescent drug use (Oetting & Beauvais, 1986,1987). However, family members still play a role in modeling. Siblings' role in adolescent substance usehas identified them as influential role models who are of the same generation and may serve as a bridge between family and peers literature review by a social worker (Vakalahi, 2001). Furthermore, this samereview reported that parents do shape adolescents' personality and environment by the length andintensity of their relationship and significant relationships exist with parental substance use/attitudes andadolescent substance use. One sociological study found that the relationship between older siblings' self-reported tobacco and alcohol use remained significant with younger siblings' tobacco and alcohol usecontrolling for numerous shared family experiences (Fagan & Najman, 2005). In this same study,maternal tobacco and alcohol use was also related to their younger children's tobacco and alcohol use. 701  J.A. Epstein et al. / Addictive Behaviors 32 (2007) 700  –  713  Family exposure to drugs (cigarettes, alcohol and other drugs) also increased the likelihood that urban black youth would use drugs according to a study conducted by a pediatrics group (Feigelman, Li, &Stanton, 1995).Reviews of research on the development of drug use all report that drug use of peers and friends is amajor risk factor for adolescent drug use (Belcher & Shinitzky, 1998; Copans & Kinney, 1996; Hawkins,Donovan, & Miller, 1992). In a longitudinal analysis of friendships and substance use conducted by childclinical psychologists, the strongest proximal correlate of adolescent substance use is the tendency tocluster into peer groups that use substances and that the power of drugs connects individuals (Dishion &Owen, 2002). Furthermore, reduced levels of substance use were undermined by exposure to deviant  peers (Dishion & Skaggs, 2000). These studies confirm the ethnographic and other research about adolescent substance use and the peer group. Perceived peer norms tend to be the strongest predictor of gateway drug use in middle school and high school (Jenkins, 1996). Much of this research was conductedwith primarily white middle class samples.Research conducted with predominantly black and Hispanic youth residing in the inner-city also foundthat friends' and peers' drug use and attitudes were related to smoking (Epstein, Botvin, & Diaz, 1999),alcohol use (Epstein, Botvin, Baker, & Diaz, 1999), marijuana use (Epstein, Botvin, Diaz, Toth, & Schnike, 1995) and for all three substances separately (Walter, Vaughan, & Cohall, 1993). Interestingly, the child's perception of friends' use was found to be more important than actual friends' behavior amonga sample of young black urban fourth and fifth graders in the public health literature (Iannotti & Bush,1992). Factors meant to protect against vulnerability to drug use include competence skills, such asassertiveness (Belcher & Shinitzky, 1998; Miller et al., 2000). Among a sample of inner-city adolescents,more frequent use of refusal assertiveness skills prospectively predicted less smoking (Epstein, Griffin, &Botvin, 2000a) and less drinking (Epstein, Griffin, & Botvin, 2000b). Susceptibility to peer pressure to misbehave (whose items resembled a risk-taking tendency, e.g.,  “ If your best friend is skipping school,would you skip school too? ” ) contributed to drunkenness (Schulenberg et al., 1999).The vast majority of etiology research concentrates on testing main effects of models of drug use. A far smaller number of studies examined interactions between predictors of substance use (e.g., Brook,Whiteman, Balka, Win, & Gursen, 1997; Brook, Whiteman, Gordon, & Cohen, 1986, 1989; Cooper,Peirce, & Tidwell, 1995; Curran, White, & Hansell, 1997). In one longitudinal study, a number of  personality variables (liberalism, self-acceptance, and extraversion) moderated the effect of socialinfluences to use drugs on individual drug use measures of marijuana use and cocaine use (Stacy, Newcomb, & Bentler, 1992). In another study, decision-making and self-reinforcement diminished theimpact of peer drinking on alcohol use among rural youth (Botvin, Malgady, Griffin, Scheier, & Epstein,1998). Another study found that high risk-taking tendency and low refusal assertiveness each increasedthe effect of friends' drinking among an inner-city adolescent sample (Epstein & Botvin, 2002). Since theinfluence of protective factors (refusal assertiveness, decision-making skills, high efficacy, psychologicalwellness) comes to light in interaction models, this points to the importance of developing more complexmodels. Risk-taking tendency also appears to be another independent risk factor, in addition to norms for substanceuse and perceptions of use among friends and family, for substanceuse that should be examinedin interactions with protective factors. Both of these previously cited studies were cross-sectional so that causality cannot be drawn and focused on only one drug (alcohol). Moreover, no one has examined poly-drug in adolescent urban youth, which is regarded as a more serious problem.Over the past 10 years, the rates of single-risk behaviors have declined, but the rates of multiple-risk  behaviors have remained stable among adolescents (Lindberg et al., 2000). Adolescence has been 702  J.A. Epstein et al. / Addictive Behaviors 32 (2007) 700  –  713  identified as a time when developmental changes increase vulnerability to risky behaviors including potentially health-damaging behaviours like drug use and the presence of multiple-risk behaviors cansubstantially worsen health outcomes (Irwin, Burg, & Cart, 2002).A measure of poly-drug use more accurately captures overall health risk. Unfortunately studies of adolescent drug use often examine the drug use singly. Some work that developed poly-drug measures(including one that combined stage-intensity of involvement measure) found that adolescent protectivefactors weakened the effect of childhood risk factors resulting in lower drug involvement (Brook et al.,1989).While prior research that focused on the etiology of specific drugs (cigarettes, alcohol or marijuana) in adolescence is informative, such work overlooks the more general process of druginitiation and progression among inner-city adolescents that could take combination of multiplesubstances and future use into account. Also research does not often focus on intentions to use in thefuture, which is another important outcome according to theory of planned behavior (Ajzen &Fishbein, 2004). Few studies have focused on social competence factors as predictors of substanceuse among inner-city minority youth and none that we know of have investigated the moderating roleof these protective factors for friends' use, peer norms and adults norms for substance use, perceivedfamily smoking, including older sibling smoking and parental smoking (other measures of drug usewere unavailable because the srcinal parent project was a smoking prevention trial) and risk takingtendency on poly-drug use. This study will test the moderating role of protective factors (refusalassertiveness, sound decision-making skills, high efficacy, psychological wellness, and low risk-takingtendency) in the relationship between risk factors (such as perceived norms for drug use  –  friends'use, peer norms, adult norms, siblings' smoking, mother's smoking, father's smoking) and poly-druguse, while controlling for sociodemographic and background characteristics (ethnicity, gender, age,grades, and family composition). This protective factor (refusal assertiveness) is of importance as a primary role player as well as a moderator because it serves as a major component of many of current  prevention programs including refusal skill programs and competence enhancement programs (seereview by Botvin, 1998). The study also predicted future smoking intentions with many of the same predictors, substituting smoking versions of variables relevant to substance use, such as friends' use, peer norms and adult norms. 1. Method 1.1. Overview Data for these analyses are from the control group of a longitudinal smoking prevention trial describedin detail in previous work (Botvin et al., 1992). Participants are from 22 predominantly Hispanic middleand junior high schools in New York City. The majority of the schools served inner-city youth fromfamilies with average incomes well below the Federal poverty level. Bilingual and special educationclasses were not included in the srcinal study and all surveys were conducted in English. At baseline,2400 students completed questionnaires. The panel sample across baseline, 1-year, and 2-year follow-upconsisted of 1459 students (61% of baseline participants). The retention rate over the course of the 2-year follow-up compared favorably with school-based studies whose 2-year follow-up rates ranged around60% in our work with inner-city samples (e.g., Botvin, Schinke, Epstein, Diaz, & Botvin, 1995). For  703  J.A. Epstein et al. / Addictive Behaviors 32 (2007) 700  –  713
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