Benefit-Cost Analysis of a Randomized Evaluation of Communities That Care: Monetizing Intervention Effects on the Initiation of Delinquency and Substance Use Through Grade 12

Family-Based Interventions to Prevent Substance Use Among Youth: Community Guide Systematic Economic Review

INTRODUCTION

This paper presents a systematic review of evidence from economic evaluations of family-based interventions that was recommended by the Community Preventive Services Task Force to prevent substance use among youth.

METHODS

The search covered studies published from inception of databases through October 2023 and was limited to those based in the U.S. and other high-income countries. This review reports results from peer-reviewed studies and government reports as separate sources of evidence. Analyses were conducted in June 2023 through September 2024. Monetary values are in 2023 U.S. dollars.

RESULTS

The search yielded 11 peer-reviewed studies and 2 government reports: 1 from the Washington State Institute for Public Policy that evaluated 14 programs and 1 from the Substance Abuse and Mental Health Administration that evaluated 8 programs. The median intervention cost ranged from $655 to $1,672 per family and $677 to $753 per youth or participant across the 3 sources of evidence. The median benefit to cost ratio were 5.8, 3.9, and 8.9 from peer-reviewed studies, Washington State Institute for Public Policy, and Substance Abuse and Mental Health Administration, respectively, with all 3 estimates indicating that benefits exceed cost. Substance Abuse and Mental Health Administration's report found some interventions to be cost saving and the others to have a median cost per quality-adjusted life years gained of $21,426.

DISCUSSION

The Community Preventive Services Task Force determined that cost-benefit evidence across the 3 sources showed that societal benefits exceeded cost of family-based interventions to prevent substance use among youth. The Task Force determined that there were not enough studies to reach a conclusion about cost-effectiveness.

A systematic review and meta-analysis of the effect of community treatment orders on aggression or criminal behaviour in people with a mental illness

AIMS

There has been concern about violent acts and other criminal behaviour by people with a possible history of mental health problems. We therefore assessed the effects of community treatment orders (CTOs) on self-, third-party-, and agency-reported criminal behaviour when compared to voluntary treatment.

METHODS

A systematic search of PubMed/Medline, Embase, PsycINFO and criminal justice bibliographic databases for observational or randomised controlled trials (RCTs) comparing CTO cases with controls receiving voluntary psychiatric treatment. Relevant outcomes were reports of violence and aggression or contacts with the criminal justice system such as arrests and court appearances.

RESULTS

Thirteen papers from 11 studies met inclusion criteria. Nine papers came from the United States and four from Australia. Two papers were of RCTs. Results for all outcomes were non-significant, the effect size declining as study design improved from non-randomised data on self-reported criminal behaviour, through third party criminal justice records and finally to RCTs. Similarly, there was no significant finding in the subgroup analysis of serious criminal behaviour.

CONCLUSIONS

On the limited available evidence, CTOs may not address aggression or criminal behaviour in people with mental illness. This is possibly because the risk of violence is increased by comorbid or nonclinical variables, which are beyond the scope of CTOs. These include substance use, a history of victimisation or maltreatment, and the wider environment. The management of risk should therefore focus on the whole person and their community through social and public health interventions, not solely legislative control.

Kindergarten conduct problems are associated with monetized outcomes in adolescence and adulthood

BACKGROUND

Across several sites in the United States, we examined whether kindergarten conduct problems among mostly population-representative samples of children were associated with increased criminal and related (criminal + lost offender productivity + victim; described as criminal + victim hereafter) costs across adolescence and adulthood, as well as government and medical services costs in adulthood.

METHODS

Participants (N = 1,339) were from two multisite longitudinal studies: Fast Track (n = 754) and the Child Development Project (n = 585). Parents and teachers reported on kindergarten conduct problems, administrative and national database records yielded indexes of criminal offending, and participants self-reported their government and medical service use. Outcomes were assigned costs, and significant associations were adjusted for inflation to determine USD 2020 costs.

RESULTS

A 1SD increase in kindergarten conduct problems was associated with a $21,934 increase in adolescent criminal + victim costs, a $63,998 increase in adult criminal + victim costs, a $12,753 increase in medical services costs, and a $146,279 increase in total costs. In the male sample, a 1SD increase in kindergarten conduct problems was associated with a $28,530 increase in adolescent criminal + victim costs, a $58,872 increase in adult criminal + victim costs, and a $144,140 increase in total costs. In the female sample, a 1SD increase in kindergarten conduct problems was associated with a $15,481 increase in adolescent criminal + victim costs, a $62,916 increase in adult criminal + victim costs, a $24,105 increase in medical services costs, and a $144,823 increase in total costs.

CONCLUSIONS

This investigation provides evidence of the long-term costs associated with early-starting conduct problems, which is important information that can be used by policymakers to support research and programs investing in a strong start for children.

[Evidence-based prevention for child and adolescent mental health: the "Communities That Care" (CTC) approach for Germany]

Intersectoral collaboration, evidence base, and sustainable implementation are central challenges in community health promotion. The international prevention system Communities That Care (CTC) addresses these challenges. CTC aims to prevent alcohol and drug abuse, violence, delinquency, school dropout, and depressive symptoms among adolescents with a systemic multi-level strategy. The evidence-based and cost-effective prevention system developed in the USA was adapted to Germany; at present, a replication study evaluates the cost-effectiveness.CTC is based on empirical theory and follows a five-phase process model. Essential for acceptance and evidence-based implementation is the formation of an intersectoral coalition, whose members receive advisory support and training over several years. The actors are empowered to use a system change model at the municipal level and to implement it in the long term. The aim is to select evidence-based measures in a data-driven and needs-oriented manner and to implement them in consideration of the local contextual conditions in order to reduce risk factors, promote protective factors, and thus improve the health of adolescents. Validated instruments such as the CTC Children and Youth Survey and a registry with evidence-based prevention programs ("Grüne Liste Prävention") support the process.As a systemic intervention, CTC integrates existing local structures and agencies and involves them in the entire process through new decision-making and development bodies. In this way, the potential in the municipality is used and, as much as possible, resources are bundled, strengths are developed, and transparency is created.

Interventions to prevent alcohol use: systematic review of economic evaluations

BACKGROUND

Alcohol use is a leading risk factor for death and disability worldwide.

AIMS

We conducted a systematic review on the cost-effectiveness evidence for interventions to prevent alcohol use across the lifespan.

METHOD

Electronic databases (EMBASE, Medline, PsycINFO, CINAHL and EconLit) were searched for full economic evaluations and return-on-investment studies of alcohol prevention interventions published up to May 2021. The methods and results of included studies were evaluated with narrative synthesis, and study quality was assessed by the Drummond ten-point checklist.

RESULTS

A total of 69 studies met the inclusion criteria for a full economic evaluation or return-on-investment study. Most studies targeted adults or a combination of age groups, seven studies comprised children/adolescents and one involved older adults. Half of the studies found that alcohol prevention interventions are cost-saving (i.e. more effective and less costly than the comparator). This was especially true for universal prevention interventions designed to restrict exposure to alcohol through taxation or advertising bans; and selective/indicated prevention interventions, which involve screening with or without brief intervention for at-risk adults. School-based interventions combined with parent/carer interventions were cost-effective in preventing alcohol use among those aged under 18 years. No interventions were cost-effective for preventing alcohol use in older adults.

CONCLUSIONS

Alcohol prevention interventions show promising evidence of cost-effectiveness. Further economic analyses are needed to facilitate policy-making in low- and middle-income countries, and among child, adolescent and older adult populations.

Costs and benefits of cooperative learning as a universal school-based approach to adolescent substance use prevention

Substance use during early adolescence implies a greater likelihood of abuse and dependence in later adolescence or adulthood. In turn, substance abuse and dependence are linked to a variety of maladaptive long-term health-related outcomes that imply significant individual and societal costs. In this paper, we evaluated an approach to substance use prevention that relies on the vital role of peers, who comprise a key risk factor for adolescent substance use. This approach (i.e., cooperative learning, CL) focuses on interrupting the process of deviant peer clustering and providing at-risk youth with the opportunity to build social skills and cultivate friendships with low-risk youth. In addition to testing the efficacy of CL in reducing the number of students who become regular substance users, we also conducted a cost-benefit analysis. Using four waves of data from a cluster-randomized trial (N = 15 middle schools, 1890 students, 47.1% female, 75.2% White, 13.9% of students were receiving special education services), we found that significantly lower percentages of students in the intervention (CL) schools became regular users of tobacco, alcohol, and marijuana. We estimated that the reduction in substance use associated with the implementation of CL resulted in total lifetime benefits of between $1027 and $4621 per student (in 2019 dollars), or between $8.79 and $39.54 for each dollar invested in CL. Benefit/cost ratios would go up to $22.54-$101.39 per dollar invested with the continual implementation of CL, assuming retraining every 5 years. Implications and future research directions are discussed.

Parent-focused prevention of adolescent health risk behavior: Study protocol for a multisite cluster-randomized trial implemented in pediatric primary care

Evidence-based parenting interventions play a crucial role in the sustained reduction of adolescent behavioral health concerns. Guiding Good Choices (GGC) is a 5-session universal anticipatory guidance curriculum for parents of early adolescents that has been shown to reduce substance use, depression symptoms, and delinquent behavior. Although prior research has demonstrated the effectiveness of evidence-based parenting interventions at achieving sustained reductions in adolescent behavioral health concerns, public health impact has been limited by low rates of uptake in community and agency settings. Pediatric primary care is an ideal setting for implementing and scaling parent-focused prevention programs as these settings have a broad reach, and prevention programs implemented within them have the potential to achieve population-level impact. The current investigation, Guiding Good Choices for Health (GGC4H), tests the feasibility and effectiveness of implementing GGC in 3 geographically and socioeconomically diverse large integrated healthcare systems. This pragmatic, cluster randomized clinical trial will compare GGC parenting intervention to usual pediatric primary care practice, and will include approximately 3750 adolescents; n = 1875 GGC intervention and n = 1875 usual care. The study team hypothesizes that adolescents whose parents are randomized into the GGC intervention arm will show reductions in substance use initiation, the study's primary outcomes, and other secondary (e.g., depression symptoms, substance use prevalence) and exploratory outcomes (e.g., health services utilization, anxiety symptoms). The investigative team anticipates that the implementation of GGC within pediatric primary care clinics will successfully fill an unmet need for effective preventive parenting interventions. Trial registration: Clinicaltrials.govNCT04040153.

Which aspects of coalition functioning are key at different stages of coalition development? A qualitative comparative analysis

Background

Coalitions are increasingly utilized to promote positive community health outcomes. Typically, coalitions produce more desirable outcomes when coalition functioning is strong and the coalition model is implemented with fidelity. Although theory indicates that coalitions proceed through predictable stages of development, minimal research explicitly examines functioning and fidelity at these different stages.

Method

Within a larger evaluation of Washington State Community Prevention and Wellness Initiative, this cross-sectional study employs qualitative comparative analysis to illuminate the coalition functioning conditions necessary and sufficient to produce high model fidelity at different stages of development in 43 substance misuse prevention coalitions in one state.

Results

In the formation stage, only the presence of high levels of coalition leadership was sufficient to produce high model fidelity. In the maintenance stage, three combinations of conditions were sufficient: (1) sustainability planning if, and only if, accompanied by the absence of coalition participation costs, (2) coordinator leadership, and (3) a combination of coalition leadership and team cohesion. In the institutionalization stage, two solutions were sufficient: (1) coalition leadership if, and only if, accompanied by the absence of sustainability planning, and (2) sustainability planning if, and only if, accompanied by the absence of coordinator leadership.

Conclusions

This study illustrates several tangible steps technical assistance providers may take to increase the likelihood of achieving model fidelity. In the formation stage, skillful and inclusive coalition leadership is important. In the maintenance stage, technical assistance should focus on reducing participant-perceived costs; increasing sustainability planning; enhancing coordinator-specific leadership; and developing team cohesion and coalition leadership. For coalitions in the institutionalization stage, coalition leadership and sustainability planning may be prime targets for technical assistance. Plain Language Summary: Community coalition approaches to addressing social problems are common and have some evidence of producing positive community outcomes. Research shows that coalitions produce more desirable outcomes when coalition functioning is strong and the coalition model is implemented as it was designed. Although theory suggests that coalitions proceed through predictable stages of development, few studies look at which supports are most needed, at each stage, to improve coalition functioning and implementation. This study aims to help answer that question by determining which aspects of coalition functioning, in which combinations, are key to strong, well-functioning coalitions at different developmental stages in a sample of prevention coalitions in Washington State focused on youth substance misuse. The results suggest that having a strong coalition leadership team is key for all coalitions, regardless of development stage. For coalitions earlier in their formation, this was especially true. For coalitions further into their development, the combination of strong coordinator leadership and strong team cohesion was particularly important. Finally, for the most well-established coalitions, if sustainability planning was weak, strong coalition team leadership was key; but if coordinator leadership was weak, strong sustainability planning was critical to offset the lack of strong leadership. The results can be used to inform the types of technical assistance provided to support coalitions at different developmental stages.

Predicting suicidal thoughts and behavior among adolescents using the risk and protective factor framework: A large-scale machine learning approach

INTRODUCTION

Addressing the problem of suicidal thoughts and behavior (STB) in adolescents requires understanding the associated risk factors. While previous research has identified individual risk and protective factors associated with many adolescent social morbidities, modern machine learning approaches can help identify risk and protective factors that interact (group) to provide predictive power for STB. This study aims to develop a prediction algorithm for STB among adolescents using the risk and protective factor framework and social determinants of health.

METHODS

The sample population consisted of more than 179,000 high school students living in Utah and participating in the Communities That Care (CTC) Youth Survey from 2011-2017. The dataset includes responses to 300+ questions from the CTC and 8000+ demographic factors from the American Census Survey for a total of 1.2 billion values. Machine learning techniques were employed to extract the survey questions that were best able to predict answers indicative of STB, using recent work in interpretable machine learning.

RESULTS

Analysis showed strong predictive power, with the ability to predict individuals with STB with 91% accuracy. After extracting the top ten questions that most affected model predictions, questions fell into four main categories: familial life, drug consumption, demographics, and peer acceptance at school.

CONCLUSIONS

Modern machine learning approaches provide new methods for understanding the interaction between root causes and outcomes, such as STB. The model developed in this study showed significant improvement in predictive accuracy compared to previous research. Results indicate that certain risk and protective factors, such as adolescents being threatened or harassed through digital media or bullied at school, and exposure or involvement in serious arguments and yelling at home are the leading predictors of STB and can help narrow and reaffirm priority prevention programming and areas of focused policymaking.

Advancing Applied Research in Conservation Criminology Through the Evaluation of Corruption Prevention, Enhancing Compliance, and Reducing Recidivism

Concomitant with an increase in the global illegal wildlife trade has been a substantial increase in research within traditional conservation-based sciences and conservation and green criminology. While the integration of criminological theories and methods into the wildlife conservation context has advanced our understanding of and practical responses to illegal wildlife trade, there remain discrepancies between the number of empirical vs. conceptual studies and a disproportionate focus on a few select theories, geographical contexts, and taxonomic groups. We present three understudied or novel applications of criminology and criminal justice research within the fields of fisheries, forestry, and wildlife conservation. First, we highlight criminological research on the application of corruption prevention in combating the illegal wildlife trade. Corruption has increasingly been getting attention from the non-governmental sector; however, there has been limited research aimed at understanding institutional opportunity structures, local conceptualizations of corruption, and the corresponding prevention strategies within conservation contexts. Second, we discuss the pre-emptive application of compliance theories when designing and monitoring Community-Based Conservation (CBC) programs such as community forestry, non-timber forest products, and community patrol programs. Applying opportunity theory and social development strategies are two suggestions to improve the effectiveness of CBCs in forestry and beyond. Finally, we present a discussion on recidivism (i.e., repeat offending) and non-instrumental or novel responses, utilizing illegal fishing as a case study. We present two alternative methods to traditional forms of punishment: restorative justice and community-based approaches. Lastly, we will present a diversity of priority research agendas within each of these topics.

Long-term Impacts and Benefit-Cost Analysis of the Communities That Care Prevention System at Age 23, 12 Years After Baseline

This study estimated sustained impacts and long-term benefits and costs of the Communities That Care (CTC) prevention system, implemented and evaluated in a longitudinal cluster-randomized trial involving 24 communities in seven states. Analyses utilized reports from a longitudinal panel of 4407 participants, followed since the study's baseline in grade 5, with most recent follow-up 12 years later at age 23. Impacts on lifetime abstinence from primary outcomes of substance use and antisocial behavior were estimated using generalized linear mixed Poisson regression analysis, adjusted for individual and community-level covariates. Possible cascading effects on 4-year college completion, major depressive disorder, and generalized anxiety disorder through age 23 were evaluated as secondary outcomes. CTC had a statistically significant global effect on primary outcomes and also on combined primary and secondary outcomes. Among primary outcomes, point estimates suggested absolute improvements in lifetime abstinence of 3.5 to 6.1% in the intervention arm and relative improvements of 13 to 55%; 95% confidence intervals revealed some uncertainty in estimates. Among secondary outcomes, 4-year college completion was 1.9% greater among young adults from intervention communities, a 20% relative improvement. Mental health outcomes were approximately the same across trial arms. Although CTC had small sustained effects through age 23, benefit-cost analyses indicated CTC was reliably cost beneficial, with a net present value of $7152 (95% credible interval: $1253 to $15,268) per participant from primary impacts and $17,919 ($306 to $39,186) when secondary impacts were also included. It remained cost beneficial even when impacts were adjusted downward due to the involvement of CTC's developer in the trial. Findings suggest that broader dissemination of CTC could improve public health and individual lives in the long term and generate positive net benefits to society.

Health economic design for cost, cost-effectiveness and simulation analyses in the HEALing Communities Study

BACKGROUND

The HEALing Communities Study (HCS) is designed to implement and evaluate the Communities That HEAL (CTH) intervention, a conceptually driven framework to assist communities in selecting and adopting evidence-based practices to reduce opioid overdose deaths. The goal of the HCS is to produce generalizable information for policy makers and community stakeholders seeking to implement CTH or a similar community intervention. To support this objective, one aim of the HCS is a health economics study (HES), the results of which will inform decisions around fiscal feasibility and sustainability relevant to other community settings.

METHODS

The HES is integrated into the HCS design: an unblinded, multisite, parallel arm, cluster randomized, wait list-controlled trial of the CTH intervention implemented in 67 communities in four U.S. states: Kentucky, Massachusetts, New York, and Ohio. The objectives of the HES are to estimate the economic costs to communities of implementing and sustaining CTH; estimate broader societal costs associated with CTH; estimate the cost-effectiveness of CTH for overdose deaths avoided; and use simulation modeling to evaluate the short- and long-term health and economic impact of CTH, including future overdose deaths avoided and quality-adjusted life years saved, and to develop a simulation policy tool for communities that seek to implement CTH or a similar community intervention.

DISCUSSION

The HCS offers an unprecedented opportunity to conduct health economics research on solutions to the opioid crisis and to increase understanding of the impact and value of complex, community-level interventions.

A tailored cognitive behavioral program for juvenile justice-referred females at risk of substance use and delinquency: A pilot quasi-experimental trial

This pilot quasi-experimental trial tested a gender-responsive cognitive behavioral group intervention with 87 court-involved female adolescents (5 juvenile courts) who were at indicated risk for substance use disorder. Participants in the intervention (n = 57) received twice weekly group sessions for 10 weeks (20 sessions) focused on building emotional, thought and behavior regulation skills and generalizing these skills to relationally-based scenarios (GOAL: Girls Only Active Learning). Youth in the control condition (n = 30) received services as usual, which included non-gender-specific aggression management training, individual counseling and no services. The GOAL program was found to be acceptable to youth and parents and feasible to implement within a juvenile court setting using skilled facilitators. Compared to services as usual, the program significantly and meaningfully reduced self-reported delinquent behavior (β = 0.84, p < 0.05) over 6 months, and exhibited trend level effects for reduced substance use (β = 0.40, p = 0.07). The program had mixed or no effects on family conflict and emotion regulation skills. These findings are discussed in light of treatment mechanisms and gender-responsive services.

Social Determinants of Mental Health: Where We Are and Where We Need to Go

PURPOSE OF REVIEW

The present review synthesizes recent literature on social determinants and mental health outcomes and provides recommendations for how to advance the field. We summarize current studies related to changes in the conceptualization of social determinants, how social determinants impact mental health, what we have learned from social determinant interventions, and new methods to collect, use, and analyze social determinant data.

RECENT FINDINGS

Recent research has increasingly focused on interactions between multiple social determinants, interventions to address upstream causes of mental health challenges, and use of simulation models to represent complex systems. However, methodological challenges and inconsistent findings prevent a definitive understanding of which social determinants should be addressed to improve mental health, and within what populations these interventions may be most effective. Recent advances in strategies to collect, evaluate, and analyze social determinants suggest the potential to better appraise their impact and to implement relevant interventions.

Economic Evaluation of the Juvenile Drug Court/Reclaiming Futures (JDC/RF) Model

Juvenile drug court (JDC) programs are an increasingly popular option for rehabilitating juvenile offenders with substance problems, but research has found inconsistent evidence regarding their effectiveness and economic impact. While assessing client outcomes such as reduced substance use and delinquency is necessary to gauge program effectiveness, a more comprehensive understanding of program success and sustainability can be attained by examining program costs and economic benefits. As part of the National Cross-Site Evaluation of JDC and Reclaiming Futures (RF), an economic analysis of five JDC/RF programs was conducted from a multisystem and multiagency perspective. The study highlights the direct and indirect costs of JDC/RF and the savings generated from reduced health problems, illegal activity, and missed school days. Results include the average (per participant) cost of JDC/RF, the total economic benefits per JDC/RF participant, and the net savings of JDC/RF relative to standard JDC.

A Cluster-Randomized Trial of Getting To Outcomes' Impact on Sexual Health Outcomes in Community-Based Settings

The USA has high teen pregnancy rates compared to other developed nations. Many community-based organizations need assistance conducting evidence-based teen pregnancy prevention programs (EBPs) appropriately. This study evaluated the impact of an implementation support intervention called Getting To Outcomes (GTO) designed to help such organizations. This cluster randomized controlled trial compared 16 Boys and Girls Clubs (BGCs) implementing a teen pregnancy prevention EBP called Making Proud Choices for two years, with 16 BGCs implementing MPC augmented with GTO training, tools, and technical assistance. Participating middle school youth were compared on proximal outcomes (knowledge, attitudes, and intentions about sex and condoms from baseline to post) and sexual behaviors (frequency of sex and condom use, from baseline to 6-month follow-up). In year 1, there were no significant effects of GTO for any proximal outcome. After GTO-stimulated quality improvement in year 2, the GTO group improved significantly more on condom attitudes and use intentions. Frequency of sex and condom use did not differ between the two groups in either year; however, base rates of these behaviors in the sample were very low. Findings suggest that in typical community-based settings, detailed manuals and training common to structured EBPs may be sufficient to yield some improvement in key proximal outcomes, but that more systematic implementation support is needed to achieve greater improvement in these outcomes. Using GTO with many communities, as currently supported by various federal agencies, could yield public health impact via improvements in condom attitudes and use intentions.

Trial protocol: a clustered, randomised, longitudinal, type 2 translational trial of alcohol consumption and alcohol-related harm among adolescents in Australia

Background

This cluster randomised control trial is designed to evaluate whether the Communities That Care intervention (CTC) is effective in reducing the proportion of secondary school age adolescents who use alcohol before the Australian legal purchasing age of 18 years. Secondary outcomes are other substance use and antisocial behaviours. Long term economic benefits of reduced alcohol use by adolescents for the community will also be assessed.

Methods

Fourteen communities and 14 other non-contiguous communities will be matched on socioeconomic status (SES), location, and size. One of each pair will be randomly allocated to the intervention in three Australian states (Victoria, Queensland and Western Australia). A longitudinal survey will recruit grade 8 and 10 students (M = 15 years old, N = 3500) in 2017 and conduct follow-up surveys in 2019 and 2021 (M = 19 years old). Municipal youth populations will also be monitored for trends in alcohol-harms using hospital and police administrative data.

Discussion

Community-led interventions that systematically and strategically implement evidence-based programs have been shown to be effective in producing population-level behaviour change, including reduced alcohol and drug use. We expect that the study will be associated with significant effects on alcohol use amongst adolescents because interventions adopted within communities will be based on evidence-based practices and target specific problems identified from surveys conducted within each community.

Trial registration

The trial was retrospectively registered in September, 2017 (ACTRN12616001276448), as communities were selected prior to trial registration; however, participants were recruited after registration. Findings will be disseminated in peer-review journals and community fora.

Effects of Communities That Care on Males' and Females' Drug Use and Delinquency 9 Years After Baseline in a Community-Randomized Trial

This study tested sustained effects of the Communities That Care (CTC) prevention system on health-risking behaviors 9 years after baseline in a community-randomized trial involving 24 towns in seven states. Earlier analyses found sustained effects on abstinence from drug use and delinquency through Grade 12 in a panel of fifth graders. At age 19, 91 % (n = 3986) of the living panel completed the survey. Data were analyzed using generalized linear mixed models. The prevalence of lifetime and current substance use and delinquency were the primary outcomes. Secondary outcomes included substance use disorders, major depression, suicidality, educational attainment, and sexual risk behaviors. CTC had a significant overall effect across lifetime measures of the primary outcomes for males, but not for females or the full sample, although lifetime abstinence from delinquency in the full sample was significantly higher in CTC communities (ARR = 1.16). Males in CTC communities also continued to show greater lifetime abstinence from cigarette smoking (ARR = 1.22). CTC did not have a sustained effect on current substance use and delinquency nor did it improve the secondary outcomes at age 19 for either gender. Communities using CTC may need to extend their prevention planning to include the high school years to sustain effects on drug use and delinquency beyond high school for both genders.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01088542.