Addictive Behaviors 32 (2007) 700 713

Which psychosocial factors moderate or directly affect substance

use 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 smoking
among inner-city adolescents. A panel sample of baseline, 1-year and 2-year follow-ups (N = 1459) from the control
group of a longitudinal smoking prevention trial participated. We focused on the main effects, as well as, interaction
effects between psychosocial protective factors and various risk factors, including perceived norms of friends, peers and
adults to use drugs. Significant effects were identified for intensity of poly-drug use and future smoking. The analysis of
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
psychological wellness. The significant interactions between perceived friends' drug use with refusal assertiveness and
decision-making skills were observed for future smoking. Moreover, perceived peer smoking norms, 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 family
smoking

Research relevant to adolescent drug use has been shifting from a focus on risk factors to one that also
incorporates 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
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

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protect against vulnerability. Accordingly, such an approach posits that both risk factors and vulnerability
significantly contribute to a model of adolescent drug use and furthermore that resilience moderates the
effects of individual vulnerabilities and environmental hazards. Akers' criminology model of Social
Structure 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 social
learning process accounted for substantial portions of the variations in adolescent substance use and
mediate substantial or in some cases nearly all the effects of gender, SES, age, family structure and
community size on these forms of deviance (Lee, Akers, & Borg, 2004).
Perceived drug norms and family use play a tremendous role in adolescent drug use. Psychological
social 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 by
intentions, attitudes, and normative beliefs (Ajzen & Fishbein, 2004). Ethnographic research indicated
that drinking is useful for manipulating social relationships in many places including the United States
and 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 problem
drinking 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 adolescents
smoke is not because they crave or desire nicotine, but rather because of their perceived need to use
cigarettes 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 from the social aspect of smoking, adolescents identified an empowering aspect helping them to
gain a sense of identity and independence: they could exert control over others either by sharing or by
selectively withholding cigarettes. According to this study, some forms of dependence may exist among
young smokers who might be classified as light or irregular smokers. A study conducted by medical
anthropologists regarding nicotine dependence among adolescents found that dependency does not mean
that one smokes all day; cigarettes were used to make them feel better from stress, peak smoking occurred
on Friday and Saturday nights at social events or hanging out with friends (Nichter, Nichter, Thompson,
Shiffman, & Moscicki, 2002).
Adolescents become less reliant on parental influences in making drug use decisions and turn instead to
friends 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 use
has 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 same
review reported that parents do shape adolescents' personality and environment by the length and
intensity of their relationship and significant relationships exist with parental substance use/attitudes and
adolescent substance use. One sociological study found that the relationship between older siblings' selfreported tobacco and alcohol use remained significant with younger siblings' tobacco and alcohol use
controlling 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.

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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 a
major 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 child
clinical psychologists, the strongest proximal correlate of adolescent substance use is the tendency to
cluster 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 conducted
with primarily white middle class samples.
Research conducted with predominantly black and Hispanic youth residing in the inner-city also found
that 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 among
a 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 as
assertiveness (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 social
influences 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 the
impact 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 increased
the effect of friends' drinking among an inner-city adolescent sample (Epstein & Botvin, 2002). Since the
influence of protective factors (refusal assertiveness, decision-making skills, high efficacy, psychological
wellness) comes to light in interaction models, this points to the importance of developing more complex
models. Risk-taking tendency also appears to be another independent risk factor, in addition to norms for
substance use and perceptions of use among friends and family, for substance use that should be examined
in 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 polydrug 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

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703

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 can
substantially 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 protective
factors 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 drug
initiation and progression among inner-city adolescents that could take combination of multiple
substances and future use into account. Also research does not often focus on intentions to use in the
future, 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 substance
use among inner-city minority youth and none that we know of have investigated the moderating role
of these protective factors for friends' use, peer norms and adults norms for substance use, perceived
family smoking, including older sibling smoking and parental smoking (other measures of drug use
were unavailable because the original parent project was a smoking prevention trial) and risk taking
tendency on poly-drug use. This study will test the moderating role of protective factors (refusal
assertiveness, sound decision-making skills, high efficacy, psychological wellness, and low risk-taking
tendency) 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-drug
use, 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 (see
review 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 described
in detail in previous work (Botvin et al., 1992). Participants are from 22 predominantly Hispanic middle
and junior high schools in New York City. The majority of the schools served inner-city youth from
families with average incomes well below the Federal poverty level. Bilingual and special education
classes were not included in the original 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-up
consisted 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 around
60% in our work with inner-city samples (e.g., Botvin, Schinke, Epstein, Diaz, & Botvin, 1995). For

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example, research with Project ALERT conducted in Oregon and California has shown retention rates
ranging from 60% to 64% (Ellickson, Bell, & Harrison, 1994; Hays & Ellickson, 1990). A smoking
prevention evaluation with a shorter follow-up conducted with an urban Los Angeles sample of AfricanAmerican and Latino youth had 60% retention rate (Sussman et al., 1995). Our retention rate is similar to
other studies. We restricted our analyses to the 1459 participants, who completed baseline, 1-year and 2year follow-up merged into a final data set.
1.2. Participants
The mean age at baseline for the panel sample was 12.4 (S.D. = 0.75) and the sample was 46% boys. In
terms of ethnicity, this sample was 54% Hispanic, 20% black, 7% Asian, 16% white, and 3% other.
Approximately 70% of participants lived in two-parent households. Demographic and background
characteristics are summarized in Table 1.
1.3. Procedure
Students completed surveys containing measures of smoking, drinking, marijuana use and
psychological factors. Surveys were completed during a 40-min class period at baseline (in the fall)
and about 1- and 2-year intervals later (in the spring). To encourage full disclosure, data collectors were
members of the same ethnic groups as the participating students, school administrators and teachers were
not involved in data collection activities. Surveys were identified through numerical codes, not by
students' names.
1.4. Measures
1.4.1. Outcome measures
An 11-point smoking index assessed smoking frequency. Specifically, students responded to the
question, How often do you currently smoke? Response options ranged from I have never smoked (1)
to A pack or more each day (11). Students indicated how often (if ever) they drank alcoholic beverages
on a 9-point scale ranging from 1 (never) to 9 (more than once a day). They completed a similar 9point scale regarding their marijuana use. Finally, a 5-point future smoking item assessed intentions to be
a cigarette smoker in 2 years, Do you think you'll be a cigarette smoker two years from now? The scale
ranged from I definitely will not (1) to I definitely will (5).
A measure of multiple drug use created from the three drug frequency scales was used as one
outcome. Specifically, a composite poly-drug use index of the three behavioral indices (smoking,
drinking and marijuana) was created to take frequency of use into account. The smoking index was
recoded from an 11-point scale to a 9-point scale to correspond to the scales for alcohol and
marijuana use. Each drug index is weighted by the drug's position on stage of drug use (helping to
equalize the variance of the individual measures) and summed for a composite index following Brook
et al. (1989). Such measures take increased level of substance involvement into account based on a
stage like progression from one substance to more than one substance (Kandel, 1975). The same
sequence of drug initiation has been found among black, Hispanic and Asian adolescents (Brook,
Hamburg, Balka, & Wynn, 1992; Ellickson, Hays, & Bell, 1992). In the current study, the dependent
measures were: poly-drug use intensity and future smoking intentions. Prior research conducted with

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705

Table 1
Baseline characteristics of participating students (N = 1459)
Characteristics
Sociodemographic and background factors
Ethnicity (%)
Latino/Hispanic
Black/African-American
White/Caucasian
Oriental/Asian
Male (%)
Age at baseline (mean (S.D.))
Grades (%)
Mostly or some A
Mostly B or some B
Mostly C or lower
Living with both parents (%)

54
20
16
7
46
12.4 (0.75)
39
40
21
70

Social influences and environment

Friends' smoking or drinking (%)
Peers' smoking or drinking (%)
Siblings' smoking a (%)
Adults' smoking b (%)

40
39
16
85

Psychosocial and behavioral factors c

High refusal assertiveness (%)
High risk-taking tendency (%)
Low psychological wellness (%)
High self-efficacy (%)
Low decision making skill (%)

46
43
42
52
49

Outcomes
Poly-drug use intensity (mean/median (S.D.))
Future smoking (mean/median (S.D.))

5.0/4 (1.83) with range = 423

1.4/1 (0.75) with range = 15

S.D. = standard deviation.

a
If there is no sibling, then the answer is coded as No.
b
Think at least half of the adults smoke cigarettes.
c
Dichotomized by median.

predominantly minority samples in this age group (Botvin, Epstein, Baker, Diaz, & Ifill-Williams,
1997; Catalano et al., 1992; Wells et al., 1992) has used such a poly-drug use measure and future
smoking.
1.4.2. Predictor measures
1.4.2.1. Background characteristics. Sociodemographic factors and other background characteristics
controlled for in the models are: ethnicity, gender, age, academic grades and family structure. Ethnicity
was categorized as African-American, Hispanic, White and Asian (with the largest group Hispanic, as the
reference group). Family composition was dichotomized by whether or not the participants were from
two-parent families, while age and grade were used as continuous scales.

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1.4.2.2. Perceptions of friends' use, family smoking and normative beliefs for peers and adults. To
measure smoking and drinking among friends, respondents were asked how many friends smoked
cigarettes/drank alcohol with responses ranging from 1 = none to 5 = all/nearly all. Friends are defined
as someone to hang out with or talk to in school, after-school organizations, the neighborhood or religious
organizations, according to focus groups. This definition would also be offered if a child asked about the
meaning of friend while completing the survey. A perceived use of friends measure was then created and
then categorized as high, if the respondent reported that any friends smoked or drank and low if the
student reported that none of his/her friends smoked or drank. Similarly, adult and peer norms for smoking
and drinking were measured by items asking In your opinion, how many adults/people your age smoke
cigarettes/drink alcoholic beverages? Thus what we refer to as peers are simply people of the
respondents' age as indicated on the survey, though not necessarily friends. Adults are clearly understood
to be individuals over 18 years old. The scales for these variables ranged from none (1) to almost all
(5). Categorization of these variables was the same as for friends' use.
1.4.2.3. Risk-taking tendency. Seven items ( = .66) taken from the Eysenck Personality Inventory
(Eysenck & Eysenck, 1975) assessed impulsive and daring behavior. Items included: I would do almost
anything on a dare and I enjoy taking risks. Students indicated responses on a scale ranging from
really not true for me (1) to really true for me (5).
1.4.2.4. Refusal assertiveness. Refusal assertiveness was measured with three items ( = .77) derived
from the Gambrill-Richey Assertion Inventory (1975). The three items from the refusal assertiveness
scale are: Say no when someone asks you to do something you do not want to do, Say no when
someone tries to ask you to smoke, Say no when someone tries to get you to drink. Each item had
response options ranging from never (1) to almost always (5).
1.4.2.5. Self-efficacy. Five items from the personal efficacy subscale of the Spheres of Control Scale
(Paulhus, 1983) assessed Self-Efficacy ( = .75). This scale measured the extent to which respondents
believed they could achieve personal goals through their own efforts (e.g., When I get what I want it's
because I worked hard for it, I can learn almost anything if I set my mind to it). Responses were scored
on a 5-point Likert scales ranging from strongly disagree (1) to strongly agree (5).
1.4.2.6. Psychological wellness. Four items ( = .77) from the Mental Health Inventory (Veit and Ware,
1983) assessed psychological wellness (e.g., I generally enjoyed the things that I did, I felt that I was a
happy person). Each item had response options on a 5-point Likert scale ranging from None of the time
(1) to Most of the time (5) over the last month.
1.4.2.7. Decision-making. Five items derived from a subscale of the Coping Inventory (Wills, 1986)
related to problem-solving and direct action measured decision-making skills ( = .80). These items
assessed sound decision-making skills (e.g., When I have a problem I think about which of the alternatives
is best). Responses were rated on a 5-point scale which ranged from never (1) to almost always (5).
1.4.3. Statistical analysis
Our primary goal is to examine the interactions effects between protective psychosocial and risk
factors, as well as their main effects, on poly-drug use intensity and future smoking intentions. To make all

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707

interaction effects have positive estimates and to render more straightforward interpretations, we defined
the level of each protective psychosocial factor that incurs lower risk as referent (coded as 0) in our
regression models (e.g., low refusal = 1 and high risk taking = 1, etc.). Both outcomes were analyzed as
continuous variables by the generalized estimating equations approach (Diggle, Heagerty, Liang, &
Zeger, 2002). Both methods were implemented by the PROC GENMOD procedure in SAS 9.1 (SAS,
2002) with unstructured covariance and normality assumptions. For sensitive checking, we replicated the
same set of analyses using different distributional assumptions such as the gamma distribution.
In the multivariate regression models for longitudinal data, time (in years since baseline) and the main
effects of individual variables listed in Table 1 along with the two-way interactions among behavioral and
psychosocial measures were entered as covariates. For the analysis of the students' perspective about
smoking in their later life, we used smoking-related information for covariates, not drinking. However, for
the poly-drug outcome, we tried to combine smoking and drinking statuses together (siblings' drinking
status was not available). The final parsimonious model was established with all the significant factors
with p-value less than 0.05. If the effect modification was significant, the associated main effects
remained in the model regardless of their statistical significance. For robust inference, empirical standard
errors were employed, and two-sided hypothesis and 5% type I error were assumed.

2. Results
Table 1 displays the prevalence of psychosocial and behavioral risk factors, which ranged from 43% to
52% based on median splits. About 40% of students thought their friend and peers smoke or drink. About
16% reported one or more brothers or sisters smoke cigarettes and only 15% believed that less than half of
adults smoke. Mean and median of drug use intensity measure were 5 and 4, with those for the future
smoking index were 1.4 and 1, where the level 1 in future smoking variable corresponds to I definitely
will not.
Multivariate regression analyses are presented in Tables 2 and 3. The parameter estimate can be
interpreted as the difference in the response variable for 1 unit change of the given covariate with all other
conditions fixed. White students engaged in higher intensity of poly-drug use than Hispanic students
( p = 0.03) and Asian students tended to report they would not smoke in the future ( p = 0.01). All other
ethnicity-related differences compared to Hispanic were not significant. Drug use tended to increase as
time progressed ( p-value < 0.0001) and students' concepts about smoking in the future is pretty much
time-invariant, as would be anticipated. Lower grades were a strong linear predictor for both outcomes
( p < 0.003). Girls showed more willingness to smoke in the future ( p = 0.002).
We found that the interaction effect of low refusal assertiveness with friends' smoking/drinking was
highly significant, incurring a 1 unit increase in the drug use outcome under the joint condition
( p < 0.0001), as shown in Table 2. Similar multiplicative effects were observed for friends' smoking/
drinking status and risk-taking tendency, and siblings' smoking status and refusal skill with somewhat
reduced interactive effects. Low psychological wellness and peers' smoking/drinking demonstrated
significant direct effects ( p < 0.002) but those effects were not modified by other factors. When an
interaction term is significant, the two associated main effects should be understood jointly, not singly.
Table 3 presents the analysis of future smoking intentions, which showed two significant interactions
among psychosocial and relationship factors. Specifically, low refusal assertiveness and decision making
skills intensified the direct effect of having smoker friends towards smoking tendency in 2 years. Three

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Table 2
Longitudinal multivariate regression model for poly-drug use intensity
Characteristics
Years since baseline
Ethnicity
Black/African-American
White/Caucasian
Oriental/Asian
Grade
Friends' smoking or drinking
Peers' smoking or drinking
Siblings' smoking
Low refusal assertiveness
Low psychological wellness
High risk-taking tendency
Friends' smoking or drinking * Low refusal assertiveness
Friends' smoking or drinking * High risk taking tendency
Siblings' smoking * Low refusal assertiveness

Estimate (95% CI)

p-value

0.37 (0.28, 0.47)

< 0.0001

0.21 ( 0.47, 0.06)

0.33 (0.03, 0.63)
0.21 ( 0.59, 0.16)
0.15 ( 0.25, 0.05)
0.26 (0.05, 0.47)
0.36 (0.15, 0.57)
0.67 (0.41, 0.94)
0.09 ( 0.09, 0.27)
0.33 (0.12, 0.54)
0.10 ( 0.07, 0.28)
1.00 (0.70, 1.30)
0.53 (0.24, 0.83)
0.51 (0.05, 0.96)

0.13
0.03
0.27
0.003
0.02
0.001
< 0.0001
0.32
0.002
0.24
< 0.0001
0.0004
0.029

For ethnicity, Latino/Hispanic is the reference and for all others, the absence of each condition is the reference.
A * B denotes the interaction term for A and B.

other factors (i.e., peers' smoking, siblings' smoking and high risk-taking) greatly increased the outcome
of future smoking intentions ( p < 0.0001), while high self-efficacy was significant ( p = 0.03). Results from
the analyses using different distributional assumptions for the outcomes also yielded consistent findings
(results not shown), which further supports the robustness of the results we reached. Students' perceptions
of adult smoking behavior did not predict either outcome.
Table 3
Longitudinal multivariate regression model for future smoking
Characteristics

Estimate (95% CI)

Years since baseline

Ethnicity
Black/African-American
White/Caucasian
Oriental/Asian
Sex (Girls)
Grade
Friends' smoking
Peers' smoking
Siblings' smoking
Low refusal assertiveness
High risk-taking
High self-efficacy
Low decision-making skill
Friends' smoking * Low refusal assertiveness
Friends' smoking * Low decision-making skill

0.005 ( 0.03, 0.02)

0.06 ( 0.15, 0.02)
0.01 ( 0.07, 0.10)
0.10 ( 0.18, 0.02)
0.10 ( 0.16, 0.04)
0.06 ( 0.08, 0.04)
0.03 ( 0.05, 0.10)
0.11 (0.06, 0.16)
0.29 (0.19, 0.38)
0.07 (0.02, 0.12)
0.13 (0.08, 0.19)
0.06 (0.01, 0.11)
0.03 ( 0.03, 0.09)
0.31 (0.21, 0.40)
0.14 (0.04, 0.24)

For ethnicity, Latino/Hispanic is the reference and for all others, the absence of each condition is the reference.
A * B denotes the interaction term for A and B.

p-value
0.72
0.11
0.80
0.01
0.002
< 0.0001
0.46
< 0.0001
< 0.0001
0.01
< 0.0001
0.03
0.32
< 0.0001
0.006

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709

3. Discussion
This study found that refusal assertiveness significantly mitigated the impact of friends' use on polydrug use and future smoking intentions among adolescents residing in inner-city regions. Conversely, the
high perceived friends' use combined with low refusal assertiveness showed the highest incidence of
poly-drug use and future smoking intentions. These findings were borne out in our prospective
longitudinal data analysis focusing on interaction effects between refusal assertiveness and friends' use
for two different outcomes: poly-drug use intensity and future smoking intentions. This indicates an
advance over past work that was cross-sectional, did not examine future intentions or only examined the
main effects of drugs individually rather than poly-drug use. Similarly, siblings' smoking and refusal
assertiveness interacted in predicting poly-drug use intensity. Another interaction showed that two risk
factors (friends' use and high risk-taking tendency) led to greater intensity of poly-drug use.
These findings show how critical it is to consider interactions between risk and protective factors in the
etiology of adolescent substance use. This study adds to the literature examining more complex
relationships in predicting substance use (Brook et al., 1997, 1986, 1989; Cooper et al., 1995; Stacy et al.,
1992). In this case, social risk factors like friends' smoking and friends' drinking can be migrated with
competence skills, such as refusal assertiveness and decision-making skills. This longitudinal work
expands on earlier cross-sectional research demonstrating that competence skills (refusal assertiveness,
decision-making and self-reinforcement) decreased the impact of friends or peers on alcohol use among
rural youth (Botvin et al., 1998) and inner-city youth (Epstein & Botvin, 2002). These studies confirm
various theories that suggest drug use develops from the interplay between social and personal factors
(Botvin, 1998).
Of note, students' belief about adults' smoking behaviors was not a significant predictor in either
analysis, nor was family smoking. Moreover, among friends, peers, siblings and adults, siblings' behavior
seemed to be most influential in the both analyses. Siblings do appear to be the most influential members
of the family for this age group, as suggested by earlier works (Fagan & Najman, 2005; Vakalahi, 2001).
High self-efficacy was positively associated with the future smoking, which seems counterintuitive.
However, it is possible that adolescents who believed that they would smoke in 2 years derived some
sense of self-efficacy from this belief. Perhaps, they believed they would be more popular, cool, happier
and part of their peer crowd if they smoked in the future. Such feelings might lead them to feel greater
self-efficacy. More attention to the role and validity of this measure will be desirable, as well as testing for
these other various possibilities, in subsequent studies on adolescent smoking behavior. Low
psychological wellness predicted poly-drug use intensity. This suggests that feeling unhappy may lead
to intense poly-drug use.
This study has a number of advantages. Performing longitudinal analyses showed advancement over
cross-sectional findings that are known to be an inferior design, especially for establishing causality.
Moreover, some results were consistent across the measures of poly-drug use and future smoking
intentions. Another strength is the focus on inner-city youth, a study population that is underrepresented
in the literature. Finally, examining interactive or joint effects rather than only main effects helped
highlight the complexity of the relationships in predicting poly-drug use in the regression context. The
proper detection of effect modifications with sufficient statistical power requires larger sample sizes and
we believe that the large number of participants that were longitudinally observed strengthens the
findings. The weaknesses of the study tend to concern the generalizability of the results. Since the study
was conducted in the schools, the findings cannot be extended to adolescents who are not in school. Yet, it

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should be pointed out that the study was conducted with students in the early years of middle school when
dropout rates remain low for a mobile inner-city population (particularly relative to high school where the
drop-out rates would have been much greater) and absentees were pursued on at least one return data
collection. Our analyses only included successful completers and so they may be limited due to possible
selection bias. It is not certain that the results would apply to other inner-city regions outside of New York
City or to areas that are considered suburban or rural. Future research should test these models by studying
adolescents in urban areas besides New York City, as well as suburban and rural locations, but we do not
have any reason to suspect different findings in this particular model.
The findings of the current study support the inclusion of competence skills training in interventions
designed to prevent poly-drug use among inner-city adolescents. This is particularly important because
some have argued that social norm approaches that correct the norms for drug use are sufficient for
reducing drug use and that skills training may not be a critical ingredient. Our findings indicate, to the
contrary, that competence skills may be crucial to such programs and that the influence of such skills
needs to be further and more closely examined in at-risk populations. Some earlier research conducted
among inner-city youth has indicated the relevance of skills training; refusal assertiveness mediated the
effects of a competence enhancement prevention program (Botvin et al., 1995).
A competence enhancement approach to preventing drug use includes both a way for migrating
perceptions of friends, peers and siblings' use. This is accomplished through discussion of myths and
realities of substance use, including the actual prevalence rates for drug behavior and the lack of social
acceptability of using these substances. The myths and realities of substance use include: the majority
of teenagers and adults do not smoke cigarettes or marijuana; most adults drink only occasionally and
in moderation; smoking cigarettes, drinking alcohol, and using marijuana have immediate and longterm effects on the body; provision of the actual figures for how many teenagers and adults use various
substances, which tend to be much lower than the students believed. For eighth graders, 82%
disapproved of occasional marijuana use (Johnston, O'Malley, & Bachman, 2005). Moreover, units
cover the importance of an a positive self-image and alternative to improving one's image rather than
using drugs with friends, as well as specific skills training relevant to refusal skills and broader skills
training (decision-making skills, goal setting skills, self-efficacy) meant to encourage refusal skills
further. Moreover, other studies using a competence enhancement approach have proven effective with
inner-city populations residing in New York City (Botvin et al., 1992, 1997; Botvin, Griffin, Diaz, &
Ifill-Williams, 2001). In summary, the results from these prior studies and the present study suggest
that refusal assertiveness should be included in prevention programs for inner-city adolescents. It
should be noted that future smoking is one of the determinants of smoking behavior (Ajzen &
Fishbein, 2004). And smoking appears related to increased rates of use of other substances. Moreover,
abuse starts with drug use early in life.
The National Household Survey on Drug Abuse (2003) reported that almost 60% of recent marijuana
initiates had used both cigarettes and alcohol prior to using marijuana. Moreover, this survey also reported
that earlier use of marijuana (prior to the age of 14 years which corresponds to the age of the current
sample) is associated with illicit use during adult years. Other research found that becoming cannabisdependent was linked with use of using three other drugs and cannabis onset before later adolescence
(18 years) is related to substantially increased risk of becoming cannabis-dependent soon after onset
(Chen, O'Brien, & Anthony, 2005). Cigarette smoking poses not only an immediate threat to the health of
the adolescents but is also a risk factor for marijuana use (Graves, Fernandez, Shelton, Frabutt, &
Williford, 2005).

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711

Therefore, if substance use can be stopped or delayed later substance use is less likely. Not
unsurprisingly, adolescent poly-drug use has been found to predict such behavior in adulthood;
specifically poly-drug use at the start of the study predicted poly-drug use at the 12-year follow-up in
adulthood for white, Hispanic and black individuals (Galaif & Newcomb, 1999). These authors conclude
that since early drug use was the only consistent predictor of future drug use for these three ethnic groups,
prevention programs should be aimed at reducing teenage drug use.
Acknowledgement
This study was supported by Grant 1 R03 DA 12432 from the National Institute on Drug Abuse to Dr.
Epstein. The smoking prevention trial research from which the data for this study was collected was
supported by Grant 1 R18 CA 39280 from the National Cancer Institute to Dr. Botvin.
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