ARTICLE
The Adolescents Training and Learning
to Avoid Steroids Program
Preventing Drug Use and Promoting Health Behaviors
Linn Goldberg, MD; David P. MacKinnon, PhD; Diane L. Elliot, MD; Esther L. Moe, PhD;
Greg Clarke, PhD; JeeWon Cheong, MA
Background: Use of alcohol and other illicit drugs by
adolescent male athletes is a significant problem. Participation in sports may encourage use of drugs that enhance athletic performance, especially anabolic steroids
(AS). Because, to our knowledge, no other intervention
has successfully altered substance abuse by athletes, we
developed and assessed the efficacy of a team-centered,
sex-specific education program designed to reduce adolescent athletes’ intentions to use and use of AS and alcohol and other illicit drugs.
Methods: We studied 31 high school football teams that
comprised 3207 athletes in 3 successive annual cohorts
(1994-1996). The intervention included interactive classroom and exercise training sessions given by peer educators and facilitated by coaches and strength trainers.
Program content included discussion of sports nutrition, exercise alternatives to AS and sport supplements,
and the effects of substance abuse in sports, drug refusal
role-playing, and the creation of health promotion messages. Questionnaires assessing AS, the use of sport supplements and alcohol and other illicit drugs, and potential
risk and protective factors were administered before and
after the intervention (before and after the football season) and up to 1 year after the program.
Results: At season’s end, intentions to use (P<.05)
and actual AS use (P<.04) were significantly lower
among students who participated in the study.
Although AS reduction did not achieve significance at
1 year (P<.08), intentions to use AS remained lower
(P = .02). Illicit drug use (marijuana, amphetamines,
and narcotics) was reduced at 1 year, whether alcohol
was included (P = .04) or excluded (P = .02) from the
index. Other long-term effects included fewer students
reporting drinking and driving (P = .004), less sport
supplement use (P = .009), and improved nutrition
behaviors (P<.02).
Conclusions: Use of alcohol and other illicit drugs and
associated harmful activities can be prevented with a sexspecific, team-centered education. School athletic teams
provide an optimal environment in which to provide drug
prevention and health promotion education.
Arch Pediatr Adolesc Med. 2000;154:332-338
Editor’s Note: Back in July 1996, when the preliminary study
was published, I stated that I’d be “eagerly awaiting the long-term
outcomes.” My eagerness for the intervention has faded, but that
for the follow-up, large-study population is as strong as ever.
Catherine D. DeAngelis, MD
From the Department of
Medicine, Oregon Health
Sciences University, Portland
(Drs Goldberg, Elliot, and
Moe); the Department of
Psychology, Arizona State
University, Tempe
(Dr MacKinnon and
Ms Cheong); and the Center
for Health Research, Kaiser
Permanente, Portland, Ore
(Dr Clarke).
P
ARTICIPATION IN schoolsponsored sports can benefit adolescents.1 However, it
does not protect young male
athletes from alcohol and
other illicit drug (AOD) use.2-4 Importantly, these athletes use anabolic steroids (AS) more frequently than their nonathlete peers, with a total of 4% to 12% of
all athletes using AS at some point in their
lives according to national and regional
studies.5-11 While illicit drug use in gen-
ARCH PEDIATR ADOLESC MED/ VOL 154, APR 2000
332
eral decreased during 1998, AS use increased 12% and 28% among 12th and 8th
graders, respectively.9 The 1998 Monitoring the Future study9 reported the highest rate of lifetime anabolic steroid use
since initial assessments began in 1991.
Again, during 1999, AS use increased
“broadly across different regions and communities of different sizes,” with a 17% increase among 8th graders and a 35% increase among 10th graders from 1998
levels.10 However, for adolescent males, the
increase in anabolic steroid use was even
more dramatic, with use by 8th- and 10thgrade boys increasing by more than 56%
and 47%, respectively, from 1998 to 1999.
In the United States, the highest adolescent user group consists of high school
football players.5-8
Anabolic steroids are testosterone derivatives, used by athletes to enhance
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SUBJECTS AND METHODS
STUDY DESIGN
The Figure provides a schematic of the study’s cohort, assessments, and intervention timing. All cohorts were assessed before and after each football season (1994, 1995, and
1996, respectively). The initial intervention year included
players from grades 9 through 12. Cohorts 2 and 3 included players from all of these grades, but mostly consisted of 9th- and 10th-grade students. One-year follow-up
program effects were available for cohorts 1 and 2, and are
combined in the long-term follow-up assessment. Cohorts
were combined to increase statistical power to detect changes
in lower prevalence behaviors such as AS use.
RECRUITMENT AND FOLLOW-UP
Thirty-four high schools in the Portland metropolitan area
agreed to participate and were matched in dyads, based on
salient demographics including school size, family socioeconomic status, and the football team’s prior win-loss record.
After randomization but prior to student recruitment, 3 schools
in the experimental group withdrew, owing to time commitment and curriculum control issues. Two of 3 unpaired control schools were rematched, with 1 randomly reassigned to
the experimental group, producing 15 schools in the experimental group and 16 in the control group.
This investigation was approved by the Institutional
Review Board of the Oregon Health Sciences University.
All athletes were approached for study inclusion. Students and parents provided written consent. Research staff
administered confidential questionnaires at baseline (prior
to the intervention), at season’s end, and at long-term
follow-up (school year’s end for seniors and 1-year follow-up for returning players).
recommended high-protein, high-carbohydrate, and lowfat food choices, with suggested meal plans. A weighttraining booklet supplemented the exercise sessions and
further described strength-training techniques. Parents
received an expanded version of the sports nutrition
guide.
Instructional materials were highly scripted to enhance program fidelity. Cohort 1 received 7 classroom and
7 weight-room sessions. Participants in cohorts 2 and 3 received the same content in a compressed, 8-session version (5 classroom and 3 weight-room sessions).
Implementor Training
Coaches in the experimental group participated in a single
curriculum in-service. Coach-selected peer leaders were instructed in small groups during similar sessions.
Control Condition
Control students were provided with a commercially produced, anti-AS pamphlet29 or similar handout, emphasizing
the adverse effects of AS and benefits of a sports nutrition diet.
Questionnaires
The program, integrated into team practice sessions, had 2
components: a classroom curriculum and weight-room skill
training sessions. The 45-minute classroom activities were
facilitated by coaching staff and/or surrogates. Approximately 60% of classroom curriculum was given in small student groups (6-8 students) by coach-selected volunteer team
members who were trained as peer facilitators. Trainers selected by the authors taught the exercise sessions.
Preintervention athletes in the experimental and control
groups completed a 168-item self-report questionnaire, developed from national surveys and earlier research.10,30,31 Many
individual items were grouped as constructs to assess theoretical risk and protective factors and proximal and distal
program outcomes (Table 1).30,32 These construct assessments included a student’s belief in coach tolerance to AS
use, susceptibility of AS adverse effects, and knowledge of exercise, sport supplements, and the effects of AS and AOD, emphasizing the consequences of drugs and alcohol use on athletic performance. Distal outcomes included intent to use and
actual AS use, use of alcohol and illicit drugs (marijuana, amphetamines, and narcotics), drinking and driving, sport
supplement use, and healthy alternatives to substances that
enhance athletic performance (eg, nutrition habits, such as
a high-carbohydrate, relatively high-protein diet with less than
30% of the calories derived from fat and strength training
self-efficacy). Follow-up questionnaires were similar to the
preintervention surveys, without certain demographic characteristics and with some items not related to outcomes. Drug
use questions were similar to Monitoring the Future surveys.9 Most other questions were measured on 5- to 7-point
agreement scales, used in prior research.30,31
Experimental Group Intervention
STATISTICAL ANALYSIS
The curriculum addressed normal adolescent physiology
and potential effects of AS and AOD use in sports. Strength
training and sports nutrition education were provided as
alternatives to AS and sport supplement use. Athletes analyzed supplement claims, located advertisements for treatments of the adverse effects of AS treatments (eg, hair
replacement, breast reduction surgery, and acne therapies) in bodybuilding magazines, created health promotion media messages, and practiced drug refusal through
role-playing.
Two pocket-sized guides were distributed to participants in the experimental group. A sports nutrition guide
Program effects were estimated with the conditional regression model using individuals and schools as units of
analyses. Follow-up measures were used as the dependent
variables, while preintervention measures and program exposure were independent variables. Program effects were
the difference between control and experimental groups at
follow-up, adjusted for the preintervention assessment. Ethnicity and father’s education differed between groups at the
baseline assessment. All analyses were repeated, with age,
ethnicity, and father’s education used as covariates in the
PREVENTION PROGRAM
Instruction
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Continued on next page
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Cohort 1
regression model. School-level effects were analyzed because participants were clustered within each
school’s football team.
Whether the subject was a senior was a covariate in the long-term follow-up analyses to control
for the difference in measurement time and the possible differences between graduating and remaining
students. For season’s-end effects, all cohorts were
combined, while cohorts 1 and 2 were combined for
the long-term effects, as 1-year follow-up data are
available only for these cohorts.
A variety of sport supplements, AS, alcohol, and
each illicit drug’s use were measured and analyzed
by single items. The remainder of the individual questionnaire items were combined to represent constructs for the analyses, as is common in health research.32 The questionnaire items used have shown
substantial reliability.33
The program was designed as a primary prevention intervention to reduce the incidence of new
AS users (ie, the number of athletes who began
using AS after baseline assessments). Comparisons
between experimental and control groups used
logistic regression analysis. For school-level analysis, we assessed cumulative percentages of new
users, examining effects with the conditional model
using ordinary regression analysis. The same analyses were conducted on the cumulative index of new
sport supplement use and drinking and driving
behavior. The cumulative sport supplement index
was a combination of various sport supplements
(excluding vitamins and minerals). Differences in
the experimental and control groups were incorporated in these analyses by weighting the frequencies
of new users and nonusers among groups.
The intervention measured new and cumulative use of AOD, sport supplements, and drinking and
driving behavior. We assessed an illicit drug index
by calculating the sum of dichotomized responses
(ever used vs never used) for marijuana, amphetamines, and narcotics. Because alcohol is not legal
for adolescents, we included alcohol and illicit drugs
as an AOD index in the analyses, and then assessed
the estimated effects with the conditional model using ordinary regression analysis.
P Intervention E
Cohort 2
P Intervention E
1996
O
1996
1995
Cohort 3
O
1995
1994
1997
P Intervention E
1997
1996
Adolescents Training and Learning to Avoid Steroids implementation
timeline. P indicates preseason questionnaire; E, end-of-season
questionnaire; and O, 1-year follow-up questionnaire.
roids (ATLAS) program, designed to deter substance use
in school-sponsored athletics.
RESULTS
SCHOOL AND SUBJECT RETENTION
All schools were retained in the follow-up periods. Student attrition was expected from 3 sources: team withdrawal, school transfer, or study withdrawal. Only study
withdrawal was potentially modifiable by investigators. A
total of 3207 adolescent athletes were enrolled in the study
and assessed at baseline. Because football rosters shrink during the first few weeks of school owing to dropouts (from
quitting or injury), precise estimates of the total subject pool
are not available. Coaches estimate that approximately 20%
fail to complete the season.31 Of those students assessed during the preseason, 78.5% (N = 2516; 1371 in the control
group and 1145 in the experimental group) were present
at the season’s end, the expected team attrition rate.
The 1-year follow-up retention rate was consistent
with the annual retention rate in Portland Public Schools
(71.6% for nongraduating students). We achieved a comparable retention among cohorts 1 and 2, postseason to
1-year follow-up: 68.7% (N = 1291; 700 in the control
group and 591 in the experimental group), a rate similar to other school-based prevention studies.34 The attrition rate among the experimental and control groups at
the 1-year follow-up did not differ.
BASELINE CHARACTERISTICS
muscle mass and strength.12,13 Their use is associated with
many significant adverse physical and emotional outcomes.13-24 Moreover, adolescent AS users do not confine drug use to athletic-enhancing substances, often
using a variety of illicit substances.25
Most school-based substance abuse prevention programs are directed at younger children, rather than older
adolescents; unfortunately, the beneficial effects from these
programs may not persist into high school.26-28 Furthermore, no prior interventions have successfully addressed AS or other drug use in sports.26,28 We conducted a randomized, controlled trial designed to address
these shortcomings. This report describes results of 3 successive cohorts of adolescent football players, enrolled
in the Adolescents Training and Learning to Avoid Ste-
Mean age for each cohort was between 15 to 16 years
(3-cohort mean, 15 years 5 months). Table 2 shows
demographics for subjects who took both the preseason
questionnaire and the end-of-season questionnaire.
Group differences were tested with t tests for the continuous variables and x2 tests for categorical variables.
The experimental group had more African Americans
(P,.001) and fewer whites (P,.05) than the control
group. Parental education of the experimental group
was lower than for the control group (father’s education,
P,.001; mother’s education, P,.01).
Baseline equivalence was assessed for each construct. Individual-level, 2-tailed analyses indicate that
subjects in the experimental group reported greater
knowledge of AS effects (P,.01), higher normative AS
use (P,.05), poorer nutrition behavior (P,.01), and
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Table 1. Program Effects Preseason, End of Season, and at 1-Year Follow-up Analyzed by Subject and School*
P
Experimental Group
Control Group
% Change in
SD Units†
% Change in
SD Units†
Preseason to
End of Season
1-Year Follow-up
Variables
SD‡
Mean
Score,
Preseason§
Intent to use AS
Nutrition behaviors
Use of school instead
of private gym
Strength training
self-efficacy
Perception of athletic
competence
Ability to turn down drug
offers
Belief in media
advertisements
Team as an information
source
Peers as an information
source
Knowledge of effects
of AS
Knowledge of effects of
alcohol
Knowledge of
supplements/exercise
Perceived coach tolerance
of AS use
Perceived peer tolerance
of drug use
Normative beliefs about
AS use
Self-esteem
Impulsivity
Perceived harm of
AS use
Negative attitudes toward
AS users
Perceived susceptibility to
AS effects
Knowledge of marijuana
effects
Concern about what
friends think
Reasons for using AS
Reasons for not using
AS
Cumulative supplement
use (vitamins not
included)\
Cumulative lifetime AS
use\
Illicit substance use
(alcohol not included)
Alcohol and illicit drug use
Cumulative occurrences of
DUI\
1.15
1.13
2.49
1.63
4.09
1.44
11.0
−4.5
13.5
6.5
−5.7
−2.4
1.56
3.94
1.48
7.5
26.6
19.2
0.4
11.2
10.1
,.18
,.001
,.14
,.04
,.001
,.02
1.19
5.81
−13.4
−6.9
5.56
21.6
31.7
,.001
,.001
1.00
6.09
−10.7
−8.3
6.12
0.3
−2.9
.10
.003
,.09
,.02
1.41
6.00
−10.6
−7.3
6.02
−1.2
−1.8
.009
.004
,.21
,.03
1.29
2.89
0.6
−3.2
2.84
−28.4
−30.8
,.001
,.001
1.18
5.55
−14.7
−6.4
5.51
15.4
17.9
,.001
,.001
,.02
,.001
1.55
4.57
−3.2
4.8
4.56
41.4
38.1
,.001
,.001
,.001
,.001
4.68
10.19
−8.5
5.6
10.72
29.8
30.9
,.001
,.001
,.001
,.001
0.80
1.86
3.1
3.5
1.91
19.2
19.0
.004
,.001
.007
,.001
1.21
1.79
−8.4
1.6
1.87
61.7
44.3
,.001
,.001
,.001
,.001
1.30
2.22
17.8
12.9
2.24
−3.7
−1.3
,.01
,.001
,.02
,.02
1.89
3.25
5.5
25.6
3.38
−1.0
20.2
,.05
.35
.41
,.44
1.66
2.34
−8.5
−5.8
2.49
−15.5
−16.8
,.09
,.38
,.24
,.34
1.16
1.32
1.31
5.94
2.95
5.79
−18.2
6.5
−15.6
−5.8
4.7
−17.6
5.94
3.00
5.81
−8.8
−9.1
6.6
0.1
−1.0
4.6
.04
,.001
.001
,.02
,.001
,.001
,.12
,.13
.004
,.06
,.12
,.001
1.37
4.97
−6.9
−5.0
4.94
2.9
0.6
.02
.007
,.08
,.11
2.14
5.96
−8.4
−7.4
5.98
10.4
7.3
,.001
,.001
,.02
0.68
2.36
2.5
0.4
2.40
17.2
10.4
.005
,.001
0.94
2.97
−13.0
−10.1
2.96
−2.9
−18.0
,.02
2.18
3.68
1.40
6.69
−15.6
0.3
−12.6
0.7
1.48
6.80
2.3
16.0
11.9
−0.3
,.001
.007
,.001
,.001
End of
Season
1-Year
Follow-up
Mean
Score,
Preseason§
End of
Season
1-Year
Follow-up
School
Level
Subject
Level
School
Level
Subject
Level
,.07
,.02
,.03
,.02
,.02
,.04
.003
.002
.004
.003
,.001
,.001
.001
,.01
,.45
,.30
.001
,.50
.001
,.27
.009
NA
33.2
38.8
47.3
30.5
35.6
41.4
,.23
,.15
.005
NA
1.5
2.5
3.4
1.0
1.5
1.7
,.12
,.04
.15
,.07
0.64
0.36
−5.8
14.2
0.37
0.9
2.1
,.04
,.01
.010
,.02
0.88
NA
1.08
4.6
−10.2
7.6
8.4
12.1
1.10
5.0
−3.6
7.2
−3.9
10.7
,.04
,.09
.009
.13
,.02
,.08
,.04
.004
*AS indicates anabolic steroids; NS, not significant; DUI, driving under the influence. Pretest and posttest are based on subjects measured at both waves. Follow-up
values are based on subjects measured at pretest and follow-up.
†Percent change in pretest SD units, based on the sample of participants at pretest-posttest and pretest follow-up.
‡SD for the pretest-posttest sample, control and experimental groups combined.
§Mean questionnaire item scores.
\Cumulative lifetime AS use, cumulative supplement use, and cumulative DUI were determined by pretest use and new reported use at posttest and follow-up. All the
students who were present at the pretest were dealt with as if they had stayed through posttest, and if the student used AS at an earlier wave, he was considered a user
at a later wave. The percentage of cumulative lifetime AS use and DUI at the posttest was calculated based on all 3 cohorts (N = 3207), whereas the percentage at the
follow-up was based on cohorts 1 and 2 (N = 2390).
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INDIVIDUAL FACTORS
Table 2. Individual Comparison of Demographic
Characteristics Between Experimental and
Control Subjects Who Took Both the Preseason
and the End-of-Season Questionnaires
Although ATLAS-trained students reported higher selfesteem (P,.02) and less impulsivity (P,.001) at the season’s end, students in the experimental group had greater
confidence in their athletic abilities both at the season’s
end (P = .003) and at long-term follow-up (P,.02).
Group*
Demographics
Age, y, mean (SD)
Grade point average, mean (SD)†
Race/ethnicity, %
Asian
Native American
Hispanic
African American‡
White§
Mixed heritage
Father graduated from college, %‡
Mother graduated from college, %\
Parents are divorced, %
Control
(n = 1371)
Experimental
(n = 1145)
15.42 (1.20)
3.08 (0.62)
15.48 (1.19)
3.04 (0.62)
3.9
0.8
3.7
3.7
80.7
7.2
55.6
43.8
31.2
3.6
0.7
3.6
7.4
77.1
7.6
46.5
38.6
34.5
*N = 2516.
†Based on a 4.0 scale.
‡P,.001.
§P,.05.
\P,.01.
TEAM INFLUENCES
At both follow-up evaluations, athletes in the experimental group believed that their teammates were more
reliable sources for information about drugs, nutrition,
and exercise (both, P,.001). Athletes in the experimental group perceived their coach as less tolerant of AS use
at both follow-up evaluations (P,.001 and P,.02,
respectively). Self-reported ability to reject drug offers
from peers (ie, resistance skills) was greater in the experimental group than the control group at the season’s
end (P = .004) and long-term (P,.03).
NEW SPORT SUPPLEMENT USE
lower strength-training self-efficacy (P,.05) compared
with controls. School-level baselines found differences
only in nutrition behavior (P,.05) and strengthtraining self-efficacy (P,.01). Outcomes were not
altered when baseline differences, including age, were
used as covariates.
PROGRAM EFFECTS
The analyses used 1-tailed significance for the program
effects, justified by the positive findings detected in the
pilot and cohort 1 findings.30,31 Both school and subjectlevel analyses are shown in Table 1. In the text, we describe effects at the subject level, because school-level
results were similar (90% long-term concordance).
KNOWLEDGE
Athletes in the experimental group showed improved
knowledge of the effects of exercise and sport supplements at the season’s end and on long-term follow-up
(both, P,.001). Athletes in the experimental group had
greater knowledge of AS and alcohol’s effects at both
follow-up periods (both, P,.001), and marijuana use at
the season’s end (P,.001) and at 1-year follow-up
(P,.02).
ATTITUDES/BELIEFS
Subjects in the experimental group more strongly believed that AS has harmful effects and perceived greater
susceptibility to their effects at both follow-up assessments (both, P,.001). Likewise, subjects in the experimental group were less likely to believe advertisements
for sport supplements and positive AS use images at both
assessments (both, P,.001).
New sport supplement use (excluding vitamins and minerals) among those in the experimental group was not
lower than control subjects at the season’s end, but was
reduced significantly at 1-year follow-up (P = .009).
AS: INTENT TO USE AND NEW USE
The athletes in the experimental group reported lower intent to use AS than the control group at the season’s end
(P,.05) and at 1 year (P,.03). At the end of the season,
more new AS users (P,.04) were found in the control group
(n = 18) than in the experimental group (n = 7). In the 2
cohorts available for long-term follow-up, 19 new users
(cumulative from baseline) were found in the control group
and 9 were found in the experimental group (P = .072).
AOD USE
The index of AOD use (marijuana, amphetamines, and
narcotics) was not lower in the experimental group at
the season’s end, but was lower among the experimental group at 1-year follow-up (P,.05). When alcohol was
excluded from the index, use of illicit drugs remained
lower (P,.03) at 1 year among the experimental group.
OTHER HEALTH BEHAVIORS
New occurrences of drinking and driving were lower
among the experimental group at 1 year (P = .004). Those
in the experimental group reported improved nutrition
behaviors compared with the controls at the season’s end
(P,.001) and at 1 year (P,.02) and reported enhanced
strength-training self-efficacy at both follow-up periods
(both, P,.001).
COMMENT
This study substantiates the benefits of a sex-specific,
sports team–centered approach to improve adolescent
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health risks and behaviors.30,31 Program participants reported lower use of alcohol and illicit drugs (marijuana,
amphetamines, and narcotics), and less occurrence of
drinking and driving 1 year after the intervention. In addition, ATLAS is the first intervention to achieve a significant reduction in new AS use, with more than twice
as many new AS users in the control group after the football season. Although twice as many new AS users were
in the control group at the 1-year follow-up (n = 19 vs
n = 9), this difference did not achieve statistical significance. However, durable reductions in the intention to
use AS (a likely predictor of future drug use35) of those
in the experimental group remained lower at the 1-year
follow-up.
Corroborating these program effects are improved
nutrition behavior and less use of sport supplements. This
latter finding may be important in deterring AS use, as
sport supplements that claim athletic enhancement were
highly correlated with performance-enhancing drug use
in this study. Previous methods to reduce AS and other
substance abuse in sports have relied on cognitive education and drug testing.36-39 A knowledge-only AS education program improved understanding of adverse effects but did not alter intentions to use or actual use of
anabolic steroids,36 while an approach that emphasized
only the harmful consequences of AS37 had a rebound effect, generating more interest in those drugs.40 Although the legality of drug testing adolescent athletes has
been upheld by the courts,41 no prospective, controlled
studies substantiate the prevention efficacy of testing programs.42
The ATLAS program’s format is based on social learning theory43 and uses an established social unit (the sports
team) to redirect the students’ goal-directed behavior.30,31 Sports nutrition and strength training for performance enhancement are stressed as healthy alternatives
to AS use. With team-centered programming, content can
be sex-specific and address the causes and risks of substance abuse unique to male adolescents.44 Emphasizing the effect of alcohol and other drugs on immediate
sport performance rather than long-term complications
(eg, addiction and risks of disease) appeals to adolescents’ focus on the present. The success of this intervention model is supported by the findings that ATLAStrained athletes believed their teammates were more
reliable sources of information about AS, drugs, nutrition, and strength training than control teammates, and
coaches of the experimental group were perceived as more
intolerant of AS use.
There are limitations to the investigation. Study
power was limited as AS use was lower than expected.6-8,25,45 Several factors may have contributed to this.
Participation was voluntary, requiring active student and
parental consent. Questionnaires were confidential but
not anonymous; research staff (not school personnel or
parents) could identify respondents through codes. Thus,
some students who used or were considering using AS
may have been reluctant to enroll. Alternatively, these
students may have enrolled in the study but not admitted to drug use. For these reasons, we expected and observed a lower base rate of AS use than in anonymous,
point prevalence surveys.6,8,25,45 Despite this, AS use was
significantly less among students in the experimental
group after the season, and intent to use, a predictor of
future drug use35 was significantly lower at both follow-up periods.
Curriculum time differed between the first and later
cohorts, with a reduction in class contact hours. However, program content remained similar in scope. Furthermore, the team format allows reinforcement of classroom materials during other team sessions so that
curriculum time underestimates the effect of the intervention. Although this reduction could be detrimental
to an intervention’s efficacy,26 substantial improvements were maintained. Also, despite small differences
in age of the cohorts, outcomes, assessed as a covariate,
were not age-related.
High school athletes are an important group for
health promotion and AOD prevention. High school–
sponsored athletic groups enroll approximately 50% of
the entire student body at some point during the school
year.46 Importantly, athletes can be role models and opinion leaders for other students because of their elevated
social status,47,48 and have been used to facilitate drug prevention interventions.48 While an athlete’s drug use may
lead others to initiate substance use,49 their abstinence
has a potential deterrent effect.41
The ATLAS program demonstrates widespread and
sustained 1-year drug prevention and health promotion
effects for male adolescent athletes. Sex-specific, sports
team–centered education is a new paradigm that can favorably influence adolescent behavior.
Accepted for publication August 18, 1999.
This project was supported by grant DA-07356 from the
National Institute on Drug Abuse, Bethesda, Md (Dr Goldberg).
We thank Angela Lapin, MA, for substantial help with
the manuscript development, preparation, and revision.
Reprints: Linn Goldberg, MD, Oregon Health Sciences University, 3181 SW Sam Jackson Park Rd, Portland, OR 97201-3098 (e-mail: goldberl@ohsu.edu).
REFERENCES
1. Coakley J. Sport and socialization. In: Holloszy JO, ed. Exercise and Sports Sciences Reviews. Vol 21. Baltimore, Md: Williams & Wilkins; 1993:169-200.
2. Aaron DJ, Dearwater SR, Anderson R, Olsen T, Kriska AM, LaPorte RE. Physical
activity and the initiation of high-risk health behaviors in adolescents. Med Sci
Sports Exerc. 1995;27:1639-1642.
3. Faulkner RA, Slattery CM. The relationship of physical activity to alcohol consumption in youth. Can J Public Health. 1990;81:168-169.
4. Kokotailo PK. Substance use and other health risk behaviors in collegiate athletes. Clin J Sport Med. 1996;6:183-189.
5. Yesalis CE, Kennedy NK, Kopstein AN, Bahrke MS. Anabolic-androgenic steroid
use in the United States. JAMA. 1993;270:1217-1221.
6. Buckley WE, Yesalis CE III, Friedl KE, Anderson WA, Streit AL, Wright JE. Estimated prevalence of anabolic steroid use among male high school seniors. JAMA.
1988;260:3441-3445.
7. Johnson MD, Jay MS, Shoup B, Rickert VI. Anabolic steroid use by male adolescents. Pediatrics. 1989;83:921-924.
8. Yesalis CE, Barsukiewicz CK, Kopstein AN, Bahrke MS. Trends in anabolicandrogenic steroid use among adolescents. Arch Pediatr Adolesc Med. 1997;
151:1197-1206.
9. Johnston LD, O’Malley PM, Bachman JG. Monitoring the Future Study 1998: Trends
In Prevalence of Various Drugs for 8th Graders and High School Seniors. Rockville, Md: National Institute on Drug Abuse, National Institutes of Health; 1998.
10. Johnston LD, O’Malley PM, Bachman JG. Drug trends in 1999 are mixed [press
ARCH PEDIATR ADOLESC MED/ VOL 154, APR 2000
337
WWW.ARCHPEDIATRICS.COM
©2000 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 06/10/2020
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
release]. Ann Arbor: University of Michigan News and Information Services; December 1999.
DuRant RH, Escobedo LG, Health GN. Anabolic steroid use, strength training,
and multiple drug use among adolescents in the United States. Pediatrics. 1995;
96:23-28.
Yesalis CE, Bahrke MS. Anabolic-androgenic steroids: current issues. Sports Med.
1995;19:326-340.
Council on Scientific Affairs. Medical and nonmedical uses of anabolicandrogenic steroids. JAMA. 1990;264:2923-2927.
Haupt HA, Rovere GD. Anabolic steroids: a review of the literature. Am J Sports
Med. 1984;12:464-484.
Ajayi AA, Mathur R, Halushka PV. Testosterone increases human platelet thromboxane AZ receptor density and aggregation responses. Circulation. 1995;91:
2694-2698.
Cabasso A. Peliosis hepatis in a young bodybuilder. Med Sci Sports Exerc. 1994;
26:2-4.
Frankle MA. Anabolic-androgenic steroids: a guide for the physician. J Musculoskeletal Med. 1989;6:69-88.
Ishak KG. Hepatic neoplasms associated with contraceptive and anabolic steroids. In: Lingeman CH, ed. Carcinogenic Hormones. New York, NY: SpringerVerlag NY Inc; 1979:73-128.
Baldo-Enzi G, Giada F, Zuliani G. Lipid and apoprotein modification in body builders during and after self-administration of anabolic steroids. Metabolism. 1990;
39:203-208.
Kleiner SM, Calabrese H, Fielder KM, Naito HK, Skibinski CI. Dietary influences
on cardiovascular disease risk in anabolic steroid-using and nonusing body builders. J Am Coll Nutr. 1989;8:109-119.
Huie MJ. An acute myocardial infarction occurring in an anabolic steroid user.
Med Sci Sports Exerc. 1994;26:408-413.
Pope HG, Katz DL. Affective and psychotic symptoms associated with anabolic
steroid use. Am J Psychiatry. 1988;145:487-490.
DuRant RH, Ashworth CS, Newman C, Rickert VI. Stability of the relationship
between anabolic steroid use and multiple substance use by young adolescents. J Adolesc Health. 1994;15:111-116.
Scott MJ, Scott MJ. HIV infection associated with injections of anabolic steroids. JAMA. 1989;262:207-208.
DuRant RH, Escobedo LG, Heath GN. Anabolic steroid use, strength training, and
multiple drug use among adolescents in the United States. Pediatrics. 1995;96:
23-28.
Making the Grade: A Guide to School Drug Prevention Programs. Washington,
DC: Drug Strategies; 1996.
Bell RM, Ellickson PL, Harrison ER. Do drug prevention effects persist into
high school? how Project ALERT did with ninth graders. Prev Med. 1993;22:
463-483.
Dusenbury L, Falco M, Lake A. A review of the evaluation of 47 drug abuse prevention curricula available nationally. J Sch Health. 1997;67:127-132.
About Steroids. South Deerfield, Mass: Channing L Beete Co; 1994.
Goldberg L, Elliot DL, Clarke GN, et al. The Adolescents Training and Learning to
Avoid Steroids (ATLAS) prevention program: background and results of a model
intervention. Arch Pediatr Adolesc Med. 1996;150:713-721.
31. Goldberg L, Elliot DL, Clarke GN, et al. Effects of a multidimensional anabolic
steroid prevention program: the Adolescents Training and Learning to Avoid Steroids (ATLAS) program. JAMA. 1996;276:1555-1562.
32. DeVellis RF. Scale Development: Theory and Applications. Thousand Oaks, Calif:
Sage Publications; 1991.
33. MacKinnon D, Goldberg L, Lapin A, Clarke G, Elliot DL, Moe EL. Psychometric
Properties of Anabolic Steroid Questionnaire: The Adolescents Training and Learning to Avoid Steroids (ATLAS) Project. Tempe, Ariz: Arizona State University; 1998.
34. Biglan A, Hood D, Borzovsky P, Ochs L, Ary D, Black C. Subject attrition in prevention research. In: Leukefeld CG, Bukoski WJ, eds. Drug Abuse Prevention Research: Methodological Issues. Rockville, Md: National Institute on Drug Abuse;
1991. NIDA Research Monograph 107, DHHS publication (ADM) 91-1761.
35. Flay BR, Petraitis J. Methodological issues in drug use prevention research: theoretical foundations. In: Leukefeld CG, Bukoski WJ, eds. Drug Abuse Prevention
Intervention Research: Methodological Issues. Rockville, Md: National Institute
on Drug Abuse; 1991. NIDA Research Monograph 107, DHHS publication (ADM)
91-1761.
36. Goldberg L, Bosworth EE, Bents RT, Trevisan L. Effect of an anabolic steroid education program on knowledge and attitudes of football players. J Adolesc Health
Care. 1990;11:210-214.
37. Goldberg L, Bents R, Bosworth E, Trevisan L, Elliot DL. Anabolic steroid education and adolescents: do scare tactics work? Pediatrics. 1991;87:283-286.
38. Radford PF. Recent developments in drug abuse and doping control in sport.
J R Coll Surg. 1990;35:S2-S6.
39. Ferstle J. Evolution and politics of drug testing. In: Yesalis C, ed. Anabolic Steroids in Sport and Exercise. Champaign, Ill: Human Kinetics; 1992.
40. Goldberg L, Elliot DL, Bosworth E, Bents R. Boomerang effects of drug education programs. Pediatrics. 1991;88:1079.
41. Vernonia School District 47 v Acton, 15 S Ct 2386 (1995).
42. Normand J, Lempert RO, O’Brian CP, eds. Under the Influence? Drugs and the
American Work Force. Washington, DC: National Academy Press; 1994.
43. Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice Hall; 1986.
44. Selected Findings in Prevention: A Decade of Results From the Center for Substance Abuse Prevention (CSAP). Rockville, Md: Substance Abuse and Mental
Health Services Administration; 1997. DHHS publication (SMA) 97-3143.
45. Cleary B, Folker R, Thompson H, Carlson H, Jarrett G, Elliot D, et al. Increasing
adolescent anabolic steroid use: 5-year data. Med Sci Sports Exerc. 1992;24:
S45.
46. US Department of Health and Human Services. Physical Activity and Health: A
Report of the Surgeon General. Atlanta, Ga: US Dept of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion; 1996.
47. Thirer J, Wright SD. Sport and social status for adolescent males and females.
Soc Sports J. 19845;2:164-171.
48. Danish SJ. Athletes Coaching Teams (ACT) for Substance Abuse Prevention: ERIC
Model Programs Inventory Project. Richmond, Va: Clearinghouse for Higher Education, Virginia Commonwealth University; 1990.
49. Role model, sports and youth: a youthful perspective. In: School Safety. Malibu,
Calif: National School Safety Resource Center; 1989:24.
ARCH PEDIATR ADOLESC MED/ VOL 154, APR 2000
338
WWW.ARCHPEDIATRICS.COM
©2000 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 06/10/2020