Attitudes of Rural Middle-School Youth Toward Alcohol, Tobacco, Drugs, and Violence

Since 1996, our research team has conducted 15 focus groups with 169 middle-school youth in small communities as formative research for campaigns against alcohol, tobacco, drugs, and violence. Some key findings of a synthesis of focus-group results are that girls and boys perceive different risks to alcohol and tobacco use; peer relationships are important, but there is great potential for parents to increase influence; females and Hispanic youth are most concerned about serving as good role models; and youth prefer campaign materials that feature typical youth and activities.

Rural youth were at one time thought to be isolated from urban problems such as substance use and violence, but recent studies suggest that any protection that may have existed is no longer the case (Barrow, VanZommeren, Young, & Holtman, 2000;Edwards, 1997;Peters, Oetting, & Edwards, 1992). To address this issue, our group of researchers has conducted prevention campaigns targeted at rural youth with funding from the Center for Substance Abuse Prevention, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism.
As formative-research for our multicomponent campaigns (which include media and other school-or community-wide interventions), we have conducted 15 focus groups with 169 youth participants in 7 small-to mid-sized communities across the United States. The primary goal of the focus groups has been to lay a foundation for developing media and other communication materials for our target groups -to brainstorm ideas, to formulate message strategy, and to ensure that campaign concepts will be culturally appropriate. The purpose of this article is to summarize major findings that were consistent across all of the focus groups we have conducted, as well as to point out differences that emerged by issue, gender, and ethnicity.
Implications for prevention education and programming are also discussed.

Background
There is evidence that substance use and violence are more prevalent in rural areas than once thought. Cronk and Sarvela (1996) found that amphetamine use, excessive drinking, and smoking were more common in rural than urban youth from 1976 to 1992. With respect to rural violence, Donnermeyer (1994) reported that there was a 430 percent increase in rural violence between 1959 and 1991. Further, recent surveys of youth gangs showed that gang members in rural areas are more likely to be younger than are gang members in urban areas, and counter to nationwide decreasing trends for 1996-98, the number of gang members in rural counties increased 43 percent (Office of Juvenile Justice and Delinquency Prevention, 2000).
Despite the need for prevention communication targeted at rural communities, many national campaigns against drugs and violence contain urban references that may not be effective in rural areas. Our team of researchers has aimed to bridge that gap by providing effective localized campaigns that were designed for and pretested in rural communities. In our approach aimed at rural communities, we "tailor" materials to reflect the image and character of rural communities participating in our projects, and this approach has proven to decrease substance use (Kelly, Stanley, & Edwards, 2000;Kelly, Swaim, & Wayman, 1996;Slater & Kelly, 2002).
Especially because many of our materials are customized, formative research is essential to ensure our campaigns are congruent with the needs of rural communities. A valuable formative-research technique is the focus group, which has a long history of use in consumer and social research (Frey & Fontana, 1993). The method is particularly useful in designing health campaigns because of the complexity of health behavior, potential barriers to action, and the myriad social influences on the process (Morgan & Krueger, 1993). While the data from focus groups is difficult to quantify and statistically project, the richness of the data provides unmatched insight into the needs of target groups.

Participants
Focus-group members were 169 youth from 7 different communities located in Arkansas, Colorado, Florida, and New Jersey. The communities ranged in size from 6,000 to 50,000 in population, although more than half of the participants were from communities that had 10,000 or less in population. Given the target audiences of our research projects, the participants were 6th-, 7th-, and 8th-grade students. Most focus groups contained roughly equal numbers of females and males, although we had a few focus groups that were all-female and all-male. Because Hispanic youth have been a primary target of one of our funded projects, four focus groups were comprised of all-Hispanic participants and at least a few Hispanic youth have participated in numerous other groups. The majority of participants, however, have been Caucasian.
Researchers worked with local school districts to schedule focus groups and to obtain informed consent from both youth and their parents. We did not conduct focus groups exclusively with youth who are heavy drug users or who have committed serious violent acts. This is because our research is focused on prevention rather than on intervention or remediation of existing problems.

Procedures
Each focus group contained 6 to 12 participants. Trained facilitators conducted the semi-structured sessions, which lasted approximately 90 minutes. If an observer was not able to accompany the moderator to take notes, the session was recorded. Moderator's guides were used to ensure consistency and efficiency. The guides were developed by the principal investigator, who was the same on all projects. Moderators requested that participants refrain from sharing any information about their own substance use and not to use names in referring to anyone not included in the focus group. At the conclusion, moderators asked for any other comments or feedback and thanked students for their participation. Within 24 hours of each focus group session, moderator and observer met to debrief and to write up a summary of findings. If the session was recorded, a transcription was produced.

Measures
Questions stimulated discussion about beliefs, attitudes, and norms regarding the target behavior. Moderators also pretested concepts, copy, visuals, and taglines and asked for feedback about themes, messages, and presentation. In some cases, participants were also asked to come up with their own suggestions for effective appeals that they would present to the rest of the group. Table 1 provides samples of questions used to guide discussion.

Findings
The findings we report are typical comments across all focus groups, and are based on a thematic analysis by the principal investigator of all post-focus-group reports and transcripts. We report both direct answers to moderator's questions, as well as topics that came up in the course of discussion.

Leisure-time activities and values
It is clear that youth value spending unstructured time with their friends (i.e., "hanging out"). Many youth also said that they like to relax by listening to music; favorite genres (even in smaller communities) are alternative and hip-hop. When asked what they would take with them if they were stranded on a deserted island, the most common answers were a TV, a radio, or a popular actor or singer of the opposite sex. Interestingly, some participants in the allgirl focus groups said they would take their mothers. "A friend" was also a common response from both boys and girls across all focus groups.

Concerns about substances
Participants reported that the main reason a young person in their community would use substances is boredom, a finding consistent with Iso- Ahola and Crowley (1991). In terms of smoking, most youth who smoke rejected the notion that they do it in order to appeared "cool," as also noted by Balch (1998) in focus groups with high schoolers. Rather, both girls and boys who smoke often said they do it as a means of rebelling against parents.

I smoke because my parents don't want me to -it makes em' crazy. (girl)
However, despite their desire to rebel against parents, both girls and boys also worried more about getting "caught" by their parents rather than by someone at school.
Among females, the consequences of drinking that concerned them the most revolve around drinking and driving. For example, girls who are dating (typically in the 8 th grade) stated they would be concerned if their date has too much to drink and will not be able to drive. They also worried that an inebriated date may pressure them to have sex. In terms of smoking, females expressed the most concern about the effects of smoking on physical attractiveness rather than on physical health. Among their concerns were the smell of smoke on clothes and hair; bad breath; yellow teeth; and smoker's cough ("sounds disgusting").

Violence
Most participants indicated that a certain amount of fighting or bullying is inevitable in school and that sometimes "adults make too big a deal out of it." Both girls and boys agreed that girls spread rumors more often than boys, while boys are more likely to engage in direct verbal violence (i.e., "talking trash" or "talking smack") or physical violence. Further, both girls and boys agreed that girls tend to hold grudges longer than do boys. Most students reported that they feel safe at school most of the time, and that they feel a responsibility to keep their school safe. Most also agreed that it is important to resolve fights before they get out of hand. However, responses reflected an uncertainty in dealing with the conflict between perceived peer expectations to fight back and the knowledge

Peer and dating relationships
In general, participants were familiar with the various groups they might encounter at school (e.g., preps, skaters, jocks, nerds, cowboys, Goths). Further, they very seldom spoke negatively about any of the groups. In fact, most youth asserted that it is important to get to know others, accept differences, and not judge people based on common stereotypes. However, participants also said that they do not necessarily associate with or go out of their way to meet people from other groups. Also, participants indicated that they are conscious of the expectations of different behaviors associated with different groups. For example, youth reported that "Goths" would be more likely than members of other groups to use "harder" drugs, and that "skaters" or "stoners" use marijuana.
Most youth stated that they do not have low opinions of peers who use substances, and they were very critical of advertisements that appeareded to be "putting down" others for certain behaviors.
Virtually all participants distinguished between their feelings about the action and about the person. Youth also distinguished between "talking to" and "preaching to" a friend who is using substances.
Smoking's a stupid thing to do, but just because someone smokes doesn't mean they're stupid. (girl) I wouldn't like it if my friend started getting drunk and stuff, but I wouldn't like preach at him. It's not like I'm his mother. (boy) Both boys and girls frequently said that they would distance themselves if one of their friends were to start using drugs. If they were to talk to that friend, however, girls said they would approach the matter out of concern, whereas boys typically said something about the behavior or person being stupid.
"I'm worried about you. Is something wrong?" (girl) "What're you thinking, man? You're being stupid." (boy) In terms of dating, non-using males were less likely to date someone who uses alcohol, tobacco, or other substances than are non-using females. Females said they are more willing to date someone who uses substances as long as "he doesn't do it when he's with me." Even some of these females conceded, however, that their parents would definitely not want them to date boys who use substances or who drink and drive.

Family and community relationships
Fewer than half of participants said that their parents had talked to them about the dangers of substance use. Of the youth who indicated that their parents had talked to them about "drugs," it was virtually always about cigarettes and alcohol and rarely any other drugs. Parental sanctions appeared to be stronger against drinking than smoking. Most female participants believed that while their parents would not necessarily try to stop them from dating someone who smokes, their parents would definitely try to stop them from dating someone who drinks.
Youth whose parents had talked to them about substances said that their parents discussed both the health risks and social consequences. According to girls, parents emphasize to them that it would look improper (i.e., the girl might look "easy"), whereas boys said that their parents emphasized the consequence of getting kicked out of sports if it appeared that substance use was taking place.

My parents tell me 'it looks bad' and that I'll get a reputation. People will start to talk about me. (girl) My parents don't want me to get in a wreck or something and get hurt, and they don't want me getting kicked out of basketball. (boy)
Participants reported that they are conscious of the potential to harm younger kids (particularly siblings) with second-hand smoke and of the obligation to serve as a good role model. This was a strong trend among females in particular, and with both male and female Hispanic youth.

Advertisement copy
The campaign themes that tested most positively in focus groups revealed that youth want positive messages that celebrate the capabilities of the individual or group to take action. The winning taglines in our campaigns have been "Be Under Your Own Influence" (drug prevention), "Resolve It. Solve It." (violence prevention), "Girl Power" (alcohol and tobacco prevention in females), and "Too Smart to Smoke" (tobacco prevention in Mexican-American and White-American youth). Participants said they like copy that is clear and reflects the way kids speak. They were especially disdainful of copy that tries too hard to sound "hip." Further, participants stated that copy should talk about real experiences and stimulate thinking about the issue.
You don't want it to sound like somebody your age (referring to the moderator's age) would said it. It's gotta be like we're saying it but don't try too hard. Like even though we said "dude" and "man," it'd sound like you're trying too hard and it just wouldn't work. (boy)

Advertisement visuals
Although some participants said that cartoon characters would be appealing visuals, discussions focused primarily on the use of human models in print ads. In general, both girls and boys felt strongly that the people in the ads should be people they can relate to, and who are involved in typical youth activities. Both girls and boys prefer a lot of activity (such as sports) in visuals.
We're not perfect, so we don't want to see models that look perfect. (girl) We want to see kids having a good time doing things they like to do. (boy) Further, participants reported that they want ads that contain both girls and boys. Interestingly, this was the case even in focus groups for a tobacco-prevention campaign aimed specifically at girls.

Types of appeals
Although youth said they like positive ads, when given the opportunity to discuss alternative approaches, youth often mentioned fear appeals. Middle-school males, in particular, seemed to favor the strongest fear appeals with the most graphic visuals (e.g., bloody car crashes). In addition, many youth suggested a before-after approach.
"This is you going out to have fun, and this is you in the accident you caused because you were drinking and driving." (boy) You've gotta scare us.

You've got to show us looking good and then show us how bad we look because we've been smoking. (boy)
However, when probed, the youth reported that they already know the risks involved in using most drugs, but they suggested that fear appeals are attention-getting.

Discussion & Implications
Our analysis of focus groups revealed some things that may be intuitively clear about youth but also some inconsistencies and surprising findings. First, our findings showed that both girls and boys place great importance on peer relationships. However, responses also suggested that parents have some influence on youth, and that there is great potential for increasing this influence. This is based on our finding that fewer than half of participants said that their parents have talked to them about substance use, and of those whose parents had, discussions were almost always about tobacco and/or alcohol than about any other drug. Moreover, our findings showed that youth are more concerned about getting "caught" by parents than by anyone else. One implication for health educators is to include efforts to increase the frequency and depth of parent-child communication about substance use. Communications about sanctions against substance use may be especially important in reducing youth substance use (Kelly, Comello, & Hunn, 2002;Sargent & Dalton, 2001).
Gender differences were among the most interesting of our findings. In terms of substance use, girls seemed to be more driven than boys by concerns about their physical attractiveness and availability for dating. Non-using girls were more likely to date a user than were non-using boys. With respect to tobacco, girls were more concerned with effects that are detrimental to beauty than to health. Based on these findings, one approach to consider is to emphasize the connection between health and appearedance. There is the risk, however, that this type of message may not be effective if the appearedance issues addressed in the message can be remedied easily, such as bad breath (Pechmann, Zhao, Goldberg, & Reibling, 2003). Further, messages should emphasize the overall attractiveness of non-use for all groups, consistent with recommendations by Pechmann and colleagues (2003) to underscore social disapproval risks of cigarettes.
Girls and boys also reported different strategies their parents use to discuss substance use with them. Whereas females said that their parents suggest using substances would give them an "easy" reputation, males said that their parents emphasize potential consequences for getting kicked out of sports. An implication for educators and prevention specialists is that parents play a role in reinforcing social norms and expectations of groups outside the family. Thus, comprehensive prevention campaigns should include efforts to educate parents on actual norms and to dispel myths about rampant use. Further, prevention activities should aim to give parents more guidance and "talking points" to facilitate discussion about substance use. In an effort to accomplish this, most of our projects have included mediaadvocacy materials such as informational articles submitted to newspapers and other publications aimed at parents. Future research might also focus on parents' views of norms within their children's social groups.
With respect to race, Hispanic youth felt strongly about the impact of their decisions on younger siblings. This finding is consistent with the emphasis placed on family in Hispanic culture, as noted by Valdés (2000) and others. An important implication here is that prevention materials aimed at Hispanic youth should make reference to family and younger kids in copy and visuals. For example, in a campaign we currently have underway, models in print ads represent a wide range of ages, including early-elementaryschool aged children. Also, ad copy refers to the dangers of second-hand smoke on younger children and on the need to set an example because "younger kids look to us." The importance of positive social norms and family relationships suggests the need to involve the wider community in prevention planning. Further, a communitybased effort would serve as the ideal framework for addressing the most common reason given for drug useboredom. As suggested by other researchers (Iso-Ahola & Crowley, 1991), school activities alone may not provide adequate stimulation for youth. Thus, more frequent and varied community-wide activities may be in order. Given that rural schools often serve as a hub for many community activities (Parker, 2001), efforts spearheaded by the schools may be more potent than they would in a larger urban area. For example, posters and flyers posted in and distributed by the school may reach a larger percentage of the community population in rural areas, giving the opportunity for developing broader-based community support for prevention efforts with relatively low cost. The school will also likely have contact with more than just parents of students due to the central nature of schools as meeting places that is often the case in rural communities. This provides the opportunity for education of adults in how they can help reduce substance use -i.e., awareness of signs of substance use, reducing availability of substances that can be abused, how to talk to youth about issues relating to substance use, etc. Further, we have addressed the issue of community involvement in our projects by encouraging networking among schools, agencies, and community members by hosting workshops for community leaders to assess community needs and to develop readiness-based strategies to meet those needs (see Edwards, Jumper-Thurman, Plested, Oetting, & Swanson, 2000, for a description of the community-readiness model).
A major finding in terms of violence is that although most youth expressed the ideals of acceptance of everyone and of avoiding conflict-escalation, many youth lacked clear ideas on how to act in accordance with these ideals. An implication for prevention specialists is to design messages to reinforce these ideals and to provide concrete examples on how to put them into action. Prevention messages can also acknowledge that sometimes it is difficult to translate these ideals into behavior. As an example, copy we created for a violence-prevention promotional item addresses the dilemma of fighting back versus walking away from a fight by stating, "They both can seem pretty hard to do! But you can show them you've got guts and brains -walk away." Other interventions, such as in-school interventions and counseling, may also be indicated given the challenges of learning such skills.
In terms of media materials, it appeareds that youth prefer ads that accurately reflect their culture. This is based on the findings that youth want to see models who look like them and who are involved in familiar activities. Also, most youth want believable language and are critical of language that tries too hard to sound "hip." This finding underscores the need to conduct formative research to ensure that all of the elements of the campaign resonate with the target group. Particularly for rural communities, prevention planners who wish to implement national campaigns may want to first test the campaign in focus groups with local youth to make certain that the campaign is appealing and to determine ways to adapt the campaign if necessary.
Findings also indicate that some youth believed that fear appeals would be the most effective way to prevent substance use. This result is intriguing since the use of messages that may arouse fear has been criticized by some (e.g., Austin, 1995;Hastings & MacFayden, 2002;Schneider, Salovey, Pallonen, Mundorf, Smith, & Steward, 2001), particularly for messages aimed at youth (Sturges & Rogers, 1996). The result also appeareds to be at odds with youths' generally positive reactions to ads that empower rather than scare. Perhaps the belief arises from mistaken perceptions of norms regarding substance abuse. Other researchers have found a disparity between actual and perceived norms regarding substance use (e.g., Haines & Spear, 1996). If youth perceive that substance use is much greater than it actually is, then the drama and urgency of scare tactics may seem to youth to be the method of choice. Further, without much knowledge of the mediating process involved in substance use, the straightforwardness of scare tactics and before-after approaches may seem attractive. Moreover, many youth might be accustomed to seeing fear appeals in various media, and thus a fear-based appeal may come most readily to mind as an alternative approach. Future research should explore the discrepancy between the common belief that fear appeals would be effective, and participants' positive reactions to empowering messages that reflect "typical" youth and activities.
Given the target audiences of our campaigns, our findings are limited in their generalizability. Because most of the focus groups were conducted in small-to mid-sized cities that were largely Caucasian in ethnic representation, the results may have limited applicability to very diverse and/or large urban youth populations. Furthermore, because there were more all-female focus groups than all-male, it was difficult to establish a level basis for comparing findings based on gender.
On the whole, our focus-group testing suggests that focus groups continue to serve as an invaluable formativeresearch tool in social marketing efforts. Campaigns with credible models that deliver positive messages about ideals, social norms of non-use, and empowerment may have the best success in the years ahead. Parents need to be targeted as a secondary audience with information on actual norms of non-use as well as encouragement and assistance in talking to children. Finally, our analysis supports increased use of media-advocacy and other community-level interventions to complement advertising materials and to reinforce social norms of non-use. Rural schools are uniquely positioned to spearhead such efforts and should take an active role in community-based efforts to pave the way for behavior change.