Integrating Primary and Secondary Prevention in U.S. School-Based Substance Use Programs: A Scoping Review from Initiation to Harm Reduction

Summary

This scoping review highlights that most U.S. school-based substance use programs are primary universal prevention, and integration of secondary prevention strategies remains limited. Incorporating theory, peer engagement, cultural adaptation, and technology could enhance impact and support equitable, comprehensive prevention for diverse adolescents.

Abstract

School-based substance use prevention programs in the United States (U.S.) have traditionally emphasized primary prevention. Although widely implemented, many programs overlook students who are already using substances. The incorporation of secondary prevention strategies, including resource-oriented approaches, acknowledges the full spectrum of student experiences and may enhance the relevance and responsiveness of prevention curricula while advancing health equity. Such integration is particularly important given increasing concerns regarding youth mental health, polysubstance use, and barriers to treatment access. The objective of this review was to assess the integration of secondary prevention components within school-based substance use prevention programs. Following PRISMA-ScR guidelines, a systematic search of EBSCOHOST, PubMed, and Google Scholar was conducted in July 2025. Eligible studies included peer-reviewed articles published between 2000 and 2025 that evaluated U.S.-based middle and high school programs integrating resource-oriented strategies, such as harm reduction and help-seeking, during school hours. Non-U.S. programs, elementary school and college-based interventions, and grey literature were excluded. Among the twenty-four studies included, most (n = 16) focused primarily on prevention strategies such as refusal skills and substance use awareness, whereas eight studies incorporated resource-oriented elements, including harm reduction and help-seeking components. Theoretical grounding was inconsistent, with three studies lacking an explicit theoretical framework. Most programs were teacher-led and peer-enhanced (n = 18) and targeted universal student populations (n = 20). Few interventions were tailored to high-risk subgroups, such as adolescents with prior substance use, and cultural adaptation was uncommon. School-based substance use prevention programs commonly emphasize universal skills, normative education, and peer engagement approaches; however, several methodological limitations remain. Future research would benefit from more rigorous evaluation, clearer theoretical grounding, greater attention to cultural adaptation, and exploration of scalable, tiered hybrid models capable of supporting equitable and comprehensive prevention across diverse adolescent populations.

Introduction

Adolescent substance use poses a significant public health challenge in the United States (U.S.), with many adolescents reporting substance use. According to the 2024 Monitoring the Future survey, approximately 42% of high school seniors reported using alcohol in the past 12 months, 21% of high school seniors reported ever vaping nicotine, and more than 1 in 4 (26%) reported using cannabis within the past 12 months¹. Substance use initiation in adolescence has been linked to multiple adverse outcomes over the life course, including impaired cognitive development, increased likelihood of mental health issues, and substance use disorders in adult....