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Theoq of Triadic Influence

Chapter 3

The Theory of Triadic Influence:Preliminary Evidence Related to

Alcohol and Tobacco Use

Brian R. Flay, D.Phil., John Petraitis, Ph.D.,and Frank B. Hu, M.P.H.

There has been relatively little re-search on how biological influencescontribute to tobacco and alcoholuse. Our recent reviews of the theo-ries of tobacco use (Flay and Petraitis1994) and illicit drug use (Petraitis etal. 1995) concluded that biologicalinfluences are scarcely mentioned inthe theories that dominate the field(e.g., the problem behavior theory).This is unfortunate because no under-standing of tobacco and alcohol use iscomplete unless biological influencesare addressed. and the mechanisms bywhich biological kctors contribute tothe use of tobacco and alcohol arecarefully described.

In this chapter we want to showhow the biological views presented inother chapters in this monograph rep-resent one piece of a larger puzzlethat includes both biological andnonbiological influences. The nonbi-ological influences include (a) the in-fluence of modeling, when parentsshow children how much ple’asurethey derive from alcohol and tobacco;(b) developmental influences, inwhich lifelong patterns of alcohol andtobacco use might begin in an adoles-cent’s otherwise healthy desire forindependence from parents; and(c) cultural influences, like advertis-ing, in which tobacco and alcohol use

B.R. Flay, D.PhiI., is a professor and the director ofthc Prcvcution Research Center,School of Pa&c Health, University of ILlinois at ClJicn30, GO West Jackson Blvd., Suite400, Chicago, IL 60607. J. Petraitis, Ph.D., is an assistant professor in the Department ofPsychology, University of Alaska at Anchorage, 3211 Providence Drive, Anchorage, AK99508. F.B. Hu, M.P.H., is a research associate wit/~ the PI mention Research Center,School of Public Health, Univetrity of Illinois at ChicnJo.

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Alcohol and Tobacco

become linked as rewarding activitiesthat people do to relax, to be socia-ble, and to treat themselves. We alsowant to focus on factors that causeadolescents to start smoking and startusing alcohol, Toward these ends, wewill describe ( 1) a theoretical frame-work that captures most (if not all)influences on experimental tobaccouse (ETU) and experimental alcoholuse (EAU) among adolescents;(2) some evidence for the causal pro-cesses that are articulated in our theo-retical model, including researchevidence on the onset of use of alco-hol, tobacco, and ‘other drugs(ATOD); and (3) implications of ourmodel for understanding the causesof ETU and EAU, and for preventingETU and EAU.

A THEORETICALFRAMEWORK OFINFLUENCES ON ETUAND EAU

The dominant theories of ETA andETU among adolescents include along and diverse list of causal influ-ences, ranging from factors that areintrinsically tied to ATOD use (e.g.,beliefs about the consequences ofsmoking) to factors that on the sur-face have little to do with these prob-lem behaviors (e.g., parenting stylesand school characteristics) (Flay andPetraitis 1994; Petraitis et al. 1995).The diversity of theories and causalinfluences is not surprising given thatATOD use, like most behaviors, has acomplex etiology. In fact, numerousscholars (e.g., Magnusson 1981;

ENVIRONMENTENVIRONMENTCultural Environment,Cultural Environment,

Societal Factors,Societal Factors,

Figwe 1.Figwe 1. Three ultimate causes of behavior: reciprocal determinism.Three ultimate causes of behavior: reciprocal determinism.

.

Bandura 1986; Sadava 1987; Frank-enhaeuser 1991; Jessor et al. 1991;De&y and Buss 1992) have arguedpersuasively that a thorough under-standing of any behavior must look at“the big picture.” That picture mustbe based on a comprehensive and in-tegrative analysis of (a) the broad SO-cial environment or cultural milieusurrounding the behavior, (b) themore immediate social situation orcontext in which the behavior occurs,(c) the characteristics or dispositionsof the person performing the behav-ior, (d) the behavior itself and closelyrelated behaviors, and (e) the interac-tion among all of these.

Figure 1, in a very general sense,represents “the big picture.” It re-minds researchers and theorists thatETU and EAU have roots in broadenvironmental or cultural factors(e.g., media depictions of smokingand alcohol use), situational factors(e.g., poor relationships with par-ents), and personal hctors (e.g., indi-vidual sensitivities to nicotine) andthat all of these factors affect eachother and are also influenced by thebehavior itself (i.e., reciprocal deter-minism). It also reminds us that anyone f3ctor is just one small part of alarger picture and is only likely to ex-plain small portions of variance in ei-ther ETU or EAU.

The model depicted in figure 1 isnot a testable theory; it is far too gen-eral and lacks important informationabout variables and relationshipsamong variables. It is, however, thefoundation of a theory that we call

Thcov of Triadic Influcncc

According to TTI, the general cul-tural environment in which adoles-cents mature, the more immediatesocial situation in which adolescentsfind themselves from day to day, andintrapersonal differences among ado-lescents are the starting points forthree “streams” of influence-streamsthat flow through different mediatingvariables and flow to different termi-nating variables.

THETHREESTREAMS:DEFNTIONSAND~~MINATINGVARIABLES

Figure 2 begins to reveal these threestreams in more detail. According toTX, the first stream represents char-acteristics of the broad cultural envi-ronment and general social values thatcontribute to or terminate at adoles-cents’ personal attitudes concern-ing ETU and EAU. Such cultural/attitudinal influetzces include localcrime and employment rates, mediadepictions and government policiesconcerning tobacco and alcohol use,lack of commitment to conventionalvalues, and social alienation. The sec-ond stream represents characteristicsof adolescents’ more immediate socialsituations and more intimate socialsupport systems that contribute to orterminate at the social pressure ado-lescents feel to experiment with to-bacco or alcohol. Such interpersonalor social/normative influences includeparenting styles, the strength ofbonds between parents and adoles-cents, the strength of bonds betweenpeers and adolescents, and tobaccoand alcohol use by parents and peers.the theory of triadic influence (‘TTI). . -

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Alcohol and Tobacco

SELF-EFFICACY/TOWARD THE BEHAVIORAL

1 BEHAVIOR i

Figure 2. Basis of the theory of triadic influence: ultimate causes and proximalpredictors.

The third stream represents character-istics of individual adolescents’ biolog-ical makeup and basic personality thatundermine their ability to resist pres-sures to smoke cigarettes and drink al-cohol. Such intrapersonal influencesinclude (among others) biologicalsensitivities to nicotine and alcohol,fundamental and stable personalitycharacteristics (e.g., neuroticism, ex-traversion, openness, agreeableness,intellect), more transient affectivestates (e.g., depressed affect, lowself-esteem), social skills, and, ulti-mately, resistance or refusal skills.

TIERS OF INFLUENCE

So far, our description of TTI has fo-cused explicitly on its three streams of

influence. Figure 3, however, revealsthat there is more to TTI than juststreams of influence; there are alsoseveral tiers or levels of influence. Thelowest three tiers of figure 3 representthe most proxi’mal level of influence.Proximal influences are fairly narrowlydefined (e.g., intentions to smoke acigarette within the next 30 days), areinherently tied to ETU and EAU(e.g., smoking-related attitudes), areprobably the most immediate* causesof ETU and EAU, and are thestrongest predictors of ETU (Flayand Pet ra i t i s 1994) and EAU(Petraitis et al. 1994a).

The third and fourth tiers (fromthe bottom) of figure 3 are factorsfrom more intermediate or distal lev-

__-___ --..---.- .____._. ~-.

Theory of Triadic Influcncc

culluml/ ScJoiall Intm-Atliiinal No- personal

stream Slnam Stream

Figure 3. The theory of triadic influence. The causal streams are indicated by numbrrsl-6, and the interstream influences are indicated by letters a-f (see text for an explanationof these pathways and influences).

els of influence. Distal influences are iMPIRICAL EVIDENCEfactors that probably contribute indi- FOR TTIrectly to ETU and EAU by contribut-ing directly to tobacco- and alcohol-specific attitudes, normative beliefs,and self-efficacy.

Finally, the highest tier of figure 3represents the ultimate influences.Unlike proximal and distal influences,ultimate influences (a) are beyond the

\ easy control of adolescents, (b) are notinherently tied to alcohol or tobaccouse, (c) are broader in scope and notas narrowly defined, and (d) are moredeeply rooted in an adolescent’s envi-ronment, personality, or biologicalmakeup. As such, ultimate influencesare likely to Sect ETU and EAU in avariety of ways.

In the previous section we arguedthat TTI’s three streams of influencehave different tiers or levels of influ-ence. According to TTI, however,each stream also has a unique set ofmediating variables and causal path-ways through which causal influencesprimarily flow. Furthermore, causalprocesses are not thought to exist ex-clusively within one stream or theother. Rather, factors in one streammay cross streams and influence fac-tors in another stream. In this sec-tion, we briefly describe thesepathways and some of their empiricalsupport. We provide a detailed review

rI_ _______...______ .- --.._. - . - .---.. ------ -.

Alcohol and Tobacco

of studies of causal process in anotherpaper (Flay et al. unpublished manu-script 1995).

PATHs~MED~TINGVWLES IN THE CULTURAL/ATTITUDINALSTREAMAccording to TTI, the cultural/attitudinal stream begins in the gen-eral cultural environment in whichadolescents mature, the informationthey derive from their culture abouttobacco and alcohol, and the generalsocial values they adopt from theirculture. In turn, these factors com-bine to affect (a) adolescents’ subjec-tive expectations about the personalconsequences of ETU or EAU,(b) their personal evaluations con-cerning the goodness- badness ofthose consequences, and (c) theiroverall attitudes toward their ownETU or EAU. This causal process isrepresented by path 1 in figure 3 andis supported by numerous empiricalstudies. For instance, after comparingthe causal processes that lead to alco-hol use in the United States andGreece, Marcos and Johnson (1988)concluded that teen alcohol use inthe United States, unlike that inGreece, is a sign of social alienationand deviant attitudes. Grube andWallack (1994) found that culturalimages of beer in the United States(as provided by television advertise-ments) might affect attitudes towarddrinking by leading many children tolink “drinking with positively valuedactivities and consequences such asromance, sociability, and relaxation”(pp. 257-258).

‘ITI then argues that tobacco- oralcohol-related expectations, evalua-tions, and attitudes play a major rolein shaping adolescents’ decisions orintentions to use (or avoid) tobaccoand alcohol in the future (see path 2of figure 3). In line with this, severalstudies have demonstrated that atti-tudes influence drug use through themediating effects of intentions (e.g.,Bentler and Speckart 1979; Schlegelet al. 1992; Flay et al. 1994; Flay etal. unpublished manuscript 1994;Petraitis et al. 19946).

PATHS AND MEDIATING%lRIABLES IN THE SOCIAL/NORMATNESTRELMSocial/normative influences have theirroots in the characteristics of adoles-cents’ parents, peers, and immediatesurroundings, especially the tobacco-and alcohol-related attitudes and be-haviors of family members and thosepeers to whom adolescents mostclosely bond. As depicted by path 3,TTI asserts that these characteristicsaffect (a) adolescents’ subjective per-ceptions about the normativeness ofETU and EAU, (b) with whom ado-lescents are most motivated to comply(e.g., conventional parents or deviantpeers), and (c) the social pressuresadolescents feel to experiment with ei-ther tobacco or alcohol. Several stud-ies support this assertion. Forinstance, we found that parental andpeer smoking indirectly affected ado-lescents’ smoking initiation and esca-lation by first affecting adolescents’outcome expectancies regardingsmoking, perceived approval of smok-

1 . ‘y .Thco~ of Triadic Influcncc

ing, and refusal skills self-efficacy (Flayet al. 1994).

Perceived norms, motivation tocomply, and social normative beliefsare important because they are amongthe few factors that directly affectadolescents’ decisions or intentions touse (or avoid) ETU or EAU in thefuture (see path 4 on figure 3).Several studies have demonstratedthat attitudes influence drug usethrough the mediating effects of in-tentions (Ellickson and Hays 1991,1992; Flay et al. 1994; Flay et al. un-published manuscript 1994).

of control influenced alcohol use in-directly by first affecting adolescents’self-esteem, social competence, andsocial skills.

PATHSANDMEDUTINGVARZABLESINTHE%I~W?ERS~NALSTR.EAM

The second link in the causal pro-cess of intrapersonal influences runsto tobacco- or alcohol-related deci-sions or intentions from refusal skills,self-determination, and self-efficacy(see path 6 on figure 3). Supportingthis link, Ellickson and Hays (1991)found that resistance self-efficacy re-garding use of alcohol, cigarettes, andmarijuana affected adolescents’ use ofthese drugs both directly and indi-rectly through intentions.

Whereas the first two streams beganwith characteristics of the general cul-ture in which adolescents mature andcharacteristics of their more immedi-ate social situations, the intrapersonalstream begins with fundamental andstable characteristics of the individualadolescents (e.g., their personalitiesand biological makeups), their gen-eral levels of competence (e.g., socialand academic skills), and their senseof self (e.g., the strength of theirself-concepts). As depicted by path 5on figure 3, these influences arethought to affect (a) adolescents’skills at dealing with situations wherethey are offered cigarettes or alcohol,(b) their determination to either useor avoid cigarettes and alcohol, and(c) their tobacco- and alcohol-relatedself-efficacy. In support of this causalprocess, Dielman and colleagues(1989) found that adolescents’ locus

INTERSTREAM PATHS:INTERACTIONSANDMODERATION

So far, this section has focused onwithin-stream, or intrastream, path-ways. Paths l-6 probably explainmost of the variance in ETU andEAU. However, we do not believethat all causal processes lie neatlywithin one stream or the other.Rather, factors in one stream mightexert some influence on factors inother streams. Moreover, such inter-stream influences are sometimes theeffects of variables on a higher levelwithin one stream being mediated. byvariables at a lower level in anotherstream. These interstream influencesare depicted by paths a-f in figure 3.

Interstream influences may alsotake the form of statistical interactionssuch that the effect of a variable inone stream moderates the influenceof a variable in another stream. Forinstance, intrapersonal influences

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Alcohol and Tobacco

(e.g., personality characteristics andbiological makeups) might makesome adolescents more susceptible tosome social influences (e.g., peerpressures to smoke). In line with this,Bauman and colleagues (1992)showed that high testosterone levels(an intrapersonal characteristic ofadolescents) exaggerate the effects ofpeer or parental smoking (which aresocial influences in TTI). Thestress-coping model (see chapter 6 inthis monograph; see also Wills andShiffman 1985) is a special case ofthis type of interaction. This modelpostulates that experiences of stress(from higher in the intrapersonalstream) may be moderated by ex-pectancies, reasons for use, or copingfunctions (from lower in the cultural/attitudinal stream).

Interstream influences of ethnicityand gender are of particular interest.Although we assume that TTI de-scribes the causal process of ETU andEAU for all ethnic groups, we also as-sume that the specific weights appliedto particular paths probably vary byethnicity. For example, we found thatthe effects of friends’ smoking onadolescents’ initiation of smokingwere both direct and indirect-thelatter mediated through refusal skills

r whites and Hispan-e effects of friends’

smoking for blacks were only direct(Flay et al. 1994). The TTI describesthe causal process of ETU and EAUfor both males and females, eventhough the specific weights applied topaths probably differ and males andfemales probably react differently to

some known predictors of ATODuse. As with ethnicity, we suspect thatsome of these differences are due tobiological differences whereas othersare due to cultural differences in howmales and females are raised.

Several studies suggest that factorsin one stream do, in fact, moderatefactors in the other two streams. Riskfactors from two (sub)streams mayinteract such that one increases theeffects of the other. For example,high-risk-taking adolescents may beless susceptible to family influencesthan are low-risk-takers because theformer are more likely to seek inde-pendence. Similarly, adolescents withlow refusal skills are more prone topeer pressure than those with ade-quate refusal skills. We tested thesehypotheses in the context of smokingonset from grade 7 to grade 8. Datafor the analyses were collected as partof the Television, School and FamilyProject (TVSFP) smoking preventionprogram in Southern California (Flayet al. 1988, 1995). Baseline datawere collected in 1986 from 6,695seventh grade students from 47schools in Los Angeles County andSan Diego County.’

Figure 4 shows the interactive ef-fects of two distal risk factors: familyconflict (a 3-item scale, Cronbach’salpha = 0.74, median split into low ”and high family conflicts) andrisk-taking (a 3-item scale, Cron-bath’s alpha = 0.77, median splitinto low- and high-risk-takers).Smoking onset rates were 25.9 per-cent for low-risk-takers with lowfamily conflict and 41.8 percent for

Theory of Triadic Influence

low-risk-takers with high family con-flicts, whereas the onset rates forhigh-risk-takers were 34.6 percentand 38.4 percent for low and highfamily conflict, respectively. The rel-ative risk of smoking onset imposedby family conflict is higher for low-risk-takers than for high-risk-takers(odds ratios 2.06 versus 1.18). Thesefindings suggest that low-risk-taking

risk of smoking onset imposed byfriends’ smoking shows a decreasingtrend with increasing refusal skills(odds ratios are 2.97, 2.73, and1.75, respectively, for low-, medium-,and high-refusal-skill adolescents).These results indicate that adoles-cents with inadequate refusal skillsself-efficacy are more susceptible topeer pressure.

adolescents are more reactive to fam-ily environment than high-risk-

FEEDBACK A N D LO N G I T U D I N A L

taking adolescents.EFFECTS

Figure 4 also shows the interac- Feedback or reciprocal effects postu-tive effects between two proximal lated by TTI (Flay and Petraitisrisk factors: friends’ smoking and re- 1994) reflect the broad idea of recip-fusal skills self-efficacy. The relative rocal determinism (cf. Bandura

A. More Distal Risks:Family Conflict BYRisk Taking Score

Low Risk Taker Hugh Rak TakerFmlcaalo 0 25.9 CU.6FrnMH I) 41.8 55.4

WRaaz 2.66 l1.415.00l 1.1u.w.1.5*

B. More Proximal Risks:Friends’ Smoking BYRefusal Skills Self-Efficacy

Low RS. . . .NoFtimds’&noh~ I 15.5

Ftic~Smob.e I 40.5

Mtd RS25.545.7

Nonrmoken at grade 7

-Figure 4. Risk of smoking onset by grade 8: Two interactions of grade 7 social andintrapersonal risks. (A) Interactive cff’cts of family conflict and risk-taking. (B) Intrracrivccffccts of friends’ smoking and refusal skills (RS) self-efficacy. Data are from the Television,School and Family Project smokin& prcvcntion propm in Southrrn California.

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Alcohol and Tobacco

1986). Feedback influences areconcerned with the role of prior be-havior. Though it has been well doc-umented that prior drug use is thebest predictor of later drug use,there is little research on how experi-ences derived from prior drug use in-fluence later drug use. TTI proposesa feedback mechanism by which thismight happen. Specifically, ‘feedbackloops connecting prior and later be-haviors are formed in each stream ofinfluence through a dynamic inter-play betieen causal factors and be-haviors (figure 5). Initially, drug useis affected by variables such as socialbonding and attitudes. Once adoles-cents start to use drugs, the causal

ordering reverses and these variablesare subsequently shaped by the druguse behavior. These modified fac-tors, in turn, affect later drug use.

Several studies have provided sup-port for the idea of a feedback mech-anism. For example, Cohn andcolleagues (1985) found that priorsmoking affected smoking mainte-nance both directly and indirectlythrough positive and negative conse-quences of smoking. Similarly,Kaplan and colleagues ( 1988) foundthat earlier drug use influenced laterdrug use both directly and throughits impact on association withdrug-using peers and perceived neg-ative social sanctions. In a well-

Figure 5. Longitudinal and developmental effects according to the theory of triadicinfluence. ATT = attitudes; BEH = behavior; ENV I cultural environment; PER -biology/personality; SE = self-efficacy; SNB - social normative beliefs; SOC - socialsituation; tl-t5 I times l-5.

Theory of Triadic Influence

known study, Bentler and Speckart fects on intentions to smoke in the(1979) tested the effects of prior be- future and on future smoking.havior within the framework of Unfortunately, these studies onlyFishbein and Ajzen’s (1975) theory fof reasoned action and found that

ocused on two-wave data and ig-

some of the effects of prior drug usenored the dynamic nature of the ef-

were mediated by intention andfects. In figure 6, we model both

some of the effects were direct. In afeedback and longitudinal effects us-

replication and extension of thising three-wave data from the TVSFP.

study, our group (Petraitis et al. In this model, drug use is a latent vari-

1994b) found that prior smoking able with smoking and alcohol use as

had several indirect (mediated) ef- indicators. Risk-taking and friends’

fects: (1) it promoted more positive smoking are latent predictor con-attitudes toward smoking, (2) it al- structs measured over time. Note howtered adolescents’ beliefs in the nor- drug use at one wave “feeds back” tomative nature of smoking, and (3) it cause changes in the risk predictorundermined adolescents” resolve to variables. Note also that the size ofresist smoking; it also had direct ef- these effects may change over time.

Wave A: Grade 7 Wave C: Grade 8 Wave D: Grade 9

Figure 6. Three-wave latent variable model of two risk factors and drug USC. x2 =122.09 (df - 33). Adjusted goodness-of-fit index = 0.970. All coefficients arc standardizedand are significant at p < 0.05. Data arc from the Television, School and Family Projectsmoking prevention program in Southern California.

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Alcohol and Tobacco

ROLEOFRELATEDBEHAVIORS

Influence of Related Behaviors

Related behaviors (e.g., tobacco, al-cohol, and marijuana use) may influ-ence each o ther . I t has beenfrequently found that adolescentswho use one drug are more likely touse another one, leading to thewidely accepted conclusion that theuse of one drug serves as a gatewayfor use of other drugs. This unidi-mensional conceptualization of druguse behaviors, however, may be toosimplistic without considering otherrisk factors.

diets, but much more so for thosewho do not attend church, and moreso for those with low refusal skillsself-efficacy.

The preceding example (figure 7)describes how other risk factors affectthe influence of alcohol use on theuse of cigarettes. This moderatingprocess, however, does not stopthere. The line in figure 8 shows thewell-known phenomenon of prior al-cohol and tobacco use increasing therisk for marijuana use, illustrating thegateway drug hypothesis.

,^. . . ~.TTI postulates that the influence of

The gateway metaphor, however,may be too simplistic when we con-sider the effects of risk factors in theprocess of drug escalation, becauserelated behaviors may also interact

*~*.yN&“- --ci ass --. ~~.~~-q.,l_ ._-. ~L’.T,-x .-.. :‘.11.8 :.o.r.--i<._..., - __.. -_-,. ‘.-:- ‘&la-ted, behaviors ..might. be modified._, I_ .E:...,:.II‘f_:L---- 7by psychosocial factors. Figure 7shows the interactions of two vari- ,-with risk factors to influence subse- Iables, one cultural and one intraper-sonal, with prior alcohol use on theonset of cigarette smoking. Amongthose who did not regularly attend re-ligious worship, prior alcohol userswere more likely to initiate cigarettesmoking than those who had not usedalcohol (odds ratio = 3.5). For thosewho regularly attended religious wor-

ship, the risk for the transition fromalcohol use to cigarette smoking wasmuch less (odds ratio - 1.9).

Figure 7 also shows that the riskfor the transition from alcohol use tocigarette smoking was much *higherfor those who had low refusal skillsself-efficacy than for those who hadmedium and high refusal skills self-efficacy (odds ratios were 3.76, 2.00,and 1.90, respectively). Alcohol useputs students at risk for future smok-ing, as the gateway hypothesis pre-

..-

quent behavior. Figure 8 shows thatthe basic gateway drug hypothesis istrue only for students who are other-wise also at high risk (who score highon risk-taking and whose friends alsosmoke cigarettes); it is not true forthose not otherwise at risk (who scorelow on risk-taking and whose friendsdo not smoke). Specifically, for thosestudents who were low-risk-takersand had no smoking peers, marijuanause was independent of prior use ofalcohol and cigarettes. For those whowere high-risk-takers but had nosmoking peers and for those whowere low-risk-takers but had smokingpeers, marijuana use was much higherfor prior’ cigarette smokers comparedwith those who used alcohol. Thiskind of “stepping-stone” phe-nomenon of adolescent drug involve-ment was most pronounced for the

Theory of Triadic Influence

A. A cultural background variable: B. An intrapersonal variable:Religous Worship or not Refusal Skills Self-Effkzacy

AkNOOAkYe1rn

o&s Ralior:

Worship No17.843.3

3.5 (1.96.4)

Worship Yes25.640.2

1.9 (Q-2.4)

RS SE Low RS SE Mcd RS SE HighUcNoO 16.5 295 24.1AJCY-I 426 45.9 35.3

006s Raltoc 3.76 (2.36.2) 2.0 (1.5-2.6) 1.9 (1.5.2.4)

Nonsmokers at Grade 7

Figure 7. Risk of smoking by grade 8: Two interactions with prior (grade 7) alcoholuse. (A) Interaction of religious worship with -prior alcohol use. (B) Interaction of refusalskills self-efficacy (RS SE) with prior alcohol USC. Data are from the Television, School andFamily Project smoking prevention program in Southern California.

students at highest risk (they were mensional structure, that is, problemboth high-risk-takers and had smok- behaviors (Jessor and Jessor 1977).ing peers). These findings suggest TTI suggests that closely related be-that relying on a single risk fictor ori- haviors may have the same, or veryentation runs counter to the known similar causes, and less related behav-heterogeneity of behavior. We need iors less so (Flay and Petraitis 1994).to consider multiple risk factors and The more dissimilar the behavior, thetheir interactions to find out who is at less the overlap of the causal struc-risk and under what conditions. ture. The overlap varies most at the

Prediction of Closely Related *most proximal levels and least at the

Behaviorsmost distal levels (see figure 7 in Flayand Petraitis 1994). The ultimate or

Researchers are often asked whether root causes of related behaviors areor not the various drug use behaviors generally the same.are part of the same latent construct. Related behaviors obviously doThese behaviors have been conceptu- correlate with each other (that is, af-ally characterized to form a unidi- ter all, part of what we mean by

.. .

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Alcohol and Tobacco

2013 low risk, low peer use (n=1008)

m high risk, low peer use (n=66)

* Mean

m low risk, high peer use (n=1582)

m high risk, high peer use (n=303)

Never --> Marij Alcohol --> Marij Smoking --> Marij

l3g-u.x 8 . Risk of marijuana use by grade 8: Effects of prior behavior (grade 7), peerbehavior, and risk-taking. Data arc from the Television, School and Family Projectsmoking prevention program in Southern California.

“related”). They probably also havemost of the same causes. We may askwhether these causes interrelate witheach other and influence related be-haviors in the same ways. If alcoholuse and smoking had a similar causalstructure and influenced related be-haviors in the same ways, the modelshown in figure 9 would describe therelations among their causes. In thismodel, smoking and alcohol behav-iors are characterized as one latentphenomenon, which is influenced byrisk-taking preferences and the num-ber of smoking friends. Demographicvariables like gender and race mainlyaffect the adolescents’ risk-taking(personality) and the exposure tosmoking friends. This model does, in-

Jdeed, provide a good statistical fit toour data.

Despite the good fit of the “one-factor” model, we can fit an alternative“two-factor” model. In this model,smoking and alcohol use are treated asseparate constructs, but they are as-sumed to have the same causes.However, the model allows for thecauses to behave in different ways; thatis, it allows for different causal pro-cesses. Even the same causes may actin slightly different ways with respectto different behaviors. The modelshown in figure 10 (which does fit bet-ter than the model of figure 9 at a sta-tistically significant level), suggests thatgender, ethnicity, risk-taking andfriends’ smoking all act differently for

Theory of Triadic Influcncc

Figure 9. One-factor model of smoking and alcohol onset. x2 = 91.46 (df = 10).Adjusted goodness-of-fit index - 0.947. All coefficients are standardized. Data are fromthe Television, School and Family Project smoking prevention program in SouthernCalifornia.

alcohol and tobacco use. In particular, IMPLICATIONS ANDgender and race still have differential CONCLUSIONSdirect effects on smoking and alcoholuse, even after accounting for their in-direct effects through the other riskfactors. In broad terms, white adoles-cents drink more (and- earlier) thanadolescents of other races, and girlsdrink less than boys.

This finding suggests that we re-visit our earlier model of the longitu-dinal effects of drug use, this timeseparating alcohol and tobacco use.In figure 11, we see that the risk vari-ables not only predict the two behav-iors at different levels, but thatexperience with the behavior alsochanges these relationships over time.

The relations between alcohol useand cigarette smoking are complex.The traditional gateway or unidimen-sional explanations for experimenta-tion may be too simplistic. So far, wehave demonstrated four main points.First, alcohol use and cigarette smok-ing do share several causes and path-ways, which are described by thegeneric theoretical framework pro-vided by TTI. Second, the relationbetween alcohol use and cigarettesmoking can be modified by otherrisk factors. For example, the transi-tion from alcohol use to cigarette

Alcohol and Tobacco

smoking is more likely to occuramong adolescents who have otherrisk factors, such as low refusal skillsand exposure to smoking peers.Third, alcohol use and cigarettesmoking can be conceptualized eitheras one latent phenomenon or as dif-ferent behaviors. Generally speaking,the two behaviors (perhaps alongwith other deviant behaviors) havemore similarities than differences interms of causes. However, differencesin causal processes may have impor-tant implications for understandingand prevention. Fourth, the relationbetween alcohol use and cigarette

smoking is dynamic, as are the rela-tions between other risk factors anddrug use. In order to understand thedevelopmental process of drug use,we need to take several effects intoconsideration, including growth ef-fects (longitudinal or time effects), re-ciprocal effects, mediating effects, andmoderating effects. These effects areall incorporated into TTI.

All of the points made above haveimplications not only for understand-ing why adolescents start to experi-ment with alcohol or tobacco, butalso for behavior change in generaland prevention in particular. The mul-

trar -:E (III) .02i(nI)hck .w -%iHlprriC .ms (lu) .m1 @.I) .omMm -.a9 (IL@ .rm 04 -.lO3Riskmka .251 .121 .243Fll-mk .W ASS .399

Figure 10. Two-factor model of smoking and alcohol onset. x2 - 2.38 (df = 5).Adjusted goodness-of-fit index - 0.997. All coefficients arc standardized. Data arc fromthe T&vision, School and Family Project smoking prevention program in SouthernCalifornia.

Theory of Triadic Influence

tilevel and multidimensional nature ofTTI suggests that intervention andprevention programs for adolescent al-cohol and tobacco use should also bemultilevel and multidimensional (fig-ure 12). At more distal levels, TTIsuggests that legislative, media, andcommunity interventions are neededto change the informational, cul-tural/values, normative, and socialsupport aspects of the broader culturalor social environment. At more proxi-mal levels, adolescents (and parents)need to be taught appropriate atti-tudes (and supportive knowledge andvalues), normative beliefs (with appro-priate models and social approval/

disapproval), and social skills (with ap-propriate opportunities for practiceand reinforcement).

RECOMMENDATIONS FORFUTURE RESEARCH

Research is needed to establish moreclearly the links and causal relation-ships between intrapersonal, interper-sonal, and environmental risks andprotective factors, and the relation-ships of all of these with behavior. Wemake the following recommendationsfor future research:l Studies of causal process. In general,

we encourage more studies of the

F i g u r e 11. Three-wave latent variable model of two risk fictors and two drug USC

behaviors, showing changes over time in influence of risk factors on behavior and ofbehavior on risk factors. x2 - 168,40 (df = 27). Adjusted goodness-of-fit index = 0.950. Allcoefficients arc standardized and arc significant at p < 0.05. Data are from the Television,School and Family Project smoking prevention program in Southern California.

1 7

Alcohol and Tobacco

3m-s awareness I I I 1 Individual Skill and1

DeMon-making and

Figure 12. Major points of intervention for behavior change according to the theory oftriadic influence.

causal processes by which riskfactors contribute to adolescents’experimental use of tobacco and al-cohol. As TTI postulates, the etiol-ogy of ETU and EAU use iscomplex and involves both directand indirect paths, moderating ef-fects, and feedback or reciprocal ef-fects. Unfortunately, past research

has too rarely reflected this com-plexity. Although there are signs ofchange among more recent studies,too often past studies have stoppedat describing univariate or multi-variate predictors of alcohol and to-bacco use and have not describedthe complex causal process bywhich variables contribute to drink-ing and smoking. Therefore, we

encourage researchers to movefrom finding predictors to describ-ing causal processes.

9 Studies of causal processes involvingsociocultural environmental factors.Although future studies should fo-cus on causal processes in general,there is a particular need for stud-ies that focus on the causal pro-cesses by which socioculturalfactors contribute to tobacco andalcohol use. More research isneeded to examine the influencesof macrolevel sociocultural factors,such as public policies, neighbor-hood, poverty, and media. Grubeand Wallack (1994) provided oneof the few examples of such a studyby examining how exposure to al-

I.0 ______. _-.. .-.

Theory of Triadic Influence

. I

cohol advertisements influencesadolescents’ drinking intentions.

l Studies of causul processes invoivin~intrapersonal characteristics. Wealso recommend that more studiesfocus on the causal pathways bywhich ETU and EAU are rootedin intrapersonal characteristics, es-pecially biological factors and fun-damental personality traits. In fact,our recent review of theories of ex-perimental drug use (Petraitis et al.1995) suggested no clear causalpathways that link biological orpersonality variables to drug use.More research is also needed onthe interactive effects of biologicaland psychosocial factors on to-bacco and alcohol use.

l Studies of causal processes Leadingto dependence and addiction. Al-though there are numerous studieson the etiology of ETU (Flay andPetraitis 1994) and experimentaldrug use (Petraitis et al. 1994a;Flay et al. unpublished manuscript1995), few studies describe thepredictors of tobacco or alcoholdependence and addiction, andeven fewer studies describe .thecausal processes of becoming de-pendent or addicted. Therefore,more research is needed to exam-ine the natural history of tobaccoand alcohol use and the potentiallydifferent etiologic fictors and path-ways associated with experimentaluse and abuse.

l Studies of developmental changes. Inaddition, we recommend morestudies of developmental changesin the influence on tobacco and al-

cohol use. Influences on tobaccoand alcohol use may vary with dif-ferent stages of adolescence. Atime-varying design (e.g., multiplewaves of observations over criticalperiods of adolescence) and atime-varying statistical analysis(e.g., random effects or multilevelmodels) are crucial in investigatingthe developmental paths leading totobacco and alcohol use.

l Multiwave and intervention studiesof tobacco and alcohol use. The pre-ceding recommendations are basedon our belief that too few studieshave attempted to untangle thecomplex etiology that leads to theuse of tobacco, alcohol, or both.Our final recommendation is thatresearchers design more studiesthat can untangle the causal fac-tors, moderating effects, feedbackeffects, and other direct and indi-rect effects and can test complexcausal processes. In particular, werecommend that researchers designfuture studies of etiology withenough waves of data (probably sixor more) to allow them (a) to carryout sensitive tests of complex andinterwoven causal processes, (b) totest feedback mechanisms and re-ciprocal effects, and (c) to test fordevelopmental change? over time.In addition, the suggested causalrelationships should be subjectedto the ultimate test-by designinginterventions to change the pre-sumed causes and then determin-ing if such change leads to changesin behavior (less or no alcohol ortobacco use). It is only with such

1A

__I - 7 I

Aldohol and Tobacco

linked tests of theory and preven-tive interventions that a true sci-ence of prevention can developfully (Kellam 1994).

ACKNOWLEDGMENTS

. This chapter was prepared with sup-port from National Institute on DrugAbuse grant DA06307. Ohid Sid-diqui, M.S., helped with data analysis.

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