“cool and clean”: does prevention of substance abuse work in sport?

Balthasar A^1
1 Department of Political Science, University of Lucerne, Frohburgstrasse 3, Postfach 4466, CH-6002 Lucerne

Abstract

There is a strong belief among the general population that sport has positive effects. However, only some preventive effects of sport meet these high expectations. Numerous studies have specifically shown that sport does not protect people from the consumption of legal and illegal drugs such as alcohol, tobacco and cannabis. For this reason, the umbrella organisation of Swiss sports associations (Swiss Olympic), the Federal Office of Sport (FOSPO) and the Federal Office of Public Health (FOPH) teamed up as early as 2003 and launched the “cool and clean” prevention programme. Over the last 14 years, it has developed into Switzerland’s largest national prevention programme and has also attracted international attention. This article summarizes how “cool and clean” works and what the programme achieved so far.

Keywords:
Prevention of substance abuse, impact, living environment, sport, young people, evaluation, life skills

Zusammenfassung

Der Glaube der Bevölkerung an die positiven Effekte des Sports ist hoch. Die präventiven Wirkungen des Sports entsprechen jedoch nur zum Teil den hohen Erwartungen. Zahlreiche Studien zeigen, dass Sport nicht vor dem Konsum von legalen und illegalen Drogen wie Alkohol, Tabak und Can­nabis schützt. Aus diesem Grund haben sich die Dachorganisation der Schweizer Sportverbände (Swiss Olympic), das Bundesamt für Sport (BASPO) und das Bundesamt für Gesundheit (BAG) bereits 2003 zusammengeschlossen und das Präventionsprogramm «cool and clean» lanciert. Es wurde in den letzten 14 Jahren zum grössten nationalen Präventionsprogramm der Schweiz und hat auch international Beachtung gefunden. Der folgende Artikel zeigt auf, wie «cool and clean» funktioniert und was das Programm bisher erreicht hat.

Schlüsselwörter:
Suchtprävention, Wirkung, Lebensraum, Sport, Jugendliche, Evaluation, Lebenskompetenzen

Initial situation

There is no doubt about the harm caused to young people when they consume addictive substances – whether it is alcohol, tobacco or cannabis. According to the latest findings of the Health Behaviour in School-aged Children (HBSC) study, 17.6 % of 15-year-old boys and 15 % of girls the same age smoked in 2014 [1]. The HBSC survey also shows that 9.8 % of 15-year-old boys and 5.7 % of 15-year-old girls drink alcohol at least once a week [1]. From a sporting perspective, it is alarming that young people actively engaged in sports tend to drink high levels of alcohol and practice binge-drinking and more frequently state that they consume snus or snuff [2,3].
The “cool and clean” prevention programme has been addressing this issue since 2003 with considerable financial support from the Swiss Tobacco Control Fund. To date, a total of more than 290,000 young people have signed to keep to the commitments of “cool and clean”. All Swiss sports schools (Swiss Olympic “label schools”) are implementing the prevention programme. More than 2,400 sports camps were organised in line with “cool and clean” guidelines. By mid-2016, the programme had had a presence at 1,100 sporting events. Since health promotion and prevention are under the responsibility of the Swiss cantons, it is also highly ­relevant that 20 cantons are now actively involved in the ­programme.
This article takes a look at the “cool and clean” concept and the activities it involves. In addition, the methodology and selected evaluation results will be presented.

The concept behind “cool and clean”

The prevention concept behind “cool and clean” relies on the combination of behaviour-related and structural measures [4,5].

Target groups
“cool and clean” focuses on three target groups. The first target group are young people between the ages of 10 and 20 years who live in Switzerland and who actively engage in sports within organised club structures and association structures. Organised sport is an important setting within which many young people in Switzerland are active. 62 % of 10- to 14-year-olds and 43 % of 15- to 19-year-olds are members of a sports club [6]. The “cool and clean” programme managers consider the sports setting as an especially suitable setting for implementing prevention targets because various life skills which can protect against substance abuse are learnt and practised in this setting. These life skills include dealing with success and failure, experimenting with physical and mental limits or developing a team and community spirit [7]. Organised sport and associated events are also often occasions and places where young people familiarise with substance consumption, and this can unfortunately become the norm (“beer after training”, smoking in the stadium, doping, etc.) [8].
The second target group of “cool and clean” are team coaches and teachers of young people actively engaged in sports. First, this group should be supported and should be encouraged to meet the commitments themselves. Second, they should motivate the young people to sign up to and meet the commitments [9].
Third, “cool and clean” works closely with association and club managers, organisers of sporting events, operators of sporting facilities and the relevant cantonal authorities to promote tobacco and alcohol-related structural prevention in sports settings.

Behavioural measures of “cool and clean”
“cool and clean” pursues the objective of strengthening young people’s personal resources and reducing behaviour which endangers their health. A key role in this respect is played by young people who agree to meet certain commitments. The effectiveness of these commitments is strengthened by getting entire sports teams on board (peer groups) [10,11]. “cool and clean” is based on a multidimensional prevention approach aimed at influencing young people’s addictive behaviour [12].

If team coaches register with “cool and clean”, they receive a starter package for implementing prevention activities with their youth team. This package includes a signature sheet and instructions with some suggestions on how the leader can introduce the commitments to young people and discuss these with them. If the young people agree to the commitments, they then sign them on a prepared document. During this process, the young people can formulate an additional personal commitment together with their leader. The “cool and clean” registration as well as the young people’s written commitment to “cool and clean” must be renewed every year.
All “cool and clean” documents refer to a commitment. For example, suitable game formats which are used during the sporting module of the training trigger experiences in relation to the commitments. In one of these game formats, for instance, the young people are only allowed to breathe through a straw, which teaches them what it feels like if the lungs’ full capacity is no longer available due to smoking. The sporting part of the game format is followed by a brief reflection period initiated by the leaders. During this process, the link to the corresponding commitment is established. “cool and clean” recommends to integrate one game format per month in the training.
The leaders attend professional development courses ­offered by the national sport promotion programme Youth + Sports or the cantonal sports departments, where they receive further information on the implementation of “cool and clean” and on the commitments.

Structural measures
“cool and clean” is investing a lot into the implementation of structural changes. The aim is to create a sports setting which promotes good health. This includes the call for smoke-free sporting events and smoke-free sporting facilities. In relation to alcohol consumption, measures are supported which ensure the implementation of youth protection measures. All in all, the aim of “cool and clean” is to set standards for fair and clean sports based on motivation. For instance, it should become an accepted norm that smoking is banned not just in indoor sporting facilities but also on outdoor sports grounds [13].

Organisation of “cool and clean”

The responsibility for managing “cool and clean” lies with Swiss Olympic, the umbrella organisation of Swiss sports associations. The 85 member associations of Swiss Olympic have more than 1.6 million members. In organisational terms, the programme is divided into four sub-programmes which are directed at key institutional contexts in which the programme’s objectives are to be established over a long-term period.

“cool and clean” Y + S sub-programme
The “cool and clean” Y + S sub-programme implements the programme in cooperation with the responsible authorities within the national sport promotion programme Youth + Sports (Y + S). Y + S conducts about 3,500 education and further training modules, cooperates with more than 70,000 leaders and addresses some 400,000 young people every year. The objective of the “cool and clean” Y + S sub-programme is to motivate all young people registered with Y + S to sign up to the “cool and clean” commitments. The 2015 evaluation showed that “cool and clean” is very popular with the Y + S managers in every respect [14]. Unfortunately, the ­attainment of specific intervention targets, such as the integration of particular and relevant prevention topics into the courses of all Y + S specialist leaders, was made more difficult by a reorganisation within the responsible federal office.

“cool and clean” label schools sub-programme
The “cool and clean” label schools sub-programme is being implemented in collaboration with Swiss Olympic’s label schools. Label schools provide talented athletes with an ­ideal environment for combining sport and education. The evaluation established that the school heads welcome and support cooperation with “cool and clean”. However, it also makes it clear that the minimum requirements have not yet been met in all schools [14].

“cool and clean” associations sub-programme
The “cool and clean” associations sub-programme is aimed at sports associations. Swiss Olympic concludes 4-year ­service-level agreements with all associations. Swiss Olympic makes payments to sports associations depend among others on the implementation of measures relating to the ethics charter. The charter’s eighth principle is: “Abstain from tobacco and alcohol while engaging in sporting activities” [15].
The “cool and clean” associations sub-programme is thus structurally preventive on the one hand. For example, an agreement is reached with the collaborating associations that training camps and events must be organised in accordance with the “cool and clean” guidelines. The clubs are also supported in their efforts to ensure that both their own sporting facilities and the ones they use externally offer a smoke-free environment. Over and above this, “cool and clean” is integrated into associations’ and clubs’ education and further training courses. On the other hand, “cool and clean” seeks access to young athletes through the associations. Team coaches are motivated and supported to sign up to and stick to the commitments together with their athletes. In 2015, around 50,000 young people signed the commitments.
The evaluation of the “cool and clean” associations sub-­programme shows that financial incentives for associations at a national level are effective. In 2014, 22 of the 80 associations had explicitly conducted an activity linked to “cool and clean”. The evaluation goes on; thanks to the support of “cool and clean” it has become more common that sales staff at sporting events are increasingly trained to comply with youth protection laws. Spot checks made clear that the youth protection laws were being adhered to and that non-alcoholic drinks were ­being sold at a lower price than alcoholic drinks everywhere [20].

“cool and clean” cantons sub-programme
The fourth “cool and clean” sub-programme is aimed at the 26 cantons, of which 20 are currently involved. The evaluation shows that in 2015, about one-third of all cantonal Y + S camps were registered with “cool and clean”. According to the cantonal sport managers, almost all cantonal camps were conducted in a smoke-free environment. One major effect can be attributed to “cool and clean” in conjunction with alcohol consumption in camps: all cantonal managers are of the opinion that a responsible attitude to alcohol is encouraged in the camps, and almost three-quarters attribute this to “cool and clean” [20].
On the other hand, “cool and clean” has had a comparatively small impact in terms of establishing smoke-free outdoor sporting facilities. According to statements made by the surveyed operators of municipal facilities, only two of nine facilities to date have implemented smoking bans. In general, it has been established that smoking bans have not yet been imposed in outdoor areas of sporting facilities [20].

Evaluation of “cool and clean”

As already mentioned, the evaluation of “cool and clean” is of great importance. On the one hand, this includes an annual self-evaluation of the programme managers which first and foremost helps them to further develop the programme. On the other hand, every four years a third-party evaluation is performed by a group of international experts from the fields of health promotion, prevention and sports. This group bases its conclusions on scientific studies commissioned by “cool and clean” [14,16 – 20] and on visits of selected sites where “cool and clean” is being implemented. For instance, the group of experts travelled to a label school and attended a youth training session in a sports stadium in order to get an impression of how “cool and clean” is being implemented on site. These site visits were complemented by numerous discussions with responsible stakeholders at various levels, such as programme managers, youth sport managers at sports associations, school heads and teachers as well as team coaches.
The evaluation is based on an impact model which shows in what way which performance and impact targets are to be achieved (Fig. 1).

Starting with the four sub-programmes, the impact model distinguishes between 17 different “cool and clean” activities. The effects of “cool and clean” on associations, clubs, Youth+Sports (Y + S), Swiss Olympic label schools and cantonal authorities have already been dealt with [20,14].
The evaluation pays special attention to the impact of “cool and clean” on young people actively engaged in sports [16]. The main focus is on changes relating to substance abuse. To that end, surveys on “cool and clean” were conducted with young people in 2007, 2009, 2011 and 2015 [21–23]. The evaluation also took note of the international survey entitled “Health Behaviour in School-Aged Children”, which was conducted in 2006, 2010 und 2014 [1] as well as on the results of Addiction Monitoring in Switzerland’s “Continuous Rolling Survey on Addictive Behaviours and Risks” (2011 and 2014) [24]. However, due to the differences in methodology between the three studies, only changes and not different levels of consumption could be interpreted.
In the evaluation 2015, mainly two main indicators of the effectiveness of the “cool and clean” programme were studied.
The first indicator is the impact of the programme on the attitude, e. g. the assessments of people who are participating in the programme were compared to those who are not participating in it. The finding that young people from the experimental group had a more critical attitude towards tobacco, alcohol and cannabis than young people from the control group is deemed to be relevant because the critical attitude helps to prevent or delay them from starting to consume such substances [25].
The second indicator is the programme’s verifiable influence on substance consumption. In this respect, it must be stated that “cool and clean” failed in its efforts to have a demonstrable effect on the behaviour of broad segments of young people actively engaged in sport, particularly in relation to tobacco consumption. There was no measurable effect on either smoking or any other target dimension in the experimental compared to the control group.
In summary, the evaluators who studied the effects of “cool and clean” on young people actively engaged in sports are nevertheless cautiously optimistic about the effectiveness of “cool and clean”. They state that there are considerably more findings which point in the right direction than ones which contradict expectations [16]. It is also worth noting that a more intensive implementation of the programme is shown to result in lower substance consumption rates, a more critical attitude towards substance consumption and better values on the sport-related target dimensions, like team cohesion, fair play and motivation [16]. The evaluators interpret these findings on implementation of the programme as a clear indication of its effectiveness.

Conclusion

The group of international experts who was performing the summary third-party evaluation of “cool and clean” came to the conclusion that the programme “lived up to its promise of being an ambitious national public health programme” [23]. The fact that it was not possible to prove the impact of “cool and clean” on substance consumption is not regarded as a problem by the experts. They made the assessment that this result could also have methodological reasons. The experts ­consider the key strengths of “cool and clean” to be the large reach and acceptance of the programme, its excellent organisational network and the strong integration of structural prevention measures. The group of experts also emphasised the importance of focussing the programme on young people. How­ever, at the same time, they criticised the insufficient level of cooperation with this target group. They recommended developing the prevention programme by following a more bottom-up approach and paying greater attention to participatory approaches.
The expert report also contains criticisms in relation to the activities of “cool and clean” in alcohol prevention which is assessed as not being effective. Although the group of experts acknowledged the difficulties facing the programme in this respect and are aware of the fact that the cultural acceptance of alcohol in Swiss society makes it more difficult to consistently speak to and warn young people about consuming alcohol, the experts are of the opinion that a clearer indication of the health risks associated with alcohol is required.

The next steps
In its capacity as important financing partner of “cool and clean”, the Swiss Tobacco Control Fund is currently preparing a comprehensive tobacco prevention programme for children and young people. This programme will be embedded in the federal government’s and cantons’ National Strategy on the Prevention of Non-communicable Diseases [26]. It is planned to better coordinate national and regional efforts in prevention with a national children’s and young people’s programme. “cool and clean” will be implemented from 2018 as part of this programme.

Conflict of interest
The author has no conflicts of interest relevant to this article.

Corresponding author

Prof. Dr. Andreas Balthasar
Department of Political Science
University of Lucerne
Frohburgstrasse 3
Postfach 4466
CH-6002 Lucerne
E-Mail: andreas.balthasar@unilu.ch
http://www.goo.gl/kz8EJy

Practical implications

Sport does not protect people from the consumption of legal and illegal substances such as alcohol, tobacco and cannabis. It is therefore advisable that physicians as well as clinics support prevention programmes focussing on sport like “cool and clean” in Switzerland. This can be accomplished by motivating children and young adults to participate together with their clubs in the programme “cool and clean” or by supporting the implementation of structural changes, like smoking bans on outdoor sport grounds or sport events without alcohol advertisement.

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