Youth Leadership

It's Complicated

Initiation of cannabis use is common during the high school years.

For many adolescents, escalation of cannabis use during this period is associated with risk of negative health outcomes, including development of cannabis use disorder. It’s Complicated is a cannabis peer-teaching program for high schools. Three lessons are taught to a selected group of heterogeneous juniors and seniors. Those peers then teach the lessons to freshmen and sophomores.

A dedicated faculty sponsor is KEY to the program’s success. The sponsor is responsible for recruiting the peers, practicing with the peers, scheduling the program implementation, and collecting survey results.

For more information on how to bring It’s Complicated to your school or community, please contact ewilson@prevented.org.


Adolescence is a critical period of brain and social development. Initiation of cannabis use is common during the high school years. For many adolescents, escalation of cannabis use during this period is associated with risk of negative health outcomes, including development of cannabis use disorder. High schools are a natural venue for delivering educational and risk reduction interventions. However, such approaches should be rooted in empirical evidence, feasible to integrate into the school curriculum, and perceived as useful and credible by youth. Building upon years of experience in the delivery of school-based preventive and educational intervention, PreventEd designed a 3-session, peer-delivered cannabis education curriculum and piloted it at a large high school in a rural community in the midwestern U.S. It’s Complicated cannabis curriculum was feasible to deliver as part of high school health classes, well-received by students, and effective in increasing cannabis knowledge and perceived risks.

Implementation Process

With funding from the Missouri Foundation for Health, and process and outcome evaluation provided by Friends Research Institute, PreventEd designed a 3-session, peer-delivered cannabis education curriculum.  Two pilot high schools were selected for the curriculum development phase, and one school, Hillsboro High School, was selected for a cluster-randomized, delayed intervention design.  Health classrooms were randomly assigned to provide the It’s Complicated curriculum Early vs. Late in the semester.

Students completed brief surveys three times during the semester on a fixed schedule (N= 195 students in 15 classrooms; 82% freshmen/sophomores; 52% female) . Surveys queried self-appraised cannabis knowledge on seven domains, perceived risks and harms of cannabis use, and behavioral intentions to use cannabis and express concern to about a friend’s cannabis use. Data were analyzed using generalized linear mixed modeling to examine differential trends as a function of curriculum exposure, accounting for repeated measurement and nesting within class cohort.

Results and Outcomes

  • The curriculum was well-received by students, with nearly 95% agreeing or strongly agreeing that the information presented was useful.
  • The It’s Complicated curriculum yielded a significant increase in cannabis knowledge on the composite outcome (p< 0.001), as well as on 5 of 7 domains in the full sample (ps< 0.05).
  • Exposure to the It’s Complicated curriculum was associated with an increase in the perceived risk of infrequent (once a month) cannabis use (p< 0.05).
  • There were no significant curriculum effects found for behavioral intentions to use cannabis or likelihood of expressing concern about a friend’s cannabis use.

Key Takeaways

The evaluation of It’s Complicated found significant curriculum effects using a methodologically strong random assignment design.  There were significant curriculum effects for self-rated cannabis knowledge (overall and across multiple knowledge items) and perceived risks of infrequent cannabis use.

But there were no effects on behavioral intentions regarding cannabis use or expressing concern to a friend, perceived risk of frequent cannabis use, or perceived health risks.

It’s Complicated is currently undergoing refinement and expansion to other schools statewide.  This will allow for a larger trial of It’s Complicated to support national dissemination.

References Cited

  1. Substance Abuse and Mental Health Services Administration (SAMHSA).(2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001, NSDUH Series H-55). Rockville, MD: Center for Behavioral Health Statistics and Quality. Retrieved from https://www.samhsa.gov/data.
  2. Connor, J. P., Stjepanović, D., Le Foll, B., Hoch, E., Budney, A. J., & Hall, W. D. (2021). Marijuana use and marijuana use disorder. Nature Reviews Disease Primers, 7(1), 1-24.
  3. Hennessy, E. A., & Tanner-Smith, E. E. (2015). Effectiveness of brief school-based interventions for adolescents: A meta-analysis of alcohol use prevention programs. Prevention Science, 16(3), 463-474.
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