In 1997, a photograph was taken in downtown Reykjavík, Iceland, that would later become emblematic of a major national problem. It shows a city block jammed thick with people—the heads are mostly blond, with a few brunettes sprinkled in. It’s summertime in Iceland, when the sun doesn’t really set so much as take a breather for a few hours. So even though the photo was shot at 3:00 a.m., all those faces are pretty easy to see, and almost every last person in the picture is a drunk teenager.
The teens have taken over the city.
In 1998, 42 percent of Icelandic 15- and 16-year-olds reported having been drunk in the previous 30 days. Almost a quarter smoked cigarettes daily, and 17 percent had already tried cannabis. “I remember having helped a friend of mine to puke in an alley,” said Dagur Eggertsson, a physician who became mayor of Reykjavík in 2014. “And another friend actually fell into the sea—he was trying to balance on an oil pipe in the harbor area. . . . These were normal stories. This was part of growing up. This was part of getting your first paycheck, when you were working during the summer, when you were 14.”
This behavior went beyond normal teenage hijinks. Among 22 European countries, Icelandic tenth-graders had the second-highest rate of accidents or injuries related to alcohol use. They were near the top, too, in other disturbing categories: the percentage who’d been drunk at the age of 13 or younger and the percentage who’d been drunk 10 or more times during the previous year. To the Icelandic teenagers, this was all normal—it was the world they knew. But as the rate of substance abuse crept up almost every year during the 1990s, a group of leaders grew concerned.
The leaders had awoken from problem blindness—they were no longer willing to write off this teenage behavior as natural or inevitable. They resolved to move upstream—to prevent the problem rather than simply react to it. So, now what?
Many upstream efforts are a kind of volunteer work. Chosen, not obligated. That was true in Iceland: Many people and government agencies had to cope with the consequences of teenage substance abuse, but it was no one person’s or agency’s job to prevent it (at least at the beginning). But many people cared enough to try. So the first step, as in many upstream efforts, was to surround the problem—to recruit a multifaceted group of people and organizations united by a common aim.
In 1997, a handful of those people—primarily academic researchers and politicians—launched an anti-substance-abuse movement called Drug-free Iceland. The campaign team eagerly courted help from anyone who was willing to assist: researchers, policymakers, schools, police, parents, teenagers, singers/musicians, NGOs, government agencies, municipalities around Iceland, private companies, churches, health care centers, sports clubs, athletes, media members, and the State Alcohol and Tobacco monopoly. This may sound like a sprawling set of collaborators, but keep in mind that most Icelanders live in or around the capital city of Reykjavík, which has a population of less than 250,000. In land area, the whole nation is about the size of Kentucky (the key distinguishing features from Kentucky being its active volcanoes, massive glaciers, and Björk). The point being, in Iceland a few hundred leaders from different domains could be connected together relatively quickly.
The leaders had awoken from problem blindness—they were no longer willing to write off this teenage behavior as natural or inevitable. They resolved to move upstream—to prevent the problem rather than simply react to it. So, now what?
What attracted these parties was a brand-new vision for combatting drugs and alcohol. Traditionally, the work had focused on individual behavior change: getting teenagers to abstain from alcohol or drugs. But the campaign leaders in Iceland believed that the historical focus on “saying no” missed the big picture: What if the drugs were never offered at all? Or what if the teens enjoyed some other activity—soccer or theater or hiking—so much that they didn’t feel like getting drunk? In short, what if drug and alcohol use came to feel abnormal in their world rather than normal? “We wanted to change communities in order to change behavior among the kids,” said Inga Dóra Sigfúsdóttir, a social scientist and one of the campaign’s key leaders.
Academic research has identified a number of risk factors for teenage substance abuse: Having friends who drink or smoke is an obvious risk. Another is having lots of unstructured time available to hang out with those friends—at parties or, say, in downtown streets at 3:00 a.m. There are also protective factors that reduce the risk of substance abuse.
Most of them boil down to having better ways for teens to spend their time: by participating in sports and extracurricular activities, or simply by hanging out more with their parents. (Interestingly, research suggests the quantity of time spent matters more than quality—which was not altogether welcome news for many Icelandic parents, Sigfúsdóttir reported.) In short, a teenager’s discretionary hours are finite, so a well-behaved hour can crowd out a badly behaved one.
The campaign’s guiding philosophy, then, was simple: Change the culture surrounding teenagers by reducing the risk factors for substance use and boosting the protective ones. The people involved—from parents to politicians to sports club leaders—had different resources at their disposal, but what they shared was an ability to influence one or more of those factors.
Traditionally, the work had focused on individual behavior change: getting teenagers to abstain from alcohol or drugs. But the campaign leaders in Iceland believed that the focus on “saying no” missed the big picture. . . What if drug and alcohol use came to feel abnormal in their world rather than normal?
Communities and parents worked to change the culture around popular festivals, where many teens had hung out unsupervised, to encourage families to attend together. Teenagers were recruited to script and shoot anti-drinking television commercials.
Most of the efforts relied on cooperation by multiple players. One example: Iceland had long prescribed certain hours when kids could be outside, depending on their age. This “outside hours” policy was basically a friendlier version of a curfew, with no legal penalties for kids caught in violation. And the policy was frequently ignored. All those kids jamming the streets of Reykjavík in that memorable photograph, for instance—they were all breaking the rules.
To combat this nonchalance, the campaign sent a letter from Reykjavík’s mayor and police chief to all parents of young people, encouraging them to honor the outside hours. The letter also included a refrigerator magnet, which showed the specific times when young people were allowed outside.
Previously, said Sigfúsdóttir, enforcement of the outside-hours laws was largely left to parents, which made a villain of the lonely parents trying to stick to the policy. Teens would predictably protest, “Nobody else’s parents care about the curfew!” The magnets made the curfews seem more “official” somehow, and compliance increased significantly. (Parents in some communities also took organized walks at night, nudging any teens found outside to go home.)
One of the most creative aspects of the campaign arose from the research of Harvey Milkman, an American clinical psychologist who specializes in addiction. “I had the realization that people were not getting addicted to drugs so much as changing the chemistry of their brains,” said Milkman. “So the corollary to that was natural highs.” In other words, we shouldn’t fight teenagers’ instinct to “get high.” Instead, we should give them safer ways to get high. The campaign leaders had already known that kids needed better ways to spend their time—that was a classic protective factor—but Milkman’s insight added some nuance. Teens don’t just need more activities of any kind, they need activities with natural highs: games, performances, workouts, exhibitions. Activities that compel them to take physical or emotional risks.
Teens don’t just need more activities of any kind, they need activities with natural highs: games, performances, workouts, exhibitions. Activities that compel them to take physical or emotional risks.
After the school day ends, Icelandic kids often go to “sports clubs”: facilities where students can play a variety of different sports, ranging from soccer to golf to gymnastics. Many communities invested in better coaching in the clubs, so that the soccer coach was no longer a volunteer parent but a paid, experienced veteran. This “professionalization” of the sports was critical: The Iceland team’s work on substance abuse draws a distinction between informal and formal sports participation, and it’s the latter that counts. If you play pickup basketball down the block with your friends, you’re likely to drink just as much (or more) than another teenager who doesn’t. But if you play in a basketball league, it’s different. You’ve made a commitment. You’re on a team. Your social network orbits a healthy activity. To support participation in sports clubs and other recreational activities, the City of Reykjavík—and later other cities—gave every family what amounted to a gift card, worth hundreds of dollars, to spend on membership fees or lessons.
All these efforts made a difference. An annual survey, “Youth in Iceland,” was conducted to measure the alcohol and drug habits of the country’s teenagers—and it also tracked the risk and protective factors the campaign had identified (e.g., time spent with parents). The survey served as a kind of scoreboard for the campaign. To review these results, and to plan each successive wave of action, there were meetings. Always meetings. Doctors prescribe, miners dig, teachers teach, and upstreamers meet. The steering committee alone met 101 times during the first five years of the campaign. But these meetings are not the same glazed-eye snooze fests that you suffer through at work. When they’re done right, upstream meetings can be energizing: creative and honest and improvisational, with the kind of camaraderie that emerges from the shared struggle to achieve something meaningful.
Even in the first few years, the movement saw progress: Participation in formal sports was up. Time spent with parents was up. Compliance with outside hours was up. And that feeling of success—that’s the emotional payoff that keeps people engaged in the work and attracts new collaborators to the mission. In 2018, twenty years after the campaign began, teenage culture had been transformed. To make the results tangible, imagine a high school class with 40 students. In 1998, 17 of those students would have been drunk in the last 30 days; in 2018, only 3 had been. Before, 9 students would have smoked every day; after, only 2. Before, 7 would have tried cannabis; after, only 1. The plummeting lines in the graph below tell the story:
Perhaps the most astonishing part of the story in Iceland is that its success has been so complete as to be invisible. Most teenagers today aren’t really aware of it. They’ve simply grown up in a world where substance abuse is largely absent.
Iceland’s campaign became the envy of the world, and teams from cities in other countries—including Spain, Chile, Estonia, and Romania—have been quick to adopt the approach. “There’s this one element of this model that is the most important, and it’s empowerment,” said Sigfúsdóttir. “It’s giving communities, giving parents, giving kids a voice. For all of the players in the system, each one of them gets a role. I think that’s the driving force behind it.”
Perhaps the most astonishing part of the story in Iceland is that its success has been so complete as to be invisible. Most teenagers today aren’t really aware of it. They’ve simply grown up in a world where substance abuse is largely absent.
As Iceland’s work suggests, preventive interventions often require a level of cooperation that isn’t necessary for reacting to problems. If a child is drowning in a public pool, a single lifeguard can rescue them. But if you want to prevent the need for a rescue, you might need many collaborators: school administrators who approve swimming lessons for elementary-school kids; trainers who show lifeguards how to scan pools more effectively; pool managers who put colored wristbands on kids that signify their swimming skill level. Upstream work requires integration. In Iceland, the campaign leaders engaged the teenagers and almost all the major influences on them: parents, teachers, coaches, and others.
To succeed in upstream efforts, you need to surround the problem. And that’s why the first question confronting upstream leaders is: How will we unite the right people? .
Excerpted from Upstream: The Quest to Solve Problems Before They Happen. Copyright (c) 2020 by Dan Heath. Used with permission of the publisher, Simon & Schuster. All rights reserved.
Disclosure: Evan Nesterak of the Behavioral Scientist served as an editorial consultant on Upstream. Two other members of the editorial team, served as one time editorial consultants.
