Physical Activity and Sport Interventions to Prevent Drug Use: A Systematic Review Including Different Intervention Paradigms

<i>Background:</i> Sport and physical activity are increasingly used in adolescent substance use prevention, but interventions differ substantially in how sport is integrated. This systematic review examined preventive effects according to physical activity implementation paradigm. <i>Methods:</i> Five databases and prior reviews were searched. Interventions were classified into three paradigms: Preventive Sport (PS), where sport alone is expected to prevent use; Prevention Combined with Sport (PCS), where sport and prevention are delivered in parallel; and Prevention Through Sport (PTS), where preventive strategies are embedded within the sport context. A structured narrative synthesis was conducted of substance use, intentions, and risk and protective factors. <i>Results:</i> Nineteen interventions (25 studies) met inclusion criteria. PS interventions showed little evidence of preventive effects. PCS and PTS interventions reported preventive effects across several outcomes, particularly for alcohol and tobacco. PCS effects appeared more consistent in the short term, whereas PTS showed more sustained effects across substances and follow-up periods. Effect sizes were generally small and heterogeneity across formats, mechanisms, and outcomes was substantial. <i>Conclusions:</i> The paradigms differ in sport use, the preventive mechanisms they activate, and outcomes. Sport alone (PS) shows insufficient evidence for recommendation, whereas combined (PCS) and through-sport (PTS) approaches show more promising patterns. This research contributes to a better understanding of the role of sport in prevention, helping professionals and decision-makers to design more effective interventions and make better decisions.