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7 SUBSTANCE USE AND ABUSE Substance Abuse Addiction and Dependence Processes Leading to Dependence

Smoking Tobacco Who Smokes And How Much? Why People Smoke Smoking and Health

Alcohol Use and Abuse Who Drinks, and How Much? Why People Use and Abuse Alcohol Drinking and Health

Drug Use and Abuse Who Uses Drugs, and Why? Drug Use and Health

Reducing Substance Use and Abuse Preventing Substance Use Quitting a Substance

Without Therapy Treatment Methods to Stop Substance Use and

Abuse Dealing With the Relapse Problem

PROLOGUE The stakes were high when Jim signed an agreement to quit smoking for a year, beginning January 2nd. The contract was with a worksite wellness program at the large company where he was employed as a vice president. It called for money to be given to charity by either Jim or the company, depending on how well he abstained from smoking. For every day he did not smoke, the company would give $10 to the charity; and for each cigarette Jim smoked, he would give $25, with a maximum of $100 for any day.

Jim knew stopping smoking would not be easy for him—he had smoked more than a pack a day for the last 20 years, and he had tried to quit a couple of times before. In the contract, the company could have required that he submit to medical tests to verify that he did in fact abstain but were willing to trust his word and that of his family, friends, and coworkers. These people were committed to helping him quit, and they agreed to be contacted by someone from the program weekly and give honest reports. Did he succeed? Yes, but he had a few ‘‘lapses’’ that cost him $325. By the end of the year, Jim had not smoked for 8 months continuously.

People voluntarily use substances that can harm their health. This chapter focuses on people’s use of three substances: tobacco, alcohol, and drugs. We’ll examine who uses substances and why, how they can affect health, and what can be done to help prevent people from using

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and abusing them. We’ll also address questions about substances and health. Do people smoke tobacco, drink alcohol, and use drugs more than in the past? Why do people start to smoke, or drink excessively, or use drugs? Why is it so difficult to quit these behaviors? If individuals succeed in stopping smoking, will they gain weight?

SUBSTANCE ABUSE

‘‘I just can’t get started in the morning without a cup of coffee and a cigarette—I must be addicted,’’ you may have heard someone say. The term addicted used to have a very limited meaning, referring mainly to the excessive use of alcohol and drugs. It was common knowledge that these chemical substances have psychoactive effects: they alter the person’s mood, cognition, or behavior. We now know that other substances, such as nicotine and caffeine, have psychoactive effects, too—but people are commonly said to be ‘‘addicted’’ also to eating, gambling, buying, and many other things. How shall we define addiction?

ADDICTION AND DEPENDENCE Addiction is a condition, produced by repeated con- sumption of a natural or synthetic psychoactive sub- stance, in which the person has become physically and psychologically dependent on the substance (Baker et al., 2004). Physical dependence exists when the body has adjusted to a substance and incorporated it into the ‘‘normal’’ functioning of the body’s tissues. For instance, the structure and function of brain cells and chemistry change (Torres & Horowitz, 1999). This state has two characteristics:

1. Tolerance is the process by which the body increasingly adapts to a substance and requires larger and larger doses of it to achieve the same effect. At some point, these increases reach a plateau.

2. Withdrawal refers to unpleasant physical and psy- chological symptoms people experience when they discontinue or markedly reduce using a substance on which they have become dependent. The symptoms experienced depend on the particular substance used, and can include anxiety, irritability, intense cravings for the substance, hallucinations, nausea, headache, and tremors.

Substances differ in their potential for producing physical dependence: the potential is very high for heroin but appears to be lower for other substances, such as LSD (Baker et al., 2004; NCADI, 2000; Schuster & Kilbey, 1992).

Psychological dependence is a state in which individuals feel compelled to use a substance for the effect it produces, without necessarily being physically dependent on it. Despite knowing that the substance can impair psychological and physical health, they rely heavily on it—often to help them adjust to life and feel good—and spend much time obtaining and using it. Dependence develops through repeated use (Cunningham, 1998). Users who are not physically dependent on a substance experience less tolerance and withdrawal (Schuckit et al., 1999). Being without the substance can elicit craving, a motivational state that involves a strong desire for it. Users who become addicted usually become psychologically dependent on the substance first; later they become physically dependent as their bodies develop a tolerance for it. Substances differ in the potential for producing psychological dependence: the potential is high for heroin and cocaine, moderate for marijuana, and lower for LSD (NCADI, 2000; Schuster & Kilbey, 1992).

The terms and definitions used in describing addiction and dependence vary somewhat (Baker et al., 2004). But diagnosing substance dependence and abuse depends on the extent and impact of clear and ongoing use (Kring et al., 2010). Psychiatrists and clinical psychologists diagnose substance abuse when dependence is accompanied by at least one of the following:

• Failing to fulfill important obligations, such as in repeatedly neglecting a child or being absent from work.

• Putting oneself or others at repeated risk for physical injury, for instance, by driving while intoxicated.

• Having substance-related legal difficulties, such as being arrested for disorderly conduct.

Psychiatric classifications of disorders now include the pathological use of tobacco, alcohol, and drugs—the substances we’ll focus on in this chapter.

PROCESSES LEADING TO DEPENDENCE Researchers have identified many factors associated with substance use and abuse. In this section, we’ll discuss factors that apply to all addictive substances, are described in the main theories of substance dependence, and have been clearly shown to have a role in developing and maintaining dependence.

Reinforcement We saw in Chapter 6 that reinforcement is a process whereby a consequence strengthens the behavior on

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which it is contingent. There are two types of reinforce- ment: positive and negative (Sarafino, 2001). In positive reinforcement, the consequence is an event or item the individual finds pleasant or wants that is introduced or added after the behavior occurs. For example, many cigarette smokers report that smoking produces a ‘‘buzz’’ or ‘‘rush’’ and feelings of elation, and drinking alcohol increases this effect (Baker, Brandon, & Chassin, 2004; Piasecki et al., 2008). People who experience a buzz from smoking, smoke more than those who don’t (Pomerleau et al., 2005). Alcohol and drugs often produce a buzz or rush and other effects. In negative reinforcement, the consequence involves reducing or removing an aver- sive circumstance, such as pain or unpleasant feelings. For instance, tobacco, alcohol, and drugs relieve stress and other negative emotions at least temporarily (Baker et al., 2004). Positive and negative reinforcement both produce a wanted state of affairs; with substance use, it occurs very soon after the behavior. Thus, dependence and abuse develop partly because users rely increas- ingly on the substance to regulate their cognitive and emotional states (Holahan et al., 2001; Pomerleau & Pomerleau, 1989).

Avoiding Withdrawal Because withdrawal symptoms are very unpleasant, people want to avoid them (Baker, Brandon, & Chassin, 2004). People who have used a substance long enough to develop a dependence on it are likely to keep on using it to prevent withdrawal, especially if they have experienced the symptoms. As an example of the symptoms, for people addicted to alcohol, the withdrawal syndrome (called delirium tremens, ‘‘the DTs’’) often includes intense anxiety, tremors, and frightening hallucinations when their blood alcohol levels drop (Kring et al., 2010). Each substance has its own set of withdrawal symptoms.

Substance-Related Cues When people use substances, they associate with that activity the specific internal and environmental stimuli that are regularly present. These stimuli are called cues, and they can include the sight and smell of cigarette smoke, the bottle and taste of beer, and the mental images of and equipment involved in taking cocaine. These associations occur by way of classical condition- ing: a conditioned stimulus—say, the smell of cigarette smoke—comes to elicit a response through association with an unconditioned stimulus, the substance’s effect, such as the ‘‘buzz’’ feeling. There may be more than one response, but an important one is craving: for people who are alcohol or nicotine dependent, words related to the substance or thinking about using it can elicit

cravings for a drink or smoke (Erblich, Montgomery, & Bovbjerg, 2009; Tapert et al., 2004).

Evidence now indicates that the role of cues in sub- stance dependence involves physiological mechanisms. Let’s look at two lines of evidence. First, learning the cues enables the body to anticipate and compensate for a sub- stance’s effects (McDonald & Siegel, 2004). For instance, for a frequent user of alcohol, an initial drink gets the body to prepare for more, which may lead to tolerance; and if an expected amount does not come for a user who is addicted, withdrawal symptoms occur. Second, studies have supported the incentive-sensitization theory of addiction, which proposes that a neurotransmitter called dopamine enhances the salience of stimuli associated with substance use so that they become increasingly powerful in directing behavior (Robinson & Berridge, 2001, 2003). These powerful cues grab the substance user’s attention, arouse the anticipation of the reward gained from using the substance, and compel the person to get and use more of it.

Expectancies People develop expectancies, or ideas about the outcomes of behavior, from their own experiences and from watching other people. Some expectancies are positive; that is, the expected outcome is desirable. For example, we may decide by watching others that drinking alcohol is ‘‘fun’’—people who are drinking are often boisterous, laughing, and, perhaps celebrating. These people may be family members, friends, and celebrities in movies—all of whom are powerful models. Even before tasting alcohol, children acquire expectancies about the positive effects of alcohol via social learning processes, such as by watching TV shows and advertisements (Dunn & Goldman, 1998; Grube & Wallack, 1994; Scheier & Botvin, 1997). Teenagers also perceive that drinking is ‘‘sociable’’ and ‘‘grown up,’’ two things they generally want very much to be. As a result, when teens are offered a drink by their parents or friends, they usually see this as a positive opportunity. Other expectancies are negative—for instance, drinking can lead to a hangover. Similar processes operate for other substances, such as tobacco (Cohen et al., 2002).

Genetics Heredity influences addiction (Agrawal & Lynskey, 2008). For example, twin studies have shown that identical twins are more similar in cigarette smoking behavior and becoming dependent on tobacco than fraternal twins, and researchers have identified specific genes that are involved in this addictive process (Chen et al., 2009; Lerman & Berrettini, 2003). Also dozens of twin and

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adoption studies, as well as research with animals, have clearly demonstrated a genetic influence in the development of alcohol problems (Campbell & Oei, 2009; NIAAA, 1993; Saraceno et al., 2009). For instance, twin studies in general have found that if one member of a same-sex twin pair is alcoholic, the risk of the other member being alcoholic is twice as great if the twins are identical rather than fraternal. And specific genes have been identified for this substance, too.

Three other findings on the role of genetics are important. First, the genes that affect smoking are not

the same ones that affect drinking (Bierut et al., 2004). Second, although both genetics and social factors, such as peer and family relations, influence substance use, their importance changes with development: substance use is strongly influenced by social factors during adoles- cence and genetic factors during adulthood (Kendler et al., 2008). Third, high levels of parental involvement with and monitoring of their child can counteract a child’s high genetic risk of substance use (Brody et al., 2009; Chen et al., 2009).

If you have not read Chapter 2, The Body’s Physical Systems, and your course has you read the modules

from that chapter distributed to later chapters, read Module 4 (The Respiratory System) now.

SMOKING TOBACCO

When Columbus explored the Western Hemisphere, he recorded in his journal that the inhabitants would set fire to leaves—rolled up or in pipes—and draw in the smoke through their mouths (Ashton & Stepney, 1982). The leaves these people used were tobacco, of course. Other early explorers tried smoking and, probably because they liked it, took tobacco leaves back to Europe in the early 1500s, where tobacco was used mainly for ‘‘medicinal purposes.’’ Smoking for pleasure spread among American colonists and in Europe later in that century. In the 1600s, pipe smoking became popular, and the French introduced snuff, powdered tobacco that people consumed chiefly by inserting it in the nose and sniffing strongly. After inventors made a machine for mass-producing cigarettes and growers developed mellower tobacco in the early 1900s for easier inhaling, the popularity of smoking grew rapidly over the next 50 years.

Today there are about 1.25 billion smokers in the world (Shafey et al., 2009). In the United States, cigarette smoking reached its greatest popularity in the mid- 1960s, when about 53% of adult males and 34% of adult females smoked regularly (Shopland & Brown, 1985). Before that time, people generally didn’t know about the serious health effects of smoking. But in 1964 the Surgeon General issued a report describing these health effects, and warnings against smoking began to appear in the American media and on cigarette packages. Since that time, the prevalence of adult smokers has dropped steadily, and today about 24% of the men and 18% of the women in the United States smoke (NCHS, 2009a). Teen smoking has also declined: today about 11% of high-school seniors smoke daily (Johnston et al., 2009).

Do these trends mean cigarette manufacturers are on the verge of bankruptcy? Not at all—their profits are still quite high! In the United States, there are still tens of millions of smokers, the retail price of cigarettes has increased, and manufacturers have sharply increased sales to foreign countries. At the same time that smoking has declined in many industrialized countries, it has increased in developing nations, such as in Asia and Africa (Shafey et al., 2009).

WHO SMOKES AND HOW MUCH? Although huge numbers of people in the world smoke, most do not. In the United States, the adolescent and adult populations have five times as many nonsmokers as smokers. Are some people more likely to smoke than others?

Age and Gender Differences in Smoking Smoking varies with age. For example, few Americans begin to smoke regularly before 12 years of age (Johnston et al., 2009), and few people who will ever become regular smokers begin the habit after their early 20s (Thirlaway & Upton, 2009). The habit generally develops gradually over several years. Figure 7-1 shows three patterns about the habit’s development. First, many people in a given month smoke infrequently—at less than a daily level. Many of them are trying out the habit, and some will progress to daily and then half a pack or more. Second, this pattern starts in eighth grade (about 13 years) for an alarming number of children and involves more and more teens in later grades. Third, teens in every grade who do not plan to complete 4 years of college are at high risk of trying smoking and progressing to heavy smoking. The percentage of Americans who smoke levels off in

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Figure 7-1 Percent of individuals in the United States at different grades or ages with different cigarette smoking statuses, depending on their college plans: either to complete 4 years or to complete less or no college. The survey assessed whether they had smoked in the last 30 days at least once or daily either at least 1 cigarette or at least half a pack (10 cigarettes). The graph does not separate data for males and females because they are very similar. (Data from Johnston et al., 2009, Tables D–89 through D–97.)

early adulthood and declines after about 35 years of age (USBC, 2010). Many adults are former smokers.

Gender differences in smoking are quite large in some parts of the world: about 1 billion men and 250 million women smoke worldwide (Shafey et al., 2009). Among Americans, the prevalence of smoking had always been far greater among males than females before the 1970s (McGinnis, Shopland, & Brown, 1987). But this gender gap has narrowed greatly—for instance, the percentage of high-school seniors today who smoke is similar for girls and boys (Johnston et al., 2009). Cigarette advertising targeted at one gender or the other, such as by creating clever brand names and slogans, played a major part in these gender-related shifts in smoking (Pierce & Gilpin, 1995). A slogan designed to induce young females to smoke is:

‘‘You’ve come a long way, baby,’’ with its strong but still subtle appeal to the women’s liberation movement. The ‘‘Virginia Slims’’ brand name artfully takes advantage of the increasingly well-documented research finding that, for many female (and male) smokers, quitting the habit is associated with gaining weight. (Matarazzo, 1982, p. 6)

Although cigarette advertising still has a strong influence on teens starting to smoke, antismoking advertisements appear to counteract this influence (Gilpin et al., 2007; Murphy-Hoefer, Hyland, & Higbee, 2008). There is an important and hopeful point to keep in mind about the changes that have occurred in smoking behavior: they show that people can be persuaded to avoid or quit smoking.

Sociocultural Differences in Smoking Large variations in smoking occur across cultures, with far higher rates in developing than in industrialized countries (Shafey et al., 2009). Over 80% of the world’s smokers live in developing countries, where it’s not unusual for 50% of men to smoke. Table 7.1 gives the percentages of adults who smoke in selected countries around the world.

In the United States, smoking prevalence differs across ethnic groups. Of high school seniors, 14.3% of

Table 7.1 Prevalence of Adult Cigarette Smoking in Selected Countries: Percentages by Gender and Overall

Country Males Females Overall

Australia 27.7 21.8 24.8 Brazila 20.3 12.8 na Canada 24.3 18.9 21.6 China 59.5 3.7 31.8 Germany 37.4 25.8 31.6 India 33.1 3.8 18.6 Italy 32.8 19.2 26.1 Netherlands 38.3 30.3 34.3 Singapore 24.2 3.5 13.7 South Africa 27.5 9.1 18.4 Sweden 19.6 24.5 22.0 Turkey 51.6 19.2 35.5 United Kingdom 36.7 34.7 35.7

Notes: adult = age 15 and older; na = data not available; data from different countries and sources may vary somewhat, reflecting different definitions or survey years. Sources: WHO, 2009, except a Shafey et al., 2009.

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Whites, 5.8% of Blacks, and 6.7% of Hispanics are daily smokers (Johnston et al., 2009). Although the prevalence of Black and White adults who smoke regularly has declined substantially since the 1960s, the percentages who smoke today depend on the people’s ages and gender (USBC, 2010). For men, far more Whites than Blacks smoke in early adulthood, but far more Blacks than Whites smoke after 45 years of age. Among women, far more Whites than Blacks smoke in early adulthood, but the percentages are similar after 45 years of age. Differences in smoking rates also vary with social class: the percentage of people who smoke tends to decline with increases in education, income, and job prestige class (Adler, 2004). Thus, high rates of smoking are likely to be found among adults who did not graduate from high school, have low incomes, and have blue-collar occupations, such as maintenance work and truck driving.

Although the percentage of Americans who smoke has decreased by about half in the years since the mid- 1960s, the effect of these changes on the total number of smokers and cigarettes consumed has been offset by rises in the number of adults in the population and the proportion of smokers who smoke heavily, more than a pack a day (McGinnis, Shopland, & Brown, 1987). The people who continued to smoke after the 1960s were the ones who needed to quit the most.

WHY PEOPLE SMOKE Cigarette smoking is a strange phenomenon in some respects. If you ever tried to smoke, chances are you coughed the first time or two, found the taste unpleasant, and, perhaps, even experienced nausea. This is not the kind of outcome that usually makes people want to try something again. But many teenagers do, even though most teens say that smoking is unhealthy (Johnston et al., 2009). Given these circumstances, we might wonder why people start to smoke and why they continue.

Starting to Smoke Psychosocial factors provide the primary forces that lead adolescents to begin smoking. For instance, teens who perceive low risk and high benefits in smoking are likely to start the habit (Song et al., 2009). Also, teenagers’ social environment is influential in shaping their attitudes, beliefs, and intentions about smoking—for example, they are more likely to begin smoking if their parents and friends smoke (Bricker et al., 2006; O’Loughlin et al., 2009; Robinson & Klesges, 1997; Simons-Morton et al., 2004). Teens who try their first cigarette often do so in the company of peers and with

their encouragement (Leventhal, Prohaska, & Hirschman, 1985). And adolescents are more likely to start smoking if their favorite movie stars smoke on or off screen (Distefan et al., 1999). Thus, modeling and peer pressure are important determinants of smoking.

Personal characteristics can influence whether ado- lescents begin to smoke—for instance, low self-esteem, concern about body weight, and being rebellious and a thrill-seeker increase the likelihood of smoking (Bricker et al., 2009; O’Loughlin et al., 2009; Weiss, Merrill, & Gritz, 2007). Expectancies are also important. Many teens believe that smoking can enhance their image, making them look mature, glamorous, and exciting (Dinh et al., 1995; Robinson & Klesges, 1997). Teens who are very concerned with how others view them do not easily overlook social images, models, and peer pressure. Do the psychosocial factors we’ve considered have similar effects with all teens? No, the effects seem to depend on the person’s gender and sociocultural background. For example, smoking by peers and family members in Amer- ica is more closely linked to smoking in girls than boys and in White than Black teens (Flay, Hu, & Richardson,

1998; Robinson & Klesges, 1997). (Go to .)

Becoming a Regular Smoker There is a rule of thumb about beginning to smoke that seems to have some validity: individuals who smoke their fourth cigarette are very likely to become regular smokers (Leventhal & Cleary, 1980). Although the vast majority of youngsters try at least one cigarette, most of them never get to the fourth one and don’t go on to smoke regularly. Becoming a habitual smoker usually takes a few years, and the faster the habit develops, the more likely the person will smoke heavily and have trouble quitting (Chassin et al., 2000; Dierker et al., 2008).

Why is it that some people continue smoking after the first tries, and others don’t? Part of the answer lies in the types of psychosocial influences that got them to start in the first place. Studies that tested thousands of adolescents in at least two different years have examined whether the teens’ social environments and beliefs about smoking were related to changes in their smoking behavior (Bricker et al., 2006, 2009; Chassin et al., 1991; Choi et al., 2002). Smoking tended to continue or increase if the teens:

• Had at least one parent who smoked.

• Perceived their parents as unconcerned or even encour- aging about their smoking.

• Had siblings or friends who smoked and socialized with friends very often.

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HIGHLIGHT

Do Curiosity and Susceptibility ‘‘Kill the Cat?’’ Whether or not you’ve tried smoking,

did you at some earlier time feel curious about what smoking is like or make a commitment never to smoke? These two factors affect the likelihood of starting to smoke: the likelihood rises as the teen’s curiosity increases and in the absence of a commitment (Pierce et al., 2005). The absence of a commitment never to smoke is called susceptibility to smoking. Researchers have examined how susceptibility combines with stages of change—that is, readiness to start smoking—to

Comparative likelihood

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Figure 7-2 Comparative likelihood of nonsmoking teenagers becoming smokers within 2 years, depending on the teens’ combination of susceptibility and stage of change. Note that the nonsusceptible, precontemplation combination arbitrarily = 1 in the graph. (Data from Huang et al., 2005, Table 2.)

affect teenagers’ likelihood of becoming smokers in the future (Huang et al., 2005). Figure 7-2 presents the findings: susceptible teenagers are more and more likely to become smokers as their stages advance from precontemplation (not considering smoking) to contemplation (considering smoking) to preparation (intending to smoke). A susceptible teenager at the preparation stage is nearly 10 times more likely to start smoking within a couple of years than a nonsusceptible teen at the precontemplation stage.

• Were rebellious, thrill-seekers, and low in school motivation.

• Were receptive to tobacco advertisements, such as by naming a favorite one.

• Felt peer pressure to smoke, for example, reporting, ‘‘Others make fun of you if you don’t smoke,’’ and, ‘‘You have to smoke when you’re with friends who smoke.’’

• Held positive attitudes about smoking, such as, ‘‘Smok- ing is very enjoyable,’’ and, ‘‘Smoking can help people when they feel nervous or embarrassed.’’

• Did not believe smoking would harm their health, for instance, feeling, ‘‘Smoking is dangerous only to older people,’’ and, ‘‘Smoking is only bad for you if you have been smoking for many years.’’

• Believed they’d be able to quit smoking if they wanted.

Three other findings are important. First, part of the way smoking by family and friends promotes teenagers’ smoking is that it reduces the belief that smoking might harm the teens’ own health (Rodriguez, Romer, & Audrain-McGovern, 2007). Second, teenagers usually smoke in the presence of other people, especially peers, and smokers consume more cigarettes when in the company of someone who smokes at a high rate rather than a low rate (Antonuccio & Lichtenstein, 1980; Biglan et al., 1984). Third, feeling negative emotions, such as depression, increases people’s smoking (Fucito & Juliano, 2009; McCaffery et al., 2008).

Reinforcement is another important factor in con- tinuing to smoke. For many smokers, the taste of a cigarette provides positive reinforcement for smoking. Research has found that people who feel that the taste

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of a cigarette is the main reason for smoking smoke less than other smokers when their cigarettes are altered to taste less pleasant (Leventhal & Cleary, 1980). Nega- tive reinforcement maintains smoking when people use the behavior as a means of coping with stress or other unpleasant emotional states (Baker et al., 2004). Smok- ing is also related to stress: the greater the stress, the more smokers smoke (Wills, 1986). And smokers report less anxiety and greater ability to express their opinions if they smoke during stressful social interactions than if they do not smoke (Gilbert & Spielberger, 1987). But even if smokers perform better and feel more relaxed in stress- ful situations when they are allowed to smoke than when they are not, they do not necessarily perform better or feel more relaxed than nonsmokers do (Schachter, 1980). Some findings suggest that smoking may reduce stress temporarily, but may increase it in the long run (Parrott, 1999). A study that tested this idea found support for it, but another did not (Orlando, Ellickson, & Jinnett, 2001; Wills, Sandy, & Yeager, 2002).

Biological factors are also involved in sustaining smoking behavior, probably by affecting the addictive effects of nicotine. The fact that adolescent smoking is strongly associated with parental and sibling smoking shows that smoking runs in families. Certainly part of this relationship results from social learning processes. But there are at least three biological routes. First, nicotine passed on by a smoking mother to her baby in pregnancy may make the child more susceptible to nicotine addiction (Kandel, Wu, & Davies, 1994). The second is heredity: genetics affect how likely people are to become smokers, how easily and strongly they become physically dependent on tobacco, and how able they are to quit (Lerman, Caporaso et al., 1999; Pomerleau et al., 1993). Third, researchers have found that an area of the brain, the insula, may control the desire to smoke: smokers who suffer a stroke with damage to that area instantly lose their desire to smoke (Naqvi et al., 2007).

The Role of Nicotine People become physically dependent on tobacco because of the chemical substances their bodies take in when they use it. A person who smokes a pack a day takes more than 50,000 puffs a year, with each puff delivering chemicals into the lungs and bloodstream (Pechacek et al., 1984; USDHHS, 1986b). These chemicals include car- bon monoxide, tars, and nicotine. Cigarette smoke has high concentrations of carbon monoxide, a gas that is readily absorbed by the bloodstream and rapidly affects the person’s physiological functioning, such as by reduc- ing the oxygen-carrying capacity of the blood. Tars exist as minute particles, suspended in smoke. Although tars

have important health effects, there is no evidence that they affect the desire to smoke. Nicotine is the addictive chemical in cigarette smoke and produces rapid and pow- erful physiological effects. Nicotine dependence does not necessarily take months or years to develop: a study found that some beginning smokers who had smoked infrequently experienced symptoms of dependence, such as craving (O’Loughlin et al., 2003).

Nicotine is a substance that occurs only in tobacco. When people smoke, alveoli in the lungs quickly absorb the nicotine and transmit it to the blood (Pechacek et al., 1984; Baker, Brandon, & Chassin, 2004). In a matter of seconds the blood carries the nicotine to the brain, where it leads to the release of various chemicals that activate both the central and sympathetic nervous systems, which arouse the body, increasing alertness, heart rate, and blood pressure. These and other consequences of nicotine form the basis for the positive and negative reinforcement effects of smoking. Then, while people smoke a cigarette, nicotine accumulates very rapidly in the blood. But it soon decreases through metabolism—in about 2 hours, half of the nicotine inhaled from a cigarette has decayed.

Biological explanations of people’s continued cigarette smoking have focused chiefly on the role of nicotine. One prominent explanation, called the nicotine regulation model, proposes that established smokers continue to smoke to maintain a certain level of nico- tine in their bodies and to avoid withdrawal symptoms. Stanley Schachter and his associates (1977) provided evidence for this model in an ingenious series of stud- ies with adult smokers. In one study, the researchers had subjects smoke low-nicotine cigarettes during one week and high-nicotine cigarettes during another week. As the model predicts, the subjects smoked more low- than high-nicotine cigarettes. This effect was especially strong for heavy smokers, who smoked 25% more of the low- than high-nicotine cigarettes. Consistent with these results, other researchers have found that peo- ple who regularly smoke ultralow-nicotine cigarettes do not consume less nicotine than those who smoke other cigarettes—ultralow smokers simply smoke more cigarettes (Maron & Fortmann, 1987).

Although the nicotine regulation model has received research support, there are reasons to think it provides only part of the explanation for people’s smoking behavior (Leventhal & Cleary, 1980). One reason is that most people who quit smoking continue to crave it, and many return to smoking, long after all the nicotine is gone from their bodies. Another reason is that some people smoke a few cigarettes a day for years and don’t increase their use—that is, they don’t show tolerance. These people usually don’t experience withdrawal symptoms

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but absorb as much nicotine from a cigarette as heavier smokers do (Shiffman et al., 1990; Shiffman et al., 1995). Why do these people continue to smoke? Each of the processes of addiction we considered earlier provides a cogent explanation. For instance, nicotine provides powerful reinforcement of smoking behavior soon after the first puff of a cigarette (Baker, Brandon, & Chassin, 2004; McGehee et al., 1995; Ray, Schnoll, & Lerman, 2009).

Researchers today generally recognize that a full explanation of the development and maintenance of smoking behavior involves the interplay of biological, psychological, and social factors (Shadel et al., 2000). An example of this interplay is seen in the finding that among depressed smokers, those with a specific gene rely more on smoking to cope than those without that gene (Lerman et al., 1998).

SMOKING AND HEALTH ‘‘Warning: The Surgeon General has determined that cigarette smoking is dangerous to your health,’’ states a cigarette pack sold in the United States. Current projections for deaths annually from smoking-related illnesses are 6 million in 2010 rising to 8 million by 2030 (Shafey et al., 2009). Smoking reduces people’s life expectancy by several years and impairs their quality of life in old age, and these effects worsen with heavier smoking (Strandberg et al., 2008). No other single behavior takes such a toll. To what extent do your odds of dying of lung cancer or heart disease increase if you smoke? Figure 7-3 shows that the odds increase greatly, especially for lung cancer. The more you smoke, the worse your odds become—and if you quit, your odds improve steadily, in about 15 years becoming similar to those of people who never smoked (Godtfredsen et al., 2002; LaCroix et al., 1991). Smoking and, specifically, nicotine also impair immune function (McAllister-Sistilli et al., 1998).

WEB ANIMATION: The Case of the Worried Smoker

Access: www.wiley.com/college/sarafino. This interac- tive animation describes the symptoms and medical test results of a woman with a smoking-related illness.

Cancer In the late 1930s, two important studies were done that clearly linked smoking and cancer for the first time (Ashton & Stepney, 1982). One study presented

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Figure 7-3 Probability of a 35-year-old man dying of lung cancer or heart disease before age 65 as a function of smoking heavily or not smoking. Data for women were less complete, but probably would reveal similar risk increases. (Data from Mattson, Pollack, & Cullen, 1987, p. 427.)

statistics showing that nonsmokers live longer than smokers. In the other study, researchers produced cancer in laboratory animals by administering cigarette tar. By producing cancer with experimental methods, these researchers demonstrated a causal link between cancer and a chemical in tobacco smoke and identified tar as a likely carcinogen, a substance that causes cancer. A few decades later the evidence was clear that tobacco tars and probably other byproducts of tobacco smoke cause cancer (Denissenko et al., 1996; USDHHS, 1986b).

Prospective research provides fairly strong evidence for a causal relationship because smokers and nonsmok- ers are identified and then followed over a long period of time to see if they develop cancer. Many large-scale prospective studies have linked smoking with cancers of various body sites, including the lung, mouth, esoph- agus, prostate, bladder, and kidney (Huncharek et al., 2010; Levy, 1985; Shopland & Burns, 1993). The last two may result because carcinogenic chemicals in tobacco smoke are absorbed into the blood and conveyed to the urine. Cancers of the mouth and esophagus can also

Chapter 7 / Substance Use and Abuse 171

result from using smokeless tobacco—chewing tobacco or snuff (ACS, 2009; Severson, 1993). Thus, carcinogenic substances exist not only in smoke, but in tobacco itself.

In the 1930s, lung cancer in America was quite uncommon and much less prevalent than many other forms of cancer, such as cancer of the breast, stomach, and prostate (ACS, 2009). Deaths from lung cancer at that time occurred at an annual rate of about 5 per 100,000 people in the population, whereas mortality rates for breast and stomach cancer were more than five times that high. Over the years, the mortality rates for most forms of cancer have either declined or remained fairly constant, but not for lung cancer. The annual death rate for lung cancer rose sharply in the second half of the 20th century per 100,000 Americans—it is now about 54 (USBC, 2010); the corresponding rate in the European Union is nearly 38 (WHO/Europe, 2010). In the United States, the deadliest form of cancer is of the lung, claiming over 159,000 lives per year and being responsible for nearly three times more deaths than cancer of the colon or rectum, the second-most-deadly form (USBC, 2010).

The correspondence between the rises in lung cancer deaths and in smoking prevalence since the 1930s is quite striking (McGinnis, Shopland, & Brown, 1987; Shopland & Burns, 1993). The rate of mortality from lung cancer began to rise about 15 or 20 years after the rate of smoking started to rise, and these rates have paralleled each other ever since. During this time, the rates of smoking and of lung cancer were higher for males than for females, but

since the mid-1960s, important gender-related changes have occurred. Smoking has decreased among men and increased among women, thus narrowing the gender gap—and corresponding changes in incidence rates of lung cancer are now evident: since the mid-1980s, the rates declined steadily for men but rose and leveled off for women (ACS, 2009).

How does smoking harm the lungs? When smoke recurrently passes through the bronchial tubes, the lining of the tubes begins to react to the irritation by increasing the number of cells just below the surface. Then,

the fine, hairlike growths, or cilia, along the surface of the lining, whose function is to clear the lungs of foreign particles, begin to slow or stop their move- ment. In time, the cilia may disappear altogether, and as a consequence carcinogenic substances remain in contact with sensitive cells in the lining of the bronchi instead of being removed in the mucus … . At this stage, a smoker’s cough may develop. It is a feeble attempt by the body to clear the lungs of foreign par- ticles in the absence of functioning cilia. (La Place, 1984, p. 326)

Lung cancer usually originates in the bronchial tubes. In most cases, it probably develops because of the extensive contact of carcinogens with the bronchial lining.

Smoking is a major risk factor for all forms of cancer, but its role is more direct and powerful in lung cancer than in other cancers. People’s environments contain many other carcinogens, and smoking is not the only

cause of these diseases. (Go to .)

Healthy lung Smoker's lung (cancerous tumor) Smoker's lung (emphysema)

An advertisement by the American Cancer Society that may motivate people to avoid starting or to quit smoking. Reprinted by the permission of the American Cancer Society, Inc. from www.cancer.org. All rights reserved.

172 Part III / Lifestyles to Enhance Health and Prevent Illness

HIGHLIGHT

Does Someone Else’s Smoking Affect Your Health? ‘‘What do you mean I can’t smoke in

this bar! It isn’t your business what I do to my body,’’ a patron said indignantly to a bartender. Some smokers have reacted strongly to smoking bans in public places. Why were these regulations introduced?

Excess tobacco smoke goes into the environment, either as sidestream smoke from the burning tip of the tobacco item or as exhaled smoke from smokers’ bodies. This excess smoke constitutes secondhand smoke that others consume (Eriksen, LeMaistre, & Newell, 1988). Breathing secondhand smoke is called passive smoking. In the mid-1980s, the United States Surgeon General issued a report on the effects of passive smoking that included three conclusions (USDHHS, 1986b, p.7):

1. Involuntary smoking is a cause of disease, including lung cancer, in nonsmokers.

2. Compared with the children of nonsmoking parents, children of parents who smoke have a higher fre- quency of respiratory infections, increased respiratory symptoms, and slightly smaller rates of increase in lung function as the lungs mature.

3. The simple separation of smokers and nonsmokers within the same air space may reduce, but does not

eliminate, the exposure of nonsmokers to environ- mental tobacco smoke.

Public places, such as worksites, have high levels of secondhand smoke when smoking is permitted (Hammond et al., 1995). Levels of secondhand smoke can be so high as to produce high nicotine levels in the blood of nonsmokers (Okoli, Kelly, & Hahn, 2007).

Evidence of the harmful effects of secondhand smoke is quite substantial. Studies of nonsmokers whose spouses smoked have generally found that passive smok- ers’ risk of lung cancer increases, sometimes doubling or tripling (Eriksen, LeMaistre, & Newell, 1988; USDHHS, 1986b). Studies have also found a higher risk of car- diovascular disease in nonsmoking spouses of smokers than nonsmokers (Humble et al., 1990), and exposure to secondhand smoke increases atherosclerosis (Howard et al., 1998; Penn & Snyder, 1993). What’s more, for people with existing cardiovascular conditions, such as angina, and respiratory problems, such as asthma and hay fever, environmental tobacco smoke can bring on attacks or aggravate acute symptoms (Eriksen, LeMaistre, & Newell, 1988). Increasingly, people are becoming aware of the health effects of secondhand smoke and making efforts to have smoke-free environments.

Cardiovascular Disease Cardiovascular disease—including coronary heart dis- ease (CHD) and stroke—is the leading cause of death worldwide (WHO, 2009). In the United States, it is respon- sible for over 34% of all deaths each year and claims more lives than cancer, accidents, and several other causes combined (USBC, 2010). When you point out these facts to smokers, some say, ‘‘Well you have to die of something.’’ Of course, that’s true—but when you will die and how disabled you will be before are the real issues. Cardio- vascular disease takes many lives early: for instance, one in six Americans it kills are under 65 years of age.

Many millions of Americans suffer from CHD and stroke. The risk of developing CHD is two to four times as high for smokers as for nonsmokers (AHA, 2010). And the more cigarettes people smoke, the greater the risk: a prospective study of smoking and CHD across 8 1/2 years found that the risk of developing heart disease was far higher for individuals who smoked more than a pack a day than those who smoked less (Rosenman et al., 1976). Two other points are important in the

link between smoking and CHD. First, the greater risks smoking conveys for CHD may be aggravated by stress. An experiment tested smokers in a stressful task and found that their stress-hormone and cardiovascular reactivity were higher if they had smoked recently (that is, they had not been deprived of smoking) than if they had not smoked for many hours (Robinson & Cinciripini, 2006). Since smoking usually increases when people are under stress, the resulting heightened reactivity raises their CHD risk. Second, smokers tend to have lifestyles that include other risk factors for CHD, such as being physically inactive (Castro et al., 1989).

How does smoking cause cardiovascular disease? The disease process appears to involve several effects that the nicotine and carbon monoxide in cigarette smoke have on cardiovascular functioning (USDHHS, 1986a). Nicotine constricts blood vessels and increases heart rate, cardiac output, and both systolic and diastolic blood pressure. Carbon monoxide reduces the availability of oxygen to the heart, which may cause damage and lead to atherosclerosis. Studies have found that the more

Chapter 7 / Substance Use and Abuse 173

cigarettes people smoke per day, the greater their level of serum cholesterol and size of plaques on artery walls (Muscat et al., 1991; Tell et al., 1994). After stopping smoking, cardiovascular risk factors, such as cholesterol levels, improve markedly within 2 months (Eliasson et al., 2001), and the risk of heart attack or stroke declines greatly in the next few years (Kawachi et al., 1993; Negri et al., 1994).

Other Illnesses Smoking can lead to a variety of other illnesses— particularly emphysema and chronic bronchitis—which are classified together as chronic obstructive pulmonary disease (COPD) (ALA, 2010; Haas & Haas, 1990). People with COPD experience permanently reduced airflow, which is especially evident when they try to exhale with force. Over 80% of cases of COPD in the United States are related to smoking (ALA, 2010). As we saw earlier, recurrent smoking irritates and damages respiratory organs. Research has shown that more damage occurs from smoking high-tar than low-tar cigarettes and that regularly smoking nontobacco (marijuana) cigarettes also damages the respiratory system (Bloom et al., 1987; Paoletti et al., 1985). COPD can incapacitate its victims, often forcing relatively young individuals to retire from work. It causes 3 million deaths each year worldwide, particularly among its victims who smoke (WHO, 2010).

Smoking may also increase acute respiratory infec- tions. This has been shown in two ways. First, studies have found that children of smokers are more likely to develop pneumonia than are children of nonsmokers (USDHHS, 1986b). Second, when exposed to common cold viruses, smokers are much more likely to catch

cold than nonsmokers, probably because their immune functions are impaired (Cohen et al., 1993).

ALCOHOL USE AND ABUSE

People’s use of alcoholic beverages has a very long history, beginning before the eras of ancient Egypt, Greece, and Rome, when using wine and beer was very common. Its popularity continued through the centuries and around the world—except in cultures that strongly prohibited its use, as in Islamic nations—and eventually reached America in the colonial period. Colonial Americans arrived with

the drinking habits and attitudes of the places they left behind. Liquor was viewed as a panacea; even the Puritan minister Cotton Mather called it ‘‘the good creature of God.’’ By all accounts, these people drank, and drank hard. (Critchlow, 1986, p. 752)

But the Puritans also realized that excessive drinking led to problems for society, so they condemned drunkenness as sinful and enforced laws against it.

Over the next two centuries, attitudes about alcohol changed in many cultures. In the United States, the temperance movement began in the 18th century and pressed for total abstinence from alcohol. By the mid- 1800s, the use of alcohol had diminished sharply and so had its reputation: many Americans at that time believed alcohol destroyed morals and created crime and degenerate behavior (Critchlow, 1986). These attitudes persisted and helped bring about Prohibition, beginning in 1920, when the production, transport, and sale of alcohol became unlawful. After the repeal of Prohibition,

Women in the temperance movement were very assertive, and some went to saloons to keep records of who bought drinks.

174 Part III / Lifestyles to Enhance Health and Prevent Illness

the use of alcohol increased, of course, and attitudes about alcohol softened. Americans today believe alcohol has both good and bad effects. (Go to .)

WHO DRINKS, AND HOW MUCH? People’s attitudes about alcohol and its use are tied to their own characteristics and backgrounds, such as their age, gender, and sociocultural experiences.

Age, Gender, and Alcohol Use Age and gender affect people’s experience with drinking alcoholic beverages in most societies. One reason for gender differences in drinking is that females on average experience more intoxication than males from the same amount of alcohol. This is because, even when body size is the same, females metabolize alcohol less quickly than males (Tortora & Derrickson, 2009).

Drinking typically begins in adolescence, and some- times in childhood. In a survey of thousands of students across the United States, high school seniors’ answers indicated that 72% had consumed an alcoholic drink at some time in their lives, 43% had a drink in the last month, 46% had been drunk in the past year, and 25% had drunk five or more drinks in a row in the pre- ceding 2 weeks (Johnston et al., 2009). Males reported more drinking than females. About 32% of eighth graders claimed they’d had a drink in the past year. Although young people sometimes have alcohol at home with the

parents present, such as at special occasions, most teenage drinking occurs in different circumstances. Even when it is illegal for high school and college students to purchase alcohol and to drink without parental supervision, many do anyway. In adulthood, more males than females continue to drink (NCHS, 2009a). Although most young adult and middle-aged Americans drink, the prevalence is much lower in older groups.

Sociocultural Differences in Using Alcohol Alcohol use varies widely across cultures around the world. Per capita, Americans each year consume 2.3 gal- lons (9.77 liters) of ethanol—the alcohol in beer, wine, and spirits (NIAAA, 2009). Table 7.2 compares several countries on the amount of alcohol consumed per per- son and alcohol-related traffic accidents. Traditionally, countries were classified into two types of alcohol use: those that integrate alcohol into daily life, as in serving it with meals in Italy and France, and those that restrict its use, such as the United States and Scandinavian nations (Bloomfield et al., 2005). Daily drinking occurred more in the former, and intoxication in the latter. But these distinctions are disappearing.

In the United States, drinking patterns differ among its many ethnic groups. The percentage of adults who drink is higher for Whites than for other ethnic groups: Black, Hispanic, Asian, and Native Americans (NCHS, 2009b). And the percentage of adults who sometimes drink several drinks in a day is much higher for White,

ASSESS YOURSELF

What’s True about Drinking? Put a check mark in the space pre-

ceding each of the following statements you think is true.

Alcohol is a stimulant that energizes the body.

Having a few drinks enhances people’s perfor- mance during sex.

After drinking heavily, people usually sober up a lot when they need to, such as to drive home.

Most people drive better after having a few beers to relax them.

Drinking coffee, taking a cold shower, and getting fresh air help someone who is drunk to sober up.

People are more likely to get drunk if they switch drinks, such as from wine to beer, during an

evening rather than sticking with the same kind of drink.

Five 12-ounce glasses of beer won’t make some- one as tipsy as four mixed drinks, such as highballs.

People seldom get drunk if they have a full meal before drinking heavily.

People can cure a hangover by any of several methods.

Most people with drinking problems are either ‘‘skid row bums’’ or over 50 years of age.

Which statements did you think were true? They are wrong—all of the statements are false. (Based on Drinking Myths distributed by the U.S. Jaycees.)

Chapter 7 / Substance Use and Abuse 175

Table 7.2 Per Capita Pure Alcohol (Ethanol) Consumption Annually and Alcohol-Related Traffic Accident Rate (per 100,000 Accidents) in Selected Countries

Consumption in Alcohol-Related Liters per Capita Traffic Accident

Country Ages 15 and Overa Rateb

Australia 9.02 na Brazil 5.76 na Canada 7.80 na China 5.20 na Germany 11.99 29.4 India 0.29 na Italy 8.02 5.1 Netherlands 9.68 12.8 Singapore 2.17 na South Africa 6.72 na Sweden 5.96 11.7 Turkey 1.37 28.2 United Kingdom 11.75 18.8

Note: The amount of pure alcohol per liter varies with the beverage: beer, wine, or spirits; na = data not available. Sources:a WHO, 2009, b WHO/Europe, 2010.

Hispanic, and Native Americans than for Black and Asian Americans. Some years ago, the percentage of adults who drank several drinks in a day was far higher for Native Americans than for all other groups, but their drinking has moderated.

Problem Drinking Figure 7-4 shows that nearly 64% of Americans age 18 and older drink alcohol at least occasionally. Most of these people are light-to-moderate drinkers, consuming fewer than, say, 60 drinks a month. Many people drink much more heavily, but not all of them meet the criteria for substance abuse we described earlier. One definition of heavy drinking is engaging in binge drinking—that is, consuming five or more drinks on a single occasion at least once in a 30-day period. Using this definition, the percentage of American current drinkers who drink heavily at least occasionally is about 10% for teenagers, 42% for 18- to 25-year-olds, and 22% for adults over 25 (USBC, 2010). In comparison, of European 15- and 16- year-olds, 43% reported having engaged in binge drinking in the past month, and 39% said they had been drunk in the past year (ESPAD, 2009). The next step toward alcohol abuse, called heavy use drinking, involves binge drinking five or more times in a month (Kring et al., 2010). Binge and heavy use drinking occur at very high levels on college campuses, especially among fraternity and sorority members (Courtney & Polich, 2009; SAMHSA, 2008). Of individuals who develop problems associated with drinking, most—but not all—do so within about

Regular drinkers 50.3%

Former drinkers 14.4%

Infrequent drinkers 13.6%

Lifetime abstainers

21.3%

Figure 7-4 Proportions of American adults with four drinking statuses: regular drinkers (12 or more drinks in the past year), infrequent drinkers (more than 1, but fewer than 12 drinks, past year), former drinkers (no drinks, past year), and lifetime abstainers (fewer than 12 drinks ever). (Data from NCHS, 2009b, Table 27.)

5 years of starting to drink regularly (Sarason & Sarason, 1984).

How many drinkers meet the criteria for substance abuse? Estimates have been made on the basis of the proportion of individuals at a given time who had ever displayed the problem. This statistic, called the lifetime prevalence rate, indicates that over 17% of adults in the United States become alcohol abusers (Kring et al., 2010). People who abuse alcohol—or problem drinkers—drink heavily on a regular basis and suffer social and occupational impairments from it. Many of them frequently get drunk, drink alone or during the day, and drive under the influence. Although alcohol abuse is more common in males than females, it is most likely to develop between the ages of 18 and 25 for both sexes (McCrady, 1988; NIAAA, 2006). More than half of those who abuse alcohol are physically dependent on it, or addicted to it, and are classified as alcoholics. These people have developed a very high tolerance for alcohol and often have blackout periods or substantial memory losses; many experience delirium tremens when they stop drinking. Although alcoholics often drink the equivalent of a fifth of whiskey (about 25 ounces) a day, 8 ounces can sometimes be sufficient to produce addiction in humans (Davidson, 1985).

Who abuses alcohol? Many people have an image of the ‘‘typical’’ alcoholic as a scruffy looking, unemployed male derelict with no family or friends. But this image is

176 Part III / Lifestyles to Enhance Health and Prevent Illness

Drinking and celebrating often occur together, and this association conveys the message that drinking is fun.

valid for only a small minority of people who abuse alcohol (Mayer, 1983; McCrady, 1988; NIAAA, 2006). Most problem drinkers are married, living with their families, and employed—and many are women. Although individuals from the lower social classes, especially homeless people, are at greater risk than those from higher classes for abusing alcohol, large numbers of problem drinkers come from the higher classes and hold high-status jobs. Problem drinking is very rare in childhood; its prevalence increases in adolescence, rises sharply in early adulthood, and gradually declines across ages thereafter (NIAAA, 2006). Alcohol abuse is a major social problem that affects substantial numbers of people from almost all segments of many societies around the world. (Go to .)

WHY PEOPLE USE AND ABUSE ALCOHOL In examining why people use and abuse alcohol, we need to consider why individuals start to drink in the first place. The chief reasons for starting to drink involve social and cultural factors, particularly the expectancies that form from watching other individuals enjoying themselves while drinking (Thirlaway & Upton, 2009; Wood, Vinson, & Sher, 2001). For example, the more teens see alcohol scenes in movies and ads on TV, the more they are likely to drink in the future (Dal Cin et al., 2009; Stacy et al., 2004). Underage drinking is more likely among teens who have high feelings of depression, believe their friends drink a lot, have low school grades, and have

parents who drink and provide little monitoring or rules against drinking (Fang, Schinke, & Cole, 2009). Children who are depressed, abused, or neglected are at risk for drinking heavily in adolescence and adulthood (Crum et al., 2008; Shin, Edwards, & Heeren, 2009).

Adolescents continue drinking partly for the same reasons they started, but these factors intensify, and new ones come into play. For one thing, the role of peers increases. Although teenagers often begin occasional drinking under their parents’ supervision, such as at celebrations, drinking increases with peers at parties or in cars. Figure 7-5 shows that the percentage of American adolescents who claim to have been drunk in the past month increases with year in school, and is higher for teens who do not plan to complete 4 years of college than for those who do. Individuals who start to drink on a regular basis in early adolescence are at heightened risk of drinking heavily in adulthood (Pitkänen, Lyyra, & Pulkkinen, 2005). In late adolescence and early adulthood, drinkers drink frequently and almost always socially, with friends at parties or in bars. The social aspect is important in two ways (McCarty, 1985; Thirlaway & Upton, 2009). First, in social drinking, modeling processes affect behavior—for example, people tend to adjust their drinking rates to match those of their companions. Second, drinking socially creates a subjective norm in individuals that the behavior is appropriate and desirable.

With continued drinking, the strength of the behavior increases through positive and negative reinforcement,

Chapter 7 / Substance Use and Abuse 177

ASSESS YOURSELF

Do You Abuse Alcohol? Ask yourself the following questions

about your drinking:

• Do you usually have more than 14 drinks a week (assume a drink is one mixed drink with 1 1/4 ounces of alcohol, 12 ounces of beer, or the equivalent)?

• Do you often think about how or when you are going to drink again?

• Is your job or academic performance suffering from your drinking?

• Has your health declined since you started drinking a lot?

• Do family or friends mention your drinking to you?

• Do you sometimes stop and start drinking to ‘‘test’’ yourself?

• Have you been stopped for drunk driving in the past year?

If you answered ‘‘yes’’ to the first question, consider changing your drinking pattern. If you answered ‘‘yes’’ to any additional questions, consult your college’s counseling office for their advice or help. (Based on TSC, 1992, and USDHHS, 1995.)

0 Eighth

Complete 4 Years

College plans:

Complete less or none

Tenth

Grade

P er

ce n t

d ru

n k

Twelfth

Figure 7-5 Percent of American adolescents at different grades in school who claimed to have been drunk at least once in the past month, depending on their college plans: either to complete 4 years or to complete less or no college. The graph does not separate data for males and females because they are fairly similar. (Data from Johnston et al., 2009, Tables D–68 to D–70.)

and substance-related cues develop (Baker, Brandon, & Chassin, 2004; Cunningham, 1998; Thirlaway & Upton, 2009). Individuals may receive positive reinforcement for drinking if they like the taste of a drink or the feeling they get from it, or if they think they succeeded in business deals or social relationships as a consequence of drinking. Having reinforcing experiences with drinking increases their expectancies for desirable consequences when deciding to drink in the future (Adesso, 1985; Stacy, 1997). In the case of negative reinforcement—that is, the reduction of an unpleasant situation—we’ve seen that

people often use alcohol to reduce stress and unpleasant emotions. They may, for instance, drink to suppress their negative thoughts or feelings of anxiety in social situations (Gilles, Turk, & Fresco, 2006; Zack et al., 2006). But the effects of alcohol on negative emotions are not so simple. Although drinkers report that alcohol reduces tension and improves their mood, it seems to do so only with the first few drinks they consume in a series. After people consume many drinks, their anxiety and depression levels usually increase (Adesso, 1985; Davidson, 1985; Hull & Bond, 1986). In cases of severe trauma, such as witnessing terrorism, alcohol use may be heightened for a couple of years (DiMaggio, Galea, & Li, 2009).

Why can most people drink in moderation, but others become problem drinkers? We’ll consider four psychoso- cial differences between these people. First, compared to individuals who do not abuse alcohol, those who do are more likely to perceive fewer negative consequences for drinking (Hansen, Raynor, & Wolkenstein, 1991). Second, heavy drinkers tend to experience high levels of stress and live in environments that encourage drinking. For instance, adolescents who abuse alcohol are more likely to have experienced a major trauma, such as physical assault, and have family members who drink heavily (Kilpatrick et al., 2000). Third, heavy drinkers may form particularly strong substance-related cues: they develop heightened physiological reactions and positive feelings to alcohol-related stimuli, such as seeing or smelling liquor, especially when alcohol is available (Turkkan, McCaul, & Stitzer, 1989). Fourth, people who drink in moderation are more likely to use alcohol control strate- gies, such as avoiding situations where heavy drinking is likely (Sugarman & Carey, 2007).

178 Part III / Lifestyles to Enhance Health and Prevent Illness

But a complete answer to why people become problem drinkers also includes developmental and biological factors. For instance,

• Heredity plays a much stronger role when the abuse begins before age 25 than after (Kranzler & Anton, 1994).

• People with a family history of alcoholism appear to develop a tolerance to alcohol, drinking increasing amounts to feel the same effects, more readily than other people (Morzorati et al., 2002).

• People with a specific gene pattern experience stronger cravings for alcohol after having a drink than other individuals do (Hutchinson et al., 2002).

• Some evidence suggests that people at high genetic risk for alcohol dependence find alcohol more rewarding each time they drink, but low-risk people do not (Newlin & Thompson, 1991).

Genetic factors seem to combine with psychosocial processes, especially conditioning, in the development

of drinking problems. (Go to .)

DRINKING AND HEALTH Drinking too much is linked to a wide range of health hazards for the drinker and for people he or she may harm. Drinkers can harm others in several ways. Pregnant women who drink more than two drinks a day place their babies at substantial risk for health problems, such as being born with low birth weight or fetal alcohol syndrome, which involves impaired nervous system development and cognitive and physical defects (Gray, Mukherjee, & Rutter, 2009; Wood, Vinson, & Sher, 2001). Drinking lesser amounts during pregnancy has been associated with impaired learning ability in the child. The safest advice to pregnant women is not to drink at all.

Drinking also increases the chance that individuals will harm themselves and others through accidents of various types, such as from unintentionally firing a gun

to having a mishap while boating or skiing (Taylor et al., 2008; Wood, Vinson, & Sher, 2001). Drunk driving is a major cause of death in the United States: over 17,600 traffic deaths each year are associated with alcohol use (NHTSA, 2008). Consuming alcohol impairs cognitive, perceptual, and motor performance for several hours, particularly the first 2 or 3 hours after drinks are consumed. The degree of impairment people experience can vary widely from one person to the next and depends on the rate of drinking and the person’s weight. Figure 7-6 gives the average impairment for driving—but for some individuals, one or two drinks may be too many to drive safely.

People’s judging how many drinks they can have before engaging in a dangerous activity can be difficult for a couple of reasons. First, many people have misconceptions about the effects of alcohol, such as believing that drinking on a full stomach prevents drunkenness, or thinking, ‘‘I’ll be OK as soon as I get behind the wheel.’’ A study found that students underestimated the impact that alcohol has 2 or 3 hours after drinking, thought that later drinks in a series have less impact than the first couple, and downplayed the effects of beer and wine relative to mixed drinks (Jaccard & Turrisi, 1987). Second, people tend to ‘‘super-size’’ a drink they make for themselves, and still count it as ‘‘a single drink,’’ especially if the glass is large (White et al., 2003). So if we try to gauge how intoxicated we’re becoming by counting drinks, we may underestimate the effect.

Long-term, heavy drinkers are at risk for developing several health problems (Thirlaway & Upton, 2009; Wood, Vinson, & Sher, 2001). One of the main risks is for a disease of the liver called cirrhosis. Heavy drinking over a long period can cause liver cells to die off and be replaced by permanent, nonfunctional scar tissue. When this scar tissue becomes extensive, the liver is less able to cleanse the blood and regulate its composition. Heavy drinking also presents other health risks: it has been linked to the

HIGHLIGHT

Drinking—Games People Play ‘‘Hey, let’s play Kings, Queens,’’ said

Julie, holding up a deck of playing cards at a party. She was referring to one of many drinking games; in this one, the players assign rules for the amount and type of alcoholic beverage they will drink when specific cards are played. The beverage can be hard liquor or soft, such as beer. Some drinking games involve team competition

or chugging (drinking a full container without pausing). Drinking games are very popular at American college campuses and lead some students to consume seven or more drinks and become quite intoxicated while playing (Zamboanga et al., 2006). Some students play these games weekly and drink at levels that suggest substance abuse.

Chapter 7 / Substance Use and Abuse 179

BE CAREFUL DRIVING BAC TO .05%

240 1

220 1

200 1

180 1

160 1

140 1

120 1

100 1

Drinks (Two-hour period) 1.2 ozs. 80-Proof Liquor or 12 ozs. Beer

W ei

gh t

DO NOT DRIVE .10% & UP

Source: NHTSA

DRIVING IMPAIRED .05%–.09%

Figure 7-6 Chart developed by the National Highway Traffic Safety Administration (NHTSA) showing the average effects of blood alcohol concentration (BAC) on driving. Although alcohol impairment varies from one person to the next, three drinks (the equiv- alent of three 12-ounce bottles of beer) in a 2-hour period will make most adults’ driving unsafe.

development of some forms of cancer, high blood pressure, and heart and brain damage. Let’s look at two of these. First, the more alcohol people consume over years, the higher their blood pressure becomes (Taylor et al., 2009). Second, the brain damage in heavy drinkers occurs in several structures of the central nervous system and can impair their perceptual and memory functions (Anstey et al., 2006; Parsons, 1986). These functions may recover gradually after the person stops drinking, but some impairments may persist for years or never disappear. As you might expect, long-term heavy drinkers have higher death rates than do other people (Schutte et al., 2003; Thun et al., 1997). But if they quit, their mortality risk declines greatly in several years.

Some people believe that drinking in moderation— having, say, a drink or two each day—is good for their health, and they may be right. Long-term prospective studies of many thousands of people have found that individuals who drink light or moderate amounts of alcohol, especially wine, each month have lower morbidity and mortality rates than those who drink heavily or who do not drink at all (Grønbæk et al., 2000; Sacco et al., 1999; Thun et al., 1997). Does moderate drinking cause better health? It appears that it does, largely by yielding substantial improvements in cardiovascular risk factors, such as blood cholesterol levels (Mukamal & Rimm, 2001). Although all types of alcohol, consumed as one or two drinks a day, can improve health, wine appears to have the strongest effects because of substances it contains (Corder et al., 2001; Klatsky et al., 2003; Stein et al., 1999). Another reason for the health benefits of moderate drinking is that alcohol affects the body’s response to stress, reducing cardiovascular and endocrine (for example, catecholamine production) reactions (Levenson, 1986). But as we’ve seen, larger amounts of alcohol can impair health.

DRUG USE AND ABUSE

The word ‘‘drug’’ can refer to many substances, including illegal chemicals and prescription and nonprescription medicine, that people may take into their bodies. We will limit the term drug to mean psychoactive substances other than nicotine and alcohol that can cause physical or psychological dependence. Like smoking and drinking, the use of drugs has a long history—for example, the Chinese evidently used marijuana 27 centuries B.C. In the United States, addiction to narcotics was widespread among people of all ages in the 19th century. Many ‘‘patent medicines’’ in those days contained opium and were sold without government regulation. As a result, large numbers of people became addicted at early ages (Kett, 1977). Laws were enacted in the early 1900s against

the use of narcotics in America. (Go to .)

WHO USES DRUGS, AND WHY? Drug use has become a serious problem in many countries of the world, especially in North America and Europe, but its worldwide prevalence is very low (Thirlaway & Upton, 2009). In societies where drugs are a problem, certain individuals and segments are more likely than others to use drugs.

Age, Gender, and Sociocultural Differences in Drug Use We have seen that smoking and drinking are more likely to begin in adolescence than at any other time in the life span. This developmental pattern is true for using most drugs, too. Three types of drugs that are exceptions to this pattern are tranquilizers, barbiturates, and painkillers (such as OxyContin): use commonly begins in adulthood,

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HIGHLIGHT

Types and Effects of Drugs ‘‘Oh, I feel so light, like a feather,’’ said

Dolores, after taking several hits from a ‘‘joint.’’ That lightness of feeling is a common effect people get from smoking a marijuana cigarette. Each drug has its own set of general psychological and physiological effects (Kring et al., 2010; NCADI, 2000; Schuster & Kilbey, 1992). Some drugs are highly addictive, and others have little potential for producing physical dependence. Drugs are usually classified into four categories: stimulants, depressants, hallucinogens, and narcotics.

Stimulants are chemicals that produce physiolog- ical and psychological arousal, keeping the user awake and making the world seem to race by. This category of drugs includes amphetamines, caffeine, and cocaine, which can be inhaled, injected, or smoked (‘‘crack’’). Chronic use of stimulants can produce mental confusion, exhaustion, and weight loss; it can lead to psychological and phys- ical dependence. Withdrawal symptoms for stimulants are often subtle, but are still very influential on behavior.

Depressants decrease arousal and increase relax- ation. People use these drugs to reduce anxiety and induce sleep. Depressants include various tranquilizers (such as Valium) and barbiturates, which are commonly called ‘‘downers.’’ Chronic, heavy use of depressants interferes with motor and emotional stability and pro- duces psychological dependence. Addiction can develop with long-term use of depressants and can occur rapidly for barbiturates.

Hallucinogens produce perceptual distortions, such as when the body or mind feels light. The most commonly used drug of this type is marijuana, which people use for the relaxation and intoxication it causes. Other hallucinogens, such as mescaline, LSD (lysergic acid diethylamide), and PCP (phencyclidine), often produce a feeling of exhilaration. Hallucinogens have a relatively low potential for causing physical dependence, but chronic use of these drugs can lead to psychological dependence.

Narcotics or opiates are sedatives that relieve pain. In many people, but not all, they produce a euphoric and relaxed feeling. The narcotics include morphine, codeine, and heroin. These drugs, especially heroin, generally cause intense physical and psychological dependence when used in large doses continually.

The effects of drugs can vary. The same dose of a drug from the same batch may produce quite different reactions in different people and in the same person on different occasions (Bardo & Risner, 1985). Why? Physiological processes, such as metabolism and absorption by tissues, vary from one person to the next and within each individual over time. People with low metabolism rates, such as the elderly, tend to experience relatively strong reactions to drugs. Stress can also influence a drug’s effects, causing physiological changes that may increase its impact.

often with prescriptions from physicians (AMA, 2003; Kring et al., 2010).

One of the most popular drugs in the world is marijuana. In the United States, the percentages of people aged 12 and older who have used it in their lifetimes and abused it in a given year are about three times as high as for any other drug (NCADI, 2006). Using marijuana often begins by the eighth grade, and nearly 43% of American teenagers try it before they graduate from high school (Johnston et al., 2009). Teenagers’ use of most other drugs tends to begin somewhat later and is much less prevalent—for instance, about 7% try cocaine before graduation. In comparison, of European 15- and 16-year-olds, 19% had tried marijuana and 7% had tried some other drug (ESPAD, 2009). Drug use in the United States has fluctuated over time and has been decreasing in recent years, which coincides with adolescents’ beliefs about whether drugs are harmful, rather than changes in drug availability (Johnston et al., 2009). The prevalence

of adolescent drug use in a given month is far greater in males than females and increases with age. Drug use reaches its highest prevalence in early adulthood and declines thereafter (USBC, 2010).

Table 7.3 shows that drug use in the United States increases with grade in school and varies depending on the students’ college plans and race or ethnicity. Although the prevalence of drug use is lower among seniors who plan to complete 4 years of college than those who do not, the drug use of college-bound students after leaving high school catches up or even exceeds that of students who do not go to college (Johnston et al., 2009). Ethnic patterns are interesting: marijuana use is similar for White, Black, and Hispanic students, but Black teens report less use of other drugs. Black- and Hispanic-American drug use appears to depend on two factors (Szapocznik et al., 2007). First, minority teens are less likely to use drugs if they have a strong racial or ethnic identity. Second, Hispanic teens become more

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Table 7.3 Percentage of American Students Using Illicit Drugs in a Given Month by Grade in School, College Plans, and Race or Ethnicity

Any Drug Except Marijuana Marijuana

Student Grade 8 Grade 12 Grade 8 Grade 12 characteristic

College plans Complete

4 years 3.1 8.1 4.5 17.7

Under 4 years or none

11.4 13.1 19.1 24.9

Race or ethnicity White 3.7 11.0 5.0 20.1 Black 1.8 3.4 6.1 16.3 Hispanic 4.5 6.7 7.1 15.3

Note: These data come from the annual Monitoring the Future survey, which tested about 16,800 eighth-graders and 14,700 twelfth- graders; the data do not reflect individuals who dropped out of school. Source: Johnston et al., 2009, Table 4.7.

likely to use drugs after they have lived in the United States a long time and become acculturated.

Many individuals engage in polysubstance use—that is, using more than one substance. Does using one substance affect the use of another? The likelihood that individuals will progress from a less serious drug, such as marijuana, to a more serious drug, such as cocaine, is related to how heavily the earlier drug was used (Kandel & Faust, 1975; Newcomb & Bentler, 1986). Heavy users of a less serious drug are more likely to begin using more serious drugs than light users are. Similarly, smoking cigarettes and using alcohol have been linked to subsequent drug use (Pérez et al., 2010; Petraitis et al., 1998). What’s more, for people who use marijuana and alcohol at least twice a week, the more they drink, the greater their risk of becoming dependent on marijuana (Smucker-Barnwell, Earleywine, & Gordis, 2006).

Why Adolescents Use Drugs Why do teens use marijuana and other drugs? They do so for many of the same reasons they drink or smoke cigarettes (Hansen et al., 1987; Stein, Newcomb, & Bentler, 1987). Genetic, psychosocial, and environmental factors are involved (Gillespie et al., 2009). If drugs are available, drug use is linked to social factors and certain personality traits, such as high levels of thrill seeking (Newcomb, Maddahian, & Bentler, 1986). Many teens see peers and important adults, such as parents and celebrities, model behaviors and positive attitudes for drug use, which encourages them to try drugs. Studies have shown that adolescents are more likely to use marijuana and other drugs if their family and friends

use mood-altering substances, such as alcohol and marijuana (Petraitis et al., 1998; Gillespie et al., 2009). Teenagers’ marijuana use seems to be affected more by their friends’ than their parents’ substance use, and the first introduction of most youths to marijuana is through a friend (Kandel, 1974).

After people try using a drug, they tend to continue if they like the experience—that is, if the drug makes them ‘‘feel good’’ or helps them feel better than they felt before taking it (Barrett, 1985). Many people claim that taking drugs reduces their anxiety and tension. In other words, drugs have reinforcing effects. Then, with continued use, drug-related cues become conditioned to the drug, can elicit effects like those the drug itself produces, and compel the user to use it again (Childress, 1996; Robinson & Berridge, 2003). Because people often use drugs in the presence of friends and other peers, social pressure and encouragement also tend to maintain and increase drug use.

Why do some individuals progress from drug use to drug abuse? One factor is personality. Compared to individuals who use drugs occasionally, those who go on to abuse drugs tend to be more rebellious, impulsive, accepting of illegal behavior, and oriented toward thrill seeking; and they tend to be less socially conforming and less committed to a religion (Brook et al., 1986; Cox, 1985; Newcomb, Maddahian, & Bentler, 1986; Stein, Newcomb, & Bentler, 1987). Social factors are also important: heavy users of a drug, such as marijuana, report having friends and relatives who use substances (Scherrer et al., 2008).

DRUG USE AND HEALTH The effects of drug use and abuse on people’s health are not as well documented as those of drinking and cigarette smoking. This is because drug use did not become widespread until the 1960s, it is still much less prevalent than drinking and smoking, and many drug users are unwilling to admit to researchers that they use drugs—a criminal offense—for fear of being prosecuted. Nevertheless, some health effects are known. For example, drugs taken by women during pregnancy cross the placenta and may harm the fetus; and babies born to addicted mothers are likely to be addicted, too (Cook, Petersen, & Moore, 1990). Also, each year millions of teens and young adults drive under the influence of drugs (SAMHSA, 2008; Terry & Wright, 2005). What’s more, long-term marijuana smoking is linked to damage to the user’s lungs that is similar to that caused by tobacco smoking (Bloom et al., 1987; Moore et al., 2005).

The harmful effects of cocaine and metham- phetamine on the cardiovascular system are becoming clear (AMA, 2003; Kaye et al., 2007; Mittleman et al., 1999). Using these drugs can cause the person’s blood

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vessels to constrict, heart rate to speed up, and blood pressure to increase suddenly. They can also trigger car- diac arrhythmia. These events can lead to a stroke or myocardial infarction and can cause death. Cocaine also produces many other health problems. For example, the more people use it in their mid-20s, the more likely they will have neurological symptoms and poor general health 10 years later (Chen, Scheier, & Kandel, 1996). Also, poor health leads to continued cocaine use.

REDUCING SUBSTANCE USE AND ABUSE

How can we help prevent people from using or abusing substances and help them stop using tobacco, alcohol, and drugs if they start?

PREVENTING SUBSTANCE USE The focus for prevention is on helping people avoid beginning to use specific substances in the first place. To do this effectively, prevention programs must consider

A demonstration against the use of drugs.

two factors: when and why individuals start to use the substances, and the information we’ve already discussed on these issues can be applied. The first factor is straight- forward and easily addressed. Because tobacco, alcohol, and drug use often begins during the junior high school years and increases sharply in the high school years, pre- vention programs should begin early, usually before chil- dren reach the age of 12 or so (Evans, 1984). To address why people start using substances, programs usually try to combat psychosocial factors that encourage use.

Another risky time for youth to start or increase substance use is at college, particularly if they join a fraternity or sorority. A 3-year longitudinal study monitored the substance use of nearly 5,900 American high school seniors who went to college, with 17% joining a fraternity or sorority (McCabe et al., 2005). Before entering college, the prevalence of using tobacco, alcohol, and marijuana and of engaging in binge drinking was far higher among students who later joined a fraternity or sorority than those that did not. After entering college, substance use increased for those that did and did not join a fraternity or sorority, but the increase was much greater for those who joined. Binge drinking in a given 2-week period was reported by about 70% of fraternity members and 42% of male nonmembers, and about 50% of sorority members and 29% of female nonmembers. These findings suggest that colleges need to increase prevention efforts for all students, with particular focus on those who want to join or are already members of a fraternity or sorority.

Interventions years ago to prevent substance use usually focused on only one substance, but programs today recognize that beginning to use tobacco, alcohol, and drugs happens mainly during adolescence and for similar reasons. As a result, many programs now try to address all three substances. A program of this type that does not seem to work is the widely publicized Project DARE, in which police officers lead sessions in school to prevent substance use (Lynam et al., 1999). The most common and effective prevention approaches have had three focuses: public policy and legal issues, health promotion and education, and family involvement; the last two are implemented by professionals trained in preventing substance use.

Public Policy and Legal Approaches Governments apply public policy and legal approaches to reduce per-capita consumption of tobacco, alcohol, and drugs by creating barriers to buying and using them. For tobacco, effective approaches include increasing the price of cigarettes through taxation and restricting the advertisement and purchase of cigarettes, such as by underage adolescents (Altman et al., 1999; Cummings,

Chapter 7 / Substance Use and Abuse 183

Fong, & Borland, 2009). For alcohol, two methods are effective: increasing the price of alcoholic beverages through taxation and prohibiting underage persons from buying or consuming alcohol (Ashley & Rankin, 1988; Thirlaway & Upton, 2009). These methods reduce alcohol consumption and related automobile accidents among individuals in the late adolescent and early adulthood years. Another approach has not been very effective in reducing drinking: limiting the number of outlets where alcoholic beverages can be bought and restricting the times when they are on sale. For preventing drug use, the main approaches have been to outlaw possessing, selling, and consuming drugs.

Health Promotion and Education Programs to prevent substance use focused originally on giving fear-arousing warnings of the health consequences of smoking, drinking, and using drugs (Evans, 1984). These programs did not take into account the past social experiences and current psychosocial forces that have a strong influence on teenage behavior. Although knowing the health consequences can change children’s beliefs and attitudes about a substance, such as tobacco, it is usually not sufficient to stop them from starting to use it (Bruvold, 1993; Larimer & Cronce, 2007). This failure points out the need for prevention programs to address why youth begin to use substances.

As we saw earlier, researchers have identified sev- eral psychosocial reasons why young people start using tobacco, alcohol, and drugs. Personality and social influ- ences appear to have stronger effects on adolescents’ substance use than long-range health consequences that seem remote, both in time and in likelihood. Researchers recognized this and implemented school-based pro- grams to curb teenage substance use by addressing psychosocial factors. Let’s consider two types of inter- ventions to prevent smoking for examples of useful methods

• Social influence approaches focus on training skills to help individuals resist social pressures to smoke. They include (1) discussions and films regarding how peers, family members, and the media influence smoking; (2) modeling and role-playing of specific refusal skills, such as saying, ‘‘No thank you, I don’t smoke’’; and (3) having each student decide his or her intention regarding whether to smoke and announce that decision publicly to classmates (Flay et al., 1985).

• Life skills training approaches address general social, cognitive, and coping skills. Because many teens who begin smoking seem to lack these skills, this approach focuses on improving (1) personal skills, including critical thinking for making decisions, techniques for

coping with anxiety, and basic principles for changing their own behavior; and (2) general social skills, including methods for being assertive and making conversation (Botvin & Wills, 1985).

Studies have tested these approaches for smoking prevention, usually with children in sixth or seventh grade (about age 12) and with follow-up assessments spanning 2 years or longer. The students’ self-reports of smoking were usually verified, using biochemical analyses of saliva or breath samples.

Were these approaches successful? Compared with the control subjects, children who received each type of program were far less likely to begin to smoke during the next couple of years or so (Botvin & Wills, 1985; Bruvold, 1993; Flay et al., 1985; Murray et al., 1988; Sussman & Skara, 2004). Longer-term studies have found that although the programs’ beneficial effects diminish greatly by 4 years or so (Flay et al., 1989; Murray et al., 1989), about 10% to 15% fewer individuals begin smoking in the next 15 years if they received the programs than if they did not (Sussman & Skara, 2004).

The success of these approaches may be enhanced in several ways, such as by adding periodic ‘‘booster’’ sessions, starting at earlier ages and focusing on attitudes about smoking, and involving the parents. By the time children enter fifth grade many already have positive attitudes about smoking, and having these attitudes at that time is linked with beginning to smoke by the ninth grade (Dinh et al., 1995). Involving the parents is important: if they smoke and quit in the program, their child is much less likely to start smoking, especially if the parents’ quitting occurs before the child is 9 years old (Farkas et al., 1999). One other strategy may help: using an Internet program, such as Smoking Zine, to assist smoking prevention and quitting interventions in schools (Norman et al., 2008). This program is available at http://www.smokingzine.org and includes interactive self-assessments with tailored feedback to prevent teens from starting to smoke, advance the person’s readiness to change, and help smokers design a plan for quitting.

Because of the successes psychosocial programs have had with smoking, they have been extended for preventing alcohol and drug use. Programs like these effectively reduce teenage and college drinking (Carey et al., 2007; Fromme & Corbin, 2004; Kivlahan et al., 1990) and marijuana use (Chou et al., 1998). A psychosocial program that addressed and followed tobacco, alcohol, and marijuana use over 18 months prevented seventh and eighth graders from starting to use substances they hadn’t begun using and reduced the use of substances the students were already using (Ellickson et al., 2003).

184 Part III / Lifestyles to Enhance Health and Prevent Illness

Family Involvement Approaches Parents can be involved in preventing or reducing teens’ substance use by participating in an intervention and supervising their children more actively (Szapocznik et al., 2007). Family involvement makes sense, and the need for it is supported by three findings from research. First, children of parents who provide little monitoring, rules, and supervision are four times more likely to try drugs in the future than children with actively involved parents (Chilcoat, Dishion, & Anthony, 1995). Second, children are far less likely to use a substance if they know their parents would disapprove of it and would punish that behavior (Komro et al., 2003; SAMHSA, 2008). Third, most parents of teenagers who use a substance are not aware of it: the percentages of parental awareness for each substance are 39% for tobacco use, 34% for alcohol use, and 11% for drugs (Williams et al., 2003).

An intervention using family involvement to prevent tobacco, alcohol, and marijuana use was applied with sixth grade students, whose substance use was followed for 4 years (Spoth, Redmond, & Shin, 2001). The families were recruited from the general population—that is, they were not selected on the basis of the children’s using or not using a substance. The programs were presented in several weekly sessions and were designed to teach parenting skills that should help the children delay starting to use the substances or reduce their current use of them. For example, the parents learned how to monitor the child’s behavior and use appropriate discipline, teach the child ways to resist peer pressure to use substances, and reduce family conflict. Comparisons in tenth grade with a control group revealed that the children in the family program were far less likely to have begun smoking, drinking, or using marijuana; and for those who used substances, they used much less.

QUITTING A SUBSTANCE WITHOUT THERAPY Alcohol and drug abuse have been viewed in most societies as deviant behaviors for centuries, and today cigarette smoking is viewed more and more like a deviant behavior. Many nonsmokers resent people smoking in their presence, and many smokers feel guilty when smoking because they know it offends others and believe it is unhealthy, irrational behavior. Smokers often have negative thoughts about their smoking and claim they’d like to quit (Köblitz et al., 2009; Solberg et al., 2007). Still, most teenage and young adult smokers think they’re at least as healthy as nonsmokers their age, and many are not concerned about potential health problems, even if they’ve already developed a smoker’s cough (Prokhorov,

2003). And only about half of smokers who have an asthma attack quit (King et al., 2007). Few substance abusers seek therapy to stop—for example, less than 29% of Americans who think they need treatment for drug or alcohol use seek it (SAMHSA, 2008). Let’s look at the process of quitting substances without therapy.

Stopping Smoking on One’s Own You probably know people who were smokers—perhaps heavy smokers—who have quit. Chances are they quit on their own, without any sort of professional help, like millions of people do around the world. What motivates smokers to quit? The main motivation is to protect their health (Falba, 2005; McCaul et al., 2006). But only a small percentage of individuals who begin smoking in adolescence quit in the next 20 years (Chassin et al., 2000). Smokers are more likely to try to quit and succeed when others in their social networks do so (Christakis & Fowler, 2008). Are people usually effective at stopping on their own, and does it take enormous effort?

Stanley Schachter (1982) interviewed adults with his- tories of having smoked regularly and found that over 60% of those that tried to quit eventually succeeded—virtually all had not smoked in the last 3 months, and the average length of abstinence was more than 7 years. Was it harder for heavy smokers (smoking at least three-quarters of a pack a day) to quit than light smokers? Yes, much harder. Nearly half of the heavy smokers who quit reported severe withdrawal symptoms, such as intense cravings, irritability, sleeplessness, and cold sweats; less than 30% reported having no difficulties. In contrast, almost all of the light smokers said quitting had been easy, even if they had failed! A similar study conducted by researchers at another university found very similar results (Rzewnicki & Forgays, 1987).

The results of these studies suggest that most people can stop smoking on their own, even if they smoke heavily. Other studies have clarified the process of quitting on one’s own (Carey et al., 1993; Cohen et al., 1989; Curry, Wagner, & Grothaus, 1990; DiClemente et al., 1991; Gritz, Carr, & Marcus, 1991; Pallonen et al., 1990; Rose et al., 1996). Most people do not succeed in one attempt, but eventually succeed after several tries, and certain factors differentiate those people who do and don’t succeed. Compared to smokers who do not succeed in quitting, those who do are likely to:

• Have decided that they want and are ready to quit.

• Feel confident that they can succeed.

• Have smoked less than a pack a day.

• Experience less stress.

Chapter 7 / Substance Use and Abuse 185

• Feel less nicotine dependence and experience less craving for tobacco and fewer and less-severe withdrawal symptoms, such as restlessness and tension.

• Be highly motivated, especially by intrinsic factors, such as a feeling of self-control or a concern about their health.

• Be willing to try again if they don’t succeed. Many people fail the first few times they try, but learn from their mistakes.

People often decide to quit smoking when rules restrict- ing smoking are introduced at work, especially if the worksite offers a program to help them stop; the above factors seem to affect their success, too (Bauer et al., 2005; Fielding, 1991; Klesges et al., 1999).

What methods do smokers use when trying to quit? To answer this question, researchers interviewed participants in a month-long communitywide stop- smoking contest that had a grand prize of a trip to Disney World (Glasgow et al., 1985). These interviews revealed that:

• The vast majority of the men and women attempted to quit cold turkey rather than trying to reduce their smoking gradually before the contest began.

• Most participants used oral substitutes, such as candy or mints, in place of cigarettes.

• Most tried to go it alone, without involving other people, but many others used a buddy system or made bets with others.

• Most used cognitive strategies, such as telling them- selves, ‘‘I don’t need a cigarette,’’ or reminding them- selves of the health risks in smoking, the commitment they made to quit, or the possibility of winning a prize.

• A minority of individuals provided themselves with material rewards for sticking with quitting or punishment for backsliding.

Fifty-five participants—about 40%—remained abstinent throughout the month (which was verified through biochemical saliva or breath analyses). Quitting cold turkey rather than gradually and providing rewards for abstaining were more strongly related to successful quitting than some other methods the smokers used.

Several factors other than how heavily a person smokes can make quitting relatively difficult. One of these factors is invalid beliefs. For example, some smokers have low rates of quitting because they switched to ‘‘light’’ cigarettes with the incorrect notion that doing so will reduce their health risks (Tindle et al., 2006). Other smokers don’t try to quit because they generate illogical thoughts (‘‘I don’t need to stop because some smokers live to 90 years’’) to justify continuing to smoke (Kleinjan et al., 2006). Smokers are also likely to have a difficult

time quitting if they are having emotional problems, such as depression; drink heavily; or use smoking to manage their stress (Agrawal et al., 2008; Dollar et al., 2009; Yong & Borland, 2008).

Stopping Alcohol and Drug Use on One’s Own Most of the little we know about quitting alcohol and drug use on one’s own deals with problem drinkers’ reducing their alcohol intake without treatment. How many people who abuse alcohol recover without treatment? Researchers have estimated that about 20% markedly reduce or stop drinking on their own (Miller & Hester, 1980; Moyer & Finney, 2002). This estimate is based on data from studies of treatment effectiveness in which some problem drinkers were randomly assigned to control groups and stopped drinking with no treatment. How do drinkers who quit on their own differ from those who do not? Those who quit have higher self- esteem, fewer past experiences of intoxication, and social networks with members who drink less (Russell et al., 2001). And they have social support from a spouse and changed the way they weighed the pros and cons of drinking—for example, realizing ‘‘I was sick and tired of it, really weary of it’’ (Sobell et al., 1993).

Early Intervention Efforts for early intervention try to identify people at high risk for substance abuse and then provide information to reduce that risk (Ashley & Rankin, 1988). Although early intervention can be used for smoking and drug use, we’ll focus on alcohol use. Most high-risk drinkers are identified on the basis of current drinking patterns or problems, such as being charged with drunk driving. Although interventions for them have been successful only with people who are relatively light drinkers—heavy drinkers often get worse after an intervention (McGuire, 1982)—the picture is brighter for interventions with most other people who are at high risk for abusing alcohol. If drinking problems are detected early, successful interventions can simply involve giving information and advice, and the individuals may be able to reduce their drinking to a moderate level (Ashley & Rankin, 1988; NIAAA, 1993; Sobell et al., 2002).

Early interventions have been successful with high- risk drinkers identified at colleges, in medical settings, and at worksites; these people are often identified by having them fill out a survey that includes questions on drinking. In medical settings, identified high-risk drinkers who received an intervention of information and advice on reducing drinking incurred lower expenses for health care and for legal and motor vehicle events over the next year than did drinkers who did not get the intervention

186 Part III / Lifestyles to Enhance Health and Prevent Illness

(Fleming et al., 2000). In worksites, many employers and unions provide employee assistance programs (EAPs) to help individuals who have personal problems, such as with drinking or stress (USDHHS, 1990). EAPs can be helpful, but workers with addictions seek help far less often than workers with other problems (Chan, Neighbors, & Marlatt, 2004). This may be because EAPs usually don’t identify high-risk drinkers until the problem is severe, and workers may worry that counselors will leak information to their bosses. A worksite should be a good place for preventing alcohol abuse because most individuals who abuse alcohol have jobs, and drinking is often related to stress on the job (Mayer, 1983).

TREATMENT METHODS TO STOP SUBSTANCE USE AND ABUSE Of the substance users who are willing to try to quit or reduce their use, the ones who seek professional help are likely to be psychologically and physically dependent on the substance, making it hard for the effort to succeed. Therapies can vary in their structure and methods—some, such as stop smoking quitlines, simply offer telephone counseling that helps people quit a substance (Lichtenstein, Zhu, & Tedeschi, 2010). Therapists can design programs that use a variety of

methods to help. (Go to .)

Psychosocial Methods for Stopping Substance Abuse Substance abuse involves entrenched behaviors that are difficult to stop, particularly if physical dependence has developed. In many cases, chemical approaches are useful to decrease craving and other withdrawal symptoms, as we’ll see later. For now, we’ll focus on psychosocial methods. Because the psychosocial processes leading to and maintaining substance abuse are similar for using tobacco, alcohol, and drugs, the approaches health psychologists apply to help people stop or reduce using them are basically the same for all three substances. We’ll concentrate on methods for which there is good evidence for their success. Other methods, such as hypnosis and acupuncture, for stopping substance use have received much media hype, but research has not yielded clear evidence of success (Nash, 2001; White, Rampes, & Campbell, 2006).

An initial issue in treating substance abuse is the person’s desire and readiness to change. Although most people who seek treatment to stop or reduce their substance use want to change, not all do—some were coerced or required to enter therapy by their family,

employer, or the justice system. And clients who do want to change vary in their degree of commitment. We saw in Chapter 6 that professionals can use the stages of change model to describe people’s readiness to modify health- related behaviors. A critical transition occurs when the person’s stage of readiness moves from contemplation, or thinking about changing, to preparation and action. According to psychologist William Miller (1989), this transition is like a door that opens for a period of time and closes if the substance abuser doesn’t use it in that time. Family, friends, coworkers, physicians, or therapists can encourage the transition in several ways, such as:

• Giving the person clear advice about why and how to change.

• Removing important barriers for change.

• Introducing external consequences, such as rewards for changing or real threats (for example, of being fired) if no change occurs.

• Offering help and showing a helping attitude.

Bolstering the person’s self-efficacy is critical for initiat- ing his or her efforts to change (Baldwin et al., 2006). Family members who receive training in motivational methods can be very successful in helping substance users decide to start therapy (Meyers et al., 2002; Miller, Meyers, & Tonigan, 1999). These methods are based on the technique of motivational interviewing we discussed in Chapter 6. Therapists also use motivational interview- ing methods during treatment to enhance its success; although these methods can help smokers quit, they appear to be more effective with drinking and drug use (Burke, Arkowitz, & Menchola, 2003; Lai et al., 2010).

Another effective psychosocial method for treating substance use is to provide the user with positive reinforcement for stopping or reducing use. Compared to treatments that don’t include reinforcement, treatments that do use it are more successful in reducing the use of tobacco, alcohol, and a variety of drugs, including marijuana, cocaine, and opiates (Higgins, Heil, & Lussier, 2004). The reinforcers are mainly monetary based—for instance, vouchers that can be exchanged for desirable items—and programs usually spend several times more per client to treat opiate abuse than to treat smoking (about $150). Some researchers have designed and tested programs with reinforcers that cost less, as one study did with cocaine abusers who were randomly assigned to either a standard treatment or the same treatment with reinforcement (Petry & Martin, 2002). The clients in both conditions submitted urine samples two or three times a week, which was analyzed for opioids and cocaine. If they were abstinent—the sample was negative—they could participate in a lottery that

Chapter 7 / Substance Use and Abuse 187

HIGHLIGHT

Where Should Treatment Occur, and What Should Be the Goals and Criteria for Success?

Because of the physical dependence when alcohol and drug abusers enter treatment, the first step in their recov- ery is detoxification—the drying out process to get an addicted person safely through the period of withdrawal from a substance. This is an essential step before treat- ment can proceed. Because withdrawal symptoms can be severe enough to cause death, detoxification often occurs in hospitals under medical supervision, using medication to control the symptoms (Digiusto et al., 2005; Miller & Hester, 1986). Improved assessment pro- cedures and detoxification methods today enable many addicted people to undergo detoxification at home if they receive careful assistance and support from trained individuals. After that, the question becomes: should treatment be carried out in a residential setting or on an outpatient basis? Most problem drinkers and drug users can be treated as outpatients. But with alcoholics, for example, those who are strongly addicted appear to benefit more from inpatient than outpatient care (Finney & Moos, 1997; NIAAA, 1993; Rychtarik et al., 2000). In the United States, most substance users who receive treatment do so as outpatients (USBC, 2010).

Ideally, treatment should ‘‘cure’’ the person’s sub- stance problem forever, but at what point can ther- apists expect that their treatment will have durable effects? On this issue, there is considerable agreement among researchers: They generally recommend and use a minimum follow-up interval of 12 to 18 months to determine the success of treatment (Emrick & Hansen, 1983; Nathan, 1986). Many programs today also attempt to verify self-reports of substance use through other sources—reports by the ex-abuser’s spouse or through

blood or breath tests, for instance—and measure other outcomes of treatment, such as physical health, employ- ment status, and legal problems encountered.

Because of legal and medical considerations, the treatment goal for tobacco and drug users is to quit completely. But what about alcohol use—should treatment aim to have drinkers become permanently abstinent, or can some return gradually to controlled drinking? This distinction generated a bitter controversy in the 1980s (Marlatt, 1983; Peele, 1984). Although the controversy is not completely resolved, it does appear that some problem drinkers can learn through treatment to drink in moderation (Maisto, 2004; Walitzer & Connors, 2007). Problem drinkers who have the best prospects for controlled drinking:

• Are relatively young.

• Are socially stable, such as married or employed.

• Have had a relatively brief history of alcohol abuse.

• Have not suffered severe withdrawal symptoms while becoming abstinent.

• Prefer trying to drink in moderation.

In other words, the less severe the drinking problem, the better the chances of succeeding in controlled drinking. What’s more, long-term alcoholics who choose abstinence as their goal have fewer drinking problems at 1-year follow-up than those who choose controlled drinking (Hodgins et al., 1997). For long-term alcoholics to pursue a goal of controlled drinking is unrealistic and probably not in their best interests (Nathan, 1986; Sandberg & Marlatt, 1991).

determined whether they would win a prize and what it would be. Most prizes were small, such as a choice of a $1 coupon for fast food or some toiletries, and some were larger (worth $20); each drawing also offered a slim chance of winning a much larger prize, such as a small TV or a boombox. Compared to the clients with the standard treatment, those in the reinforcement condition were far more abstinent during the 12-week program and for the following 3 months. The reinforcement program cost $137 per client.

Therapists sometimes use aversion strategies, which pair unpleasant stimuli with substance use,

making the behavior less pleasant. One way to make smoking unpleasant is called satiation: the person doubles or triples his or her usual smoking rate at home for some period of time (Lichtenstein & Mermelstein, 1984). For some smokers, satiation may be useful as a first step in a program for quitting. Aversion strategies have also been applied to treat alcohol abuse: an injection of an emetic drug, such as emetine, is given that induces nausea when alcohol is consumed. In each half-hour session, the person receives emetine and then repeatedly drinks an alcoholic beverage, each time quickly becoming nauseated and vomiting (Miller & Hester, 1980). The

188 Part III / Lifestyles to Enhance Health and Prevent Illness

person undergoes several of these sessions, typically as an inpatient in a hospital, and then receives booster sessions periodically after discharge. A study of hundreds of problem drinkers who received emetine therapy revealed that 63% of the men and women remained abstinent during the 12 months after treatment, and half of these individuals remained abstinent for the next 2 years (Wiens & Menustik, 1983).

Because of the role of substance-related cues in maintaining smoking, drinking, and drug use, therapists use a method called cue exposure to counteract the classical conditioning that occurs with long-term substance use. Let’s use drinking as an example. The cues, such as seeing a liquor bottle, had been paired with substance use, drinking, to gain the ability through conditioning to produce internal responses like those that happen with alcohol use. In using cue exposure to reduce these internal reactions to conditioned stimuli, therapists expose problem drinkers repeatedly to substance-related cues, such as holding a beer can, while not allowing them to drink. Cue exposure has had some success in treating substance abuse, particularly drinking (Brandon, Vidrine, & Litvin, 2007; Drummond & Glautier, 1994; Rohsenow et al., 2001).

We saw earlier that one reason people use a sub- stance is that they gain negative reinforcement from it: they use it to regulate emotional states—that is, to cope—and need to learn ways to deal with stress that are more adaptive. As a result, therapists often help substance abusers learn to manage their stress with behavioral and cognitive methods for stress man- agement that we described in Chapter 5. These methods include:

• Progressive muscle relaxation, in which people alter- nately tighten and relax individual muscle groups.

• Meditation, an alternative relaxation method.

• Cognitive restructuring, in which people learn to replace stress-provoking thoughts with more constructive and realistic ones.

Cognitive–behavioral methods are among the most effective approaches in treating problem drinking (Finney & Moos, 1997; Stockwell & Town, 1989) and drug use (Maude-Griffin et al., 1998; Tims, Fletcher, & Hubbard, 1991). They are also useful in helping people stop smoking. (Go to .)

Self-Help Groups Alcoholics Anonymous (AA) is a widely known self-help program that was founded in the 1930s by people with

drinking problems (Dolan, 2004; McCrady & Irvine, 1989). The program now has thousands of chapters throughout the United States and around the world and has set up organizations to help alcoholics’ families, such as Alateen for their adolescent children and Al-Anon for adults in the family. The AA philosophy includes two basic views. First, people who abuse alcohol are alcoholics and remain alcoholics for life, even if they never take another drink. Second, alcoholics must commit to the goal of permanent and total abstinence, and their approach is aimed at helping their members resist even one drink. A critical feature of the AA approach is the person’s developing a social network that does not support drinking (Litt et al., 2009). A similar organization for drug users is called Narcotics Anonymous.

Because the AA philosophy has its roots in evangel- ical Protestantism, the program emphasizes the individ- ual’s needs for spiritual awakening, public confession, and contrition (McCrady & Irvine, 1989; Peele, 1984). This philosophy can be seen in the Twelve Steps AA uses to help drinkers quit—for example, one step is, ‘‘Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.’’ Members attend frequent AA meetings, which use the Twelve Steps to promote frank discussions about the members’ experiences with alcohol and difficulties resisting drinking. An important feature of the AA approach is that its members develop friendships with other ex-drinkers and get encourage- ment from each other and from knowing individuals who have succeeded.

Does AA work, and is it more effective than other approaches for helping drinkers quit? Until the late 1990s, AA’s effectiveness was unknown because its membership is anonymous and the organization does not keep systematic information about people who attend. Today, there are two lines of evidence for its success. First, studies compared different methods conducted by professional therapists and found that treatments using the AA approach produced as much improvement as other treatments (Ouimette, Finney, & Moos, 1997; PMRG, 1998). Second, research has shown that the greater the duration and frequency of alcoholics’ involvement in AA, the less their binge drinking and the better their social functioning in the following years (McKellar, Stewart, & Humphreys, 2003; Moos & Moos, 2004). But AA may not be appropriate for problem drinkers who reject aspects of the AA approach, such as the belief in God, and other social networks may be substituted (Litt et al., 2009; Tonigan, Miller, & Schermer, 2002. AA is often used as an approach to prevent relapse after other forms of treatment (NIAAA, 1993).

Chapter 7 / Substance Use and Abuse 189

CLINICAL METHODS AND ISSUES

Behavioral Methods for Treating Substance Abuse Psychologists apply behavioral meth-

ods to gain control over environmental conditions that sustain an undesirable behavior, such as smoking or drinking (Sarafino, 2001). These methods are based on the recognition that modifying behavior requires chang- ing the behavior itself and its antecedents and consequences. For example, the consequences can be changed by intro- ducing rewards for not using a substance and penalties for using it, as occurred for Jim at the start of this chapter. These techniques are often taught to clients to use in self-management procedures, which we discussed in Chapter 6. Let’s look at some behavioral methods that can help clients stop or reduce substance use.

• Self-monitoring is a procedure in which people record information pertaining to their problem behavior, such as how often they smoked or drank and the circumstances, place, and time of each instance. Although this technique is used mainly in gathering data, it is a very important method for making self- management procedures effective (Michie et al., 2009).

• Stimulus control procedures address the antecedents by altering elements of the environment that serve as cues and lead a person to perform the problem behavior. For example, many smokers report that they regularly have (and ‘‘need to have’’) a cigarette in certain situations, such as after meals, or with alcohol, or when talking on the phone. And many problem drinkers are unable to resist having a drink when friends are drinking. These environments can be altered in many ways—for example, by making the substance less available, removing cues such as ashtrays, or restricting the time spent in situations where the behavior occurs,

such as watching TV or sitting at the table after meals. Stimulus control procedures can help a great deal: a study on quitting smoking found that getting rid of cigarettes is a critical factor in remaining abstinent on the first day (O’Connell et al., 2002).

• Competing response substitution involves performing and rewarding a behavior that is incompatible with or not likely to be performed at the same time as the problem behavior. For instance, a smoker who ‘‘has to have a cigarette with coffee after breakfast’’ would receive a reward for skipping coffee and taking a shower right after breakfast. People are not likely to smoke in the shower (but some smokers do!).

• Scheduled reduction is a method in which the person uses the substance only at specified regular intervals, and these intervals get longer and longer across days. So far, scheduled reduction has been used mainly with smoking and is effective (Catley & Grobe, 2008; Cincirpini et al., 1995).

• Behavioral contracting is a technique for spelling out conditions and consequences regarding the problem behavior in writing. Behavioral contracts usually indicate the conditions under which the behavior may or may not occur and specify reinforcing and punishing consequences that will be applied, and when. Contracts for quitting substance use often have the person deposit a substantial sum of money, which is then meted out if he or she meets certain goals.

Although each of these methods is useful in changing behavior, such as smoking or drinking, they are most effective when combined and used together.

Chemical Methods for Treating Substance Abuse Treatments for substance abuse often use prescribed drugs that the person is required to take regularly to combat the conditions that maintain the behavior. Some of these drugs interact with the abused substance, such as alcohol, producing unpleasant reactions, such as nausea and vomiting. The chemical methods we are discussing here are different from the use of emetine that we described earlier, which is not taken on a regular

basis but is used in conditioning sessions as an aversion strategy.

Different chemicals are used in treatments for different substances. In stopping tobacco use, the main chemical used is nicotine, which the person can administer as a gum, a lozenge, a patch placed on the skin, an inhaler, or a nasal spray. Using nicotine decreases craving and withdrawal symptoms, such as sleeplessness, and helps toward short-term and long- term quitting success (Cummings & Hyland, 2005; Ferguson, Shiffman, & Gwaltney, 2006; Stead et al.,

190 Part III / Lifestyles to Enhance Health and Prevent Illness

2008). And if an abstinent smoker uses a fast-acting version, such as the lozenge, when exposed to smoking cues, it reduces the resulting craving (Shiffman et al., 2003). Two other useful chemicals for reducing smoking are bupropion hydrochloride, an antidepressant drug, and varenicline (Hughes, 2009). Using a nicotine lozenge with any of the other chemicals enhances success in quitting (Smith et al., 2009). Because genetic processes influence the effects of specific anti-smoking chemicals (Uhl et al., 2008), medical tests may help select the best chemical for each person.

Two types of chemicals are used in treating alcohol abuse. One chemical is an emetic drug called disulfiram (brand name Antabuse) that the person needs to take each day orally (Maisto, 2004; Schuckit 1996). In addition to producing nausea if the person drinks, it has some important side effects that can preclude its use—it causes drowsiness, raises blood pressure, and has physiological effects that make it inappropriate for people with heart and liver diseases. For those who can use it, disulfiram can be an effective therapy, but getting them to take the drug consistently is often a problem. The second chemical is naltrexone, a drug that blocks the ‘‘high’’ feeling that alcohol and narcotics produce (AMA, 2003). Alcohol-dependent individuals treated with naltrexone experience fewer days of heavy drinking and fewer drinks on days when they drink than those in control groups that receive a placebo (Garbutt et al., 2005; Monti et al., 2001).

Several chemical agents can be used for treating narcotic addiction. The most widely used of these agents is methadone, a chemical that has physiological effects that are similar to those of opiates. However, methadone does not produce euphoria and, when taken regularly, it prevents euphoria from occurring if the person then takes an opiate (Mattick et al., 2003; Sindelar & Fiellin, 2001). Methadone is usually taken orally. Having a narcotics addict take methadone—or a similar agent, levoalpha acetylmethadyl (LAAM)—regularly to reduce opiate use is called methadone maintenance. Another chemical agent that blocks the euphoria from opiates taken after it is buprenorphine, which has advantages over methadone, such as its staying active longer, but seems to be less effective (Mattick et al., 2003; Sindelar & Fiellin, 2001). Naltrexone, which we just discussed for treating alcohol abuse, blocks opiate euphoria but isn’t used often for narcotic abuse.

Multidimensional Programs You may know someone who tried to quit smoking just by using a nicotine patch, and failed. Research has shown that the psychosocial and chemical methods we’ve

discussed are useful in stopping or reducing substance use, but none is highly effective alone—as a result, the methods are usually combined in a multidimensional program to improve their success. For instance, studies of treatments to stop smoking have found that combining cognitive–behavioral methods with the nicotine patch is far more effective than using either approach alone (Alterman, Gariti, & Mulvaney, 2001; Cinciripini et al., 1996). For drug abuse, treating narcotic addiction with methadone and psychosocial methods is far more effective than methadone alone (McClellan et al., 1993). And treating marijuana dependence with motivational interviewing and rewards for providing marijuana-free urine samples is more effective than either approach alone (Carroll et al., 2006).

Five other features should be considered in design- ing multidimensional programs to curb substance use. First, using biochemical analyses to verify self-reports of use and demonstrating these verification procedures at the beginning of treatment enhances the success of a program (Glynn, Gruder, & Jegerski, 1986). Second, a brief daily phone call to the clients improves their performance of certain procedures, such as keeping records of smoking (McConnell, Biglan, & Severson, 1984). Third, involving the client’s family or significant person in the program improves the outcome (Carlson et al., 2002; Fals-Stewart & O’Farrell, 2003). Fourth, physician involvement helps. For example, people are more likely to try to quit smok- ing and stick with it if they are advised to stop by their physician, receive a prescription for nicotine, are shown on an apparatus how impaired their respiratory system is, and have been diagnosed with a serious smoking- related disease (Fiore, Jorenby, & Baker, 1997; Ockene et al., 1991, 1994; Risser & Belcher, 1990; USDHHS, 1986a). Fifth, supplementing standard treatment with a computer-based intervention improves abstinence and helps it last (Carroll et al., 2009).

DEALING WITH THE RELAPSE PROBLEM Quitting substance use is one thing—staying quit is another. As Mark Twain noted, ‘‘To cease smoking is the easiest thing I ever did; I ought to know because I’ve done it a thousand times’’ (Grunberg & Bowen, 1985). The methods we have considered work well in helping people stop or reduce substance use, but preventing backsliding is a major problem.

The Relapse Problem Regardless of how smokers quit, their likelihood of relapse—that is, returning to the full-blown pattern of behavior—is very high in the first weeks and months

Chapter 7 / Substance Use and Abuse 191

after stopping. Most people who quit smoking start again within a year, and most relapses occur in the first 3 months (Ockene et al., 2000). Estimates of relapse rates vary from 50 to 80%, depending on many factors, including the methods used in quitting, how heavily the person smoked, and characteristics of the individual and his or her environment (Curry & McBride, 1994; Ossip-Klein et al., 1986).

The problem of relapse is at least as severe in efforts to stop drinking and using drugs as it is in quitting smoking. Many of the more successful treatment approaches for alcohol abuse produce very high rates of success initially, but these rates decline sharply by the end of the first year and again during the next 2 years (Nathan, 1986). For drug use relapse, researchers have estimated that 60% or more of individuals return to using drugs after quitting (Donovan, 2003).

Why People Relapse Withdrawal symptoms probably contribute strongly to immediate relapses. But these symptoms decline over time. For instance, nicotine withdrawal declines sharply in the first week or so after stopping (Gritz, Carr, & Marcus, 1991; Killen & Fortmann, 1994; Piasecki et al., 1997). Smokers who are trying to quit need reassurance that their cravings and negative feelings will diminish greatly in less than a month. Another factor that can affect relapse is satisfaction: the more satisfied people are with the results of having quit the less likely they are to relapse (Baldwin et al., 2006).

What other factors lead people to return to using a substance they quit? Table 7.4 describes several, and research has clarified the role of the first two. First, self-efficacy during quitting is dynamic—when quitting smoking, for instance, it remains fairly high before a lapse

and drops after the lapse; the sharper the drop, the more likely a relapse will occur (Shiffman et al., 2000). Second, the role of emotion is particularly important: for example, people who experience high levels of stress are more likely to start smoking again than those who experience less stress (Cohen & Lichtenstein, 1990; Lichtenstein et al., 1986; Shiffman et al., 1996). Ex-smokers who go back to smoking often report that acute episodes of anxiety or frustration at work or at home led to their relapse (Shiffman, 1986).

Two other factors in relapse relate mainly to smoking. First, an interesting thing happens to smokers’ beliefs when they relapse: they tend to lower their perceptions of the health risks of smoking. A study of people who relapsed after completing a treatment program to stop smoking found that they reported strong beliefs that smoking could harm their health when they entered the program, but after the relapse these beliefs decreased (Gibbons, McGovern, & Lando, 1991). Why? They probably used cognitive processes, such as motivated reasoning or denial, to cope with the fact that their attempt to quit smoking failed. This finding is important because it means people who relapse may not be ready to retry quitting until their beliefs change back again. Many smokers deny or minimize the health risks of smoking, thereby decreasing the likelihood that they will try to quit (Lee, 1989; Strecher, Kreuter, & Kobrin, 1995).

Second, some people who go back to smoking claim they did so because they were gaining weight (Jeffery et al., 2000). Smokers tend to weigh less than nonsmokers, and this difference is greater among middle-aged than younger individuals (Klesges et al., 1998). When people stop smoking, most—but not all—do, in fact, tend to gain several pounds over the next few years (Klesges et al., 1997; Parsons et al., 2009). There are two reasons

Table 7.4 Several Factors That Can Lead to a Relapse of a Changed Behavior Factors Description of Factor’s Influence

Low self-efficacy Maintaining self-efficacy for staying abstinent is not always easy: people who quit a behavior and experience a lapse may lose their confidence in remaining abstinent and see their violation as a sign of a personal failure. As we saw in Chapter 6, these events can lead to a full relapse through the process called the abstinence violation effect.

Negative emotions and poor coping

Because people often use substances to regulate their emotional states, they tend to lack good coping skills to take the place of the substance when difficulties arise.

High craving The greater the craving, the more likely a relapse. Expectation of

reinforcement People tend to relapse if they think that using the substance again would be rewarding, such as

‘‘Having a drink would taste great and make me feel so relaxed.’’ Low motivation People at lower levels of readiness to change when they try to quit are more likely to relapse than

people at higher readiness levels. Interpersonal issues Substance users who quit, but lack constructive social support or have social networks that

promote substance use, are more likely to relapse than others who have strong, helpful support.

Source: Witkiewitz & Marlatt, 2004.

192 Part III / Lifestyles to Enhance Health and Prevent Illness

why this is so (Klesges, Benowitz, & Meyers, 1991). First, ex-smokers often increase their caloric intake, sometimes by eating more fats and sweet-tasting foods. Second, the amount of energy they expend in metabolism declines, for at least a short time, after quitting. To prevent weight gain, many ex-smokers may need to control their diets, get more exercise, and perhaps use a nicotine supplement. Ex-smokers who use nicotine gum or patches during the weeks after quitting gain much less weight than controls with a placebo (Allen et al., 2005; Doherty et al., 1996). Some programs for quitting smoking are now incorporating methods to prevent weight gain (Parsons et al., 2009).

Can Relapses Be Prevented? One approach for reducing relapse uses a process called the relapse prevention method, which is based on G. Alan Marlatt’s view that relapses develop through the cognitive events of the abstinence violation effect that follow a lapse (Marlatt & Gordon, 1980; Witkiewitz & Marlatt, 2004). The cognitive events involve mainly guilt and reduced self-efficacy. The relapse prevention method is basically a therapist-supervised self-management program in which clients take the following steps:

1. Learn to identify high-risk situations by generating a list and descriptions of antecedent conditions in which lapses are most likely to occur.

2. Acquire competent and specific coping skills through training in specific behaviors and thought patterns that will enable the person to deal with high-risk situations and

avoid lapses. For example, people who get treatment for stopping smoking need to receive training in ways to cope with stress without relying on smoking as a coping strategy (Shadel & Mermelstein, 1993).

3. Practice effective coping skills in high-risk situations under a therapist’s supervision. For example, a problem drinker might go with the therapist to a bar and practice ways to avoid drinking.

This method provides an important component of relapse prevention, but its success in helping individuals stay abstinent for a substance after quitting has been modest when used by itself (Brandon, Vidrine, & Litvin, 2007; Hajek et al., 2009).

Three additional approaches may enhance relapse prevention. First, interventions can provide booster ses- sions—extra sessions periodically to shore up or refresh the treatment’s effects. Providing booster sessions or contacts with training on ways to cope with lapses and maintain self-efficacy reduces relapses (Brandon et al., 2000; Irvin et al., 1999; McKay et al., 2004). Second, clients can continue using a chemical method after formal treatment ends: for example, they’d continue to use nicotine if they quit smoking or methadone if they quit a narcotic (Klesges, Benowitz, & Meyers, 1991; Mattick et al., 2003). Third, clients can be helped to develop social networks that provide constructive support for abstinence and minimize negative support, such as friends expressing doubt that they will stay quit (Lawhon et al., 2009; Litt et al., 2009). AA attendance is one way to develop social networks that can help ex-drinkers remain abstinent.

SUMMARY

People’s use of tobacco, alcohol, or drugs can affect their health. Addiction is a condition that involves a physical and psychological dependence on a substance. People who are physically dependent on a substance have developed a tolerance for it and suffer withdrawal symptoms when they abruptly stop using it. Substance abuse exists when a person shows a clear pattern of pathological use with resulting problems in social and occupational functioning. Processes leading to dependence include positive and negative reinforcement, classical conditioning of substance-related cues, expectancies, and heredity.

Smoking tobacco is a worldwide problem. In the United States, it reached its greatest popularity in the mid-1960s and then declined after its harmful health effects were publicized. Most people who become cigarette smokers begin the habit in adolescence. Although a larger percentage of men than women smoke, this gap has decreased in recent years. Americans are more likely to

smoke if they are from the lower rather than the higher social classes. Psychosocial factors influence whether individuals start to smoke; going on to smoke on a regular basis is determined by biopsychosocial factors. The likelihood of individuals becoming regular smokers increases if they have peer and adult models of smoking, experience peer pressure to smoke, and find that smoking helps them relax and have less tension.

Cigarette smoke contains tars, carbon monoxide, and nicotine, a chemical that appears to produce physical dependence. One theory that describes why established smokers continue to smoke is the nicotine regulation model, which proposes that they smoke to maintain a certain level of nicotine in their bodies and avoid with- drawal. Smoking reduces the person’s life expectancy and increases the risk of lung cancer, other cancers, car- diovascular disease, and chronic obstructive pulmonary disease. Breathing secondhand smoke is called pas- sive smoking and is also harmful to one’s health.

Chapter 7 / Substance Use and Abuse 193

Alcohol use varies widely across cultures and time peri- ods. Most American adults drink at least occasionally, and many adolescents and adults engage in binge drink- ing. Many individuals who drink abuse alcohol and are classified as problem drinkers; those who are physically dependent on alcohol are classified as alcoholics. People who are addicted to alcohol suffer withdrawal symptoms when they quit drinking. Psychosocial factors—such as modeling, social pressure, and reinforcement—have a very powerful influence on drinking. Heredity plays an important role in the development of alcohol abuse. Heavy drinking is related to a variety of health problems, including fetal alcohol syndrome in babies of drinking mothers, injuries from accidents, and such diseases as cirrhosis of the liver and brain damage.

Drugs can be classified as stimulants, depressants, hallucinogens, and narcotics; they differ in their potential for producing physical and psychological dependence. Drug abuse is related to a number of psychosocial factors, such as modeling, social pressure, reinforcement, and personality traits. The health effects of drug use and abuse are becoming increasingly clear. For example, using cocaine produces cardiovascular reactions that can cause a potentially fatal myocardial infarction.

Programs to prevent smoking and alcohol and drug abuse attempt to address relevant psychosocial factors by providing information and teaching important social skills. These programs teach children and adolescents

about the immediate and long-term consequences of the substances, the ways modeling and peer pressure influence their tendency to use substances, and the ways they can resist these forces. Some programs also teach general social, cognitive, and coping skills. Once people become regular users of tobacco, alcohol, or drugs, many are able to quit on their own, but many others are not, especially if they use the substances heavily. Alcoholics Anonymous and Narcotics Anonymous are self-help groups that help substance users to quit.

People who can’t stop or reduce their substance use on their own or through a self-help group can receive professional treatment. Alcohol or drug abusers typically undergo detoxification. Effective psychosocial treatment approaches for substance use include reinforc- ing abstinence, aversion strategies (which can involve using an emetic drug for alcoholics), substance-related cue exposure, and behavioral and cognitive methods. Chemical treatments are also effective and include administering nicotine for smokers and methadone for narcotics users. Combining effective methods in a mul- tidimensional approach improves treatment success. Many people who quit eventually return to smoking. Although the relapse prevention method helps reduce relapse rates, its effects can be enhanced by provid- ing booster sessions, continuing chemical methods after treatment ends, and developing constructive social networks.

KEY TERMS

addiction physical dependence tolerance withdrawal psychological dependence substance abuse positive reinforcement

negative reinforcement classical conditioning carbon monoxide tars nicotine nicotine regulation model passive smoking

binge drinking problem drinkers alcoholics stimulants depressants hallucinogens narcotics

detoxification aversion strategies emetic drug cue exposure relapse prevention

method

Note: If you read Module 4 (from Chapter 2) with the current chapter, you should include the key terms for

that module.

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