2. Substance Abuse Prior to engaging in this discussion, review Chapters 7 and 8 in your text, read “Recovering Health Through Cultural Traditions” by Krohn (2013).

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Home >Social Science homework help >2. Substance Abuse Prior to engaging in this discussion, review Chapters 7 and 8 in your text, read “Recovering Health Through Cultural Traditions” by Krohn (2013).

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Learning Objectives

1. Define and understand the major constructs associated with substance use

2. Define and understand the theoretical paradigms that shape drug policy regimes

3. Examine the prevalence of illegal drug use in the contemporary United States

4. Examine the prevalence of legal substance use in the contemporary United States

5. Examine the two types of social control applicable to the use and abuse of legal and illegal substances

6. Apply Bronfenbrenner’s ecological model of human development to tobacco and alcohol use

7. Examine a series of public health, drug policy, criminal justice, and other case studies associated with illegal drugs

8. Compare and contrast substance use prevention and education campaigns

Substance Use 8

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CHAPTER 8Section 8.1 Introduction to Substance Use

Case Study: An Ethnographic Study of Substance Abuse Righteous Dopefiend (2009), a defining ethnography in the study of substance abuse, describes a sub- culture that is anything but righteous, or even pleasurable (according to its subjects). Armed with the desire to live among this population in order to better understand it, beginning in 1994, anthropologist Philippe Bourgois and photo-ethnographer Jeff Schonberg embarked on a 12-year research project. Their research method was participant observation; that is, they embedded themselves in the daily, lived experiences of nearly 25 homeless, marginalized, chronic heroin addicts. For the majority of the study, these homeless “righteous dopefiends” lived in makeshift encampments, broken-down vehi- cles, and anywhere else they could, near a maze of freeway overpasses and highway embankments in San Francisco.

Bourgois, a professor of anthropology and family and community medicine at the University of Penn- sylvania, teamed up with Schonberg, who at the time was a graduate student pursuing a doctoral degree in medical anthropology. Together they crafted a gritty photo-ethnography portrait that vividly displays the mutually constitutive micro, meso, and macro challenges of hard-core drug addiction, homelessness, and poverty. Their research connected the deindustrialization of shipyard industries in San Francisco decades earlier (a macro factor) with individual psychological abuse and trauma (micro factors)—both facilitating the addiction and desperation of the study’s subjects. The shadowy lifestyle of these addicts was perpetuated by their chronic fear of being caught by law enforcement or having to share their dope with others. Social stigma likely played a role in the way they viewed themselves, as it does for many drug-addicted people.

Righteous Dopefiend is a vivid window into illegal drug use by the poor and disenfranchised; however, it is only part of the picture of drug use in the contemporary United States. Rates of drug use and abuse are higher among the mentally ill, the homeless, and likely other members of marginalized groups. Even so, this problem is truly a transcendent one, and a significant number of privileged individuals regularly use, abuse, manufacture, and sell illegal drugs. Whether the hip and wealthy using powder cocaine in the 1980s, the millennium generation illegally using prescription drugs, or affluent college students who use and deal drugs, no identifiable group seems immune to the drug problem (Mohamed & Fritsvold, 2010).

8.1 Introduction to Substance Use

This chapter applies pivotal theoretical frameworks to the complex and interconnected issues associated with substance use and abuse, much like Bourgois and Schonberg’s (2009) ethnography described in the feature box. This chapter also examines the social conse- quences of substance abuse and its attendant public health effects through the lens of human ecol- ogy. It presents the sociolegal history of various drugs and alcohol, with a view to their respective micro, meso, and macro environments. The chapter also critically examines the results of recent prevention and education campaigns attempting to deter drug use among both juveniles and adults. Students will assess various substance abuse control initiatives, their respective strengths and weaknesses, and the outcomes for society. Themes and features of successful programs emerge that will help guide future harm reduction and public health programs. This approach presents the reader with an empirically driven (evidence-based) yet holistic (human ecological) account of the impact of substance abuse on public health in the contemporary United States.

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CHAPTER 8Section 8.3 Substance Abuse Paradigms

8.2 Substance Abuse, Addiction, and Dependence Defined

Not all substance use is created equal. Sociology and public health experts distinguish among varying levels of substance use and their related biological, sociological, and psy-chological consequences. Although there are differences among disciplines as to how “substance use” and “abuse” are defined, the American Psychiatric Association (APA) offers a broad and practical definition of substance use disorders in the widely used Diagnostic and Sta- tistical Manual of Mental Disorders (5th ed.; APA, 2013). According to the APA, substance use dis- order refers to “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems . . . that occur in a broad range of severity, from mild to severe” (APA, 2013, p. 483–484).

Inciardi and McElrath (2008) also defined a series of terms central to a broad understanding of the use and consequences of drugs. They defined drug misuse as “the inappropriate use of a prescrip- tion or nonprescription drug; that is, using it in greater amounts than, for purposes other than, or for longer than it was intended” (p. xviii). Relatedly, they defined a series of concepts essential to understanding the consequences of drug misuse. Drug abuse is “any use of an illegal drug, or the use of a legal drug in a manner that can cause problems for the user” (p. xviii). Drug addiction they define as “drug craving accompanied by physical dependence, which motivates continuing usage and . . . tolerance to the drug’s effects” (p. xviii). At the end of the spectrum, drug dependence “indicates the central role that a substance has come to play in an individual’s life” (p. xviii) with a series of negative biological, social, and psychological consequences.

As our investigation of substance use and the sociology of public health moves forward, it is important to apply these cornerstone constructs to our analysis of both legal and illegal substance use in the United States. Moreover, applying cornerstone constructs is paramount to understand- ing larger theoretical frameworks that shape public health and criminal justice policies related to substance use.

8.3 Substance Abuse Paradigms

An adequate investigation of health, illness, disability, and health care necessitates examining the larger theoretical paradigms that often shape related public policies. Punitive prohibition, harm reduction, and medicalization are not necessarily mutually exclusive in practice, but analytically, they are often treated as distinct.

Punitive Prohibition Punitive prohibition, which treats drug use as a criminal justice system issue and focuses on strict punishment and deterrence, has largely been the guiding paradigm of U.S. attempts to control drugs in the modern era. In 1971, President Richard Nixon declared a “war on drugs” and marshaled law enforcement and military resources to increase the policing of drug use,

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CHAPTER 8Section 8.4 Illegal Substance Use in Modern America: An Empirical Overview

manufacturing, and distribution. Later presidential administrations, including those of presi- dents Ronald Reagan, George H. W. Bush, and Bill Clinton, continued to rely on punitive prohibi- tion for both domestic and international drug control efforts. Subsequently, Presidents George W. Bush and Barack Obama expanded the war on drugs to include intervention in countries that supply drugs to the United States—Mexico in particular. The U.S.–Mexican efforts to crack down on drug trafficking have led to huge expenditures of money and manpower and many killings by the drug cartels and police, but the trade continues because the demand for drugs does as well (see Section 8.4).

Harm Reduction A harm reduction approach to substance use attempts to reduce the biological, social, and psy- chological harm associated with the use and abuse of drugs. Prevention, education, and holistic drug treatment regimens are central to any harm reduction approach. Although the drug policies of other westernized, industrial democracies are diverse, harm reduction approaches have gener- ally been more prominent in European drug policy than in the United States. For example, many workers in Europe have access to programs that facilitate support services for a variety of physical and mental health issues, including those involving drugs and alcohol.

Medicalization Medicalization locates substance use primarily within the realm of the medical profession: Med- ical practitioners, counselors, psychiatrists, researchers, and scientists all play a prominent role in such a regime. Although medicalization is often embedded within a broader harm reduction approach, it focuses more on expertise derived from the medical science of drug use, depen- dence, and addiction.

8.4 Illegal Substance Use in Modern America: An Empirical Overview

Illegal substance use in contemporary America is relatively widespread. Annually, the U.S. Department of Health and Human Services (HHS) oversees the National Survey of Drug Use and Health, which is administered via in-person interviews to a nationally representative sam- ple of U.S. households. According to this survey, in 2011 an estimated 22.5 million individuals in America over 12 years of age were current drug users, defined as having used any illegal drug one or more times in the past month. Those 22.5 million Americans over 12 years of age consti- tute nearly 9% of the U.S. population in that age category. Moreover, varying levels of use and abuse characterize these current drug users across a variety of illegal drug categories used either alone or in combination (Inciardi & McElrath, 2011; Substance Abuse and Mental Health Services Administration [SAMHSA], 2012).

The prevalence of illegal drug use (or the illegal use of legal prescription drugs) in the United States varies considerably by drug type (Figure 8.1). Of all illegal drugs, marijuana is overwhelmingly the most frequently used. (Note, however, that it is legal in some states, and the active ingredient

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CHAPTER 8Section 8.4 Illegal Substance Use in Modern America: An Empirical Overview

in marijuana, commonly known as THC, can be prescribed in pill form.) In 2011, an estimated 18.1 million Americans had used marijuana at least once in the past month, a modest increase in marijuana usage rates compared with previous years. Thus, about 80% of all current illegal drug users in the United States use marijuana. Of these 18.1 million current users, many use marijuana exclusively, though a significant percentage use it in combination with other illegal drugs (Inciardi & McElrath, 2011; SAMHSA, 2012).

In some states, changes in marijuana policy represent a retreat from traditional punitive prohibi- tion approaches. Since the recent relaxation of marijuana laws in certain states, allowing “med- ical marijuana” with a doctor’s prescription or even recreational use (in Washington and Colo- rado) and decriminalizing the possession of small amounts (e.g., in Massachusetts), marijuana use rates may or may not be increasing. Many opponents of recent marijuana legislative changes contend that softening marijuana laws will “send the wrong message” and ultimately lead to an increase in marijuana use rates. However, proponents tend to argue that relaxing marijuana laws will decrease drug use by eliminating the forbidden fruit effect—when prohibiting a behavior by policy inherently makes that behavior more enticing and alluring. In addition, proponents cite cross-national comparisons, with nations such as Holland, whose minister of health noted after decades of less-punitive marijuana policies: “We have succeeded in making pot boring” (“Should pot be legal,” 2009, p. 4; see also MacCoun & Reuter, 2001).

Figure 8.1: Past month illicit drug use among persons aged 12 or older, 2011

Marijuana, though legal to use in certain states, is the most frequently used illegal drug.

Source: Substance Abuse and Mental Health Services Administration (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of national findings. NSDUH Series H-44, HHS Publication No. (SMA) 12-4713, figure 2.1. Rockville, MD: Author. Retrieved from http://www.samhsa.gov /data/nsduh/2k11results/nsduhresults2011.pdf

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CHAPTER 8Section 8.4 Illegal Substance Use in Modern America: An Empirical Overview

After marijuana, the illegal use of prescription drugs is the next most prevalent substance use in the United States. SAMHSA defines illegal use of prescription drugs as using “prescription-type psychotherapeutic drugs non-medically in the past month.” (SAMHSA, 2011, p. 1) According to this definition, in 2011 there were approximately 6.1 million current illegal prescription drug users in the United States, nearly 1 million fewer than the previous year. In the drug policy literature, these drugs are often referred to as psychotherapeutics (or psychotropics) and include pain relievers such as oxycodone; stimulants such as Ritalin and MDMA (street name “Ecstasy”); tran- quilizers; central nervous system (CNS) depressants; and anesthetic sedatives such as ketamine (street name “Special K” or “Cat”). Given the prevalence of illegal use of prescription drugs, they constitute a critically important element in modern American drug use, culture, and policy. More- over, because many prescription drugs originate from a legal or pseudo-legal source (a family member, or an unscrupulous physician, for example), law enforcement and policy initiatives can be particularly challenging (Inciardi & McElrath, 2011; SAMHSA, 2012).

Cocaine is the third most preva- lent illegal drug consumed in the United States. In 2011, an esti- mated 1.4 million Americans had used cocaine one or more times in the past month. This cate- gory comprises all varieties of cocaine, including the traditional powder form and crack cocaine (a highly addictive, smokable form of cocaine made by mix- ing powder cocaine with baking soda and water and cooking the mixture on a stove or in a micro- wave; Inciardi & McElrath, 2011; SAMHSA, 2012).

According to the 2011 National Survey of Drug Use and Health,

a variety of other illegal drugs are used in the United States that include various hallucinogenic drugs, such as LSD and peyote (972,000 current users), stimulants such as methamphetamines (439,000 current users), and opiates such as heroin (281,000 current users). The variety of types, ingestion methods, and their micro, meso, and macro implications make contemporary illegal drug use a multifaceted and complex area of study and policy. Effective medical treatment, prevention, education, and public policy require a nuanced understanding of this dynamic and complex social problem (Inciardi & McElrath, 2011; SAMHSA, 2012).

Age, Gender, Race, Social Class, and Geography From a public health perspective, illegal substance use dovetails with other variables, such as age, gender, and geography. Over time, a relatively consistent relationship has emerged between age and the propensity for illegal drug use. Illegal substance useage seems to peak between the ages of 18 and 20 years and then decreases significantly, beginning in the early 30s (Figure 8.2; SAMHSA, 2012).

Rich Pedroncelli/Associated Press

Although many prescription drugs originate from legal sources, they are often used illegally.

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CHAPTER 8Section 8.4 Illegal Substance Use in Modern America: An Empirical Overview

Figure 8.2: Illicit drug use among persons aged 12 or older, by age

Drug use tends to peak between the ages of 18 and 20.

Source: 2011 National Survey of Drug Use and Health. Retrieved from http://www.samhsa.gov/data/nsduh/2k11results/nsduhresults2011.pdf

Moreover, a person’s sex seems to dramatically and consistently influence illegal drug use rates. Reliably over time, men exhibit significantly higher rates of both legal and illegal drug use and engage in criminality more broadly. Over the past decade, the rates of substance dependence and abuse among boys and men above the age of 12 were nearly double the rate of comparable girls and women (SAMHSA, 2012).

In addition, considerable evidence suggests that sexual preference and sexual behavior dovetail with substance abuse and other health issues. For example, substance use rates tend to be higher among gay and bisexual men and within the transgendered community. Several studies have found that methamphetamine and alcohol use among gay men contribute to risky sexual behav- iors and thus to the spread of sexually transmitted diseases, including HIV and AIDS (Kurtz, 2005).

Geography and social location seem to have a more moderate, yet sustained, impact on rates of illegal substance use. According to the 2011 National Survey on Drug Use and Health, current rates of illegal drug use are highest in the western region of the United States (10.5%), followed by the northeast (8.5%) and the midwest (8.5%), and are lowest by a modest margin in the south (7.5%). Moreover, usage rates tend to be higher in urban areas and larger metropolitan centers (SAMHSA, 2012).

In addition, the same survey reveals differences in drug use rates among the included racial and ethnic groups. The survey demonstrated slightly higher rates of current illegal drug use among those 12 years old or older by Blacks (10.0%), followed by Whites (8.7%) and Hispanics or Latinos (8.4%), and significantly lower usage rates among Asians (3.8%). Other variables also seem to affect rates of illegal drug use (SAMSA, 2012).

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CHAPTER 8Section 8.5 Legal Substance Use in Modern America: An Empirical Overview

The relationship between social class and illegal drug use is complex. As an analytical starting point, both employment and education correlate with social class. The 2011 National Survey on Drug Use and Health found significantly higher rates of current illegal drug use among unemployed adults compared with employed adults. In terms of education, rates were highest for adults who had failed to complete high school (11.1%), followed by adults with some college education but who had not completed a degree (10.4%). In addition, drug use rates were lowest among adults who had finished high school and never attended college (8.9%) and college graduates (5.4%). Thus, it seems that completion of an educational goal, not simply years of education, may have the most impact on illegal drug use rates. In addition, some experts contend that poverty, limited economic opportunities, and living in a socially disorganized community may contribute to illegal drug use as a temporary escape from a marginalized social location (Goode, 2008; SAMSA, 2012).

Moreover, the use of particular illegal drugs may reveal significant differences in drug use rates by social class. As noted earlier, the use of powder cocaine in the early and mid-1980s was asso- ciated with a celebrity-driven, jet-set lifestyle of partying and indulgence. In dramatic contrast, in the late 1980s, the use of crack cocaine was associated with poverty and desperation (see a fuller discussion, see “Crack Versus Powder Cocaine,” in this chapter). More recently, the use and manufacturing of methamphetamines may disproportionately affect rural, lower socioeconomic status communities.

The use of illegal drugs intersects with a series of variables, including, but not limited to, age, sex, race, social class, and geography. As we examine the public health consequences of substance use and abuse, it is important to remember that these problems do not exist in a vacuum. Rather, substance use issues intertwine with a series of biological, psychological, and sociological factors.

8.5 Legal Substance Use in Modern America: An Empirical Overview

The use and abuse of legal drugs have been major public health concerns throughout the history of the United States—alcohol and tobacco in particular. The economic, political, and pharmacological effects of these legal drugs pose a series of challenges for human health, illness, disability, and health care. Moreover, legal drugs constitute the modal mind- altering drugs of choice in the United States. Alcohol, tobacco, and other legal drugs are prime case studies for examining the sociology of public health. In later sections, we delve into the sociocultural history of these drugs, their pharmacological consequences, and the related eco- nomic and political dynamics.

Alcohol Of all legal and illegal drugs in America, alcohol is the most frequently consumed. In the 2011 National Survey of Drug Use and Health, of all Americans aged 12 or older, 51.8% were current users of alcohol, for a total of 133.4 million current alcohol users in the United States. More worrisome, 22.6% of respondents reported engaging in binge drinking one or more times in the past month. During the life course, alcohol use rates tend to peak when users reach their early 20s and slowly and progressively decrease thereafter. Recently, however, alcohol use among middle-aged women has significantly increased (Glaser, 2013). Although social drinking is widely

Bloomberg/Getty Images

Alcohol is the most frequently consumed drug in the United States.

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CHAPTER 8Section 8.5 Legal Substance Use in Modern America: An Empirical Overview

practiced, levels that exceed moderate intake (several drinks per week, for example) can lead to serious problems or alcohol- ism (alcohol addiction).

The Centers for Disease Control and Prevention (CDC; 2011d) defines heavy drinking as “con- suming an average of more than one alcoholic beverage per day for women, and an average of more than two alcoholic bever- ages per day for men, and any drinking by pregnant women or underage youth” (p. 1). SAM- HSA defines binge drinking as consuming a minimum of five alcoholic beverages throughout the course of a single event. The CDC defines binge drinking as at least four drinks over the course of a single event for women, and at least five drinks over the course of a single event for men. Moreover, a series of mixed-methodology studies of college students determined that socially prescribed gender roles and expectations (e.g., peer pressure) may significantly affect both tobacco and alcohol consumption patterns, and binge drinking in particular (Nichter et al., 2006; Young, Morales, McCabe, Boyd, & D’Arcy, 2005).

Tobacco Tobacco comes in a variety of forms and remains a popular legal drug in contemporary Amer- ica. According to the 2011 National Survey of Drug Use and Health, 26.5% of all Americans 12 years of age or older had used a tobacco product in the previous month. Overwhelmingly, the most commonly used tobacco products are cigarettes, used by 83% of all tobacco users. Other tobacco products include cigars, smokeless tobacco or “chew,” pipe tobacco, hookahs (shared water pipes), and “electronic” cigarettes. Among all tobacco users, the highest rates of use were among the age group 18–25 years.

8.5 Legal Substance Use in Modern America: An Empirical Overview

Bloomberg/Getty Images

Alcohol is the most frequently consumed drug in the United States.

Web Field Trip Please visit the CDC’s Web page dedicated to binge drinking (http://www.cdc.gov/alcohol/fact-sheets /binge-drinking.htm). Read the evidence concerning the prevalence of binge drinking, related health problems, monetary costs, and potential interventions.

Critical Thinking Questions

1. What do you think motivates individuals to engage in binge drinking? 2. How would you create a public health campaign to reduce binge drinking behavior and prevent

its related health problems?

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CHAPTER 8Section 8.6 David Musto: The American Disease

8.6 David Musto: The American Disease

The definitive sociohistorical account of U.S. drug policy is likely David Musto’s 1999 work The American Disease: Origins of Narcotic Control. Dr. Musto was a professor of child psy-chiatry at the Yale School of Medicine, a drug policy expert, and an advisor to the Carter administration on drug abuse. His vivid, detailed chronology of drug policy in the United States is fundamentally about the process of creating social control in society.

Social scientists typically identify two types of social control: formal and informal. Formal social control can be broadly defined as attempts by legitimized authoritative groups to con- trol behavior within society. In contrast, informal social control refers to unofficial and often unrecognized power holders, norms, and values in a society that may shape or control behavior. Musto focused overwhelmingly on formal social control by examining the political actors who have shaped American drug policy, their efforts to stem drug use and drug markets, and changes in drug consumption patterns over time (Grimes, 2010; Musto, 1999).

Musto argued that the use and abuse of legal and illegal drugs in the United States is cyclical. His- torical evidence suggests that the use of certain families of drugs tends to be popular for a while, decreases significantly, and then reemerges decades later. This cyclical dynamic has been particu- larly evident in the use of heroin, amphetamines, and cocaine. These illegal drugs all experienced several eras of popularity over the last century and a half, intermingled with periods of relatively low consumption.

Based on this detailed sociohistorical account, Musto outlined a three-step cycle of a particular illegal drug’s use. First, the new drug is “discovered,” and experimentation ensues with a relatively small number of users. Second, the drug becomes more widely used, but the negative health effects soon become evident. Third, owing to the evident negative health effects, users and poten- tial users begin to view the drug negatively and use falls off, often significantly.

The absence of formal efforts at social control is noteworthy in Musto’s three-phase drug-use cycle. According to Musto’s analysis, drug use rates seem to depend primarily on informal social control: The opinions of users and potential users are driven by a “critical mass” of the population experiencing visible negative health consequences. In his view, law enforcement efforts, deter- rence, and fear-based education campaigns are not as significant. As we examine the public health ramifications of substance use and related public policy, the importance of informal social control continues to come into play (Musto, 1999). In the context of Bronfenbrenner’s human ecology model, we could say that Musto emphasized the influence on drug use of micro- and mesosys- tems, rather than exo- and macrosystems.

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CHAPTER 8Section 8.7 Using Bronfenbrenner’s Model to Better Understand Substance Abuse

Web Field Trip The University of Michigan’s Monitoring the Future Study is one of the most methodologically advanced and nuanced studies of substance use in America. Using a nationally representative sampling method, this study surveys approximately 50,000 individual students in 420 public and private schools every year. In the 8th-, 10th-, and 12th-grade years, the same sample of students completes surveys con- taining the same items. Although no research methodology is perfect (see Chapter 1), this study likely presents a reliable picture of drug use rates among young people in the United States. Please visit their Web page dedicated to an overview of their 2012 key findings on adolescent drug use (http:// www.monitoringthefuture.org//pubs/monographs/mtf-overview2012.pdf). Go to “Lessons Learned” on page 50.

Critical Thinking Questions

1. After reading the overview, how do these “lessons learned” reinforce or challenge the argu- ments David Musto made in The American Disease?

2. What are some possible micro-, meso-, and macrosystem issues?

8.7 Using Bronfenbrenner’s Model to Better Understand Substance Abuse

Bronfenbrenner’s ecological model of human development provides a powerful analytical tool for examining the consequences of substance use and abuse. Recall from previous chapters that this ecological model of human development locates an individual’s develop- ment during the life course within a series of layered environmental experiences. Each of these environments reinforces prescribed norms, values, roles, and expectations. This model not only emphasizes the role of environmental factors in human development but proposes five distinct environmental layers: microsystems, mesosystems, exosystems, macrosystems, and chronosys- tems (Bronfenbrenner, 1981). A holistic, interdisciplinary understanding of the public health ram- ifications of alcohol and tobacco use requires us to examine not only the biological pharmacology of tobacco, but the social, cultural, and psychological aspects as well.

The following sections use Bronfenbrenner’s model to analyze tobacco and alcohol use in modern America. These drugs are critical case studies from a public health perspective for several reasons: (a) they are very widely used, (b) they cause widespread and significant harm to individual users and their families, and (c) they are supported by major industries in the contemporary domestic and global economy. Of course, Bronfenbrenner’s model can also be applied to illegal drug use, which has its own set of social circumstances that influence people’s behavior.

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CHAPTER 8Section 8.7 Using Bronfenbrenner’s Model to Better Understand Substance Abuse

Tobacco The leaf of the tobacco plant contains several chemical agents, one of which is nicotine. Nicotine produces a short, relatively mild pharmacological effect and is widely considered addictive by medical professionals. This chemical can be delivered to the user via chewing, but overwhelm- ingly, the most common method of delivery is smoking cigarettes, cigars, and pipe tobacco (nico- tine patches are also available for those trying to quit smoking). In fact, cigarettes account for 90% of all sales of tobacco-related products (Goode, 2008). Tobacco production and use have a long and rich history in the United States, which can be analyzed by applying Bronfenbrenner’s model (Goode, 2008; Inciardi & McElrath, 2008).

Sociolegal History Tobacco in America dates back as far as 860 CE (Nikos, 2013). Chewing tobacco was fairly pop- ular in America beginning sometime in the early 1800s, but cigarette smoking soon dominated the tobacco industry. In 1900, U.S. consumers purchased 2.5 billion cigarettes—an average of 54 individual cigarettes for every adult. Cigarette smoking remained very popular until the end of the 20th century, evident not only in usage rates but also in the ever-present images of celebrities portrayed smoking, both on television and in film (Goode, 2008). It continues to have detrimental public health, economic, and political effects on U.S. society.

As medical science evolved, the negative public health consequences of smoking cigarettes became more apparent. In 1964, the U.S. surgeon general released a report titled “Smoking and Health,” which detailed to a wide audience the harmful effects of cigarettes on health. Tobacco use seemed to peak in the mid-20th century and decline significantly thereafter (Figure 8.3). Many experts contend that education campaigns have been key to the dramatic decline in tobacco use in America during the modern era—especially among teenagers. Also, the ban on many forms of cigarette advertising (e.g., television) helped reduce its popularity. In recent years, societal disap- proval of smoking and laws banning it in public places have further lowered smoking rates, which are now estimated to be 19% of U.S. adults (CDC, 2013m). Some argue that U.S. prevention and education campaigns targeting illegal drugs would be more effective if they were modeled after the core tenets of these tobacco initiatives (Goode, 2008; Inciardi & McElrath, 2008).

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CHAPTER 8Section 8.7 Using Bronfenbrenner’s Model to Better Understand Substance Abuse

Figure 8.3: Trends in current cigarette smoking among high school students and adults in the United States, 1965–2011

The public is more aware of the negative consequences of smoking cigarettes, but cigarette production is still a major economic industry.

Source: Centers for Disease Control and Prevention. (2012c). Smoking and tobacco use. Retrieved from http://www.cdc.gov/tobacco/data_statistics /tables/trends/cig_smoking/index.htm

According to the CDC, “cigarette smoking is the leading preventable cause of disease, disability, and death in the United States” (2013d, p. 1). Regardless of the known health hazards of smoking, however, cigarette production continues to be a major economic industry in modern America. Despite decreased tobacco production in recent decades, in 2009 the United States remained the world’s fourth largest producer of tobacco. Approximately 10,000 tobacco farms grow this crop in 16 states, with Kentucky and North Carolina accounting for 71% of all production. In 2010, tobacco consumers in America purchased more than 303 billion individual cigarettes. Of these, 85% were produced by three tobacco companies: Philip Morris USA, Reynolds American, and Lorillard (CDC, 2013n).

In addition to traditional prepackaged cigarettes manufactured by corporations, both e-cigarettes (electronic cigarettes) and bulk tobacco seem to be becoming more popular. A cylin- drical apparatus that appears to resemble a traditional cigarette, an e-cigarette is actually a small electronic heating element that turns liquid into a vapor that can be inhaled. Users can inhale fla- vored vapors, which may or may not contain nicotine. Thus, e-cigarettes can be either an alterna- tive method of ingesting tobacco or part of a smoking cessation program. Currently, many policy makers are strongly urging the U.S. Food and Drug Administration to implement strong regulations on the e-cigarette industry (Nelson, 2013).

1965

* Percentage of high school students who smoked cigarettes on 1 or more of the 30 days preceding the survey (Youth Risk Behavior Survey, 1991–2011). ** Percentage of adults who are current cigarette smokers (National Health Interview Survey, 1965–2011).

19711968 0

P e

rc e

n t

Year 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2020

HP 2020 Goal

Youth 16%

Adult 12%

2011

11.1%

10.9%

Students* Adults**

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Like e-cigarettes, bulk tobacco is becoming more popular as well. Bulk tobacco is the practice of buying larger quantities of loose- leaf tobacco of various blends that allows users to roll their own individual cigarettes. Histor- ically, bulk tobacco has not been taxed like traditional cigarettes. However, as of this writing, fed- eral lawmakers are considering legislation that would tax bulk tobacco at rates similar to those of traditional cigarettes.

Collectively, the tobacco indus- try spends almost $10 billion annually on advertising. As pub-

lic health campaigns have shrunk the U.S. market for tobacco products, tobacco companies have altered their marketing strategies to focus on blue-collar employees, women, and members of racial and ethnic minority groups (CDC, 2013n; Inciardi & McElrath, 2008) and have expanded outward by focusing on exporting their products. Whether comprising traditional cigarettes, e-cigarettes, bulk tobacco, or another nicotine delivery device, the tobacco industry remains a large and politically powerful organization, deeply entrenched in America’s cultural and political systems (Cox, 2013).

Micro Perspectives At the micro level, tobacco is addictive and detrimental to the health and vitality of the user, who can be influenced by the people he or she comes into contact with daily (e.g., peers, family, school- mates, and coworkers). The pharmacological effects of cigarettes damage virtually every organ in the human body and have been linked to a series of debilitating and fatal diseases. Conversely, approximately 85% of all deaths from lung cancer are caused by the resulting pharmacological harm of cigarette smoking. Nicotine causes blood vessels to constrict, causing the heart and the cardiovascular system to struggle to circulate adequate blood and oxygen throughout the body. Cigarette smoking and other forms of tobacco use significantly increase the risk of heart disease, stroke, chronic obstructive pulmonary disease, emphysema, cancer, and a series of complications with reproductive organs. Of paramount importance, cigarette smoking often leads to coronary heart disease, which is the “leading cause of death in the United States” (CDC, 2013o, p. 1).

According to Erich Goode, author of many academic books on the sociology of drug use, passive smoke—“the smoke inhaled by a nonsmoker from a smoker’s cigarette” (Goode, 2008, p. 197)—is a critical element of the tobacco problem at the micro level. Passive smoke causes approximately 50,000 people to die of tobacco-related illness in the United States each year. These deaths tragically include more than 5,000 infants who have inhaled passive smoke from the mother or another caregiver. Exposure to the effects of tobacco consumption and nicotine via the placenta can also be detrimental to the fetus while in utero. Some experts have concluded that tobacco use contributes to between 19,000 and 141,000 miscarriages each year.

Marty Heisey/Intelligencer Journal/Associated Press

E-cigarettes can be used to help people stop smoking.

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According to the CDC, the risk of tobacco use is shaped by other elements of the microsystem. For example, living in poverty increases the risk of tobacco use. In 2011, 29% of adults living below the federal poverty line were current smokers, compared with 17.9% of adults in all higher socioeco- nomic categories. In addition, adults who identified themselves as disabled or having a disability had higher rates of smoking (25.4%) compared with adults who did not (17.3%). Lastly, having a parent who smokes increases the risk of a child becoming a smoker. Although far from exhaustive, the evidence clearly suggests that microsystem factors shape smoking-related behaviors and the attendant public health ramifications (CDC, 2012c; Nelson, 2013).

Meso Perspectives Tobacco has substantial negative health ramifications at the meso level of Bronfenbrenner’s ecological model of human development. Cigarette smoking is responsible for an annual total of 443,000 deaths in the United States, which constitutes an astounding 20% of all nation- wide fatalities. According to the U.S. surgeon general, the majority of smoking-related deaths are caused by “early heart attacks, chronic lung disease, and cancers” (HHS, 2010b, p. i). Those 443,000 annual deaths are more than 10 times the number of deaths from all illegal drugs combined. The negative outcomes associated with chronic tobacco use on public health are sweeping—affecting the health care system, public accommodations, local governments, and other institutions (HHS, 2010b).

Viewed from the meso level of Bronfenbrenner’s model, tobacco includes various types of social- ization (Goode, 2008). For example, research has demonstrated that culture and ethnicity may play a role in substance use. Dr. Mark Nichter, a medical anthropologist and professor at the University of Arizona, explored how attitudes and behaviors related to tobacco intertwine with the cultural context at the meso level. He argued that family, peers, prominent role models, and other “authoritarian parental messages protect African American youth against higher rates of smoking” (Nichter, 2003, p. 142). These cultural traditions, communicated directly and indirectly through socialization, contribute to lower rates of smoking among Black youth. In fact, “smoking rates in African American adolescents continue to be the lowest among all racial and ethnic groups in the United States” (Gardiner, 2001, p. 1; Nichter, 2003). The American Lung Association (ALA; 2010) has also reported lower rates of smoking among Blacks, who comprise only 12% of U.S. smokers. Among all races, the ALA ascribes higher rates of smoking in part to lower educational attainment, another meso factor (e.g., poor schools combining with parents who smoke in the home environment).

Seen through the interdisciplinary lens of Bronfenbrenner’s ecological model of human devel- opment, tobacco use has important meso-level elements. The tragic health consequences of poor socialization within small groups and communities are just one example. These mesosystem dynamics, linked to micro- and macrosystem ones, enable a holistic examination of the tobacco problem in modern U.S. society.

Macro Perspectives Tobacco use intertwines with a host of macrosystem social dynamics, including, but not limited to, history, economics, politics, and social class. Economically, the tobacco industry is a politi- cally powerful business sector in the United States. Tobacco manufacturing constitutes an annual $14.8 billion industry and provides $500 million in annual job compensation. Moreover, some

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states depend heavily on the growth and production of tobacco, including North Carolina, whose annual tobacco farm sales total approximately $1 billion (Inciardi & McElrath, 2008). In addition, tobacco is a significant contributor to local, state, and national tax revenues. Federal taxes on a single pack of cigarettes were raised to $1.01 in 2009. In addition, states add an average of $1.53 per pack to cigarette sales (Campaign for Tobacco-Free Kids, 2013), varying from $0.17 per pack in Missouri to $2.75 in New York (Inciardi & McElrath, 2008; “Tobacco Taxes Up in Smoke,” 2009).

Though economic revenues from the tobacco industry are significant, so too are the related public health costs. According to HHS Secretary Kathleen Sebelius, “tobacco use imposes enormous pub- lic health and financial costs on this nation—costs that are completely avoidable” (HHS, 2010b, Message). Sebelius concluded that, in combination, the public health expenditures and loss of productivity caused by cigarette use total more than $193 billion each year. Sebelius made a com- pelling case for action on this issue:

Now is the time for comprehensive public health and regulatory approaches to tobacco control. We have the knowledge and tools to largely eliminate tobacco caused disease. If we seize this moment, we will make a difference in all of our communities and in the lives of generations to come. (HHS, 2010b, Message)

The most significant obstacle to increased regulation may be the waning, yet still substantial, political power of the tobacco industry. Politically, the tobacco industry has had a controversial yet significant and sustained influence on laws and regulations related to their products. In the 21st century, however, political candidates from both parties seem less likely to accept financial contributions directly from tobacco companies. Increasingly, candidates who do so receive dona- tions indirectly, filtered through political action committees. In 1998 Deborah Pryce, a Republican congressional representative from Ohio’s 15th District, noted that “you don’t really want to be associated with an industry that consistently lied to Congress and the American people” (Marcus & Connolly, 1998, p. 2).

Notably, November 1998 saw a landmark legal settlement—the culmination of a state-based civil suit against the five largest manufacturers of tobacco. This settlement agreement involving the U.S. attorney general, nearly every U.S. state, and these five tobacco corporations required tobacco companies to pay the states a total of $206 billion over 25 years. These funds will reimburse state Medicaid costs associated with the health effects of tobacco use as well as fund a series of public education campaigns. In addition, tobacco advertising that explicitly targets younger audiences will be prohibited. Restrictions on advertising will ban ads featuring cartoons, eliminate all out- door advertising, and restrict tobacco-related sponsorship of events with large youth constituen- cies (Wilson, 1999). This settlement is one significant moment in the lengthy history of tobacco in the United States.

The history of tobacco production in the United States is linked with social, economic, and political contexts, including the legacy of slavery. Across the southern states, slave labor was instrumental in the agricultural industry, including tobacco, beginning in the colonial era and up until the Civil War. A macrosystem analysis of tobacco accounts for how the sociohistory of racial oppression was linked with tobacco production and related economic dynamics. Moreover, it is possible that the history of racial dynamics in tobacco production have contributed, explicitly or implicitly, to the comparatively low rates of cigarette smoking among Black youth.

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Alcohol Alcohol is the most commonly used mind-altering substance in the contemporary United States. Drinkable alcohol is the by-product of fermentation using a variety of foods, sugars, and grains. Indeed, alcohol is probably the oldest and most culturally embedded intoxicant in the history of the world.

Sociolegal History Alcohol has a long and rich history. Various alcoholic beverages have played longstanding roles in cultural traditions, religious ceremonies, and other rites of passage worldwide. In the United States, alcohol has been described by experts as “a social enigma,” because

on the one hand, alcohol is the biggest killer drug in the United States; it causes more havoc, violence, damage, and death than all other drugs combined, legal and illegal. On the other hand, when used responsibly and in moderation, it can be a relatively safe and pleasant drug for the majority. (Inciardi & McElrath, 2008, p. 63)

Micro and Meso Perspectives Alcohol is a CNS depressant, ingested mainly in the form of wine, beer, or hard liquor. As a CNS depressant, alcohol alters the behavior and decision-making abilities of the user by slowing down the responses of the body’s organs, including the brain. Long-term, heavy consumption causes many serious health problems, for the liver in particular. Alcohol addiction is both psychological and physical; heavy use leads to tolerance and withdrawal symptoms when stopping. Moreover, substantial alcohol use is correlated with a host of behavioral and social adjustment problems, including drunk driving, violence, crime perpetration, and crime victimization (Goode, 2008). Fam- ily and relationship disruptions are common when alcohol is abused.

The acute pharmacological effects of alcohol depend greatly on the quantity consumed in a given time period and the potency of the alcoholic beverage. However, experts contend that many micro and meso factors shape the behavior and experience of those consuming alcohol. And, according to public health and social science experts, meso factors shape the behavioral impact of alcohol consumption. Goode argued, “Alcohol is a drug, with objective, measurable effects, and a social phenomenon, the impact of which is shaped by culture, society, and social context”

Web Field Trip Please visit the website of Tobacco Free California for a series of anti-tobacco television ads (http:// www.tobaccofreeca.com/ads/tv/), which are designed to shock the viewer. Near the bottom of the page, please click on “show all videos” and view three or four of your choice.

Critical Thinking Questions

1. How would you analyze these advertisements using Bronfenbrenner’s human ecological model? 2. What are the micro-, meso-, and macrosystem influences they invoke?

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http://www.tobaccofreeca.com/ads/tv/

CHAPTER 8Section 8.7 Using Bronfenbrenner’s Model to Better Understand Substance Abuse

(2008, p. 178). For example, consider the following question: How does the experience of consum- ing three identical alcoholic beverages differ (a) at a graduation party, (b) at a friend’s apartment, and (c) at a funeral?

Macro Perspectives From a public policy perspective, alcohol is unique in that it experienced a brief period known as Prohibition (1920–1933). In the early 1900s, U.S. cultural norms were heavily influenced by the conservative temperance movement, which at times resembled a religious revival. This move- ment emphasized hard work, deferred gratification, repentance, and sobriety. Moreover, public opinion associated alcohol use with crime, vice, and social degradation. Organizations such as the Women’s Christian Temperance Union were instrumental in the passage of the 18th Amendment to the U.S. Constitution, which was ratified in 1920.

The 18th Amendment criminalized the possession, use, manufacture, or transport of alcoholic beverages. (Exceptions were made for alcohol dispensed with a doctor’s order, similar to the way that marijuana is treated in many states today.) The law did not have the intended effect, however. Although some medical and social problems associated with alcohol abuse did abate, the enforce- ment of Prohibition proved to be daunting and expensive. Moreover, Prohibition gave rise to an

underground economy, led by hierar- chical, organized crime groups—such as that of the infamous gangster Al Capone in Chicago—and made up of bootleggers, home distillers (“moon- shiners”), and other outlaws. Owing to these and other law-enforcement and public health concerns (the con- sumption of home brew could be dangerous), as well as arguments in favor of limited government control over personal decisions and liberties, the 18th Amendment was repealed in 1933 by Congress. To repeal Pro- hibition, the states ratified the 21th Amendment to the U.S. Constitution. From both public health and drug policy perspectives, Prohibition is an important case study of the advan- tages and disadvantages of criminal- izing drugs (Goode, 2008; Inciardi & McElrath, 2008).

Applying Bronfenbrenner’s framework, we see the impact of alcohol consumption on economic productivity is another critical macro dynamic. Some experts contend that the economic costs associated with alcohol abuse may be as high as $223.5 billion annually in the United States (Bouchery, Harwood, Sacks, Simon, & Brewer, 2011; CDC, 2011d). Decreased productivity in the workplace constituted the largest category, accounting for 72%, or nearly $161 billion, of the eco- nomic losses associated with alcohol abuse and the attendant “hangover,” or recovery period. In addition, alcohol abuse results in substantial health care costs ($24.5 billion) and criminal justice system costs ($20 billion) and correlates with a host of other social problems (Bouchery et al., 2011; CDC, 2011d).

Courtesy Everett Collection.

Enforcing Prohibition was difficult and expensive. In this photo police watch as agents pour confiscated liquor down a manhole after a raid.

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According to a CDC study, breaking down the costs associated with alcohol reinforces its economic impact. The analysis revealed that each alcoholic beverage consumed in the United States con- tributes to an economic loss of $1.90. The vast majority of these costs result from binge drinking. These data led CDC Director Thomas Frieden to conclude that

unfortunately the hangover is being passed on to all of us in the workplace and the health and criminal justice systems. The cure is responsible individual behav- ior combined with the successful policies we used to decrease smoking in the United States. (CDC, 2011d, p. 1)

Conclusion Through the lens of Bronfenbrenner’s ecological model, we can locate the biological, psycholog- ical, and sociological ramifications of alcohol use and abuse. Applying this model to both alcohol and tobacco clearly reveals that these legal drugs have substantial cumulative adverse conse- quences for public health in America. Moreover, policies relating to these legal drugs will continue to be shaped by social norms and the enormous economic impact these two industries make.

8.8 Illegal Drugs: Case Studies

Although legal drugs have the widest impact on contemporary U.S. society, illegal drugs constitute a significant public health problem and a burden on the criminal justice system. The biological, psychological, and societal harm of illegal drugs are complex and beyond the scope of a single chapter. Thus, the forthcoming sections examine a single public health issue associated with each major family of illicit drug (or in the case of marijuana, quasi-illicit). Although far from exhaustive, these case studies are vivid examples of the variety of public health chal- lenges that illicit substance use poses.

Marijuana and the Gateway Theory of Substance Use Over the decades, the discourse on marijuana prohibition has been at least partly grounded in the gateway theory of substance use. Broadly construed, the gateway theory of substance use posits that the consumption of more commonly used drugs (e.g., marijuana or alcohol) will encourage the use of more dangerous “hard” drugs (e.g., cocaine, heroin, methamphetamine). From a pub- lic health perspective, understanding how some individual users progress from “soft” to “hard” drugs may be critical for planning drug education, prevention, and treatment. Although the polit- ical discourse often has assumed that marijuana is a gateway drug, the empirical reality is much more complex (MacCoun & Reuter, 2001; Morral, McCaffrey, & Paddock, 2002).

Some evidence suggests that marijuana is in fact a gateway drug. That is, the vast major- ity of hard-drug users did use marijuana regularly before progressing to harder drugs. Per- haps getting used to being moderately intoxicated on marijuana gives the user an appetite for more intense forms of intoxication produced by harder drugs. This effect is referred to as the pharmacological gateway theory. Because marijuana use often precedes harder drug use, propo- nents of the gateway theory often cite this effect and sometimes use it to support punitive drug policies. However, this version of the gateway theory suffers from a fatal logical fallacy (MacCoun & Reuter, 2001; Morral et al., 2002).

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The pharmacological gateway theory confuses correlation with causation: Just because mari- juana use typically precedes harder drug use, one does not necessarily cause the other. Critics of the pharmacological gateway model similarly argue that all users of heroin likely drank milk before moving onto hard drugs, raising another likely “spurious correlation” (MacCoun & Reuter, 2001). Moreover, other empirical evidence has challenged the pharmacological gateway model for marijuana.

Revisiting drug use data from the 2011 National Survey of Drug Use and Health also challenges the notion that marijuana is a gateway drug. According to the survey, approximately 40% of all Americans 12 years old or older have tried marijuana—a total of approximately 95 million people (Inciardi & McElrath, 2011). Moreover, in 2011, an estimated 18.1 million Americans had used marijuana at least once in the past month. If the gateway theory were sound, presumably the majority of marijuana users would pass through the gateway and move onto harder drugs. Recall from the chapter overview that in 2011 there were an estimated 6.1 million current illegal pre- scription drug users, 1.4 million Americans who had used cocaine one or more times in the past month, 972,000 current users of hallucinogens, 439,000 current users of methamphetamines, and 281,000 current users of heroin. With 95 million Americans having tried marijuana and 18.1 million current users, the pharmacological gateway theory would likely predict much higher usage rates for these harder drugs. However, although the pharmacological gateway theory may not have adequate empirical support, some experts believe it may hold true in other ways.

Preliminary evidence suggests that marijuana may be a gateway drug because it introduces users to the underground market for illegal drugs. In some communities, the illicit drug market is visible and robust, and in others, illegal street drugs are harder to find—particularly to the uninitiated (Inciardi & McElrath, 2008; Mohamed & Fritsvold, 2010). Given the prevalence of marijuana use, by definition a significant number of Americans are introduced to the underground drug market when they procure marijuana. It might be safe to assume that once someone is introduced to a drug dealer, and to the underground drug market more broadly, the opportunity to purchase hard drugs, if desired, increases. Some experts believe that this underground market gateway theory is the only valid dynamic (a type of mesosystem, where drug users intersect with the world of drug sellers) that makes marijuana a gateway drug. Specifically, marijuana markets are gateways to harder-drug markets (MacCoun & Reuter, 2001).

Crack Versus Powder Cocaine As Bronfenbrenner’s ecological model of human development illustrates, substance use and its attendant social harm do not exist in a vacuum. From a public health perspective, substance use has a wide variety of consequences at various levels of society, not just for the user’s own health. One public health and societal consequence is incarceration. Punitive drug laws and incarceration have detrimental impacts on families, employment, and community stability (the mesosystem level of human environments), likely exacerbating the conditions that contribute to drug use. Thus, punitive drug laws and incarceration figure prominently in any investigation of modern substance use. Moreover, many experts contend that punitive drug laws have disproportionately affected traditionally marginalized communities—in particular, the poor and people of color (Lusane, 1991; Mohamed & Fritsvold, 2010). In the words of U.S. District Court Judge Clyde S. Cahill:

This one provision, the crack statute, has been directly responsible for incarcerat- ing nearly an entire generation of young black American men for very long peri- ods. It has created a situation that reeks with inhumanity and injustice. The scales

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of justice have been turned topsy-turvy so that those masterminds, the kingpins of drug trafficking, escape detection while those whose role is minimal, even triv- ial, are hoisted on the spears of an enraged electorate and at the pinnacle of their youth are imprisoned for years while those responsible for the evil of the day remain free. (as cited in Inciardi, Surratt, & Kurtz, 2007, p. 252)

As Judge Cahill suggested, punitive crack cocaine laws, which have disproportionately affected racial and ethnic minorities, have been particularly controversial in the contemporary criminal justice system.

Crack cocaine is a relatively recent and particularly dangerous version of cocaine, whose powder form has been in existence since the mid-1800s. Powder cocaine had a brief period of widespread use in everyday products in the late 1800s and early 1900s, including as hay fever remedies and soft drinks (Musto, 1999). It is most often snorted but also can be injected. Crack cocaine com- prises powder cocaine mixed with baking soda and water, which is cooked over a stove or in a microwave. Vapor from the pellets of crack can be smoked by the user. Because of its method of ingestion, crack delivers a more potent and short-lived high than powder cocaine. Moreover, crack can be sold in much less expensive individual doses because it requires less cocaine per use than does the powder form. Although the origins of crack cocaine are not entirely clear, its use became popular in some American cities in the mid- to late 1980s (Reinarman & Levine, 1997).

The dangers of crack cocaine and its association with people of color were likely exaggerated by the American news media in the late 1980s and into the early 1990s. Vivid articles and television features presented crack cocaine in America’s cities as an “epidemic,” “plague,” or “national cri- sis.” Crack was overwhelmingly associated with users and dealers who were from traditionally marginalized groups, often poor men of color. Research suggests that although most crack users are White, crack is disproportionately used by members of racial minority groups (Inciardi et al., 2007). Moreover, the advent of crack cocaine likely increased the volatility and attendant violence of the underground drug market. Even so, at the height of crack use in the late 1980s, approxi- mately 96% of Americans had never tried it (Reinarman & Levine, 1997). It seems that crack use was most visible among marginalized individuals in some American cities, where addiction to it devastated many young people. However, there is no reliable evidence that crack use was epi- demic (Berger, Free, & Searles, 2009; Reinarman & Levine, 1997); rather, its incidence resembled localized outbreaks.

In the late 1980s, President Reagan signed a series of extremely punitive laws against illegal drugs, crack cocaine in particular. The Anti–Drug Abuse Acts of 1986 and 1988 created a series of man- datory minimum penalties for illegal drugs at the federal level. Mandatory minimum sentences restrict discretion in the judicial process by specifying the term of incarceration to be served based on the type and amount of drug possessed by the defendant. Although powder and crack cocaine are different versions of the same drug, they were treated very differently by this legislation.

The Anti–Drug Abuse Act of 1986 created a 100:1 ratio for penalties for crack versus powder cocaine. The mandatory minimum sentencing scheme specified that a defendant found guilty of possessing 5 g of crack cocaine would trigger a mandatory 5-year prison term (5 g of crack cocaine constitutes 10–50 individual doses of the drug and has an approximate street value of between $125 and $750). In dramatic contrast, 500 g of powder cocaine was required to trigger the same 5-year federal mandatory minimum sentence. This amount of powder cocaine likely constitutes between 2,500 and 5,000 individual doses of the drug and has an estimated street value of $32,500 to $50,000 (Berger et al., 2009; Inciardi et al., 2007; Reinarman & Levine, 1997).

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After more than 25 years in force, new legislation in 2010 altered the mandatory mini- mum sentence guidelines for crack cocaine. In August 2010, President Obama signed the Fair Sentencing Act into law. Under the act, the 500 g of powder cocaine necessary to trigger a 5-year mandatory minimum prison term remains unchanged. However, the new legislation prescribes that 28 g of crack cocaine are now required to trigger the man- datory 5-year prison sentence, replacing the old 100:1 ratio of powder to crack cocaine with an 18:1 ratio.

In the original Fair Sentencing Act, the timeline for implementing the change and whether the leg- islation would apply retroactively were not particularly precise. However, by November 2011, the legislation was amended to apply the revised sentencing guidelines retroactively to some crack cocaine offenders. Retroactive resentencing is considered only in cases involving comparatively

Damian Dovarganes/Associated Press

In 2010 the mandatory minimum sentencing system for possession of crack cocaine was altered due to the passage of the Fair Sentencing Act.

Case Study: Minimum Sentencing Laws The case of Derrick Curry demonstrates the punitive nature of the federal mandatory minimum sen- tencing laws against crack cocaine (Inciardi et al., 2007). In the early 1990s, Derrick Curry was a Black 20-year-old college student in Washington, D.C., studying criminal justice. He was also involved in the distribution of crack cocaine but seemed to be “no more than a low-level drug courier” (Inciardi et al., 2007, p. 253). Curry was caught with more than 1 lb (0.45 kg) of crack cocaine in his car after a larger network of dealers had been under surveillance by both the Federal Bureau of Investigation and the Drug Enforcement Administration (DEA). Curry was eventually sentenced to a prison term of 19 years and 7 months without the possibility of parole. The authors argued,

Derrick Curry’s sentence, by almost any available standard, is incomprehensibly severe. It is nearly three times the prison sentence served by most murderers in the United States; it is four times the prison sentence served by most kidnappers; it is five times the prison sentence served by most rapists; and it is ten times the prison sentence served by those who illegally possess guns. (Inciardi et al., 2007, p. 253)

Mandatory minimum sentences for crack cocaine have a disproportionate impact on the most visible and marginalized users of the drug, who are often young urban men of color. Throughout the 1990s and 2000s, Blacks accounted for approximately 80% of all crack arrests (Mauer, 2011). The evidence is strong that crack cocaine laws contributed to the overrepresentation of members of racial minority groups in the criminal justice system (Berger et al., 2009; Inciardi et al., 2007; Reinarman & Levine, 1997).

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small amounts of the drug and with offenders deemed not to pose a significant risk to public safety (Fields, 2010; Frieden, 2010; U.S. Sentencing Commission, 2011; 2013).

Crack cocaine laws have a particularly controversial place in the history of the U.S. criminal jus- tice system. Some critics contend that the disproportionate impact of these laws on people of color, and possibly the war on drugs more generally, was foreseeable (Tonry, 1996). Regardless, the evidence strongly suggests that members of traditionally marginalized groups (Black males in particular) have been disproportionately harmed by the harsh penalties for crack cocaine. Thus, the cumulative public health consequences of crack cocaine were disproportionately felt among traditionally marginalized groups, who could ill afford more difficulties.

The invention of crack cocaine had sweeping consequences for socially disorganized, inner-city communities in particular. Crack cocaine markets are notoriously unstable and violent. Open-air crack cocaine markets are almost always located in poor communities, disproportionately com- munities of color, and tend to be controlled by criminal street gangs. In addition, the use of crack cocaine is detrimental to the health of the user who, if caught, triggers a punitive criminal justice system response. In combination, these factors had a cumulative and devastating impact on poor communities and families in this era, whether they were individually involved with drugs or not (Lusane 1991; Moskos, 2008). The crack cocaine case study vividly illustrates how the social conse- quences of substance use are multifaceted and intertwine with criminal justice, economic, family stability, and public health dynamics.

The Meth Project The use of amphetamines has a long and sordid history. Amphetamine-based stimulants have been used in Asia and other regions for thousands of years for medicinal and recreational pur- poses. During World War II, German soldiers used a primitive version of methamphetamines to increase their energy in the field. In the 1950s, amphetamines were used freely by housewives who wanted to put a little more pep in their day. More recently, in the United States, recreational amphetamine (“speed”) use became popular within the counterculture movement of the 1960s in San Francisco. However, the more recent invention of “ice” (also known as “crystal meth” or “glass”) has taken a prominent place in the contemporary drug culture, with devastating public health consequences (Inciardi & McElrath, 2008; Miller, 1997).

Ice is a “high-potency, high-purity, and smokable methamphetamine hydrochloride” (Miller, 1997, p. 124). It became more popular in the United States beginning in the early 1980s, particularly on the west coast and in Hawaii. By the mid-2000s, methamphetamine use and abuse were the subjects of several prominent public health and educational campaigns.

The policing of methamphetamines is particularly challenging because of the method by which the drug is manufactured. Methamphetamines (or “meth”) are often produced in clandestine laboratories that can be large and sophisticated, or alternatively, crude—located in a hotel rooms, vehicles, or barns. Popular recipes for making meth include over-the-counter products that contain ephedrine and pseudoephedrine as important ingredients, such as the decongestant Sudafed-. In addition, manufacturing meth is extremely dangerous and produces a significant amount of toxic waste, which is almost always disposed of improperly and illegally. Growing evidence shows that large “superlabs” located in Mexico and other developing countries supply a substantial amount of the drug to the United States. However, small clandestine laboratories are likely to remain a mainstay in meth markets. As evidence, in 2012, the DEA reported a total of 11,210 meth lab

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CHAPTER 8Section 8.8 Illegal Drugs: Case Studies

“incidents” nationwide, including 1,825 in the state of Missouri alone. Meth lab incidents include discovering laboratories, illegal dumping of meth-related waste, and seizures of precursor chemi- cals and paraphernalia (DEA, n.d.; Jenkot, 2008; Miller, 1997).

To help combat the meth problem, the Meth Project was founded in 2005. In tandem with the Partnership for a Drug Free America (www.drugfree.org), the Meth Project is a nationwide pre- vention and education campaign that focuses on states that have higher rates of meth abuse and its attendant public health and social problems. Much like the prevention campaigns developed by the Partnership during the 1980s era (see “Just Say No” in this chapter), the Meth Project fea- tures vivid case studies in an attempt to deter meth use. Though the evidence about the efficacy of fear-based deterrence during the Just Say No era has been mixed, there may be uniquely effec- tive components of the Meth Project.

Some experts believe that the impact of ice on physical appearance may be a particularly hard- hitting component in the Meth Project’s prevention campaign (it also covers the mental and psy- chological harm); much of the campaign’s message focuses on how meth can quickly deterio- rate appearance—acne, facial sores, emaciation, and “meth mouth” (loss of teeth and damage to mucous membranes). In a status- and appearance-conscious culture, this approach may deter many potential users.

Opiates and Hillbilly Heroin Geography and social location facilitated the increased use and abuse of “hillbilly heroin” in the late 1990s and into the new millennium. Hillbilly heroin refers to OxyContin, Percocet, Roxico- done, and other name-brand versions of the painkiller oxycodone. Oxycodone is a semisynthetic narcotic (Inciardi & Syvertsen, 2003) that manages pain, and its pharmacological effects are com- parable with street varieties of heroin. Of all the brands of oxycodone, OxyContin has garnered the most attention from the media and law enforcement (Inciardi & Syvertsen, 2003; Tunnell, 2005). Hospitals and dispensaries throughout the country that stocked the drug were robbed and had to take security precautions or dispense shorter acting painkillers. In addition, as the oversight of prescription painkillers has become more stringent, and law enforcement more vigorous, it is possible that users may be pushed toward the underground market for heroin.

OxyContin was produced by Purdue Pharma beginning in the mid-1990s. In 2001, more than 7.2 million individual OxyContin prescriptions were written, generating $1.45 billion in retail reve- nue. During this period, OxyContin constituted approximately 80% of all business done by Purdue Pharma (Greenwald, 2003, as cited in Inciardi and Syvertsen, 2003).

By the late 1990s, illegal, recreational use of OxyContin had become particularly popular in the Appalachia region of the United States. According to experts, this region’s robust history of moon- shine production and distribution during Prohibition fostered an antigovernment attitude that facilitated illegal drug use and a thriving underground economy for prescription drugs. In addition, this region has relatively high levels of cancer, higher than average mean population age, and high rates of disease and injury often associated with labor-intensive, blue-collar industries such as mining and timber. Moreover, traditional street-drug markets were scarce in many of these rural communities. Lastly, some experts contend that the geographic isolation of this region led to boredom that potentially facilitated use and abuse of many types of legal and illegal substances (Inciardi & Syvertsen, 2003; Tunnell, 2005).

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www.drugfree.org

CHAPTER 8Section 8.8 Illegal Drugs: Case Studies

Web Field Trip Please visit the website of Purdue Pharma (http://www.purduepharma.com/). Under Our Products, navigate to their page dedicated to prescription drug products. Scroll down to the OxyContin section and click on several links to learn more about the intended medicinal uses of the drug.

Critical Thinking Questions

1. What dangers does the recreational use of OxyContin pose? 2. What, if any, responsibility does a corporation have when its products are ending up in the

underground economy and facilitating addiction?

OxyContin, although manufactured legally for use by prescribing doctors and in hospitals, became available for illegal recreational use through the process of diversion. Diversion is the criminal act of redirecting a legally produced prescription drug away from the licit and controlled mar- ketplace and to the underground, criminal marketplace. Common diversion practices include “doctor shopping,” in which a medical patient, or someone feigning medical problems, visits mul- tiple medical professionals to obtain multiple drug prescriptions. Other diversion methods include types of fraud, corrupt or unethical medical practices, and theft (Inciardi & Syvertsen, 2003; Tun- nell, 2005).

OxyContin abuse was widely cited as a cause of crime and social degradation more broadly across Appalachia in the early 2000s. Although some critics argue that prescription drug abuse was a significant social problem, many claims about the relationship between OxyContin and crime may have been overstated (Inciardi & Syvertsen, 2003; Tunnell, 2005). Regardless, the OxyContin case study is important for public health and drug policy for a variety of reasons and reveals the inter- connections between micro-, meso-, and macrosystems of human environments. First, the Oxy- Contin story demonstrates that geography and social location often play significant roles in the use and abuse of legal and illegal drugs. Second, it demonstrates the complex connection between macro (e.g., economic) dynamics and micro ones (i.e., substance use). And third, it serves as a vivid reminder that drug use, abuse, addiction, and attendant crime and public health challenges can adversely impact rural, suburban, and urban communities alike.

Prescription Drug Monitoring In response to prescription drug abuse in the modern era, many states and the medical commu- nity have enacted policies to better control potentially addictive painkillers. For example, Florida implemented a statewide prescription drug monitoring program in 2011. This legislation targets “pill mills”—storefront businesses that prescribe prescription medications at extraordinarily high rates. In fact, before the program was enacted, doctors in Florida prescribed 10 times as much oxycodone as all other 49 states combined.

Florida’s prescription drug monitoring program requires all pharmacies that dispense controlled substances to report the details of that prescription, including the patient’s name and informa- tion, to a central database. This database should reduce, if not eliminate, doctor shopping, which had become common practice in the state. The monitoring program continues to face funding challenges and has raised concerns over medical privacy issues. However, it undoubtedly contrib- uted to the 17% decrease in oxycodone overdose fatalities by 2012.

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http://www.purduepharma.com/

CHAPTER 8Section 8.9 Substance Use Education and Prevention Paradigms

Similar state databases to track prescription drugs exist in 35 other states nationwide. In addition, many doctors across the United States are increasingly requiring patients to take urine tests, in large part to screen for the abuse of prescription drugs. Urine tests reveal which medications the patient is taking legitimately, along with illegal use of prescription and street drugs. Ideally, testing will help practitioners create better treatment regimens for patients. Though controversial, both prescription drug monitoring programs and drug screening by doctors and will likely remain sta- ples in the medical and policy responses to prescription drug abuse nationwide (Haughney, 2013; Meier, 2013; Sawatksy, 2012).

8.9 Substance Use Education and Prevention Paradigms

Prevention and education campaigns are fundamental to a public health perspective on sub-stance use. Over time, public and private entities have executed various types of substance use prevention and education initiatives, with mixed results. Armed with longitudinal data from social science policy evaluation studies, we examine the empirical evidence associated with two prominent types of substance use programs: abstinence only programs and more reality- based ones.

Abstinence Only Abstinence-only programs have likely been the most visible and longstanding drug education models in the United States. Strictly interpreted, these approaches encourage participants to completely refrain from a certain type of behavior deemed harmful or problematic. Over

time, public education campaigns embracing an abstinence-only approach have been applied to a series of social issues: most prominently, sub- stance use and sexual activity before marriage. The abstinence-only approach guided one of the most well-known antidrug campaigns in the modern era.

“Just Say No” First Lady Nancy Reagan spearheaded the nation’s most visible public education campaign on sub- stance use in the early 1980s. Just Say No was not only the title of the campaign; it was a mantra that reaffirmed a zero-tolerance, abstinence-only approach (Just Say No, n.d.). The advice was simple and concise: When faced with peer pressure, or any other situation in which substance use is a tempta- tion, young people were advised simply to “just say no.” This response derived spontaneously from an exchange between Nancy Reagan and a group of elementary school students in Oakland, California. During the forum, a young girl asked, “Mrs. Reagan, what do you do if somebody offers you drugs?” Nancy Reagan replied, “Well, you just say no” (Just Say No, n.d.).

Courtesy Everett Collection

First Lady Nancy Reagan headed the Just Say No campaign during the 1980s.

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CHAPTER 8Section 8.9 Substance Use Education and Prevention Paradigms

Nancy Reagan was an industrious advocate for Just Say No. In 1984, she made a total of 124 public appearances and addresses on behalf of this initiative. In many of these addresses, she argued that the use of drugs was diminishing America’s ability to compete on the world stage. Moreover, substance abuse harmed the individual in many ways. Famously, Nancy Reagan stated, “Drugs take away the dream from every child’s heart and replace it with a nightmare, and it’s time we in America stand up and replace those dreams” (Just Say No, n.d.).

The Just Say No campaign corresponded with a punitive, criminal-justice–centered approach to combating illegal drugs in the United States, ushered in by the Reagan administration (Mohamed & Fritsvold, 2010). Moreover, this theme of willpower was adopted by a widespread and long- standing public education campaign dedicated to substance use.

Drug Abuse Resistance Education The Drug Abuse Resistance Education (D.A.R.E. is its well-known acronym) program was started in the early 1980s and has been the largest and most longstanding school-based prevention program dedicated to fighting substance use. Uniformed police officers present a curriculum on drugs, alcohol, tobacco, peer pressure, and decision making to students primarily in late elementary school. By the early 1990s, approximately 6,000 students went through the D.A.R.E. curriculum every year (Ringwalt et al., 1994) and as of 2008, it had been used in 80% of U.S. school districts and in 43 countries (“Is the D.A.R.E. Program Good,” 2013).

D.A.R.E. has been subject to many social science policy evaluation studies. Many studies have compared D.A.R.E. participants with a control group over time and compared the two group’s experiences with substance use and other lifestyle factors. Overall, these studies reveal mixed evi- dence for the efficacy of the program, showing little or no significant difference between D.A.R.E. participants and similar nonparticipants regarding substance use behaviors (Rosenbaum, 1999).

Policy evaluation and public health experts have identified a series of problems that limited the efficacy of D.A.R.E. One modal issue that program participants raised was that student opinions were not adequately taken into consideration. Some participants felt that information was being dictated to them rather than the class having an interactive conversation about the issues. In addi- tion, some participants felt that the curriculum failed to distinguish between drug use and drug abuse. Guided by the abstinence-only paradigm, all levels of drug use and abuse—of all legal and illegal drugs—were framed similarly and thus had limited value in promoting long-term avoidance of drugs.

Moreover, some policy evaluations argued that D.A.R.E. misrepresented drug dealers, who were overwhelmingly portrayed as outsiders from the community preying on naive young people to get them “hooked” on drugs. In contrast, criminology literature reveals that often drug dealers have a similar social location to drug consumers in a given community (inhabiting the same microsystem; Mohamed & Fritsvold, 2010). Lastly, some policy evaluations argued that D.A.R.E. misrepresented and exaggerated the harmful pharmacological effects of marijuana (Rosenbaum, 1999).

Overall, the mixed outcomes of the D.A.R.E. program reveal the challenges of implementing a structured public education campaign targeting substance use based on abstinence alone. Sup- porters of the program argue that it fosters positive relationships among police, family, and schools (several mesosystems), thereby strengthening the community and empowering individuals. As for more empirical evidence, the legacy of rich and methodologically nuanced studies of the D.A.R.E.

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CHAPTER 8Section 8.9 Substance Use Education and Prevention Paradigms

program provide an opportunity for public health experts and social scientists to reflect on the evidence and to make sound policy recommendations for future public education campaigns on substance use.

Reality-Based Approaches In contrast to the abstinence-only paradigm, some experts argue that a reality-based, less idealistic substance use curriculum may be the most effective, while encouraging personal responsibility. A prominent advocate for reality-based substance use education is Marsha Rosenbaum, director emer- ita of the Drug Policy Alliance. Her pamphlet “Safety First: A Reality-Based Approach to Teens, Drugs, and Drug Education” has been distributed to 300,000 recipients worldwide. Rosenbaum (1990) argued that, “While the abstinence-only mandate is well-meaning, it is misguided” (Rosenbaum, 1999, p. 458, cited in Inciardi & McElrath, 2008), and she thus offered a more flexible approach:

A safety-first strategy for drug education requires reality-based assumptions about drug use and drug education. Whether we like it or not, many teenagers will experiment with drugs. . . . At the same time we stress abstinence, we should also provide a fallback strategy for risk reduction, providing students with infor- mation and resources so they do the least possible harm to themselves and those around them. (Rosenbaum, 1999, p. 459, cited in Inciardi & McElrath, 2008)

A reality-based approach to substance use prevention and education makes a series of import- ant assumptions about teenagers’ critical-thinking and decision-making skills. This paradigm assumes that young people are fully capable of making reasonable decisions when provided accurate information. Moreover, it assumes that some degree of substance experimentation is likely unavoidable for a percentage of young people. And lastly, the reality-based approach assumes a qualitative difference between substance use and substance abuse, which adequate prevention and education campaigns should illustrate (Rosenbaum, 1999).

A school-based prevention program focused on “safety first” has several cornerstones. To build trust with the students, it communicates honest and empirically driven information about legal and illegal drugs. It describes the pharmacological, social, and legal harm of drugs in an honest and forthcoming manner. And its prime goal is to achieve safety via harm reduction (Rosenbaum, 1999). Moreover, it acknowledges that environmental factors may be key to a harm reduction approach to drug use and abuse.

Healthy Settings Some public health experts have identified environmental factors as central in an encompass- ing harm reduction strategy for substance use. In the context of addressing adult substance use, Bellis, Hughes, and Lowey (2002) identified several pragmatic steps that individuals, nightclubs, and communities can take to reduce the harm from substance use. Their policy suggestions are built on their research of the nightclub scene in the United Kingdom.

The authors estimated that weekly patronage of nightclubs in the United Kingdom totaled approx- imately 3.5 million individuals. These patrons likely have higher than average rates of recreational substance use, including cocaine, various amphetamines, and Ecstasy. The purpose of their study was to explore “the wide range of factors that contribute to risk in nighttime environments and

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Chapter Summary CHAPTER 8

describe initiatives that effectively address these issues without curtailing fun” (Bellis et al., 2002, p. 1025).

Their research suggested that key health problems associated with frequenting nightclubs and engaging in recreational drug use can be reduced by paying deliberate attention to creating healthy settings and environments. For example, dehydration is often caused by the use of amphetamines or alcohol in combination with the physical exertion of dancing. So a healthy setting should include abundant free, cool water; adequate ventilation and air conditioning; “chill-out areas”; the ability to leave and reenter the club; and sufficient space for the number of patrons. However, this approach is not limited to addressing pharmacological harm alone (Bellis et al., 2002).

The researchers found that a healthy settings approach could also potentially reduce violence associated with the nightclub scene. For example, staggering the closing times of nightclubs and bars in a given geographical area can reduce situational violence. Having functioning and efficient public transportation available to club-goers could also reduce the opportunities for interaction and conflict as well as driving under the influence of drugs or alcohol. Further, well-trained secu- rity staff and effective relationships with local law enforcement also potentially deterred violence (Bellis et al., 2002).

Bellis et al. (2002) identified a series of other harmful effects that could be reduced by using a healthy settings approach. They argued that a myriad of ills—the risk of fire, hearing damage, sexually transmitted diseases, unwanted pregnancy, falls, burns, and other accidents—could be mitigated by applying environmental controls. More broadly, a healthy settings approach reaf- firms the interaction among the various systems in Bronfenbrenner’s ecological model of human development. In the present example, the microsystem of groups of club-goers can be influenced by mesosystems of a healthier nightlife atmosphere and cooperation with law enforcement and public safety personnel.

Chapter Summary

Understanding the array of factors that influences illegal substance use is essential for social sci- entists and public health experts. Effective treatment regimens, prevention, and education cam- paigns require an accurate, holistic, and empirical understanding of legal and illegal drug use. To this end, we examined the social consequences of substance abuse and attendant social and pub- lic health issues through the lens of human ecology. We began by distinguishing among different severities of substance use behaviors: use, abuse, addiction, and finally, dependence. Similarly, we critically examined several key substance abuse paradigms: punitive prohibition, harm reduction, and medicalization. We saw how an empirical investigation of legal and illegal substance use in the United States can shed light on a series of related biological, psychological, cultural, and socio- logical issues.

Relying primarily on the 2011 National Survey on Drug Use and Health, we examined substance use rates for alcohol, tobacco, and a series of the most commonly used illegal drugs. Then we applied Bronfenbrenner’s ecological model of human development to the most widely used drugs in America: alcohol and tobacco. This approach revealed some of the related micro-, meso-, and macro-level harm associated with the use and abuse of legal drugs. Next, a series of case studies was presented, each associated with a family of illegal drugs; these case studies served as vivid examples of the different public health challenges that illicit substance use poses.

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Key Terms CHAPTER 8

abstinence only An approach applied, for example, to substance use prevention and education that encourages participants to com- pletely refrain from any type of substance use.

binge drinking Defined by SAMHSA as con- suming a minimum of five alcoholic beverages throughout the course of a single event. The CDC defines it as at least four drinks over the course of a single event for a woman and at least five drinks over the course of a single event for a man.

bulk tobacco Larger quantities of loose-leaf tobacco of various blends that allow users to roll their own individual cigarettes.

crack cocaine A smokable form of cocaine made by mixing powder cocaine with baking soda and water and cooking the mixture on a stove or in a microwave.

current drug user Typically defined as an indi- vidual that has consumed any illegal drug, or abused a legal drug, one or more times in the past month.

diversion The criminal act of redirecting a legally produced prescription drug away from the licit and controlled industry and to the underground, criminal marketplace.

doctor shopping The process in which a medical patient or person feigning medical problems visits multiple medical professionals to obtain multiple drug prescriptions.

drug abuse Any use of an illegal drug, or the use of a legal drug in a way that causes nega- tive consequences for the user.

drug addiction Condition of intense craving for and dependence on a drug, motivating continued usage and increased tolerance to the drug’s effects.

drug dependence Compulsive need to use a drug in order to function normally. This need results in negative consequences in one or more areas of the user’s life.

drug misuse The use of a prescription or non- prescription drug in a way other than it was intended.

e-cigarette (electronic cigarette) A cylindrical apparatus that resembles a traditional ciga- rette but is really a small electronic heating element that vaporizes liquid, which may or may not contain nicotine, so that it can be inhaled.

forbidden fruit effect Posits that by prohib- iting some behavior by policy, it inherently makes that behavior more enticing and alluring.

formal social control Attempts by legitimized authoritative groups to control behavior within society.

gateway theory of substance use See phar- macological gateway theory and underground market gateway theory.

In the final section, we analyzed well-known substance use education and prevention cam- paigns. Empirical evidence from longitudinal studies guided our comparison of abstinence-only policies (e.g., Just Say No and D.A.R.E.) with harm reduction policies such as the “safety first” approach. Having touched on these issues, we can begin to understand the value of applying mul- tilevel ecological theory to the core challenges of substance use and abuse (legal and illegal) in modern America.

Key Terms

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Key Terms CHAPTER 8

harm reduction An approach to substance use that attempts to reduce the biological, social, and psychological damage associated with the use and abuse of drugs; emphasizes preven- tion, education, and holistic drug treatment regimens.

heavy drinking Consumption of an average of more than one alcoholic beverage per day for women, an average of more than two alcoholic beverages per day by men, and any consump- tion of alcohol by pregnant women or under- age youth.

hillbilly heroin Typically, OxyContin, Percocet, Roxicodone, and other name-brand versions of the pain killer oxycodone. The nickname derives from the drug’s popularity in the Appa- lachia region in the late 1990s and early 2000s.

ice Also known as crystal meth, a high- potency, high-purity, smokable version of methamphetamine hydrochloride.

informal social control Unofficial and often unrecognized power holders, norms, and val- ues in a society that shape or control behavior.

mandatory minimum sentences Criminal justice sentences that restrict discretion in the judicial process by specifying the term of incar- ceration, for example, based on the type and amount of drug possessed by the convicted.

medicalization A drug policy paradigm that locates substance use issues primarily within the realm of the medical profession; medi- cal practitioners, counselors, psychiatrists, researchers, and scientists all play a prominent role in such a regime.

passive smoke Vapors inhaled second hand by a nonsmoker from a smoker’s cigarette, pipe, or cigar.

pharmacological gateway theory Posits that drug users who experience a moderate level of intoxication from marijuana or alcohol are likely to develop an appetite for more severe forms of intoxication produced by harder drugs.

psychotherapeutics (psychotropics) A term used by drug policy and medical experts to refer to the extensive variety of illegally used prescription drugs. Include pain relievers, stimulants, tranquilizers, CNS depressants, and sedatives.

punitive prohibition A drug policy paradigm that treats drugs as a criminal justice problem and focuses on repressive punishment and deterrence.

substance use disorder A variety of cogni- tive, behavioral and physiological symptoms demonstrating that an individual is continuing to use a substance despite significant sub- stance related problems.

temperance movement A conservative social movement in the United States in the early 1900s that emphasized hard work, deferred gratification, and sobriety (abstaining from alcohol).

underground market gateway theory Posits that once a soft-drug user is introduced to a drug dealer who sells marijuana, and to the underground drug market more broadly, the opportunity to purchase hard drugs, if desired, increases.

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Critical Thinking and Discussion Questions CHAPTER 8

Critical Thinking and Discussion Questions

1. Apply Bronfenbrenner’s model of human ecology to illegal drug use. How do the micro, meso, and macro spheres influence the user, and how do they differ from those affecting legal substance use (e.g., of alcohol and tobacco)?

2. How does the current situation with marijuana legalization in some states but criminal- ization by the federal government resemble Prohibition (1920–1933)? What lessons can be learned from public policy that drives drug use underground (e.g., in terms of public health, social harm, and criminalization)?

3. Apply the “healthy settings” approach to a setting in the United States. Might it be effective here? Why or why not? What might be some of the challenges with implementing it?

4. David Musto argues that over time the use and abuse of illegal drugs in the United States is cyclical. The historical evidence suggests that the use of certain families of drugs tends to be popular for a while, decreases significantly, and then reemerges decades later. If prescription drug abuse is more prominent today, what family of drugs do you think will be used most in the coming decades? Upon what evidence do you make this prediction?

5. Tobacco has a long and controversial economic and political history in the United States. Thirty years from now, what do you think will be the role of tobacco companies in American politics? Will civil settlements and public relations challenges make these companies less powerful? Or will their economic power continue to make them signifi- cant political forces?

6. Given that policing methamphetamine production is particularly challenging, what poli- cies do you think will be most effective for reducing methamphetamine use?

7. The initial evidence suggests that the Florida prescription drug monitoring program is helping reduce prescription drug abuse fatalities. However, this program has also raised significant privacy concerns over patient medical records and attracted the attention of the American Civil Liberties Union. What do you think? Should we as citizens sacrifice some of our medical privacy in hopes of promoting the public health? Or is privacy more important? Why?

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