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

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

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

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

Reducing Substance Use and Abuse Preventing Substance Use Quitting a Substance

Without Therapy Treatment Methods to Stop Substance Use and

Abuse Dealing With the Relapse Problem

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

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

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

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Chapter 7 / Substance Use and Abuse 163

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

SUBSTANCE ABUSE

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

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

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

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

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

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

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

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

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

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

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

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

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

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164 Part III / Lifestyles to Enhance Health and Prevent Illness

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

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

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

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

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

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

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

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Chapter 7 / Substance Use and Abuse 165

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

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

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

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

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

SMOKING TOBACCO

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

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

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

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

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

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166 Part III / Lifestyles to Enhance Health and Prevent Illness

0 5

College plans: Complete 4 years

Lesser or no college plans

Grade 8

Smoking Status

Grade 10

Grade 12

College

Grade 8

Grade 10

Grade 12

Young adults (19–28 Years)

10 15 20

Percent

25 30 35 40

Daily 1 or more cigarettes

Daily pack or more

At least once in prior 30 days

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

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

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

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

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

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

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

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

Country Males Females Overall

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

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

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Chapter 7 / Substance Use and Abuse 167

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

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

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

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

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

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

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

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

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

• Had at least one parent who smoked.

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

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

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168 Part III / Lifestyles to Enhance Health and Prevent Illness

HIGHLIGHT

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

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