Mary Lynn Mathre has 36 years of experience as an acute care nurse and has worked in the field of alcohol, tobacco, and other drugs for the past 25 years. From 1991 to 2003, she worked as the addictions consult nurse for the University of Virginia Health System. This role required much interaction with community resources to provide appropriate referrals and aftercare for the client population. From 2004 to 2007 she worked in an outpatient opioid treatment program as the executive director. Currently she works as an independent consultant on substance abuse prevention and brief interventions. She is an active member of the International Nurses Society on Addictions and serves on the editorial board for the Journal of Addictions Nursing.

ADDITIONAL RESOURCES

Website

http://evolve.elsevier.com/Stanhope

• Healthy People 2020

• Resource Tool 37.A: Smoking Cessation Resources

• Resource Tool 37.B: Useful Web Resources

• Resource Tool 37.C: Commonly Abused Drugs

• Quiz

• Case Studies

• Glossary

• Answers to Practice Application

Substance abuse is the number one national health problem, causing more deaths, illnesses, and disabilities than any other health condition. The substance abuser is not only at risk for personal health problems, but may also be a threat to the health and safety of family members, co-workers, and other members of the community.

Substance abuse and addiction affect all ages, races, sexes, and segments of society. As seen in Healthy People 2020 (USDHHS, 2010), tobacco use and substance abuse are two major topic areas, with many objectives and sub-objectives, as well as related objectives in other priority areas. The newer phrase of alcohol, tobacco, and other drug (ATOD) problems rather than substance abuse reminds us that alcohol and tobacco represent the major drugs of abuse when discussing substance abuse, drug addiction, or chemical dependency.

This chapter begins by providing a broad perspective of ATOD problems to clarify the relevant issues. A historical overview of ATOD problems and attitudes toward ATOD users and addicts is examined. Relevant terms are defined to decrease the confusion caused by frequent misuse of terms. The major drug categories are described, including information on commonly used substances and current ATOD use trends. The remainder of the chapter examines the role of the nurse in primary, secondary, and tertiary prevention and describes how the nurse can improve the outcomes for individuals, families, and various populations with ATOD problems when using a harm reduction model. The reader is encouraged to consider possible nursing strategies to apply the Healthy People 2020 objectives for ATOD problems.

Alcohol, Tobacco, and Other Drug Problems in Perspective

ATOD abuse and addiction can cause multiple health problems for individuals. Heavy ATOD use has been associated with many problems, including neonates with low birth weight and congenital abnormalities; accidents, homicides, and suicides; chronic diseases, such as cardiovascular diseases, cancer, lung disease, hepatitis, HIV/AIDS, and mental illness; violence; and family disruption. Factors that contribute to the substance abuse problem include lack of knowledge about the use of drugs; the war on drugs’ emphasis on illicit drugs and law enforcement rather than the prevention and treatment of abuse and addiction of ATODs; lack of quality control of illegal drugs; and drug laws that label certain drug users as criminals, which encourages the negative attitudes and stigma toward these persons.

Historical Overview

Psychoactive drug use has been part of most cultures since the beginning of humanity. Often a culture encourages use of some drugs while discouraging the use of others. Caffeine, alcohol, and tobacco are socially acceptable drugs in the United States and Canada, whereas other cultures prohibit their use. Conversely, marijuana, cocaine, and opium use are not accepted in mainstream U.S. society, although these substances are considered sacred or beneficial and their use is accepted in various other cultures.

The United States’ primary solution to various “drug problems” has been prohibition. During alcohol prohibition from 1920 to 1933, the United States experienced a sharp increase in violent crime and corruption among law officials as a result of the illicit marketing of alcohol. Distilled beverages were pushed because of the higher profit margin per bottle of liquor than for beer or wine. The high alcohol content in illicit moonshine caused severe health problems. The alcohol prohibition was eventually recognized as a failure and repealed (Rose, 1996).

Similar problems are occurring with the current war on drugs and the newer prohibition on marijuana, cocaine, and other drugs. An increase in both violent crime and reports of corruption among law officials as a result of the illicit market has become a major national problem (Common Sense for Drug Policy, 2007). Stronger drugs are pushed because of their greater profits. Some would say that drug prohibition laws have created mandatory sentences for drug offenders, violated civil liberties, and put more resources into law enforcement than into drug education and treatment (Common Sense for Drug Policy, 2007). As the drug war budget grows each year, most of that budget goes to law enforcement and punishment, leaving only a third for prevention and treatment. See Table 37-1 for a historical overview of the drug war budget.

TABLE 37-1

FEDERAL DRUG CONTROL SPENDING BY FUNCTION

	FY 2009 FINAL	FY 2010 ENACTED	FY 2011 REQUEST	2010-2011 CHANGE
	FY 2009 FINAL	FY 2010 ENACTED	FY 2011 REQUEST	DOLLARS	PERCENT
Function
Treatment Percent	3561.9 23.3	3745.5 24.9	3882.5 25.0	136.9	3.7%
Prevention Percent	1854.7 12.1	1514.3 10.1	1717.7 11.0	203.3	13.4%
Domestic Law Enforcement Percent	3869.4 25.3	3843.5 25.6	3917.3 25.2	73.8	1.9%
Interdiction Percent	3910.2 25.6	3640.1 24.2	3727.0 24.0	86.9	2.4%
International Percent	2082.2 13.6	2288.0 15.2	2308.1 14.8	20.1	0.9%
Total	$15,278.40	$15,031.50	$15,552.50	$521.10	3.5%
Supply/Demand Demand Reduction Percent	5416.6 35.5	5259.9 35.0	5600.2 36.0	340.3	6.5%
Supply Reduction Percent	9861.8 64.5	9771.6 65.0	9952.4 64.0	180.8	1.9%
Total	$15,278.40	$15,031.50	$15,552.50	$521.10	3.5%

A 3-year study by the National Center on Addiction and Substance Abuse (CASA) closely examined the 2005 federal, state, and local government budgets to measure the financial impact of ATOD problems on their health, social service, criminal justice, education, mental health, developmentally disabled, and other programs. The CASA study found that the government spent at least $467.7 billion ($238.2 billion, federal; $135.8 billion, state; and $93.8 billion, local) in 2005 on substance abuse and addiction, which amounted to 10.7% of the entire $4.4 trillion budgets. Of every dollar the federal and state governments spent on substance abuse and addiction, 95.6 cents was used to deal with the ATOD problems, while only 1.9 cents went to prevention and treatment, 0.4% to research, 1.4% to taxation or regulation, and 0.7% to interdiction. Almost half of this spending cannot be disaggregated by specific substance. However, of the $248 billion in ATOD-related spending, 92.3% was linked to alcohol and tobacco (National Center on Addiction and Substance Abuse, 2009).

Attitudes and Myths

Attitudes are developed through cultural learning and personal experiences. Attitudes toward ATOD problems are influenced by the way society inappropriately categorizes drugs as either “good” or “bad.” In the United States, good drugs are typically over-the-counter (OTC) or those prescribed by a health care provider as medicine, yet this makes them no less problematic or addictive. Bad drugs are the illegal drugs, and persons who use these drugs are considered criminals regardless of whether the drug has caused any problems.

Americans rely heavily on prescription and OTC drugs to relieve (or mask) anxiety, tension, fatigue, and physical or emotional pain. Rather than learning non-medicinal methods of coping, many people rely on the “quick fix” and take pills to deal with their problems or negative feelings.

Addicts are often viewed as immoral, weak-willed, or irresponsible persons who should try harder to help themselves. Although alcoholism was recognized as a disease by the American Medical Association in 1954, and drug addiction was recognized as a disease some years later, much of the public and many health care professionals have failed to change their attitudes and accept alcoholics and addicts as ill persons in need of health care.

Nurses must examine their attitudes toward ATOD use, abuse, and addiction before working with this health problem. To be therapeutic, the nurse must develop a trusting, non-judgmental relationship with the client. Systematic assessment for ATOD problems is based on awareness that there may be problems with both legal and illegal drugs. If the nurse’s attitude toward a client with a drug abuse problem is negative or punitive, the issue may never be directly addressed or the client may be avoided. If the client senses the negative attitude of the health care provider, either by words or from tone of voice, communication may cease and information may be withheld. To develop a therapeutic attitude, the nurse must realize that any drug can be abused, that anyone may develop drug dependence, and that drug addiction can be successfully treated.

WHAT DO YOU THINK?

Antiprohibitionists think that the prohibition of drugs causes greater societal problems than the use of those drugs and that the government has no right to forbid adults from what they choose to ingest. Although antiprohibitionists are often called “legalizers,” this label is misleading because it implies that by “legalizing” a drug, the government is condoning its use. Do you understand the difference between the terms? Should some drugs be prohibited, and if so, who should decide which drugs to prohibit? Should persons be incarcerated because they have consumed a prohibited drug?

Myths develop over years, and if myths are not questioned, many attitudes may be formed solely on the basis of fiction rather than fact. Some common myths are as follows:

• “An alcoholic is a skid row bum”—but less than 5% of persons with addictions fit this description.

• “If you teach people about drugs, they will abuse them”—although it is true that people may choose to use drugs if they have knowledge about them, it is more likely that people without knowledge about them will abuse them.

• “Addiction is a sin or moral failing”—addiction is recognized as a health problem involving biopsychosocial factors, and persons who use drugs do not do so with the intent to become addicted.

Paradigm Shift

We can hope to see a major shift in how the United States conceptualizes ATOD problems. The old criminal justice model is based on stereotypes, misinformation, and punishment, and it uses war tactics to fight the drug users, addicts, and suppliers. Campaigns have been launched using the slogans “zero tolerance” for drug users, “just say no” to drugs, and striving for a “drug-free America”—all of which vilify the drug user or drug addict. Gil Kerlikowske, the drug czar in the Obama administration, has said that he wants to move away from the “war on drugs” approach and that the Obama administration is likely to deal with drugs as a matter of public health rather than criminal justice alone, with the role of treatment growing relative to incarceration (Fields, 2009). Also, on the international level, experts are suggesting that national drug policies need to be more comprehensive rather than focusing on law enforcement strategies (Box 37-1).

BOX 37-1

HIGH-LEVEL PRINCIPLES FOR AN EFFECTIVE DRUG POLICY

We propose that national drug strategies should always be based on five core principles:

1. Drug policies should be developed through a structured and objective assessment of priorities and evidence.

2. All activities should be undertaken in full compliance with international human rights law.

3. Drug policies should focus on reducing the harmful consequences rather than the scale of drug use and markets.

4. Policy and activities should seek to promote the social inclusion of marginalized groups.

5. Governments should build open and constructive relationships with civil society in the discussion and delivery of their strategies.

Adapted from the Suggested principles for an effective drug policy proposed by the International Drug Policy Consortium (IDPC), published in March 2010. Available at http://www.idpc.net/sites/default/files/library/IDPC%20Drug%20Policy%20Guide_Version%201.pdf. Each chapter of the guide fully integrates the above five core principles.

The harm reduction model is a public health approach to ATOD problems initially used in Great Britain, The Netherlands, Germany, Switzerland, and Australia, and interest in it is spreading throughout Europe and in Canada. This new public health model recognizes the following:

• Addiction is a health problem.

• Any psychoactive drug can be abused.

• Accurate information can help people make responsible decisions about drug use.

• People who have ATOD problems can be helped.

This approach accepts the reality that psychoactive drug use is endemic, and it focuses on pragmatic interventions, especially education, to reduce the adverse consequences of drug abuse and get treatment for addicts. The United States has already taken a harm reduction approach with tobacco and alcohol. Educational campaigns are used to inform the public about the health risks of tobacco use. Warnings have appeared on tobacco product labels since 1967 as a result of the surgeon general’s 1966 report on the dangers of smoking. In 1971 a ban on television and radio cigarette advertising was imposed. Cigarette smoking has decreased since that time. Smoking is on the decline among eighth and twelfth graders. According to the 2007 report from Monitoring the Future drug survey data among secondary school students, 4% of eighth graders smoked in 2006, down from 5.5% in 2001. For twelfth graders in 2006, 12% smoked compared with 19% in 2001 (Johnston, O’Malley, and Bachman, 2007). Education is continuing to address the dangers of alcohol abuse and to establish guidelines for safe alcohol use.

Nurses need to seek the underlying roots of various health problems and plan action that is realistic, non-judgmental, holistic, and positive. A harm reduction model for ATOD problems facilitates such an approach.

Definitions

The terms drug use and drug abuse have virtually lost their usefulness because the public and government have narrowed the term drug to include only illegal drugs rather than including prescription, OTC, and legal recreational drugs. The current phrase alcohol, tobacco, and other drugs (ATODs) is a reminder that the leading drug problems involve alcohol and tobacco. The term substance broadens the scope to include alcohol, tobacco, legal drugs, and even foods. Substance abuse is the use of any substance that threatens a person’s health or impairs social or economic functioning. This definition is more objective and universal than the government’s definition of drug abuse, which is the use of a drug without a prescription or any use of an illegal drug. Although any drug or food can be abused, this chapter focuses on psychoactive drugs—drugs that affect mood, perception, and thought.

Drug dependence and drug addiction are often used interchangeably, but they are not synonymous. Drug dependence is a state of neuroadaptation (a physiological change in the central nervous system [CNS]) caused by the chronic, regular administration of a drug; in drug dependence, continued use of the drug becomes necessary to prevent withdrawal symptoms. For example, when a person is given an opiate such as morphine on a regular basis for pain management, the morphine needs to be gradually tapered rather than abruptly stopped to prevent symptoms of withdrawal.

Drug addiction is a pattern of abuse characterized by an overwhelming preoccupation with the use (compulsive use) of a drug, securing its supply, and a high tendency to relapse if the drug is removed. Frequently, addicts are physically dependent on a drug, but there also appears to be an added psychological component that causes the intense cravings and subsequent relapse. In general, anyone can develop drug dependence as a result of regular administration of drugs that alter the CNS; however, only 7% to 15% of the drug-using population will develop a drug addiction. The process of becoming addicted is complex and related to several factors, including the addictive properties of the substance, family and peer influences, personality, age of first use, cultural and social factors, existing psychiatric disorders, and genetics.

Alcoholism is addiction to the drug called alcohol. Alcoholism and drug addiction are recognized as illnesses under a biopsychosocial model. Simply stated, the disease concept of addiction and alcoholism identifies them as chronic and progressive diseases in which a person’s use of a drug or drugs continues despite problems it causes in any area of life—physical, emotional, social, economic, or spiritual.

Psychoactive Drugs

Although any drug can be abused, ATOD abuse and addiction problems generally involve the psychoactive drugs. These drugs, which can alter emotions, are used for enjoyment in social and recreational settings and for personal use to self-medicate physical or emotional discomfort. Psychoactive drugs are divided into categories according to their effect on the CNS and the general feelings or experiences the drugs may induce. The Internet or a pharmacology text can provide detailed information on these drug categories (e.g., depressants, stimulants [Box 37-2], hallucinogens, inhalants [Box 37-3] and marijuana), and a drug chart of commonly abused drugs is provided in the Evolve site for this book. This chapter focuses on alcohol, tobacco, and marijuana since alcohol and tobacco cause the greatest harm and marijuana is the most commonly used illicit drug. (Resource Tool 37.B on the Evolve website lists useful web resources with more information on handling substance abuse and addiction.)

BOX 37-2

COCAINE AND AMPHETAMINES: COMMON ILLICIT STIMULANTS

The most commonly used illicit stimulants include cocaine and amphetamines (not prescribed). Cocaine comes from the coca shrub cultivated by South American Indians in the Andes Mountains for thousands of years. Purified cocaine can be snorted, smoked, or injected. Crack is a cheap form of smokable cocaine that produces an intense high, but it lasts for a short period. Street cocaine ranges in purity from 50% to 60% and may be cut with other drugs, such as procaine or amphetamine, or any white powder, such as sugar or baby powder. High doses can cause extreme agitation, paranoid delusions, hyperthermia, hallucinations, cardiac dysrhythmias, pulmonary complications, convulsions, and possibly death (Cocaine, Merck Manual, 2008).

Amphetamines are a class of stimulants similar to cocaine, but the effects last longer and the drugs are cheaper. Amphetamines have a chemical structure similar to adrenaline and noradrenaline and are generally used to decrease fatigue, increase mental alertness, suppress appetite, and create a sense of well-being. Historically, amphetamines have been issued to American soldiers and pilots to decrease fatigue and increase mental alertness. They are popular among people who need to stay awake for long hours to work or study. They can be taken as pills, injected, snorted, or smoked. “Ice,” the smokable form of crystal methamphetamine, first appeared in Hawaii and the western states, but the market has moved across the United States. Methamphetamine is easy to manufacture on the illicit market and its effects can last up to 24 hours (Amphetamines, Merck Manual, 2008).

Chronic administration of these stimulants can lead to a neurotransmitter depletion (especially of dopamine), which results in an extreme dysphoria characterized by apathy, sadness, and anhedonia (lack of joy). Thus, these users can get caught up in a dangerous cycle of gaining an extreme high followed by an extreme low. To avoid that low, the person consumes more of the stimulant. Addicts who use these drugs soon are overwhelmed by their cravings and may engage in criminal activities such as theft or prostitution to get drug money.

BOX 37-3

INHALANTS

Inhalants are often among the first drugs that young children use. The primary abusers of most inhalants are adolescents who are 12 to 17 years of age. The 2008 National Survey on Drug Use and Health found that 729,000 persons aged 12 or older had used inhalants for the first time within the past 12 months and 70% of them were under the age of 18 (SAMHSA, 2009a). Use often ends in late adolescence.

Inhalants are breathable chemicals, which include gases and solvents, and they do not fit neatly into other categories. The four categories of inhalants are volatile organic solvents, aerosols, volatile nitrites, and gases. These substances are inhaled (“huffed”) from bottles, aerosol cans, or soaked cloth or put into bags or balloons to increase the concentration of the inhaled fumes and decrease the inhalation of other substances in the vapor (e.g., paint particles). (See www.inhalants.org for examples of products in these categories and specific drug information.) Inhalant users can get high several times in a short period since the inhalants are short acting and have a rapid onset. Users are predominately white. Experimental use is about equal for males and females, but males are more likely to engage in chronic use.

Depending on the dose, the user may feel a slight stimulation, less inhibition, or even lose consciousness. Other signs include paint or stains on clothes or the body; spots or sores around the mouth; red or runny eyes or nose; chemical breath odor; a drunk, dazed, or dizzy appearance; nausea and loss of appetite; and finally anxiety, excitability, and irritability. Chronic users may have poor school attendance or be delinquent and involved in theft and burglary (National Institute on Drug Abuse, 2009c). Users can die from “sudden sniffing death” syndrome, and this can occur from the first to the 100th time he or she uses the inhalant. This death appears to be related to acute cardiac dysrhythmia. Dangers with administration of gases increase when inhaling directly from pressurized tanks because the gas is very cold and can cause frostbite to the nose, lips, and vocal cords. Also, if a gas such as nitrous oxide is not mixed with oxygen, the user may die from asphyxiation (National Institute on Drug Abuse, 2009c).

Alcohol

Alcohol (ethyl alcohol or ethanol) is the oldest and most widely used psychoactive drug in the world. In 2006 a national survey found that young people between the ages of 12 and 20 are more likely to use alcohol than use tobacco or illicit drugs, including marijuana. Youth tend to drink less often than adults, but they consume more alcohol per occasion. On average, youth report consuming five drinks per occasion, and they increasingly binge drink. Alcohol abuse contributes to illness in each of the top three causes of death in the United States: heart disease, cancer, and stroke. In 2008, an estimated 22.2 million persons (8.9% of the population aged 12 or older) were classified with substance dependence or abuse in the past year based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Of these, 3.1 million were classified with dependence on or abuse of both alcohol and illicit drugs, 3.9 million were dependent on or abused illicit drugs but not alcohol, and 15.2 million were dependent on or abused alcohol but not illicit drugs (SAMHSA, 2009a).

Alcohol abuse costs billions of dollars in lost productivity, property damage, medical expenses from alcohol-related illnesses and accidents, family disruptions, alcohol-related violence, and neglect and abuse of children.

DID YOU KNOW?

Alcohol and cocaine use is independently associated with violence-related injuries, whereas opioid use is independently associated with non-violent injuries and burns.

From Blondell RD, Dodds HN, Looney SW, et al: Toxicology screening results: injury associations among hospitalized trauma patients, J Trauma 58:561-570, 2005.

Chronic alcohol abuse leads to profound metabolic and physiological effects on all organ systems. Gastrointestinal (GI) disturbances include inflammation of the GI tract, malabsorption, ulcers, liver problems, and cancers. Cardiovascular disturbances include cardiac dysrhythmias, cardiomyopathy, hypertension, atherosclerosis, and blood dyscrasias. CNS problems include depression, sleep disturbances, memory loss, organic brain syndrome, Wernicke-Korsakoff syndrome, and alcohol withdrawal syndrome. Neuromuscular problems include myopathy and peripheral neuropathy. Males may experience testicular atrophy, sterility, impotence, or gynecomastia, and females who consume alcohol during pregnancy may reproduce neonates with fetal alcohol syndrome (FAS) or fetal alcohol effects (FAE). Some of the metabolic disturbances include hypokalemia, hypomagnesemia, and ketoacidosis. Also, endocrine disturbances may result in pancreatitis or diabetes (Merck Manual, 2008).

The concentration of alcohol in the blood is determined by the concentration of alcohol in the drink, the rate of drinking, the rate of absorption (slower in the presence of food), the rate of metabolism, and a person’s weight and sex. The amount of alcohol the liver can metabolize per hour is equal to about ¾ oz of whiskey, 4 oz of wine, or 12 oz of beer. Figure 37-1 shows the effects on the CNS as the blood alcohol concentration (BAC) increases. However, with chronic consumption, tolerance will develop, and a person can reach a high BAC with minimal CNS effects.

FIGURE 37-1 Blood alcohol level and related central nervous system effects of a normal drinker (160-lb man) according to the number of drinks consumed in 1 hour. (From Kinney J, Leaton G: *Loosening the grip,* ed 5, St Louis, 1995, Mosby.)

Alcohol use in moderation may provide health benefits by providing mild relaxation and lowering the serum cholesterol level. Controlled drinking organizations such as Moderation Management (http://www.moderation.org) provide guidelines for persons who want to have alcohol in their lives. See Box 37-4 for safe limits of alcohol consumption and Table 37-2 for standard drink equivalents.

BOX 37-4

WHAT ARE THE RECOMMENDED SAFE LIMITS FOR ALCOHOL CONSUMPTION?∗

For healthy men up to age 65:

• No more than 4 drinks in a day AND

• No more than 14 drinks in a week

For healthy women (and healthy men over age 65):

• No more than 3 drinks in a day AND

• No more than 7 drinks in a week

From: National Institute on Alcohol Abuse and Alcoholism: Helping patients who drink too much: a clinician’s guide (update), NIH Pub No 07-3769, Rockville, MD, 2005, USDHHS.

TABLE 37-2

WHAT IS A STANDARD DRINK?

A standard drink in the United States is any drink that contains about 14 g of pure alcohol (about 0.6 fluid oz or 1.2 tbsp). The U.S. standard drink equivalents shown here are approximate, since different brands and types of beverages vary in their actual alcohol content.
12 oz of beer or cooler	8-9 oz of malt liquor 8.5 oz shown in a 12-oz glass that, if full, would hold about 1.5 standard drinks of malt liquor	5 oz of table wine	3-4 oz of fortified wine (such as sherry or port) 3.5 oz shown	2-3 oz of cordial, liqueur, or aperitif 2.5 oz shown	1.5 oz of brandy (a single jigger)	1.5 oz of spirits (a single jigger of 80-proof gin, vodka, whiskey, etc.) Shown straight and in a highball glass with ice to show level before adding mixer*
12 oz	8.5 oz	5 oz	3.5 oz	2.5 oz	1.5 oz	1.5 oz

Many people do not know what counts as a standard drink and so they do not realize how many standard drinks are in the containers in which these drinks are often sold. Some examples:
• For beer, the approximate number of standard drinks in
• 12 oz = 1	• 22 oz = 2
• 16 oz = 1.3	• 40 oz = 3.3
• For malt liquor, the approximate number of standard drinks in
• 12 oz = 1.5	• 22 oz = 2.5
• 16 oz = 2	• 40 oz = 4.5
• For table wine, the approximate number of standard drinks in
• a standard 750 mL (25 oz) bottle = 5
• For 80-proof spirits, or “hard liquor,” the approximate number of standard drinks in
• a mixed drink = 1 or more*	• a fifth (25 oz) = 17
• a pint (16 oz) = 11	• 1.75 L (59 oz) = 39

*Note: It can be difficult to estimate the number of standard drinks in a single mixed drink made with hard liquor. Depending on factors such as the type of spirits and the recipe, a mixed drink can contain from one to three or more standard drinks.

Tobacco

Smoking is the foremost preventable cause of death and disease in the United States, with one in five deaths attributed to cigarettes. For every person who dies from tobacco use, another 20 will suffer from at least one serious tobacco-related illness (CDC, 2010). Table 37-3 highlights cigarette smoking–related mortality in the United States. The Centers for Disease Control and Prevention (CDC) estimates an average of 443,000 deaths per year are caused by complications of cigarette smoking (CDC, 2008a). In 2008, an estimated 70.9 million Americans aged 12 or older were current (past month) users of a tobacco product. This represents 28.4% of the population in that age range. In addition, 59.8 million persons (23% of the population) were current cigarette smokers; 13.1 million (5.3%) smoked cigars; 8.7 million (3.5%) used smokeless tobacco; and 1.9 million (0.8%) smoked tobacco in pipes (SAMHSA, 2009a). Young adults ages 18 to 25 reported the highest rate of current tobacco use at 44.8% (NIDA, 2009b).

THE CUTTING EDGE

Tobacco Control State Highlights 2010 is a call-to-action report that looked at six high-impact strategies to reduce tobacco use and provides key indicators for assessing progress in every state. The World Health Organization introduced a framework to describe these strategies using the acronym MPOWER. The strategies include: (1) Monitor tobacco use and prevention policies, (2) Protect people from tobacco smoke, (3) Offer help to quit tobacco use, (4) Warn about the dangers of tobacco use, (5) Enforce bans on tobacco advertising, promotion, and sponsorship, and (6) Raise taxes on tobacco (WHO, 2008).

California has the longest running comprehensive tobacco control program, with adult smoking rates decreasing from 22.7% in 1988 to 13.3% in 2006. Compared with the rest of the states, heart disease deaths and lung cancer incidence in California have declined at accelerated rates. Research shows that the more states spend on evidence-based programs, the greater the reduction in smoking (CDC, 2010).

TABLE 37-3

CIGARETTE SMOKING–RELATED MORTALITY

DISEASE	MEN	WOMEN	OVERALL
Cancers
Lung	78,680	46,842	125,522
Other	25,792	9,534	35,326
Subtotal	104,472	56,376	160,848
Cardiovascular Diseases
Heart disease	63,878	37,181	101,059
Stroke	7,896	8,026	15,922
Other	7,415	4,151	11,566
Subtotal	79,139	49,358	128,497
Respiratory Diseases
Pneumonia/influenza	6,042	4,381	10,423
Bronchitis/emphysema	7,536	6,391	13,927
Chronic airway obstruction	40,217	38,771	78,988
Subtotal	53,795	49,543	103,338
Total	237,406	155,277	392,683

Modified from Centers for Disease Control and Prevention: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000-2004. Available at http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htm. Accessed July 9, 2010.

The economic toll from tobacco use in the United States is enormous. Between 2000 and 2004, cigarette smoking was responsible for approximately $193 billion in annual health-related losses, with $96 billion in direct medical costs and $97 billion in lost productivity (CDC, 2008a).

Nicotine, the active ingredient in the tobacco plant, is a particularly toxic drug. To protect itself, the body quickly develops tolerance to the nicotine. If a person smokes regularly, tolerance to nicotine develops within hours, compared with days for heroin or months for alcohol. Pipes and cigars are less hazardous than cigarettes because the harsher smoke discourages deep inhalation. However, pipes and cigars increase the risk of cancer of the lips, mouth, and throat.

Smoke can be inhaled directly by the smoker (mainstream smoke), or it can enter the atmosphere from the lighted end of the cigarette and be inhaled by others in the vicinity (sidestream smoke). Sidestream or second-hand smoke contains higher concentrations of toxic and carcinogenic compounds than mainstream smoke. An estimated 3000 annual lung cancer deaths and over 1 million illnesses in children are attributed to sidestream smoke (Barry, 2007). Sidestream smoke is only about 20% less dangerous than actually smoking, and most of the toxic effects occur within the first 5 minutes of exposure (Barnoya and Glanz, 2005). Smoking bans are being adopted to reduce the discomfort and health hazards among non-smokers.

Nicotine is also used as chewing tobacco or snuff. Marketed as “smokeless tobacco,” a wad is put in the mouth and the nicotine is absorbed sublingually. Higher doses of nicotine are delivered in the smokeless forms because the nicotine is not destroyed by heat. Nevertheless, this form is less addictive because nicotine enters the bloodstream less directly. Smokeless tobacco users are 20% more likely to die of heart disease than non-users (Henley et al, 2005), and they are at a higher risk for cancer of the mouth, pharynx, esophagus, stomach, and pancreas (Boffetta et al, 2005).

DID YOU KNOW?

Snus is an old Scandinavian moist tobacco product that is packaged in a small “tea bag” and placed under the upper lip. It is not noticeable and eliminates the need for spitting that normally accompanies the use of oral snuff. It has recently come into the U.S. market by tobacco companies as a harm reduction alternative to smoking tobacco. It eliminates the hazards of smoking tobacco and is less carcinogenic than snuff. However, for some cigarette smokers, it offers them a method to continue their nicotine habit while in any smoke-free environment (Koch, 2007).

DID YOU KNOW?

Caffeine is one of the most widely used psychoactive drugs in the world, with a U.S. daily per capita consumption of 211 mg. Caffeine is found in coffee, tea, chocolate, soft drinks, and various medications (Table 37-4). Moderate doses of caffeine from 100 to 300 mg per day increase mental alertness and probably have little negative effect on health. Higher doses can lead to insomnia, irritability, tremulousness, anxiety, cardiac dysrhythmias, GI disturbances, and headaches. Regular use of high doses can lead to physical dependence, and the withdrawal symptoms may include headaches, slowness, and occasional depression (Mayo Clinic Staff, 2009). Treating afternoon headaches with analgesics containing caffeine may in reality be preventing a withdrawal symptom from heavy morning coffee consumption.

TABLE 37-4

CAFFEINE CONTENT IN COMMONLY CONSUMED SUBSTANCES

DRINK/FOOD/SUPPLEMENT	AMOUNT OF DRINK/FOOD	AMOUNT OF CAFFEINE
SoBe No Fear	8 oz	83 mg
Monster energy drink	16 oz	160 mg
Rockstar energy drink	8 oz	80 mg
Red Bull energy drink	8.3 oz	80 mg
Jolt cola	12 oz	72 mg
Mountain Dew	12 oz	55 mg
Coca-Cola	12 oz	34 mg
Diet Coke	12 oz	45 mg
Pepsi	12 oz	38 mg
7-Up	12 oz	0 mg
Brewed coffee (drip method)	5 oz	115 mg*
Iced tea	12 oz	70 mg*
Cocoa beverage	5 oz	4 mg*
Chocolate milk beverage	8 oz	5 mg*
Dark chocolate	1 oz	20 mg*
Milk chocolate	1 oz	6 mg*
Jolt gum	1 stick	33 mg
Cold relief medication	1 tablet	30 mg*
Vivarin	1 tablet	200 mg
Excedrin extra strength	2 tablets	130 mg

*Denotes average amount of caffeine.

Source: U.S. Food and Drug Administration, National Soft Drink Association, Center for Science in the Public Interest. Available at http://kidshealth.org/teen/drug_alcohol/drugs/caffeine.html#. Accessed July 10, 2010.

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