Chapter 7: Substance Use and Abuse PDF

k 7 SUBSTANCE USE AND ABUSE Substance Abuse contract was with a worksite wellness program at the large Addiction and Dependence company where he was employed as a vice preside...

k 7 SUBSTANCE USE AND ABUSE Substance Abuse contract was with a worksite wellness program at the large Addiction and Dependence company where he was employed as a vice president. k Processes Leading to Dependence It called for money to be given to charity by either Jim or k the company, depending on how well he abstained from Smoking Tobacco smoking. For every day he did not smoke, the company Who Smokes, and How Much? would give $10 to the charity; and for each cigarette Jim Why People Smoke smoked, he would give $25, with a maximum of $100 for Smoking and Health any day. Jim knew stopping smoking would not be easy for Alcohol Use and Abuse him—he had smoked more than a pack a day for the Who Drinks, and How Much? last 20 years, and he had tried to quit a couple of Why People Use and Abuse Alcohol times before. In the contract, the company could have Drinking and Health required that he submit to medical tests to verify that he Drug Use and Abuse did in fact abstain but were willing to trust his word and Who Uses Drugs, and Why? that of his family, friends, and coworkers. These people Drug Use and Health were committed to helping him quit, and they agreed to be contacted by someone from the program weekly and Reducing Substance Use and Abuse give honest reports. Did he succeed? Yes, but he had Preventing Substance Use some “lapses” that cost him $325. By the end of the year, Quitting a Substance without Therapy Jim had not smoked for 8 months continuously. Treatment Methods to Stop Substance Use and Abuse People voluntarily use substances that can harm Dealing with the Relapse Problem 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 the substances can affect health, and what can be done to help prevent people from using and abusing them. We’ll also address PROLOGUE questions about substances and health. Do people The stakes were high when Jim signed an agreement smoke tobacco, drink alcohol, and use drugs more than to quit smoking for a year, beginning January 2nd. The in the past? Why do people start to smoke, or drink 167 k  k 168 Part III / Lifestyles to Enhance Health and Prevent Illness excessively, or use drugs? Why is it so difficult to it—often to help them adjust to life and feel good—and quit these behaviors? If individuals succeed in stopping spend much time obtaining and using it. Dependence smoking, will they gain weight? develops through repeated use (Cunningham, 1998). Users who are not physically dependent on a sub- stance usually experience less tolerance and withdrawal SUBSTANCE ABUSE (Schuckit et al., 1999). Being without the substance can elicit craving, a motivational state that involves a “I just can’t get started in the morning without a cup of strong desire for it. Users who become addicted usually coffee and a cigarette—I must be addicted,” you may have become psychologically dependent on the substance heard someone say. The term addicted used to have a very first; later they become physically dependent as their limited meaning, referring mainly to the excessive use of bodies develop a tolerance for it. Substances differ in the alcohol and drugs. It was common knowledge that these potential for producing psychological dependence: the chemical substances have psychoactive effects: they alter potential is high for heroin and cocaine, moderate for the person’s mood, cognition, or behavior. We now know marijuana, and lower for LSD (NCADI, 2000; Pagliaro & that other substances, such as nicotine and caffeine, have Pagliaro, 2012). psychoactive effects, too—but people are commonly said The terms and definitions used in describing to be “addicted” also to eating, gambling, buying, and addiction and dependence vary to some degree (Baker many other things. How shall we define addiction? et al., 2004). But diagnosing problematic patterns of substance use depends on the extent and impact of clear, ongoing use (Kring et al., 2012). Psychiatrists and ADDICTION AND DEPENDENCE clinical psychologists diagnose substance use disorder Addiction is a condition, produced by repeated con- when use is accompanied within a year by two or more of sumption of a natural or synthetic psychoactive about a dozen characteristics, such as tolerance, strong substance, in which the person has become physically cravings for the substance, and: and psychologically dependent on the substance (Baker Failing to fulfill important obligations, such as in k et al., 2004). Physical dependence exists when the body repeatedly neglecting a child or being absent from work. k has adjusted to a substance and incorporated it into the Putting oneself or others at repeated risk for physical “normal” functioning of the body’s tissues. For instance, injury, for instance, by driving while intoxicated. the structure and function of brain cells and chemistry Having substance-related legal difficulties, such as being change (Torres & Horowitz, 1999). This state has two arrested for disorderly conduct. characteristics: Psychiatric classifications of disorders now include the Tolerance is the process by which the body increasingly adapts to a substance and requires larger and larger pathological use of tobacco, alcohol, and drugs—the doses of it to achieve the same effect. At some point, substances we’ll focus on in this chapter. these increases reach a plateau. Withdrawal refers to unpleasant physical and psycho- PROCESSES LEADING TO DEPENDENCE logical symptoms people experience when they discon- tinue or markedly reduce using a substance on which Researchers have identified many factors associated they have become dependent. The symptoms experi- with substance use and abuse. In this section, we’ll enced depend on the particular substance used, and can discuss factors that apply to all addictive substances, are include anxiety, irritability, intense cravings for the sub- described in the main theories of substance dependence, stance, hallucinations, nausea, headache, and tremors. and have been clearly shown to have a role in developing and maintaining dependence. Substances differ in their potential for producing physical dependence: the potential is very high for heroin but Reinforcement appears to be lower for other substances, such as LSD and marijuana (Baker et al., 2004; NCADI, 2000; Pagliaro We saw in Chapter 6 that reinforcement is a pro- & Pagliaro, 2012). cess whereby a consequence strengthens the behavior Psychological dependence is a state in which indi- on which it is contingent. There are two types of reinforce- viduals feel compelled to use a substance for the effect ment: positive and negative (Sarafino, 2012). In positive it produces, without necessarily being physically depen- reinforcement, the consequence is an event or item dent on it. Despite knowing that the substance can impair the individual finds pleasant or wants that is introduced psychological and physical health, users rely heavily on or added after the behavior occurs. For example, many k  k Chapter 7 / Substance Use and Abuse 169 cigarette smokers report that smoking produces a “buzz” to use the substance (Erblich, Montgomery, & Bovbjerg, or “rush” and feelings of elation, and drinking alcohol 2009; Nickerson et al., 2011; Tapert et al., 2004). increases this effect (Baker, Brandon, & Chassin, 2004; Evidence now indicates that the role of cues in sub- Piasecki et al., 2008). People who experience a buzz from stance dependence involves physiological mechanisms. smoking smoke more than those who don’t (Pomerleau Let’s look at two lines of evidence. First, learning the cues et al., 2005). Alcohol and drugs often produce a buzz enables the body to anticipate and compensate for a sub- or rush and other effects. In negative reinforcement, stance’s effects (McDonald & Siegel, 2004). For instance, the consequence involves reducing or removing an aver- for a frequent user of alcohol, an initial drink gets the sive circumstance, such as pain or unpleasant feelings. body to prepare for more, which may lead to tolerance; For instance, tobacco, alcohol, and drugs relieve stress and if an expected amount does not come for a user and other negative emotions at least temporarily (Baker who is addicted, withdrawal symptoms occur. Second, et al., 2004). Positive and negative reinforcement both studies have supported the incentive-sensitization theory of produce a wanted state of affairs; with substance use, it addiction, which proposes that a neurotransmitter called occurs very soon after the behavior. Thus, dependence dopamine enhances the salience of stimuli associated with and abuse develop partly because users rely increas- substance use so that they become increasingly powerful ingly on the substance to regulate their cognitive and in directing behavior (Robinson & Berridge, 2001, 2003). emotional states (McKenzie et al., 2010; Pomerleau & These powerful cues grab the substance user’s attention, Pomerleau, 1989; Robinson et al., 2011). People are at arouse the anticipation of the reward gained from using risk for substance abuse if their brain reaction to reward the substance, and lead the person to get and use more reflects strong pleasure (Stice & Yokum, 2014). of it (Van Dyke & Fillmore, 2015). Avoiding Withdrawal Expectancies Because withdrawal symptoms are very unpleasant, People develop expectancies, or ideas about the outcomes people want to avoid them (Baker, Brandon, & Chassin, of behavior, from their own experiences and from 2004). People who have used a substance long enough to watching other people. Some expectancies are positive; k k develop a dependence on it are likely to keep on using it that is, the expected outcome is desirable. For example, to prevent withdrawal, especially if they have experienced we may decide by watching others that drinking alcohol the symptoms. As an example of the symptoms, for is “fun”—people who are drinking are often boisterous, people addicted to alcohol, the withdrawal syndrome laughing, and, perhaps, celebrating. These people may be (called delirium tremens, “the DTs”) often includes intense family members, friends, and celebrities in movies—all anxiety, tremors, and frightening hallucinations when of whom are powerful models. Even before tasting their blood alcohol levels drop (Kring et al., 2012). Each alcohol, children acquire expectancies about the positive substance has its own set of withdrawal symptoms. effects of alcohol via social learning processes, such as by watching TV shows and advertisements (Dunn Substance-Related Cues & Goldman, 1998; Grube & Wallack, 1994; Scheier & Botvin, 1997). Teenagers also perceive that drinking is When people use substances, they associate with “sociable” and “grown up,” two things they generally that activity the specific internal and environmental want very much to be. As a result, when teens are stimuli that are regularly present. These stimuli are offered a drink by their parents or friends, they usually called cues, and they can include the sight and smell see this as a positive opportunity. Other expectancies of cigarette smoke, the bottle and taste of beer, and are negative—for instance, that drinking can lead the mental images of and equipment involved in to a hangover. Similar processes operate for other taking cocaine. These associations occur by way of substances, such as tobacco (Cohen et al., 2002). classical conditioning: a conditioned stimulus—say, Expectancies influence whether individuals will use a the smell of cigarette smoke—comes to elicit a response substance at any given time and decide to stop using it through association with an unconditioned stimulus, the entirely (Albery et al., 2015; Bekman et al., 2011). substance’s effect, such as the “buzz” feeling. There may be more than one response, but two important ones are Personality and Emotional Factors attention and craving: for people who are dependent on a substance—such as alcohol, marijuana, or tobacco— Aspects of people’s personalities are associated with words, thoughts, or paraphernalia related to the their likelihood of substance use and abuse. Compared substance can elicit attention to the cues and cravings with individuals who do not use or abuse substances, k  k 170 Part III / Lifestyles to Enhance Health and Prevent Illness those who do tend to be impulsive, high in risk- development of alcohol problems (Saraceno et al., 2009; taking or sensation-seeking, and low in self-regulation Urbanoski & Kelly, 2012). For instance, twin studies in (King, Karyadi et al., 2011; Quinn & Fromme, 2010). general have found that if one member of a same-sex Self-regulation is the ability to control one’s own twin pair is alcoholic, the risk of the other member being thoughts, emotions, and actions toward achieving a alcoholic is twice as great if the twins are identical rather goal, even when not being monitored by someone else. than fraternal. And specific genes have been identified Adults who had adverse childhood experiences, such for this substance, too. as maltreatment, and are very depressed or anxious Four other findings on the role of genetics are are at risk for substance abuse (Elliott et al., 2014; important. First, the genes that affect smoking are not Ketcherside & Filbey, 2015). 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, Genetics their importance changes with development: substance Heredity influences addiction (Urbanoski & Kelly, 2012). use is strongly influenced by social factors during ado- For example, twin studies have shown that identical lescence and genetic factors during adulthood (Kendler twins are more similar in cigarette smoking behavior and et al., 2008). Third, high levels of parental involvement becoming dependent on tobacco than fraternal twins, with and monitoring of their child can counteract a and researchers have identified specific genes that are child’s high genetic risk of substance use (Brody et al., involved in this addictive process (Chen et al., 2009; 2009; Chen et al., 2009). Fourth, epigenetic processes are Lerman & Berrettini, 2003). Also dozens of twin and important: environmental factors can alter the operation adoption studies, as well as research with animals, of genes that are involved in substance use (Urbanoski & have clearly demonstrated a genetic influence in the Kelly, 2012; Wong, Mill, & Fernandes, 2011). If you have not read Chapter 2, “The Body’s Physical from that chapter distributed to later chapters, read k Systems,” and your course has you read the modules Module 4 (“The Respiratory System”) now. k SMOKING TOBACCO cigarette smoking reached its greatest popularity in the mid-1960s, when about 51% of adult males and When Columbus explored the Western Hemisphere, he 34% of adult females smoked regularly (NCHS, 2015). recorded in his journal that the inhabitants would set Before that time, people generally didn’t know about fire to leaves—rolled up or in pipes—and draw in the serious health effects of smoking. But in 1964 the the smoke through their mouths (Ashton & Stepney, Surgeon General issued a report describing these health 1982). The leaves these people used were tobacco, of effects, and warnings against smoking began to appear course. Other early explorers tried smoking and, probably in the American media and on cigarette packages. In because they liked it, took tobacco leaves back to Europe the following decades, the prevalence of adult smokers in the early 1500s, where tobacco was used mainly dropped steadily and has stabilized. In the United States for “medicinal purposes.” Smoking for pleasure spread today, about 18% of adults smoke (NCHS, 2015). Teen among American colonists and in Europe later in that cigarette smoking has also declined: today about 8.5% of century. In the 1600s, pipe smoking became popular, high school seniors smoke daily (Johnston et al., 2014). and the French introduced snuff, powdered tobacco that Do these trends mean cigarette manufacturers are people consumed chiefly by inserting it in the nose on the verge of bankruptcy? Not at all—their profits and sniffing strongly. After inventors made a machine are still quite high! In the United States, there are still for mass-producing cigarettes and growers developed tens of millions of smokers, the retail price of cigarettes mellower tobacco in the early 1900s for easier inhaling, has increased, and manufacturers have sharply increased the popularity of smoking grew rapidly over the next sales to foreign countries. At the same time that smoking 50 years. has declined in many industrialized countries, it has Worldwide today, about 36% of men and 8% of increased in developing nations, such as in Asia and women smoke (WHO, 2014). In the United States, Africa (Shafey et al., 2009). k  k Chapter 7 / Substance Use and Abuse 171 WHO SMOKES, AND HOW MUCH? 1960s, the prevalence of smoking was far greater among males than females (NCHS, 2015). But this gender gap Although huge numbers of people in the world smoke, has narrowed greatly. Cigarette advertising targeted at most do not. In the United States, the adolescent and one gender or the other, such as by creating clever brand adult populations have five times as many nonsmokers names and slogans, played a major part in these gender- as smokers. Are some people more likely to smoke related shifts in smoking (Pierce & Gilpin, 1995). A slogan than others? designed to induce young females to smoke is: Age and Gender Differences in Smoking “You’ve come a long way, baby,” with its strong but still subtle appeal to the women’s liberation Smoking varies with age. For example, few Americans movement. The “Virginia Slims” brand name artfully begin to smoke regularly before 12 years of age (Johnston takes advantage of the increasingly well-documented et al., 2014), and few people who will ever become regular research finding that, for many female (and male) smokers begin the habit after their early 20s (Thirlaway & smokers, quitting the habit is associated with gaining Upton, 2009). The habit generally develops gradually weight. (Matarazzo, 1982, p. 6) over several years. Figure 7-1 shows three patterns in the habit’s development. First, many people in a given month Although cigarette advertising still has a strong influence smoke infrequently—at less than a daily level. Many of on teens starting to smoke, antismoking advertisements them are trying out the habit, and some will progress to appear to counteract this influence (Gilpin et al., 2007; daily and then half a pack or more. Second, this pattern Murphy-Hoefer, Hyland, & Higbee, 2008). There is an starts in eighth grade (about age 13) for an alarming important and hopeful point to keep in mind about the number of children and involves more and more teens changes that have occurred in smoking behavior: they in later grades. Third, teens in every grade who do not show that people can be persuaded to avoid or quit plan to complete 4 years of college are at high risk of smoking. trying smoking and progressing to heavy smoking. The percentage of Americans who smoke is fairly constant Sociocultural Differences in Smoking k in early- and mid-adulthood and declines later (NCHS, k 2015). Many adults are former smokers. Large variations in smoking occur across cultures, with Gender differences in smoking are quite large in far higher rates in developing than in industrialized some parts of the world: about 80% of smokers worldwide countries (Shafey et al., 2009). Over 80% of the world’s are men (Shafey et al., 2009). Among Americans in the smokers live in developing countries, where it’s not College plans: Smoking Status Complete 4 years Daily pack or more Grade 8 Daily 1 or more cigarettes Grade 10 At least once in prior 30 days Grade 12 College Lesser or no college plans Grade 8 Grade 10 Grade 12 Young adults (19–28 Years) 0 5 10 15 20 25 30 35 40 Percent 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 similar. (Data from Johnston et al., 2014, Tables 2-3, 2-4, 4-7, and 4-8.) k  k 172 Part III / Lifestyles to Enhance Health and Prevent Illness Table 7.1 Percentages of Adult Males and Females Who and, perhaps, even experienced nausea. This is not the Smoke Tobacco in Selected Countries kind of outcome that usually makes people want to try Country Males Females something again. But many teenagers do, even though Australia 21.0 19.0 most teens say that smoking is unhealthy (Johnston et al., Brazil 22.0 13.0 2014). Given these circumstances, we might wonder why Canada 20.0 15.0 people start to smoke and why they continue. China 47.0 2.0 Germany 35.0 25.0 India 25.0 4.0 Starting to Smoke Italy 31.0 18.0 Psychosocial factors provide the primary forces that lead Netherlands 21.0 19.0 adolescents to begin smoking. For instance, teens who Singapore 39.0 19.0 perceive low risk and high benefits in smoking are likely to South Africa 28.0 8.0 Sweden 25.0 24.0 start the habit (Song et al., 2009). Also, teenagers’ social Turkey 42.0 13.0 environment is influential in shaping their attitudes, United Kingdom 22.0 22.0 beliefs, and intentions about smoking—for example, United Statesa 20.5 15.5 they are more likely to begin smoking if their parents Notes: adult = age 15 and older, except a 18 and older; data and friends smoke (Bricker et al., 2006; O’Loughlin et al., from different countries and sources may vary somewhat, 2009; Scherrer et al., 2012; Vuolo & Staff, 2013). Teens reflecting different definitions or survey years. Sources: Data from WHO, 2014, except a NCHS, 2015. 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 unusual for 50% of men to smoke. Table 7.1 gives the smoke on or off screen (Distefan et al., 1999). Thus, percentages of adult males and females who smoke in modeling and peer pressure are important determinants selected countries around the world. of smoking. In the United States, smoking prevalence differs Personal characteristics can influence whether ado- k across ethnic groups. Of high school seniors, 10.9% k lescents begin to smoke—for instance, low self-esteem, of Whites, 5.3% of Blacks, and 4.7% of Hispanics concern about body weight, and being rebellious and a are daily smokers (Johnston et al., 2014). Although thrill-seeker increase the likelihood of smoking (Bricker the prevalence of Black and White adults who smoke et al., 2009; O’Loughlin et al., 2009; Weiss, Merrill, & regularly has declined substantially since the 1960s, the Gritz, 2007). Expectancies are also important. Many percentages who smoke today depend on the people’s teens believe that smoking can enhance their image, ages and gender (NCHS, 2015). For men and women, making them look mature, glamorous, and exciting more Whites than Blacks smoke in early adulthood, but (Dinh et al., 1995; Robinson & Klesges, 1997). Teens among males after 45 years of age, more Blacks than who are very concerned with how others view them do Whites smoke. Differences in smoking rates also vary not easily overlook social images, models, and peer with social class: the percentage of people who smoke pressure. Do the psychosocial factors we’ve considered tends to decline with increases in education, income, have similar effects with all teens? No, the effects seem and job prestige class (Adler, 2004). Thus, high rates to depend on the person’s gender and sociocultural of smoking are likely to be found among adults who background. For example, smoking by peers and family did not graduate from high school, have low incomes, members in America is more closely linked to smoking and have blue-collar occupations, such as maintenance in girls than boys and in White than Black teens (Flay, work and truck driving. Americans from the higher social Hu, & Richardson, 1998; Robinson & Klesges, 1997). classes are also more likely to quit smoking if they start (Go to.) (NCHS, 2014). Becoming a Regular Smoker WHY PEOPLE SMOKE Although most youngsters try at least one cigarette, Cigarette smoking is a strange phenomenon in some most of them don’t go on to smoke regularly. Becoming respects. If you ever tried to smoke, chances are you a habitual smoker usually takes a few years, and proceeds coughed the first time or two, found the taste unpleasant, faster if the first experiences are pleasant, such as with a k  k Chapter 7 / Substance Use and Abuse 173 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 nonsus, smoking is like or make a commitment never to smoke? Susceptibility– stage combinations precon These two factors affect the likelihood of starting to smoke: the likelihood rises as the teen’s curiosity sus, increases and in the absence of a commitment (Pierce precon et al., 2005). The absence of a commitment never to smoke is called susceptibility to smoking. Researchers sus, contem have examined how susceptibility combines with stages of change—that is, readiness to start smoking—to sus, affect teenagers’ likelihood of becoming smokers in prep the future (Huang et al., 2005). Figure 7-2 presents the findings: susceptible teenagers are more and more likely to become smokers as their stages advance 1 5 10 from precontemplation (not considering smoking) to Comparative likelihood contemplation (considering smoking) to preparation Figure 7-2 Comparative likelihood of nonsmoking (intending to smoke). A susceptible teenager at the teenagers becoming smokers within 2 years, depend- preparation stage is nearly ten times more likely to start ing on the teens’ combination of susceptibility and stage smoking within a couple of years than a nonsusceptible of change: nonsus, precon = nonsusceptible, precontem- teen at the precontemplation stage. plation (arbitrarily scaled as 1 in the graph); sus, precon = susceptible, precontemplation; sus, contem = susceptible, k contemplation; and sus, prep = susceptible, preparation. k (Data from Huang et al., 2005, Table 2.) likeable taste or other sensation (Sartor et al., 2010). The Were rebellious, thrill-seekers, and low in school speed is important because the faster the habit develops, motivation. the more likely the person will smoke heavily, become Were receptive to tobacco advertisements, such as by nicotine dependent, and have trouble quitting (Chassin naming a favorite one. et al., 2000; Dierker et al., 2008, 2012). Felt peer pressure to smoke, for example, reporting, Why is it that some people continue smoking after “Others make fun of you if you don’t smoke,” and, “You the first tries, and others don’t? Part of the answer have to smoke when you’re with friends who smoke.” lies in the types of psychosocial influences that got Held positive attitudes about smoking, such as, “Smok- them to start in the first place. Studies that tested ing is very enjoyable,” and, “Smoking can help people thousands of adolescents in at least two different years when they feel nervous or embarrassed.” have examined whether the teens’ social environments Did not believe smoking would harm their health, for and beliefs about smoking were related to changes in instance, feeling, “Smoking is dangerous only to older their smoking behavior (Bricker et al., 2006, 2009; Chassin people,” and, “Smoking is only bad for you if you have et al., 1991; Choi et al., 2002). Smoking tended to continue been smoking for many years.” or increase if the teens: Believed they’d be able to quit smoking if they wanted. Had at least one parent who smoked. Five other findings are important. First, part of the way Perceived their parents as unconcerned or even encour- smoking by family and friends promotes teenagers’ aging about their smoking. smoking is that it reduces the belief that smoking Had siblings or friends who smoked and socialized with might harm the teens’ own health (Rodriguez, Romer, & friends very often. Audrain-McGovern, 2007). Second, teenagers usually k  k 174 Part III / Lifestyles to Enhance Health and Prevent Illness smoke in the presence of other people, especially peers, Pomerleau et al., 1993). Third, researchers have found and smokers consume more cigarettes when in the that an area of the brain, the insula, may control the desire company of someone who smokes at a high rate rather to smoke: smokers who suffer a stroke with damage to than a low rate (Antonuccio & Lichtenstein, 1980; Biglan that area instantly lose their desire to smoke (Naqvi et al., 1984). Third, teens who smoke tend to select et al., 2007). smokers as friends, which increases the likelihood that their smoking will continue (Mercken et al., 2012). Fourth, feeling negative emotions, such as depression, increases The Role of Nicotine people’s smoking (Fucito & Juliano, 2009; McCaffery People become physically dependent on tobacco et al., 2008). Fifth, compared with heterosexual youth, because of the chemical substances their bodies take teens who are gay, lesbian, or bisexual are more likely in when they use it. Smokers take about 12 puffs per to smoke, particularly when their communities are not cigarette (Connolly et al., 2007), which translates to 240 supportive of their sexual orientation (Hatzenbuehler, puffs a day and over 87,000 a year for a person who Wieringa, & Keyes, 2012). smokes a pack a day. These chemicals include carbon Reinforcement is another important factor in monoxide, tars, and nicotine (Grunberg, Shafer Berger, & continuing to smoke. For many smokers, the taste or Starosciak, 2012; Pagliaro & Pagliaro, 2012). Cigarette sensation from smoking provides positive reinforcement smoke has high concentrations of carbon monoxide, for that behavior. As we have seen, individuals who have a gas that is readily absorbed by the bloodstream and pleasurable initial experiences with smoking tend to rapidly affects the person’s physiological functioning, become regular smokers quickly (Sartor et al., 2010). One such as by reducing the oxygen-carrying capacity of way smoking provides negative reinforcement for that the blood. Tars exist as minute particles, suspended behavior is if it is used as a means of coping with stress in smoke. Although tars have important health effects, or other unpleasant emotional states (Baker et al., 2004). there is no evidence that they affect the desire to Smoking is also linked to stress in another way: the more smoke. Nicotine is the addictive chemical in cigarette smoke stress smokers experience, the more they smoke (Wills, and produces rapid and powerful physiological effects. 1986). And smokers report less anxiety and greater ability Nicotine dependence does not necessarily take months k k to express their opinions if they smoke during stressful or years to develop: a study found that some begin- social interactions than if they do not smoke (Gilbert & ning smokers who had smoked infrequently experienced Spielberger, 1987). But even if smokers perform better symptoms of dependence, such as craving (O’Loughlin and feel more relaxed in stressful situations when they et al., 2003). are allowed to smoke than when they are not, they Nicotine is a substance that occurs only in tobacco. do not necessarily perform better or feel more relaxed When people smoke, alveoli in the lungs quickly absorb than nonsmokers do (Schachter, 1980). Some findings the nicotine and transmit it to the blood (Grunberg, suggest that smoking may reduce stress temporarily, but Shafer Berger, & Starosciak, 2012; Pagliaro & Pagliaro, may increase it in the long run (Parrott, 1999). A study 2012). In a matter of seconds the blood carries the that tested this idea found support for it, but another did nicotine to the brain, where it leads to the release of not (Orlando, Ellickson, & Jinnett, 2001; Wills, Sandy, & various chemicals that activate both the central and Yeager, 2002). sympathetic nervous systems, which arouse the body, Biological factors are also involved in sustaining increasing alertness, heart rate, and blood pressure. smoking behavior, probably by affecting how addictive These and other consequences of nicotine form the nicotine is. The fact that adolescent smoking is strongly basis for the positive and negative reinforcement effects associated with parental and sibling smoking shows of smoking. Then, while a person smokes a cigarette, that smoking runs in families. Certainly part of this nicotine accumulates very rapidly in the blood. But it relationship results from social learning processes. But soon decreases through metabolism—in about 2 hours, there are at least three biological routes. First, a mother’s half of the nicotine inhaled from a cigarette has decayed. smoking during pregnancy increases the risk that her Biological explanations of people’s continued child will become a smoker, perhaps by making the child cigarette smoking have focused chiefly on the role of more susceptible to nicotine addiction (Weden & Miles, nicotine. One prominent explanation, called the nicotine 2012). The second is heredity: genetics affect how likely regulation model, proposes that established smokers people are to become smokers, how easily and strongly continue to smoke to maintain a certain level of nicotine they become physically dependent on tobacco, and how in their bodies and to avoid withdrawal symptoms. able they are to quit (Lerman, Caporaso et al., 1999; Stanley Schachter and his associates (1977) provided k  Chapter 7 / Substance Use and Abuse 175 evidence for this model in an ingenious series of studies 7.0 with adult smokers. In one study, the researchers had subjects smoke low-nicotine cigarettes during 1 week and high-nicotine cigarettes during another week. As 6.0 the model predicts, the subjects smoked more low- than high-nicotine cigarettes. This effect was especially strong for heavy smokers, who smoked 25% more of 5.0 Percentage dying before age 65 the low- than high-nicotine cigarettes. Consistent with these results, other researchers have found that people who regularly smoke ultralow-nicotine cigarettes do 4.0 not consume less nicotine than those who smoke other cigarettes—ultralow smokers simply smoke more cigarettes (Maron & Fortmann, 1987). 3.0 Although the nicotine regulation model has received research support, there are reasons to think it provides only part of the explanation for people’s smoking 2.0 behavior. One reason is that most people who quit smoking continue to crave it, and many return to smoking, long after all the nicotine is gone from their 1.0 bodies (Grunberg, Shafer Berger, & Starosciak, 2012). Another reason is that some people smoke a few cigarettes a day for years and don’t increase their use— 0 No Yes No Yes that is, they don’t show tolerance. These people usually Smoke Smoke don’t experience withdrawal symptoms but absorb as Lung Cancer Heart Disease much nicotine from a cigarette as heavier smokers Figure 7-3 Probability of a 35-year-old man dying of lung do (Shiffman et al., 1990; Shiffman et al., 1995). Why cancer or heart disease before age 65 as a function of do these people continue to smoke? Each of the smoking heavily or not smoking. Data for women were less processes of addiction we considered earlier provides complete, but probably would reveal similar risk increases. a cogent explanation. For instance, nicotine provides (Data from Mattson, Pollack, & Cullen, 1987, p. 427.) powerful reinforcement of smoking behavior soon after the first puff of a cigarette (Baker, Brandon, & Chassin, 2004; Grunberg, Shafer Berger, & Starosciak, 2012; Ray, with heavier smoking (Strandberg et al., 2008). No other Schnoll, & Lerman, 2009). single behavior takes such a toll. To what extent do your Researchers today generally recognize that a full odds of dying of lung cancer or heart disease increase if explanation of the development and maintenance of you smoke? Figure 7-3 shows that the odds increase smoking behavior involves the interplay of biological, greatly, especially for lung cancer. The more people psychological, and social factors (Shadel et al., 2000). smoke, the worse their odds become—and if they quit, An example of this interplay is seen in the finding that their odds improve steadily: if they smoked less than a among depressed smokers, those with a specific gene pack a day, their risk becomes similar to those of same- rely more on smoking to cope than those without that age never-smokers in about 15 years (Ahmed et al., 2015; gene (Lerman et al., 1998). Godtfredsen et al., 2002; LaCroix et al., 1991). Smoking and, specifically, nicotine also impair immune function (McAllister-Sistilli et al., 1998). SMOKING AND HEALTH “Warning: The Surgeon General has determined that WEB ANIMATION: The Case of the cigarette smoking is dangerous to your health,” states Worried Smoker a cigarette pack sold in the United States. Currently, nearly 6 million people worldwide die each year from Access: www.wiley.com/college/sarafino. This interactive smoking-related illnesses (ACS, 2015). Smoking reduces animation describes the symptoms and medical test people’s life expectancy by several years and impairs results of a woman with a smoking-related illness. their quality of life in old age, and these effects worsen  k 176 Part III / Lifestyles to Enhance Health and Prevent Illness Cancer In the 1930s, lung cancer in America was quite uncommon and much less prevalent than many other In the late 1930s, two important studies were conducted forms of cancer, such as cancer of the breast, stomach, that clearly linked tobacco smoking and cancer for the and prostate (ACS, 2015). Deaths from lung cancer at that first time (Ashton & Stepney, 1982). One study presented time occurred at an annual rate of about 5 per 100,000 statistics showing that nonsmokers live longer than people in the population, whereas mortality rates for smokers. In the other study, researchers produced cancer breast and stomach cancer were more than five times in laboratory animals by administering cigarette tar. that high. Over the years, the mortality rates for most By producing cancer with experimental methods, these forms of cancer have either declined or remained fairly researchers demonstrated a causal link between cancer constant, but not for lung cancer. The annual death rate and a chemical in tobacco smoke and identified tar as for lung cancer rose sharply in the second half of the a likely carcinogen, a substance that causes cancer. It is 20th century, but it has now declined to over 49 per now clear that chemicals in tobacco smoke, particularly 100,000 Americans (NCHS, 2015)—the corresponding nitrosamines and polycyclic aromatic hydrocarbons rate in the European Union is nearly 37 (WHO/Europe, (PAH), cause cancer (Grunberg, Shafer Berger, & 2015). In the United States, the deadliest form of cancer Starosciak, 2012). In just a few minutes, PAH are formed is of the lung, claiming about 158,000 lives per year and and produce genetic mutations (Zhong et al., 2011). being responsible for about three times more deaths Prospective research provides some evidence for a than cancer of the colon or rectum, the second most causal relationship because smokers and nonsmokers deadly form (ACS, 2015). are identified and then followed over a long period The correspondence between the rises in lung cancer of time to see if they develop cancer. Many large- deaths and in smoking prevalence since the 1930s is scale prospective studies have linked smoking with quite striking (ACS, 2015). The rate of mortality from cancers of various body sites, including the lung, mouth, lung cancer began to rise about 15 or 20 years after esophagus, prostate, bladder, and kidney (Huncharek the rate of smoking started to rise, and these rates et al., 2010; Pagliaro & Pagliaro, 2012). The last two may have paralleled each other ever since. During this time, result because carcinogenic chemicals in tobacco smoke the rates of smoking and of lung cancer were higher k are absorbed into the blood and conveyed to the urine. k for males than for females, but from the mid-1960s to Cancers of the mouth and esophagus can also result about 2000 important gender-related changes occurred. from using smokeless tobacco—chewing tobacco or snuff Smoking decreased among men and increased among (ACS, 2015; Pagliaro & Pagliaro, 2012). Thus, carcinogenic women, narrowing the gender gap—and corresponding substances exist not only in smoke, but in tobacco itself. changes in incidence rates of lung cancer occurred: Biophoto Associates/Science Source (middle); Biophoto Associates/Science Source (left); Dr. E. Walker/Science Source (right) X-rays of sections of three lungs: left, a healthy lung; middle, a smoker’s lung with cancerous tumors (whitish areas); right, a smoker’s lung with emphysema (dark areas). k  k Chapter 7 / Substance Use and Abuse 177 since the mid-1980s, the rates declined steadily for men Lung cancer usually originates in the bronchial tubes. In but rose, leveled off, and are now declining for women most cases, it probably develops because of the extensive (ACS, 2015). contact of carcinogens with the bronchial lining. How does smoking harm the lungs? When smoke Smoking is a major risk factor for all forms of cancer, recurrently passes through the bronchial tubes, the lining but its role is more direct and powerful in lung cancer of the tubes begins to react to the irritation by increasing than in other cancers. People’s environments contain the number of cells just below the surface. Then, many other carcinogens, and smoking is not the only cause of these diseases. (Go to.) the fine, hairlike growths, or cilia, along the surface of the lining, whose function is to clear the lungs of foreign particles, begin to slow or stop their move- Cardiovascular Disease ment. In time, the cilia may disappear altogether, and as a consequence carcinogenic substances remain Cardiovascular disease—including coronary heart dis- in contact with sensitive cells in the lining of the ease (CHD) and stroke—is the leading cause of death bronchi instead of being removed in the mucus.... worldwide (WHO, 2015). In the United States, it is respon- At this stage, a smoker’s cough may develop. It is a fee- sible for nearly 28% of all deaths each year and claims ble attempt by the body to clear the lungs of foreign about as many lives as cancer, diabetes, and Alzheimer’s particles in the absence of functioning cilia. (La Place, disease combined (NCHS, 2015). When you point out 1984, p. 326)7-1 these facts to smokers, some say, “Well you have to die HIGHLIGHT Does Someone Else’s Smoking Affect Your Health? k “What do you mean I can’t smoke in (Hammond et al., 1995). Laws against smoking curb k this bar! It isn’t your business what I do to my body,” nonsmokers’ exposure to secondhand smoke in public a patron said indignantly to a bartender. Some smokers places, but not at home or in private cars (Callinan have reacted strongly to smoking bans in public places. et al., 2010). When secondhand smoke exists, levels Why were these regulations introduced? can be so high as to produce high nicotine levels in Excess tobacco smoke, either from the smoker’s nonsmokers’ bodies and to increase the likelihood that body or from the burning tip of the tobacco item, goes children exposed to smoke will become smokers by early into the environment and is called secondhand smoke adulthood (Okoli & Kodet, 2015). (Eriksen, LeMaistre, & Newell, 1988; Okoli & Kodet, Evidence of the harmful effects of secondhand 2015). Breathing secondhand smoke is called passive smoke is quite substantial. Studies of nonsmokers smoking. In the mid-1980s, the United States Surgeon whose spouses smoked have generally found that pas- General issued a report on the effects of passive smoking sive smokers’ risk of lung cancer increases, sometimes that included three conclusions (USDHHS, 1986b, p. 7): doubling or tripling (Eriksen, LeMaistre, & Newell, 1988; USDHHS, 1986b). Studies have also found a higher risk of 1. Involuntary smoking is a cause of disease, including cardiovascular disease in nonsmoking spouses of smok- lung cancer, in nonsmokers. ers compared with nonsmoking spouses of nonsmokers 2. Compared with the children of nonsmoking parents, (Humble et al., 1990), and exposure to secondhand children of parents who smoke have a higher fre- smoke increases atherosclerosis (Howard et al., 1998; quency of respiratory infections, increased respiratory Penn & Snyder, 1993). What’s more, for people with symptoms, and slightly smaller rates of increase in existing cardiovascular conditions, such as angina, and lung function as the lungs mature. respiratory problems, such as asthma and hay fever, 3. The simple separation of smokers and nonsmokers environmental tobacco smoke can bring on attacks within the same air space may reduce, but does not or aggravate acute symptoms (Eriksen, LeMaistre, & eliminate, the exposure of nonsmokers to environ- Newell, 1988). Increasingly, people are becoming aware mental tobacco smoke. of the health effects of secondhand smoke and making efforts to have smoke-free environments. Public places, such as worksites, have high levels of secondhand smoke when smoking is permitted k  k 178 Part III / Lifestyles to Enhance Health and Prevent Illness of something.” Of course, that’s true—but when you will die the United States are related to smoking (Chestnutt & and how disabled you will be before are the real issues. Prendergast, 2015). As we saw earlier, recurrent smoking Cardiovascular disease takes many lives early: one in four irritates and damages respiratory organs. Research has Americans it kills are under 65 years of age. shown that more damage occurs from smoking high- Many millions of Americans suffer from CHD and tar than low-tar cigarettes and that regularly smoking stroke. The risk of developing CHD is much higher nontobacco (marijuana) cigarettes also damages the for smokers as for nonsmokers (AHA, 2015). And the respiratory system (Bloom et al., 1987; Paoletti et al., more cigarettes people smoke, the greater the risk: a 1985). CLRD can incapacitate its victims, often forcing prospective study of smoking and CHD across 8 1∕2 years relatively young individuals to retire from work. It found that the risk of developing heart disease was far causes about 6% of all deaths each year worldwide higher for individuals who smoked more than a pack a day (WHO, 2015). than those who smoked less (Rosenman et al., 1976). Two Smoking may also increase acute respiratory infec- other points are important in the link between smoking tions. This has been shown in two ways. First, studies and CHD. First, the greater risks smoking conveys for have found that children of smokers are more likely to CHD may be aggravated by stress. An experiment tested develop pneumonia than are children of nonsmokers smokers in a stressful task and found that their stress- (USDHHS, 1986b). Second, when exposed to common hormone and cardiovascular reactivity were higher if cold viruses, smokers are much more likely to catch they had smoked recently (that is, they had not been cold than nonsmokers, probably because their immune deprived of smoking) than if they had not smoked for functions are impaired (Cohen et al., 1993). many hours (Robinson & Cinciripini, 2006). Because smoking usually increases when people are under stress, the resulting heightened reactivity raises their CHD risk. Second, smokers tend to have lifestyles that include ALCOHOL USE AND ABUSE other risk factors for CHD, such as being physically inactive (Castro et al., 1989). People’s use of alcoholic beverages has a very long How does smoking cause cardiovascular disease? history, beginning before the eras of ancient Egypt, k k The disease process appears to involve several effects Greece, and Rome, when using wine and beer was that the nicotine and carbon monoxide in cigarette smoke very common. Its popularity continued through the have on cardiovascular functioning (USDHHS, 1986a). centuries and around the world—except in cultures that Nicotine constricts blood vessels and increases heart strongly prohibited its use, as in Islamic nations—and rate, cardiac output, and both systolic and diastolic blood eventually reached America in the colonial period. pressure. Carbon monoxide reduces the availability of Colonial Americans arrived with oxygen to the heart, which may cause damage and lead the drinking habits and attitudes of the places they to atherosclerosis. Studies have found that the more left behind. Liquor was viewed as a panacea; even the cigarettes people smoke per day, the greater their level Puritan minister Cotton Mather called it “the good of serum cholesterol and size of plaques on artery walls creature of God.” By all accounts, these people drank, (Muscat et al., 1991; Tell et al., 1994). After stopping and drank hard. (Critchlow, 1986, p. 752) smoking, cardiovascular risk factors, such as cholesterol levels, improve markedly within 2 months (Eliasson But the Puritans also realized that excessive drinking led et al., 2001), and the risk of heart attack or stroke declines to problems for society, so they condemned drunkenness greatly in the next few years (Kawachi et al., 1993; Negri as sinful and enforced laws against it. et al., 1994). Over the next two centuries, attitudes about alcohol changed in many cultures. In the United States, the temperance movement began in the 18th century and Other Illnesses pressed for total abstinence from alcohol. By the mid- Smoking can lead to a variety of other illnesses— 1800s, the use of alcohol had diminished sharply and particularly emphysema and chronic bronchitis—which so had its reputation: many Americans at that time are classified together as chronic lower respiratory disease believed alcohol destroyed morals and created crime and (CLRD, also known as chronic obstructive pulmonary disease, degenerate behavior (Critchlow, 1986). These attitudes COPD) (ALA, 2015; Chestnutt & Prendergast, 2015). persisted and helped bring about Prohibition, beginning People with CLRD experience permanently reduced in 1920, when the production, transport, and sale of airflow, which is especially evident when they try to alcohol became unlawful. After the repeal of Prohibition, exhale with force. About 80% of cases of CLRD in the use of alcohol increased, of course, and attitudes k  k Chapter 7 / Substance Use and Abuse 179 intoxication than males from the same amount of alcohol. This is because, even when body size is the same, females metabolize alcohol less quickly than males do (Tortora & Derrickson, 2012). Drinking typically begins in adolescence, and sometimes in childhood. In a survey of thousands of students across the United States, high school seniors’ Bettmann/Corbis Images answers indicated that 68% had consumed an alcoholic drink at some time in their lives, 39% had had a drink in the last month, 43% had been drunk in the past year, and 22% had drunk five or more drinks in a row in the preceding 2 weeks (Johnston et al., 2014). Males reported more daily drinking than females. About 22% of eighth graders claimed they’d had a drink in the past year. Women in the temperance movement were very assertive, Although young people sometimes have alcohol at home and some went to saloons to keep records of who bought with the parents present, such as at special occasions, drinks. most teenage drinking occurs in different circumstances. Even when it is illegal for high school and college about alcohol softened. Americans today believe alcohol students to purchase alcohol and to drink without has both good and bad effects. (Go to.) parental supervision, many do anyway. In adulthood, more males than females drink heavily (NCHS, 2015). Although most young adult and middle-aged Americans WHO DRINKS, AND HOW MUCH? drink, the prevalence is much lower in older groups. People’s attitudes about and use of alcohol are tied to their own characteristics and backgrounds, such as their Sociocultural Differences in Using Alcohol k age, gender, and sociocultural experiences. k Alcohol use varies widely across cultures around the world. Per capita, Americans each year consume 2.34 Age, Gender, and Alcohol Use gallons (9.9 liters) of ethanol—the alcohol in beer, Age and gender affect people’s use of alcoholic beverages wine, and spirits (NIAAA, 2015). Table 7.2 compares in most societies. One reason for gender differences in countries on the amount of alcohol consumed per drinking is that females on average experience more person. Traditionally, countries were classified into two ASSESS YOURSELF What’s True about Drinking? Put a check mark in the space pre- evening rather than sticking with the same kind ceding each of the following statements you think is of drink. true. Five 12-ounce glasses of beer won’t make someone Alcohol is a stimulant that energizes the body. as tipsy as four mixed drinks, such as highballs. Having a few drinks enhances people’s People seldom get drunk if they have a full meal performance during sex. before drinking heavily. After drinking heavily, people usually sober up a lot People can cure a hangover by any of several when they need to, such as to drive home. methods. Most people drive better after having a few beers Most people with drinking problems are either to relax them. “skid row bums” or over 50 years of age. Drinking coffee, taking a cold shower, and getting fresh air help someone who is drunk to sober up. Which statements did you think were true? They are People are more likely to get drunk if they switch wrong—all of the statements are false. (Source: Based on drinks, such as from wine to beer, during an Drinking Myths distributed by the U.S. Jaycees.) k  k 180 Part III / Lifestyles to Enhance Health and Prevent Illness Table 7.2 Per Capita Pure Alcohol (Ethanol) Consumption Annually in Selected Countries Consumption in Liters per Country Capita—Ages 15 and Over Regular drinkers Australia 12.2 51.3% Brazil 8.7 Canada 10.2 China 6.7 Germany 11.8 India 4.3 Italy 6.7 Lifetime Infrequent Netherlands 9.9 abstainers drinkers Singapore 2.0 21.0% 12.9% Former South Africa 11.0 drinkers Sweden 9.2 14.5% Turkey 2.0 United Kingdom 11.6 Note: The amount of pure alcohol per liter varies with the beverage: beer, wine, or spirits. Figure 7-4 Proportions of American adults with four Sources: Data from WHO, 2014. drinking statuses: regular drinkers (12 or more drinks in the past year), infrequent drinkers (more than 1, but fewer than 12 drinks, past year), former drinkers (no drinks, past types of alcohol use: those that integrate alcohol into year), and lifetime abstainers (fewer than 12 drinks ever). (Data from NCHS, 2014, Table 25.) daily life, as in serving it with meals in Italy and France, and those that restrict its use, such as the United States and Scandinavian nations (Bloomfield for 14- to 17-year-olds, 38% for 18- to 34-year-olds, et al., 2005). Daily drinking occurred more in the former, and 19% for adults 35 and older (NCHS, 2015). In k and intoxication in the latter. But these distinctions are comparison, of European 15- and 16-year-olds, 39% k disappearing. reported having engaged in binge drinking in the past In the United States, drinking patterns differ among month (ESPAD, 2012). Binge drinking occurs on college the many ethnic groups. The percentage of adults campuses at very high levels, especially among full time who drink is higher for Whites than for other ethnic students (SAMHSA, 2014b). Individuals who start to groups, including Black, Hispanic, Asian, and Native drink on a regular basis in early adolescence are more Americans (NCHS, 2014). And the percentage of adults likely than others to drink heavily in adulthood and who sometimes drink several drinks in a day is much develop problems related to drinking (Pitkänen, Lyyra, & higher for White, Hispanic, and Native Americans than Pulkkinen, 2005; Sher et al., 2011). for Black and Asian Americans (NCHS, 2015). Some years How many drinkers meet the criteria for substance ago, the percentage of adults who drank several drinks abuse? Estimates have been made on the basis of the in a day was far higher for Native Americans than for all proportion of individuals at a given time who had ever other groups, but their drinking has moderated. displayed the problem. This statistic, called the lifetime prevalence rate, currently suggests that over 17% of adults Problem Drinking in the United States become alcohol abusers (Kring et al., 2012). People with alcohol use disorder drink heavily Figure 7-4 shows that over 64% of Americans age 18 and on a regular basis and suffer social and occupational older drink alcohol at least occasionally. Most of these impairments from it. Many of them frequently get drunk, people are light-to-moderate drinkers, consuming fewer drink alone or during the day, and drive under the than, say, 60 drinks a month. Many people drink much influence. Although alcohol abuse is more common more heavily, but not all of them meet the criteria for in males than females, it is most likely to develop substance abuse we described earlier. One definition between the ages of 18 and 25 when the rates are of heavy drinking is engaging in binge drinking—that similar for both sexes (SAMHSA, 2014b). More than half is, consuming five or more drinks on a single occasion of those who abuse alcohol are physically dependent at least once in a 30-day period. Using this definition, on it, or addicted to it, and are often called alcoholics. the percentage of American current drinkers who report These people have developed a very high tolerance for having drunk heavily in the past month is about 9% alcohol and often have blackout periods or substantial k  k Chapter 7 / Substance Use and Abuse 181 Drinking and celebrating often occur together, and this association conveys the message that drinking is fun. Blend_Images/Getty Images memory losses; many experience delirium tremens when from watching other individuals enjoying themselves they stop drinking. Although alcoholics often drink the while drinking. For example, the more teens see alcohol equivalent of a fifth of whiskey (about 25 ounces) a day, scenes in movies and ads on TV, the more they are likely 8 ounces can sometimes be sufficient to produce to drink in the future (Dal Cin et al., 2009; Stacy et al., addiction in humans (Davidson, 1985). 2004). Very young adolescents are especially influenced k Who abuses alcohol? Many people have an image of to drink if their friends drink (Kelly et al., 2012). And k the “typical” alcoholic as a scruffy looking, unemployed underage drinking is more likely among teens who have male derelict with no family or friends. But this image high feelings of depression, believe their friends drink is valid for only a minority of people who abuse alcohol a lot, have low school grades, and have parents who (Grant et al., 2015; Kring et al., 2012). Most problem drink and provide little monitoring or rules against drinkers are married, living with their families, and drinking (Fang, Schinke, & Cole, 2009). Children who are employed—and many are women. Although individuals depressed, abused, or neglected are at risk for drinking from the lower social classes, especially homeless heavily in adolescence and adulthood (Crum et al., 2008; people, are at greater risk than those from higher Potthast, Neuner, & Catani, 2014). classes for abusing alcohol, large numbers of problem Adolescents continue drinking partly for the same drinkers come from the higher classes and hold high- reasons they started, but these factors intensify, and status jobs. Problem drinking is very rare in childhood; new ones come into play. For instance, age and future its prevalence increases in adolescence, rises sharply in plans play a role. Figure 7-5 shows that the percentage early adulthood, and declines thereafter (NCHS, 2015). of American adolescents who claim to have been drunk Alcohol abuse is a major social problem that affects in the past month increases with year in school, and is large numbers of people from almost all segments of higher for teens who do not plan to complete 4 years of many societies around the world. (Go to.) college than those who do. Also, the role of social factors increases over time (Sher et al., 2011; Thirlaway & Upton, 2009). Although teens often begin occasional drinking WHY PEOPLE USE AND ABUSE ALCOHOL under their parents’ supervision, such as at celebrations, In examining why people use and abuse alcohol, we they drink increasingly with peers at parties or in cars. need to consider why individuals start to drink in the In late adolescence and early adulthood, drinkers drink first place. The chief reasons for starting to drink involve frequently and almost always socially, with friends at social and cultural factors, particularly expectancies of parties or in bars. The social aspect is important in two desirable outcomes—such as of heightened sociability, ways. First, in social drinking, modeling processes affect reduced tension, and stimulant effects (Sher et al., 2011; behavior—for example, people tend to adjust their drink- Thirlaway & Upton, 2009). These expectancies form ing rates to match those of their companions. Second, k  k 182 Part III / Lifestyles to Enhance Health and Prevent Illness ASSESS YOURSELF Do You Abuse Alcohol? Ask yourself the following questions Do family or friends mention your drinking to you? about your drinking: Do you sometimes stop and start drinking to “test” Do you usually have more than 14 drinks a week yourself? (assume a drink is one mixed drink with 1 1∕4 ounces of Have you been stopped for drunk driving in the past alcohol, 12 ounces of beer, or the equivalent)? year? Do you often think about how or when you are going to drink again? If you answered “yes” to the first question, consider Is your job or academic performance suffering by your changing your drinking pattern. If you answered “yes” drinking? to any additional questions, consult your college’s Has your health declined since you started drinking a counseling office for their advice or help. (Sources: Based lot? on TSC, 1992; Kring et al., 2012; Pignone & Salazar, 2015) drinking socially creates a subjective norm in individuals business deals or social relationships as a consequence that the behavior is appropriate and desirable. of drinking. Having reinforcing experiences with drinking With continued drinking, the strength of the behavior increases their expectancies for desirable consequences increases through positive and negative reinforcement, when deciding to drink in the future (Sher et al., 2011; and alcohol use becomes habitual as substance-related Stacy, 1997). In the case of negative reinforcement—that cues develop (Albery et al., 2015; Baker, Brandon, & is, the reduction of an unpleasant situation—we’ve seen Chassin, 2004; Cunningham, 1998; Thirlaway & Upton, that people often use alcohol to reduce stress and k k 2009). Individuals may receive positive reinforcement for unpleasant emotions. They may, for instance, drink to drinking if they like the taste of a drink or the feeling suppress their negative thoughts or feelings of anxiety in they get from it, or if they think they succeeded in social situations (Schry & White, 2013; Zack et al., 2006). But the effects of alcohol on negative emotions are not so simple. Although drinkers report that alcohol reduces 40 tension and improves their mood, it seems to do so only College plans: with the first few drinks they consume in a series. After Complete 4 Years people consume several drinks, their emotions, such 30 Complete as anxiety and depression, often increase and become less or none unstable (Davidson, 1985; Pagliaro & Pagliaro, 2012). Percent drunk Experiencing bad consequences from drinking heavily, 20 such as blackouts or regretted sex, may lead to continued heavy drinking in the next months (Martinez, Sher, & Wood, 2014). In cases of great trauma, such as witnessing terrorism, alcohol use may be heightened for a couple of 10 years (DiMaggio, Galea, & Li, 2009). Why can most people drink in moderation, but others become problem drinkers? We’ll consider four 0 psychosocial differences between these people. First, Eighth Tenth Twelfth Grade compared to individuals who do not drink heavily, Figure 7-5 Percent of American adolescents at different those who do are more likely to perceive fewer negative grades in school who claimed to have been drunk at least and more positive consequences from drinking, such as once in the past month, depending on their college plans: feeling stimulated rather than sedated (King, de Wit et al., either to complete 4 years or to complete less or no college. 2011; Sher et al., 2011). Second, heavy drinkers tend to The graph does not separate data for males and females experience high levels of stress and live in environments because they are fairly similar. (Data from Johnston et al., 2014, that encourage drinking. For instance, adolescents who Table 4-7.) abuse alcohol are more likely to have experienced a k  k Chapter 7 / Substance Use and Abuse 183 major trauma, such as physical assault, and have family DRINKING AND HEALTH members who drink heavily (Kilpatrick et al., 2000). Third, heavy drinkers may form particularly strong substance- Drinking too much is linked to a wide range of health related cues: they develop heightened physiological hazards for the drinker and for people he or she may reactions and positive feelings to alcohol-related stimuli, harm. Drinkers can harm others in several ways. Pregnant such as seeing or smelling liquor, especially when alcohol women who drink more than two drinks a day place their is available (Turkkan, McCaul, & Stitzer, 1989). Fourth, babies at substantial risk for health problems, such as people who drink in moderation are more likely to use being born with low birth weight or fetal alcohol syndrome, alcohol control strategies, such as avoiding situations which involves impaired nervous system development where heavy drinking is likely (Sugarman & Carey, 2007). and cognitive and physical defects (Gray, Mukherjee, & But a complete answer to why people become Rutter, 2009; Pagliaro & Pagliaro, 2012). Drinking lesser problem drinkers also includes developmental and amounts during pregnancy has been associated with biological factors. For instance: impaired learning ability in the child. The safest advice to pregnant women is not to drink at all. Heredity plays a much stronger role when the abuse Drinking also increases the chance that individuals begins before age 25 than after (Kranzler & Anton, will harm themselves and others through accidents of 1994). various types, such as from unintentionally firing a gun People with a family history