Concepts of Fitness And Wellness

Lab 18C Results Rating Rating Evaluating Levels of Social Support Scores and Ratings Rating (Use Chart 2 to obtain ratings.) Rating Access to social support score Degree of social support score Getting social support score Total social support score (sum of three scores) Chart 2  Rating Scale for Social Support Rating Item Scores Total Score High 8–9 24–27 Moderate 6–7 18–23 Low Below 6 Below 18 Conclusions and Implications 1. In several sentences, discuss your overall social support. Do you think your scores and ratings are a true representa- tion of your social support? 2. In several sentences, describe any changes you think you should make to improve your social support system. If you do not think change is necessary, explain why. 378

Avoiding Destructive Behaviors  c  Section VII The Use and Abuse Concept 19 of Tobacco LEARNING OBJECTIVES After completing the study of this Concept, you will be able to: c Identify the most widely used forms of tobacco and the contents of tobacco products that contribute to negative health outcomes. c Describe the negative health and economic costs of cigarette and cigar smoking and smokeless tobacco use. c Describe secondhand smoke and identify the negative health consequences of secondhand smoke exposure. c Understand trends in the prevalence of tobacco use. c Identify important factors contributing to recent reductions in tobacco use in the United States. c Describe efforts by the tobacco industry to maintain higher rates of smoking. c Identify effective prevention and intervention approaches designed to reduce rates of tobacco use. Tobacco use is the number one cause of preventable disease and is associated with the leading causes of death in our culture. 379

380 Section 7  c  Avoiding Destructive Behaviors Tobacco is the number one cause of preventable mortality in plug forms. Rather than being smoked, the dip, chew, or the United States. It is linked to most of the leading causes chaw stays in the mouth for several hours, where it mixes of death, and it leads to various other chronic conditions. well with saliva and is absorbed into the bloodstream. Although rates of smoking in the United States have decreased Smokeless tobacco contains about seven times more nico- in recent decades due to better awareness and a changed social tine than cigarettes, and more of it is absorbed because of norm concerning smoking and tobacco use, smoking is still a the length of time the tobacco is in the mouth. It also con- major public health problem. Today, 42 million adults in the tains a higher level of carcinogens than cigarettes. United States smoke (approximately 18 percent of the popu- lation). Worldwide, 6 million people Snuff, a form of smokeless tobacco, comes in either die annually from smoking, with an dry or moist form. Dry snuff is powdered tobacco and is estimated 8  million by the year 2030. typically mixed with flavoring. It is designed to be sniffed, According to a recent Gallup poll, most VIDEO 1 pinched, or dipped. Moist snuff is used the same way, but it is moist, finely cut tobacco in a loose form and is sold in smokers (67 percent) would like to quit tea-bag-like packets. Regardless of the form, all are harmful. but find it extremely difficult to do so. Unfortunately, the per- centage of people who want to quit is down 15 percentage The Health and Economic points from the peak of 82 percent a decade ago. Costs of Tobacco Tobacco and Nicotine Tobacco use is the most preventable cause of death in our society. The 1964 landmark Surgeon General’s report Tobacco and its smoke contain over 400 noxious first called attention to the negative health consequences of chemicals, including 200 known poisons and smoking. It is now well established that tobacco use is the 50 carcinogens. Tobacco smoke contains both gases and leading cause of death in the United States (accounting for particulates. The gaseous phase includes a variety of harm- nearly one in five of all deaths), contributing to 7 of the 10 ful gases, but the most dangerous is carbon monoxide. This leading causes of death. It is estimated that between 80 and gas binds onto hemoglobin in the bloodstream and thereby 90 percent of all deaths related to lung cancer and obstruc- limits how much oxygen can be carried in the bloodstream. tive lung disease are caused by smoking, and risk for coro- As a result, less oxygen is supplied to the vital organs of nary disease and stroke is two to four times higher among the body. While not likely from smoking, overexposure smokers. Further, new information about health risks contin- to carbon monoxide can be fatal. The particulate phase of ues to emerge. For example, a recent review of the literature burning tobacco includes a variety of carbon-based com- on tobacco and dementia by the World Health Organization pounds referred to as tar. Many of these compounds found indicates that as many as 14 percent of Alzheimer’s disease in tobacco are known to be carcinogens. Nicotine is also cases worldwide may be attributed to smoking. The report inhaled during the particulate phase of smoking. Nicotine is suggests that exposure to secondhand smoke may be suf- a highly addictive and poisonous chemical. It has a particu- ficient to increase risk for dementia. Thus, the number of larly broad range of influence and is a potent psychoactive diseases resulting from tobacco use is much more extensive drug that affects the brain and alters mood and behavior. than previously thought (see Figure 1). Nicotine is the addictive component of tobacco. One way to highlight the health risks associated with smok- When smoke is inhaled, the nicotine reaches the brain in ing is to examine the health benefits associated with smoking 7 seconds, where it acts on highly sensitive receptors and cessation. Estimates suggest that reducing serum cholesterol provides a sensation that brings about a wide variety of to recommended levels can increase life expectancy by about responses throughout the body. At first, heart and breathing 1 week to 6 months. In contrast, smoking cessation may rates increase. Blood vessels constrict, peripheral circulation increase life expectancy by 21 2 to 41 2 years. The earlier people slows down, and blood pressure increases. New users may quit, the more years of life they save, with roughly 3 years experience dizziness, nausea, and headache. Then feelings saved for those who quit at 60 years of age, 6 years for those of tension and tiredness are relieved. who quit at 50, and 9 years for those who quit at 40. The most effective way to reduce health risks associated with smoking After a few minutes, the feeling wears off and a rebound, is clearly to quit; however, reducing how much one smokes or withdrawal, effect occurs. The smoker may feel also makes a difference. In one study, rates of lung cancer depressed and irritable and have the urge to smoke again. dropped by 27 percent among those who reduced their smok- Physical dependence occurs with continued use. Nicotine ing from 20 or more to less than 10 cigarettes a day. is one of the most addictive drugs known, even more addic- Smoking has tremendous economic costs. In addition tive than heroin or alcohol. to the cost of human life, smoking in the United States results in approximately $170 million in health-care expenditures, Smokeless chewing tobacco is as addictive as accounting for 8.7 percent of total health-care spending in smoking and presents similar risks. Chewing tobacco comes in a variety of forms, including loose leaf, twist, and

Concept 19  c  The Use and Abuse of Tobacco   381 Brain: Increases risk of stroke While risks clearly increase with the amount of expo- sure, recent studies suggest that even low levels of smoking Eyes: Increases risk Mouth/Throat: have negative consequences. Unfortunately, although over- of cataracts and Increases risk of cancers all rates of smoking have decreased in recent years, rates macular degeneration of nondaily smoking have increased. These “chippers” or Lungs: Increases risk of the mouth, throat, “social smokers” have lower risk relative to regular smok- of lung cancer, bronchitis, larynx, and esophagus ers, but there are negative health consequences of even emphysema, tuberculosis, low levels of smoking. For example, one study found that pneumonia, and and causes smoking one to four cigarettes per day nearly triples the asthma gum disease risk of death from heart disease. Short-term physical con- sequences of smoking include increased rates of respiratory Kidneys, Heart: infections and asthma, impairment of athletic performance, Colon, Liver, Increases and reduced benefits and enjoyment associated with recre- Bladder, ational exercise. Pancreas: risk of Increases coronary Cigar and pipe smokers have lower death rates than risk of artery disease cigarette smokers but are still at great risk. Cigar and cancer and pipe smokers usually inhale less and, therefore, have less increases and risk for heart and lung disease, but cigarette smokers who diabetes atherosclerosis switch to cigars and pipes tend to continue inhaling the risk Reproductive System: same way. As the number of cigars smoked and the depth Stomach/ Increases risk of of smoke inhalation increase, the risk for death from cigar Abdomen: breast and cervical smoking approaches that of cigarette smoking. Cigar and Increases risk cancer, erectile dysfunction, pipe smoke contains most of the same harmful ingredients of stomach cancer, birth complications, as cigarette smoke, sometimes in higher amounts. It may peptic ulcers, and unhealthy babies, also have high nicotine content, leading to no appreciable abdominal aortic and sudden infant death difference between cigarette and pipe/cigar smoking with aneurysm syndrome in babies of smokers respect to the development of nicotine dependence. Cigar and pipe smokers also have higher risks for cancer of the Blood: Impairs immune system, mouth, throat, and larynx relative to cigarette smokers. Pipe increases risk of leukemia, and decreases HDL smokers are especially at risk for lip cancer. Figure 1  c  Unhealthy effects of smoking. Secondhand smoke poses a significant health risk. When smokers light up, they expose those around them to the United States. Over and above the costs at the societal secondhand smoke. Secondhand smoke is a combination level, there are significant financial costs for the individual, of mainstream smoke (inhaled and then exhaled by the particularly with increased taxes on tobacco products. In an smoker) and sidestream smoke (from the burning end of the effort to help smokers appreciate the financial burden of cigarette). Because sidestream smoke is not filtered through smoking, the Smokefree.gov website has a tool that allows the smoker’s lungs, it has higher levels of carcinogens and users to see how much they spend on cigarettes. For some- one who smokes a pack a day for 10 years, the total would Carcinogens  Substances that promote or facilitate the growth be more than $25,000, based on current average cigarette of cancerous cells. prices. Drug  Any biologically active substance that is foreign to the The health risks from tobacco are directly related body and is deliberately introduced to affect its functioning. to overall exposure. In past years, tobacco companies Withdrawal  A temporary condition precipitated by the lack of a denied there was conclusive proof of the harmful effects of drug in the body of an addicted person. tobacco products. Now, in the face of overwhelming medi- Physical Dependence A drug-induced condition in which a cal evidence, tobacco officials have finally conceded that person requires frequent administration of a drug in order to avoid tobacco is harmful to health. It is now clear that the more withdrawal. you use the product (the more doses), the greater the health Secondhand Smoke  A combination of mainstream and side- risk. Several factors determine the dosage: (1) the number stream smoke. of cigarettes smoked; (2) the length of time one has been Mainstream Smoke  Smoke that is exhaled after being filtered smoking; (3) the strength (amount of tar, nicotine, etc.) of by the smoker’s lungs. the cigarette; (4) the depth of the inhalation; and (5) the Sidestream Smoke  Smoke that comes directly off the burning amount of exposure to other lung-damaging substances end of cigarette, cigar, or pipe. (e.g., asbestos). The greater the exposure to smoke, the greater the risk.

382 Section 7  c  Avoiding Destructive Behaviors is therefore more dangerous. Although the negative conse- for heart disease, stroke, and diabetes, and they are also at quences of secondhand smoke have been known for some increased risk of becoming smokers themselves. Second- time, a 2006 Surgeon General’s report summarized in detail hand smoke can have a negative impact even when smok- the health dangers of secondhand smoke. The report indi- ers try to protect children from exposure. A recent study cated that there is no risk-free level of exposure to second- found that babies of parents who only smoked outdoors hand smoke. Key conclusions are summarized below. had levels of cotinine (a nicotine by-product) seven times higher than babies of nonsmokers. This has been attributed ∙ Exposure to secondhand tobacco smoke has been caus- to “thirdhand” smoke that may cling to clothing and hair. ally linked to cancer, to respiratory and cardiovascular These findings have led to public health efforts to involve diseases, and to adverse effects on the health of infants pediatricians in smoking cessation efforts, as parents gener- and children. ally see their child’s pediatrician more often than their own doctor. Parents may also be more responsive to the message ∙ The estimated increase in risk for stroke from exposure to if they learn that smoking can hurt their children. secondhand smoke is about 20 to 30 percent. While not technically considered secondhand exposure, ∙ The annual cost of lost productivity from premature smoking during pregnancy harms a developing fetus. Chil- death due to exposure to secondhand smoke is more than dren of smoking mothers typically have lower birth weight $5 billion. and are more likely to be premature, placing them at risk for a host of health complications. There is also a well- ∙ The evidence is sufficient to con- VIDEO 2 established relation between maternal smoking and risk for clude that smoke-free indoor air sudden infant death syndrome (SIDS). Finally, children of policies are effective in reducing mothers who smoke are at increased risk for later physical exposure to secondhand smoke and problems (respiratory infections and asthma) and behav- lead to less smoking among those ioral problems (attention-deficit/hyperactivity disorder). covered by these policies. The best way to reduce risk for pregnant mothers and their children is for women to quit smoking altogether. However, Women and children are especially susceptible to the there is some evidence that reductions in smoking also negative effects of secondhand smoke. Adolescents have benefits. exposed to secondhand smoke may have five times the risk Secondhand smoke exposure may also negatively of developing metabolic syndrome, which increases risk affect mental health. A recent study using a national sur- vey found a significant relation between cotinine levels, an Awareness about the risks of secondhand smoke has contributed to indicator of secondhand smoke exposure, and depression. changed social norms. Among those who never smoked, risk for depression was substantially increased for those exposed to cigarette smoke in their home or at work. Exposure to secondhand smoke in both childhood and adulthood has been associated with increased risk for depression and panic disorder 10 years later. Thus, mental health problems can be added to the list of the many negative health consequences of secondhand smoke exposure. The health risks of smokeless tobacco are similar to those of other forms of tobacco. Some smokers switch to smokeless tobacco, thinking it is a safe substitute for ciga- rette, cigar, and pipe smoking. While smokeless tobacco does not lead to the same respiratory problems as smok- ing, the other health risks may be even greater because smokeless tobacco has more nicotine and higher levels of carcinogens. Because it comes in direct contact with body tissues, the health consequences are far more immediate than those from smoking cigarettes. One-third of teenage users have receding gums, and about half have precancerous lesions, 20 percent of which can become oral cancer within 5 years. Some of the health risks of smokeless tobacco are listed in Table 1.

Concept 19  c  The Use and Abuse of Tobacco   383 Table 1  c  Health Risks of Smokeless Tobacco current situation is much more positive than for many other countries. While rates have been decreasing in the United Smokeless tobacco increases the risk for the following: States, they have been increasing in many others, particularly developing countries. Prevalence rates in China and many • Oral cavity cancer (cheek, gum, lip, palate); it increases the European countries greatly exceed those in the United States. risk by 4 to 50 times, depending on length of time used The use of smokeless tobacco is not as prevalent as smoking, but the National Institute on Drug Abuse estimates • Cancer of the throat, larynx, and esophagus that nearly 9 million Americans (mostly males) have used • Precancerous skin changes smokeless tobacco in the past month. Young people are • High blood pressure among the most frequent users, with 14.3 percent of high • Rotting teeth, exposed roots, premature tooth loss, and school boys reporting smokeless tobacco use. Unfortunately, decreases in smokeless tobacco use since the 1990s have worn-down teeth been smaller than the decreases in smoking. Between 2002 and 2012, the number of new smokeless tobacco users has • Ulcerated, inflamed, infected gums remained relatively stable. • Slow healing of mouth wounds Most tobacco users begin “using” during adolescence and find it hard to quit. The initiation of smoking is • Decreased resistance to infections viewed as a pediatric problem by most public health experts. Data from the National Survey on Drug Use and Health • Arteriosclerosis, myocardial infarction, and coronary indicate that roughly 2,800 adolescents initiate cigarette use each day, with over 700 becoming daily smokers by age 18. occlusion • Widespread hormonal effects, including increased lipids, Most adult smokers began smoking before age 21, and this group finds it particularly difficult to break the habit later higher blood sugar, and more blood clots • Increased heart rate in life. Although most regular smokers begin in adolescence, a significant number start later in life, particularly during early adulthood (ages 18–25). Unfortunately, the number of new smokers over age 18 increased from 600,000 in 2002 The Facts about Tobacco Usage to 1 million in 2013. The rate of past-30-day cigarette use is slightly lower among college students than among high At one time, smoking was an accepted part of our school seniors (14 versus 16 percent), and the rate is dra- culture, but the social norm has changed. While smok- matically lower than the rate among non-college age-matched ing has always been a part of our culture, the industrializa- peers (28 percent). Smokeless tobacco use also begins early tion and marketing in the middle of the 20th century led to in life. Almost 50 percent of users report that they started tremendous social acceptance of smoking. As odd as it may before the age of 13. Fortunately, after increases in initia- sound, cigarettes were once provided free to airline passen- tion of smokeless tobacco use from 2002 to 2010, rates have gers when they boarded planes. The release of the Surgeon returned to 2002 levels in recent years. The media play a role General’s report on smoking in 1964, aggressive and well- in promoting and preventing tobacco use. Much of the blame funded antismoking campaigns, and increases in cigarette for tobacco use among youth is attributed to media campaigns prices have contributed to reductions in smoking in the United States. Since the 1950s, the prevalence of smoking has declined steadily from a high of 50 percent. Based 40 Students on data from the National Health Interview Sur- 35 Adults vey, rates of smoking in the United States dropped Percentage (%) 30 HP2020 from 25 percent in the late 1990s to 17 percent in goals 25 2014. Rates among young people (high school stu- 20 Youth 16% dents) have dropped even more dramatically, from 15 36 percent to 15.7 percent (See Figure 2). The rapid 10 Adults 12% declines in smoking among high school students 5 have already achieved the Healthy People 2020 0 goal of 16 percent; but based on the slower rates of 222222221121222222000000990009000000010900019001109010241681730394572089 decline, it will take additional efforts to reach the Year goal of 12 percent for adults by 2020. Although there Figure 2  c  Trends in cigarette smoking. is still much work to be done in the United States, the Source: Centers for Disease Control and Prevention.

384 Section 7  c  Avoiding Destructive Behaviors A CLOSER LOOK E-Cigarettes: Smoking Cessation Aid or Gateway to Smoking? There is considerable debate about e-cigarettes by pub- lic health officials and policy-makers. A recent study found that those who used e-cigarettes had a 60 percent higher quit rate than those who used nicotine gum or patches. However, studies from national longitudinal studies of risk behavior indicate that rates of e-smoking have increased dramatically in recent years, particularly among young people who have never smoked conventional cigarettes. A prominent report from the CDC documented that rates of use tripled from 2013 to 2014 in both high school youth (4.5 to 13.4 percent) and middle school youth (1.1 to 3.9 percent). These increases run counter to the continued declines in use of conventional cigarettes, but there is con- cern that use may lead a new generation to adopt the habit. Studies indicate that people who had used e-cigarettes were nearly twice as likely to have intentions to try conventional cigarettes, compared to those who had not used e-cigarettes. Does the novelty attract youth to experiment with e-cigarettes? Would stricter regulations on the availability of e-cigarettes help to reverse this trend or will youth still find ways to obtain them? ACTIVITY Figure 3  c  Warning label images. taxes resulting in prices of more than $10 a pack in areas of New York, compared to prices of about $5 a pack in many Source: U.S. Food and Drug Administration. other states. Higher state tax rates have been shown to help reduce smoking rates. of tobacco companies that target this age group. Lawsuits filed against tobacco companies have played an important Public health campaigns and policies influencing role in decreased smoking rates in the United States. Money access have also been very effective in reducing smoking. from state settlements has helped to fund smoking prevention Four states that have aggressive anti-tobacco campaigns programs and public education campaigns (Figure 3). The reported a 43 percent decrease in tobacco use—double that lawsuits also prevented companies from direct marketing to reported by other states. According to the Substance Abuse anyone under the age of 18. These lawsuits have also had an and Mental Health Services Administration (SAMHSA), impact on public opinions of tobacco companies. Documents recent efforts to cut down on tobacco sales to minors have uncovered from the files of tobacco companies, during liti- also been extremely effective. Rates of selling to minors gation against the companies, have contained incriminating decreased dramatically between 1997 and 2013, falling evidence that has undermined the reputation of tobacco com- from 40.1 to 9.6 percent. Unfortunately, progress seems to panies and contributed to unfavorable public attitudes. have stalled, as rates have been quite stable since 2008. The Public policy can affect tobacco use. A number of states overall reductions in access have been correlated to usage, have passed special tax laws to fund anti-tobacco efforts. In so the policies seemed to have had a positive effect. Bans addition to efforts at the state level, in 2009 federal taxes on indoor smoking have also been important for reducing were raised from $.39 to $1.01 a pack. These tax increases access and exposure. A total of 36 states now ban smoking have contributed to the dramatic decreases in smoking in in all restaurants, 31 ban smoking in bars, and 31 ban smok- recent years. There is, however, wide variability in state ing in the workplace. A total of 25 states plus the District of Columbia are now smoke-free in all three settings. Including local bans by cities and counties, there are now over 22,000 indoor smoking laws in the United States.

Concept 19  c  The Use and Abuse of Tobacco   385 Fortunately, recent efforts to limit exposure to second- HELP Health is available to Everyone hand smoke seem to be paying off. A recent review confirms for a Lifetime, and it’s Personal that public smoking bans decrease rates of heart attacks. As indoor smoking bans are in place in most states, out- Researchers reviewed studies conducted in the United States, door smoking bans are becoming increasingly common, Canada, and Europe, and found that heart attack rates fell particularly on college campuses. There are now more 17 percent within a year after implementing smoking bans. than 1,500 smoke-free campuses in the United States, up Although workplace smoking bans have focused on keeping from almost 500 in 2010. These policies reflect the chang- smokers from smoking at work, employers have begun to ing social norms about smoking. encourage employees who smoke to quit altogether. Smokers Is your campus smoke-free? Do you support outdoor suffer from more physical and mental health problems at a smoking bans, or is this going too far? cost to employers via higher health-care premiums. A recent study estimates the cost of smoking at nearly $6,000 per ACTIVITY smoker per year, which includes lost productivity, health- care costs, and pension benefits for smokers. Efforts to barrier to quitting among those who want to stop smoking. reduce smoking are cheap, by comparison. An evaluation The stress-management approaches covered in other Con- of the “Tips from Former Smokers” public health campaign cepts may help with managing stress more effectively during found that the cost was less than $500 per smoker who quit. attempts to quit. People who smoke cigarettes also tend to use alcohol, Tobacco companies are finding new ways to recruit marijuana, and hard drugs. Alcohol has often been con- tobacco users. Following the legal settlement, the tobacco sidered a gateway to other drug use, and marijuana is often industry responded by dramatically increasing its spending thought of as a gateway to other drugs, such as cocaine on advertising and promotion (an estimated $8.8 billion in and heroine. Although tobacco use has been studied less annual spending). The vast majority of this spending is for extensively as a gateway drug, there is strong evidence that price discounts meant to directly undermine the tax increases smoking is associated with increased risk for the use of both that have led to reduced smoking rates. The tobacco industry alcohol and illicit drugs. The combination of smoking and has also introduced new products and packaging to target drinking is particularly common in college students. Results young people. First they introduced flavored cigarettes, of a nationally representative study of college students indi- followed by dissolvable tobacco in cated that 97 percent of college smokers drink, while other pill form (e.g., Camel Orbs). Most national data report that 80 percent of all college students recently, the tobacco industry has drink. Those who drink also report higher levels of smoking. invested heavily in e-cigarettes and VIDEO 3 Rates of smoking among college drinkers range from 44 to 59 percent (compared with a national average rate of under other smokeless tobacco products. 30 percent). The combination of alcohol use and smoking Although companies manufacturing these products argue poses an even greater risk to physical health. that they are a healthy alternative to smoking, the U.S. Food The addictive nature of nicotine makes it difficult to and Drug Administration (FDA) is not convinced, and many quit using tobacco. Salient examples of the power of nico- people are concerned that e-cigarette use will be a gateway tine addiction are high rates of continued use among those to traditional cigarette use. Another approach to targeting young people is through Table 2  c  Why Young People Start Using Tobacco Internet-based sales. Although store sales to minors have decreased dramatically in recent years, it is relatively easy for • Peer influence minors to obtain cigarettes online. A recent Surgeon General’s • Social acceptance report noted that 8 out of 10 minors • Desire to be “mature” who placed online cigarette orders were • Desire to be “independent” able to fill their orders, and only 1 in • Desire to be like their role models 10 was asked to provide proof of age. VIDEO 4 • Appealing advertisements Various factors influence a person’s decision to begin smoking. The reasons for starting smoking are varied but are strikingly similar to reasons given for using alcohol and other drugs (see Table 2). Many young women begin smoking because they believe it will help them control their weight and negative mood states. Some current smokers fear they will gain weight if they quit. Also, those who smoke report higher levels of stress, and stress has been shown to be a maintaining factor among current smokers and a

386 Section 7  c  Avoiding Destructive Behaviors In the News Smoking Cessation smoking cessation aids. Given high rates of co-occurrence of smoking and alcohol use among young people (including col- Although newer smoking cessation drugs lege students), changes in alcohol response may be of particu- like Chantix have shown some promise in lar importance. helping smokers to quit, they are not without risks. Several years ago, the FDA required Pfizer to include a warning about Do the potential benefits of drugs like Chantix outweigh the increased risk for suicide and other psychiatric side effects. In risks for smokers? Given the changes in alcohol response March 2015, the FDA called for a new warning about the poten- with Chantix, should extra warnings be provided for college tial for reduced alcohol tolerance and increased intoxicated risk students and young adults? behavior (e.g., aggression) in users of Chantix. Clearly, poten- tial users must weigh the relative risks and benefits of these ACTIVITY with serious smoking-related health consequences and low 42 million smokers in the United States in 2012 had tried to rates of success for quit attempts. In a study in 15 European quit in the past year. Unfortunately, most of these attempts countries, over half of adults who suffered from serious were unsuccessful. Most people make many attempts before medical problems known to be associated with smok- they succeed. Withdrawal symptoms and cravings for nico- ing (e.g., heart attack, bypass surgery) continued to smoke tine are often cited reasons for failed quit attempts. Many 1 year later. Data from the CDC found that nearly half of the former smokers report nicotine craving months and even years after quitting. The good news is that when you quit TECHNOLOGY UPDATE you may feel better right away and your body will heal. You will feel more energetic, the coughing will stop, you Text Messaging for Smoking Cessation will suddenly begin to taste food again, and your sense of smell will return. Your lungs will eventually heal and look A federally funded website, Smokefree.gov, provides a like the lungs of a nonsmoker. Your risk for lung cancer will variety of services to help smokers quit, including a new return to that of the nonsmoker in about 15 to 20 years. If text-messaging service (smokefree.gov/smokefreetxt). you aren’t successful at first, keep try- Smokers complete a brief online questionnaire that ing, as most people eventually succeed includes their quit date, and the program sends 1–5 texts (about 50 million adults in the United per day over a 6- to 8-week period. The text messages pro- States are former smokers). VIDEO 5 vide encouragement, advice, and tips to help the smoker succeed. Users can also text keywords to get additional Exercise and medication can also help you quit. Recent support. For example, on the day before the identified quit studies suggest that regular physical activity can reduce the date, the smoker might receive the message “Tomorrow is health risks of smoking in two important ways. First, among quit day! Toss your pack in the trash & get plenty of sleep. smokers, those who exercise regularly may be at decreased For extra support, text these keywords at any time: Crave, risk for the development of cardiovascular disease due to Mood, or Slip.” The program is provided at no cost to the improved peripheral blood flow. Perhaps more important, user other than any data or texting fees from the user’s physical activity reduces the likelihood of relapse among cell phone provider. There is also a version of the program those who quit. Nicotine replacement products (patches, specifically tailored to the needs of veterans who are try- gum, nasal sprays) and medications such as Zyban and ing to quit (smokefree.gov/vet). Chantix, have helped some smokers quit. Unfortunately, not all users benefit from smoking cessation aids, and drugs like Does this seem like a promising strategy? If you or a these result in significant side effects in some users. In fact, friend wanted to quit smoking, would you use this free the FDA has required that Chantix include warning labels texting program? about significant psychiatric and behavioral side effects. Fortunately, there are also a variety of behavioral strategies ACTIVITY that can help smokers quit, even without medications (see Table 3).

Concept 19  c  The Use and Abuse of Tobacco   387 Table 3  c  Strategies for Quitting Smoking • You must want to quit. The reasons can be for health, family, money, and so on. • Remind yourself of the reasons. Each day, repeat to yourself the reasons for not using tobacco. • Decide how to stop. Methods to stop include counseling, attending formal programs, quitting with a friend, going “cold turkey” (abruptly), and quitting gradually. More succeed with “cold turkey” than with the gradual approach. • Remove reminders and temptations (ashtrays, tobacco, etc.). • Use substitutes and distractions. Substitute low-calorie snacks or chewing gum, change your routine, or try new activities. • Do not worry about gaining weight. If you gain a few pounds, it is not as detrimental to your health as continuing to smoke. • Get support. Try a formal “quit smoking” program for professional help and seek support from friends and relatives. • Consider a product that requires a prescription, such as a nicotine transdermal patch (Zyban) or nicotine chewing gum. • Develop effective stress-management techniques. The single most frequently cited reason for difficulty in quitting smoking is stress. Strategies for Action Although quitting is ultimately up Lab 19A will help you evaluate your potential risks for smoking. to you, that does not mean you If you are a smoker, an honest assessment of your background have to do it alone. A number of national organizations pro- and exposure to tobacco is an important first step to quitting. vide telephone hotlines to help those trying to quit smoking. These include the American Cancer Society (1-877-YES-QUIT), The USPHS consumer’s guide provides a list of questions the National Cancer Institute (1-877-44U-QUIT), and the U.S. you may want to ask yourself as you prepare to quit. This exer- Department of Health and Human Services (1-800-QUIT-NOW). cise may help you increase your motivation to change and In addition, an online smoking program sponsored by several decrease the likelihood of a relapse. You may want to talk about federal agencies is now available at www.smokefree.gov. The your answers with your health-care provider. U.S. Public Health Service (USPHS) has published a consumer’s guide to quitting smoking. It has determined that the following 1. Why do you want to quit? five factors are associated with the likelihood of success: 2. When you tried to quit in the past, what helped and what did 1. Get ready. not? 2 . Get support. 3. What will be the most difficult situations for you after you 3. Learn new skills and behaviors. 4. Get medication and use it correctly. quit? How will you plan to handle them? 5 . Be prepared for relapse and difficult situations. 4. Who can help you through the tough times? Your family? Friends? Your health-care provider? 5 . What pleasures do you get from smoking? In what ways can you still get pleasure if you quit? ACTIVITY

388 Section 7  c  Avoiding Destructive Behaviors Suggested Resources ∙∙ Gallup: Tobacco and Smoking. and Readings National Geographic: Thirdhand Smoke Is Real—and Risky to Your Health. ∙∙∙∙∙ Quitnet: A Free Resource to Quit Smoking. The websites for the following sources can be accessed by searching SAMHSA: Trends in Smokeless Tobacco Use and Initiation. online for the organization, program, or title listed. Specific scien- Smokefree.gov: SmokefreeTXT. tific references are available at the end of this edition of Concepts of Stop Smoking Center: Benefits of Quitting. Surgeon General’s Report (2012): Preventing Tobacco Use among Fitness and Wellness. ∙ American Nonsmokers’ Rights Foundation: 100% Smokefree Youth and Young Adults. Laws. ∙ Surgeon General’s Report (2014): The Health Consequences of ∙ American Nonsmokers’ Rights Foundation: Smokefree Colleges Smoking: 50 Years of Progress. and Universities. ∙ U.S. Public Health Service: You Can Quit Smoking, Consumer ∙ Campaign for Tobacco Free Kids: Public Education Campaigns Reduce Tobacco Use (pdf). ∙∙∙ Guide. WebMD: Smoking Cessation Health Center. ∙∙∙ CDC: Cigarette Smoking among Adults in the United States. World Health Organization: Fact Sheet: Tobacco. CDC: Fact Sheet: Health Effects of Cigarette Smoking. World Health Organization: Tobacco and Dementia (pdf). CDC: Report on Increases in use of E-Cigarettes.

Lab 19  Use and Abuse of Tobacco Name Section Date Lab 19 Purpose: To understand the risks of diseases (such as heart disease and cancer) associated with the use of tobacco or exposure to tobacco by-products. Procedures Use and Abuse of Tobacco 1. Read the Tobacco Use Risk Questionnaire (Chart 1). 2. Answer the questionnaire based on your tobacco use or exposure. 3. Record your score and rating (from Chart 2 on the next page) in the Results section. Results (total from Chart 1) What is your tobacco risk score? (see Chart 2) What is your tobacco risk rating? Chart 1  Tobacco Use Risk Questionnaire Circle one response in each row of the questionnaire. Determine a point value for each response using the point values in the first row of the chart. Sum the numbers of points for the various responses to determine a Tobacco Use Risk score. Points Categories 0 1 2 34 Cigarette use Never smoked 1–10 11–40 .40 cigarettes a day cigarettes a day cigarettes a day Pipe and cigar use Never smoked Pipe— Cigar— Cigar or pipe— Cigar—heavy use occasional use infrequent daily use frequent daily use Smoking style Don’t smoke No inhalation Slight to moderate Deep inhalation inhalation Smokeless Don’t use Occasional use: Daily use: Daily use: Heavy use: tobacco use not daily one use per day multiple use per repetitious, day multiple use daily Secondhand or No smokers Smokers at Smokers at home Smokers at home sidestream smoke at home or in workplace but not but not workplace and at workplace workplace at home Years of tobacco use Never used 1 or less 2–5 6–10 .10 Note: Different forms of tobacco use pose different risks for different diseases. This questionnaire is designed to give you a general idea of risk a­ ssociated with use and exposure to tobacco by-products. 389

Chart 2  Tobacco Use Risk Questionnaire Rating Chart Lab 19 Rating Score Very high risk 161 High risk 7–15 Moderate risk 1–6 Low risk 0 Use and Abuse of Tobacco Conclusions and Implications 1. In several sentences, discuss your personal risk. If your risk is low, discuss some implications of the behavior of other people that affect your risk, including what can be done to change these risks. If your risk is above average, what changes can be made to reduce your risk? 2. In several sentences, discuss how you feel about public laws designed to curtail tobacco use. Discuss your point of view, either pro or con. 390

The Use and Abuse Concept 20 of Alcohol LEARNING OBJECTIVES After completing the study of this Concept, you will be able to: c Understand the effects of alcohol on the body. c Describe different patterns of alcohol use and problems, including alcohol use disorders. c Identify the negative physical, psychological, and behavioral consequences of excess alcohol consumption. c List factors that have contributed to declining rates of driving under the influence of alcohol. c Explain biological and environmental factors associated with increased risk for alcohol problems. c Determine aspects of the college environment that contribute to heavy drinking among students. c Describe effective alcohol prevention and treatment approaches. c Identify steps you can take to protect yourself and others.  Alcohol is among the most widely used and destructive drugs. Abstaining from alcohol is the surest way to prevent negative consequences, but learning to drink in moderation can significantly reduce risk. 391

392 Section 7  c  Avoiding Destructive Behaviors Beer Wine Whiskey (12 ounces) (5 ounces) (1.5 ounces) Alcohol is the most widely used and destructive drug in the United States. If all of the deaths caused by this == drug are counted, it is the third leading health problem and cause of early death in the United States. Only tobacco and 5% alcohol 12% alcohol 80 Proof inactivity/poor nutrition rank ahead of alcohol use. Some (40% alcohol) consider alcohol use to be the most destructive because of the devastating results of drinking and driving (or operating Figure 1  c  Alcohol content of drinks. other vehicles) and the consequences of increased crime, physical and sexual abuse, and destroyed family relation- Source: National Institute on Alcohol Abuse and Alcoholism. ships often associated with overindulgence in alcohol. It is estimated that over 17 million people in the United States Alcohol’s effects on the body depend on many factors. (over 7 percent of the total population) meet the criteria for Alcohol is absorbed directly into the bloodstream, primarily some type of alcohol-related diagnosis. in the small intestines. It then concentrates in various organs in proportion to the amount of water each contains. The Alcohol and Alcoholic Beverages brain has a high water content, so much of the alcohol goes there. Once it is absorbed, alcohol is metabolized primarily Alcoholic beverages contain ethanol (ethyl alcohol), by the liver. An enzyme in the liver, called alcohol dehy- an intoxicating and addictive drug that is often drogenase (ADH), converts alcohol to acetaldehyde, which misused. The active drug in alcoholic beverages (ethanol) is then converted by acetate and other enzymes into carbon is a toxic chemical, but unlike methanol (wood alcohol) and dioxide and water. Individuals differ with respect to their isopropyl (rubbing alcohol), it can be consumed in small ability to metabolize alcohol, but a healthy adult takes 1 to doses. As a drug, it is classified as a depressant. However, 2 hours to metabolize one standard drink. this classification does not capture the full range of alcohol’s effects. The effects experienced by the drinker depend, in Although the basic processes of alcohol absorption and part, on whether the drinker’s blood alcohol concentration metabolism are the same for everyone, the effects of alco- is rising or falling. The sedative effects of alcohol as blood hol depend on a number of additional factors including alcohol levels fall are consistent with its classification as a stomach contents, body size/weight, rate of consumption, depressant. In contrast, primarily stimulant effects are expe- beliefs about alcohol effects, and drinking context (e.g., bar rienced by the user as blood alcohol concentration rises. vs. home). There are also important gender differences in alcohol response. Because women have lower amounts of Humans have consumed alcoholic beverages for thousands body water, a given amount of alcohol represents a greater of years. Unfortunately, many people in our culture (partic- percentage of the volume of the blood in their bloodstream. ularly college students) view drunkenness as a rite of pas- Women also have lower amounts of the enzymes needed to sage and an expectation. Indeed, there are more synonyms process alcohol. for the word drunk or intoxication than for any other word in the English language. This illustrates the importance we Because the rate of alcohol consumption is often greater give to overconsumption. Fortunately, as people mature, than the rate at which it is processed, the alcohol concentra- they tend to reduce their consumption, as responsibilities tion in the bloodstream begins to increase. The blood alco- such as work and family become more important. hol concentration (BAC) is measured as a percentage and is used by law enforcement officials to determine if a driver is Alcoholic beverages have varying concentrations of legally intoxicated. alcohol, but many have similar amounts per serving. Beverages are usually served in proportions such that a drink Alcohol Consumption of any one of the three categories (beer, wine, or liquor) con- and Alcohol Abuse tains the same amount of alcohol. Beer is usually served in a 12-ounce can, bottle, or mug. A typical glass of wine holds Risks and benefits of alcohol use depend on the 5 ounces, and a shot of liquor is 1.5 ounces. Even though amount and pattern of consumption. Making state- the percentage of alcohol in the beverages differs, the drinks ments about the consequences of alcohol consumption is would be equivalent in alcohol because each would contain difficult because the consequences vary depending on the about 14 g of alcohol (see Figure 1). Although the amount of alcohol is equivalent across these different drink types, differences in the way they are consumed may lead to differ- ences in blood alcohol concentrations. For example, because liquor is often consumed more quickly than beer or wine, blood alcohol concentrations rise more quickly.

Concept 20  c  The Use and Abuse of Alcohol   393 Table 1  c  Terms and Criteria for Patterns of Alcohol Use Term Criteria Moderate drinking (NIAAA) Men: #2 drinks/day Women: #1 drink/day Over 65: #1 drink/day At-risk drinking (NIAAA) Men: .14 drinks/week or .4 drinks/occasion Women: .7 drinks/week or .3 drinks/occasion Heavy-episodic drinking/binge Men: 5 or more alcoholic drinks consumed in a 2-hour period drinking (NIAAA) Women: 4 or more alcoholic drinks consumed in a 2-hour period Alcohol use disorder (APA) Maladaptive pattern of alcohol use leading to clinically significant impairment or distress, manifested within a 12-month period by two or more of the following: (mild: 2–3 symptoms, moderate: 4–5 symptoms, severe: 6 or more symptoms) • Use of larger amounts or over a longer time period than intended • Persistent desire or unsuccessful attempts to cut down or control use • Great deal of time spent obtaining, using, or recovering from use • Craving, or a strong desire or urge to use • Recurrent use leading to failure to fulfill role obligations at work, school, or home • Continued use despite alcohol-related social or interpersonal problems • Important social, occupational, or recreational activities given up or reduced due to use • Recurrent use in hazardous situations • Use despite knowledge of alcohol-related physical or psychological problems • Tolerance (either increasing amounts used or diminished effects with the same amount) • Withdrawal (withdrawal symptoms or use to relieve or avoid symptoms) Note: NIAAA, National Institute on Alcohol Abuse and Alcoholism; APA, American Psychiatric Association. Source: O’Conner and Schottenfeld. amount consumed and the pattern of consumption. Moder- the non-gender-specific definition of 5+, approximately ate alcohol consumption has been shown to provide some 25 percent of the U.S. population over the age of 18 (over benefits for reducing risk of heart disease, but considerable 58 million people) report binge drinking in the past 30 days. risks occur when consumed in excess. Risks for alcohol con- sumption are not the same for everyone, so it is important to Binge drinkers are 14 times more likely to drink and understand the relative risks and benefits of various levels of drive, and they are at increased risk for a host of negative alcohol consumption. outcomes, including development of alcohol use disorders (see Table 1 for characteristics). Two key signs of alcohol use Patterns of alcohol consumption are characterized in disorders are alcohol tolerance and alcohol withdrawal. a variety of ways. Over half (56.4 percent) of the U.S. Unfortunately, many people seem to think that tolerance population over the age of 18 report alcohol use in the past is a good sign, as evidenced by statements such as “I can 30 days. This makes alcohol the most widely used drug of hold my liquor” and “I’m not a lightweight.” The reality abuse in this country. Most who choose to drink develop a pattern of light or moderate drinking. The National Institute Drug  Any biologically active substance that is foreign to the on Alcohol Abuse and Alcoholism (NIAAA) characterizes body and is deliberately introduced to affect its functioning. “moderate consumption” as one drink per day or less for Intoxication  Also referred to as drunkenness; a blood alcohol women and two drinks per day or less for men (see Table 1). level of .08 percent. Those who exceed these standards are often described Alcohol Use Disorder A psychiatric condition characterized as at-risk drinkers. Heavy-episodic drinking (commonly by alcohol-related problems that cause significant impairment or referred to as binge drinking) is common among at-risk distress. drinkers. It is defined as five or more standard alcoholic Alcohol Tolerance The phenomenon of requiring more and drinks consumed on the same occasion (i.e., at the same more alcohol over time to achieve the desired effect. time or within a couple of hours of Alcohol Withdrawal Symptoms that occur when alcohol is each other), though some organiza- withdrawn after a period of prolonged heavy use. Symptoms tions (including the NIAAA) use 4 or include sweating, anxiety, tremors, and seizures. more for women (see Table 1). Using VIDEO 1

394 Section 7  c  Avoiding Destructive Behaviors is that tolerance has mostly negative implications. There protect against coronary heart disease (CHD), as outlined is also recent evidence that those who have a natural, or later in this Concept, heavier use of alcohol may increase “innate,” tolerance to alcohol effects are at increased risk the risk for CHD and other cardiovascular disease. Specifi- for developing alcohol use disorders. With the heavier use cally, heavy drinking is associated with increased risk for that comes with the development of tolerance, withdrawal hypertension, cardiomyopathy, cardiac arrhythmia, and symptoms may develop when alcohol is not administered congestive heart failure. Alcohol consumption increases the regularly. Withdrawal symptoms include anxiety, increased risk for cancer, including cancer of the oral cavity and phar- heart rate, sweating, hand tremor, nausea, and vomiting. In ynx, esophagus, liver, larynx, and female breast. The risk more severe cases, withdrawal can lead to hallucinations for certain types of stroke (hemorrhagic) is also increased and seizures. by alcohol, and there is evidence that heavy drinking may impair immune functioning, leading to increased risk for Health and Behavioral infectious diseases, including pneumonia and tuberculosis. Consequences of Alcohol Use Heavy alcohol use also has both acute and long-term effects on cognitive functions including memory, and increases risk Heavy alcohol use is associated with an increased risk for psychiatric disorders that often occur with alcohol prob- for a variety of negative health and social outcomes. lems (e.g., mood and anxiety disorders). The most well-established health risk associated with alco- Although many health risks of alcohol use are directly hol consumption is liver disease. Alcohol consumption is related to the effects of alcohol on the body, others are the leading cause of disease and death from liver dysfunc- related to the intoxicated behavior of tion, with an estimated 2 million Americans suffering from the drinker. For example, heavy epi- alcohol-induced liver disease. Although the liver is capable sodic drinking increases risk for motor of metabolizing moderate amounts of alcohol on a regular vehicle crashes, falls, burns, drown- VIDEO 2 basis, persistent, heavy drinking may lead to swollen liver cells, a condition called fatty liver. If drinking is stopped or ings, interpersonal violence, and sexu- significantly reduced at this point, the damage to the liver is ally transmitted infections. Ambitious public health goals likely reversible. With continued heavy drinking, the indi- have been set for curtailing binge drinking in the United vidual is likely to develop alcoholic cirrhosis, or permanent States, but rates have remained relatively stable. scarring of the liver. Women appear to be especially susceptible to the Heavy drinking is also a risk factor for other life- negative health consequences of heavy drinking. At threatening diseases. Figure 2 depicts all causes of mortality similar levels of alcohol consumption, women are more risk as well as mortality risk for several specific diseases likely than men to experience liver, cardiovascular, and by level of alcohol consumption, with values less than 1 brain damage from drinking. Alcohol also increases risk reflecting decreased risk and values greater than 1 reflecting of breast cancer and negatively impacts the reproductive increased risk. Although moderate alcohol consumption may system. Pregnant women should avoid alcohol because it can lead to fetal alcohol effects, including fetal alcohol Relative death risk 1.7 All causes Heart disease Cancer Accidents/ syndrome (FAS), which is associated with low violence birth weight, physical defects, mental retar- dation, and stunted growth. In summary, the 1.5 health risks of alcohol consumption are exten- sive, and must be considered in relation to the 1.3 potential benefits. 1.1 Whereas excessive drinking presents .9 many risks, moderate consumption can .7 provide some health benefits. There is evi- dence that moderate alcohol consumption (one .5 None ,1 1 2 34 5 drink per day for women, up to two drinks per day for men) is associated with decreased risk Number of drinks per day for CHD, Type II diabetes, and certain types $6 of stroke. At this point, the extent to which Figure 2  c  Alcohol consumption and death risk. moderate drinking “causes” reduced risk for cardiovascular disease is not entirely clear. It Source: American Cancer Society. may be that moderate drinkers are at lower risk based on other characteristics, such as higher

Concept 20  c  The Use and Abuse of Alcohol   395 In the News Are the Health Benefits of Alcohol Exaggerated? An editorial in the British Medical Journal relation between moderate alcohol use and health benefits. suggests that the alcohol industry has inten- For example, a recent study in England found limited evidence tionally exaggerated claims of health benefits in order to for a protective role of moderate alcohol use when appropriate promote their products. Although some studies have shown research controls were used. that moderate alcohol use is associated with a reduced risk for Given the health risks of alcohol use, do you think doctors cardiovascular disease, there is limited evidence for a causal should ever recommend even moderate drinking? influence, and some critics argue that prior studies have not sufficiently controlled for other variables that may explain the ACTIVITY education and income, better diet, and more regular exercise. Table 2  c  People Who Should Consider Abstaining Still, mechanisms for a causal role of alcohol use in protec- from Alcohol Use tion against CHD are plausible. Recent evidence suggests that moderate alcohol use may also protect against cognitive • People under age 21 (legal age) declines with aging. Although the health benefits of mod- • Athletes striving for peak performance erate alcohol consumption have largely been attributed to • Women trying to get pregnant or who are pregnant or wine consumption, beer appears to have similar benefits. In addition, there is some evidence that beer consumption may nursing benefit bone strength because it has high levels of dietary silicon, which contributes to bone density. Beers with high • Alcoholics and recovering alcoholics levels of barley and hops are particularly good sources of • People with a family history of alcoholism silicon. • People with a medical or surgical problem and/or on Although there is evidence of health benefits from mod- medications erate alcohol use, there is considerable debate about the extent of these benefits. Also, even moderate alcohol con- • Psychiatric patients or persons experiencing severe sumption may not be safe for some people. Certain groups are best off not drinking at all, despite potential health ben- psychosis efits (see Table 2). Also note that the pattern of drinking is as important as the absolute level. A woman who has seven • People driving vehicles, operating dangerous machinery, or drinks one time each week consumes an average of one drink per day but does not receive the same health benefits involved in public safety as a woman who consumes one drink each day. Moderate consumption of alcohol can be safely incorporated into a • People conducting serious business transactions or study healthy lifestyle, but heavy drinking cannot. social costs. Although the short-term costs are significant, The greatest danger of alcohol occurs when the the long-term costs of a drunk driving arrest typically far drinker gets behind the wheel of a motor vehicle. outweigh the immediate financial burden. Having an offense Alcohol-related traffic crashes are the leading cause of death on your record can lead to problems with schools, family, and and spinal cord injury for young Americans. Approximately future employers. Despite the potential short- and long-term 31 percent of fatal injury traffic accidents involved at least costs, a recent survey conducted by the National Highway one driver with a BAC of .08 percent or higher. The driver’s Traffic Safety Administration (NHTSA) found that about likelihood of causing a highway accident increases at a BAC 11 percent of drivers in the United States drove under the of .04 percent (1-2 drinks for most people). The likelihood of a fatal or serious injury crash is 6 to 12 times higher for Fatty Liver  Swelling of the cells of the liver. an individual with a BAC of .10 percent relative to a person Alcoholic Cirrhosis  Permanent scarring of the liver, resulting in with no alcohol in their system. reduced blood flow and buildup of toxins in the body. In addition to risks associated with traffic accidents, those who drink and drive face significant legal, financial, and

396 Section 7  c  Avoiding Destructive Behaviors Table 3  c  The Effects of Blood Alcohol Concentration Table 4  c  Approximate BAC Values (%) Based on the (BAC) on Driving Performance and Function Number of Drinks Consumed over a Two-Hour Period BAC .02% Number Females Males • Vision is impaired: less ability to see objects in motion; less of Drinks 120-Pound 180-Pound 140-Pound 200-Pound ability to monitor multiple objects. 1 .02 .004 .007 .001 • Attention span is lower. 2 .06 .03 .04 .02 • Reaction time slows. 3 .10 .06 .07 .04 BAC .05–.06% 4 .15 .09 .10 .06 • Inhibitions are reduced (unnecessary chances may be 5 .19 .12 .13 .08 taken). 6 .23 .15 .16 .10 • Visual abilities decrease; side vision is impaired by 30%. • Judgment is the first function to be impaired. 7 .27 .17 .19 .13 • Braking distance is extended. • Coordination is impaired. 8 .31 .20 .22 .15 • Driving performance is impaired at moderate speed. Source: National Highway Traffic and Safety Administration–NHTSA (1994). BAC .08% influence in the last year. Rates were even higher (roughly 20 • Vision is seriously impaired, especially at night. percent) among young adults aged 21 to 25. • Overconfidence in driving ability. • Less ability to concentrate. Awareness of the impact of alcohol on impairment is • Judgments are dulled; driver is more careless. important for avoiding problems. Table 3 summarizes the • Muscle control and coordination are hindered. effects of different BAC values on physical and driving per- • Driving performance is impaired at low speeds. formance. Table 4 provides estimated BACs for men and • Driver increases the use of the accelerator and brake. women at various weights, and Lab 20A provides the for- mula for calculating BAC for your precise weight. BAC .15% Stronger policies have contributed to decreases in alcohol-related traffic fatalities. Although alcohol-related • Gross motor impairment and lack of physical control. traffic fatalities remain a major public health concern, pol- • Blurred vision and loss of balance. icy changes, such as increasing the legal drinking age to 21 and decreasing the legal limit for intoxication to .08 percent, BAC .20% have led to dramatic decreases in impaired driving over the past 30 years (see Figure 3). In an effort to continue these • Disorientation and difficulty walking. declines, new approaches are being developed, including • Nausea and vomiting. • Anesthesia. • Impaired gag reflex. • Blackouts. BAC .30% • Stupor and decreased respiration. • Loss of consciousness. BAC .40% • Coma. • Death is possible, due to respiratory arrest. Source: Mothers Against Drunk Driving. A CLOSER LOOK Impaired Driving and Traffic Fatalities reviewing alcohol policies and penalties may cause you or a friend to think twice about driving while impaired. Search “CDC Rates of impaired driving and their consequences vary consid- state policies on impaired driving” online to take a closer look. erably from state to state. A Centers for Disease Control and Prevention (CDC) website lets you compare the consequences Are you surprised by the statistics on impaired driving and of driving impaired in your state with other states. The site traffic fatalities in your state? What factors might contribute to provides fact sheets for each of the 50 states, allowing you to higher or lower rates in your state, relative to national levels? see rates of drunk driving and alcohol-related traffic fatalities for your state compared to national rates. Understanding and ACTIVITY

Concept 20  c  The Use and Abuse of Alcohol   397 25,000 ignition interlock devices that prevent a driver who is over the legal limit from starting his or her car. Many states require Alcohol-related tra c deaths per year 20,000 the interlock devices in the cars of at least some offend- ers, and studies show that they decrease re-arrest by almost 15,000 70 percent. Some states are considering interlock devices for all offenders, and car manufacturers are also working on 10,000 developing alcohol sensors that can be installed in new cars. This would allow all drivers (not just DUI offenders) to know 5,000 if they are driving impaired. Perhaps in response to stricter laws, many people are testing their own blood alcohol levels 0 1982 1991 2004 2013 before getting behind the wheel. Sales of blood alcohol self- Year tests have increased dramatically in recent years. Figure 3  c  Declines in alcohol-related traffic fatalities. Risk Factors for Alcohol-Related Problems Source: Foundation for Advancing Alcohol Responsibility, www.responsibility.org. Early age of drinking onset increases risk for later TECHNOLOGY UPDATE problems. Those who begin drinking at an earlier age are at risk for the development of alcohol use disorders. Although Alcohol-Sensing Lasers the nature of the relation between age of onset and later problems is not yet clear, many believe that early use inter- In order to enforce impaired driving laws, police must be feres with a critical period of brain development. The part of able to identify drivers who may be under the influence. the brain involved in emotion regulation and impulse control This is usually detected by erratic or poor driving or by (the frontal lobe) is not fully developed until the mid-20s, screens at road blocks. However, new laser technology so, although physical maturation may be complete by the could significantly aid efforts to reduce impaired driving. age of 18, cognitive abilities are still developing during this An external laser device detects alcohol vapors in cars as period. Use of alcohol and other drugs during this important they pass by, allowing police to identify impaired drivers period of brain development may have long-term negative in much the same way they use lasers to stop speeders. consequences for young people. The same technology could be adapted to detect other chemical compounds, allowing police to identify drivers Having a family member with an alcohol problem under the influence of other drugs. Using lasers, how- places you at increased risk for developing a problem ever, does have potential limitations. The lasers might yourself. Experts have known for some time that the develop- detect alcohol vapors from passengers rather than driv- ment of alcohol use disorder has a genetic component. Alco- ers, and drivers could attempt to avoid detection (e.g., hol problems run in families, and it is estimated that genetics open windows or use window screens). There may also account for roughly half of the risk for alcohol dependence. be legal issues regarding probable cause based on the In the future, we may find out exactly how genetic differences identification of alcohol vapors. Nonetheless, this could contribute to risk, but for now we know that genetics are be a valuable new tool for reducing alcohol-related traffic important. Thus, if you have a family history of alcoholism, fatalities. you should be especially careful about your drinking behavior. Would you support the use of laser technology to stop Environment also plays a role in the initiation and potentially impaired drivers? Do you think using this tech- escalation of alcohol use. During childhood, parents play nology would violate drivers’ rights? a significant role in the socialization process, which includes socialization regarding alcohol use. Parents who talk to their ACTIVITY kids about alcohol use, provide social support, and moni- tor their children’s behavior are less likely to have children who drink excessively during adolescence. During adoles- cence, peers take on a powerful role in the development of alcohol problems. One of the best predictors of adolescent alcohol use patterns is the pattern of alcohol use among their close friends. Broader environmental influences also play a key role in the development of alcohol use. The promotion of alcohol

398 Section 7  c  Avoiding Destructive Behaviors as a social lubricant leads to the development of positive proportion of various alcohol-related problems is consider- beliefs about the effects of alcohol, referred to as “alcohol ably higher for people categorized as frequent binge drink- expectancies.” These beliefs have been shown to develop ers than for non-binge drinkers. even before personal experience with alcohol. Media por- trayals of the benefits of drinking are believed to play an Rates of binge drinking in college have remained high important role in the development of positive expectan- and rates of frequent binge drinking have increased, but cies. Adolescents are bombarded with these messages from there are also signs of progress. There are consistent an early age. Between 2001 and 2009, youth exposure to increases in the number of students who do not drink at alcohol advertising on TV increased by 71 percent, despite all. Over the past 30 years, the percentage of students implementation of new policies. During this same period, reporting no alcohol use in the past 30 days has increased youth were 22 times more likely to see an ad promoting from about 20 percent in 1983 to 37 percent in 2013. This alcohol use than a “responsibility” ad that discourages underage drinking or impaired driving. Number of alcoholic drinks per week 12 9.97 10 Alcohol Use in Young Adults 8 7.76 6 4.21 Excess alcohol consumption is a major problem on 4 6.03 most college campuses. Students may view drink- ing alcohol as a “rite of passage” during college, but it is 2 a very serious public health problem. Alcohol consump- tion by college students has been associated with hundreds 0 of thousands of cases of injuries, violence, unsafe sexual A B C D or F behavior, sexual assaults, and numerous deaths (over 1,700 Grade point average (GPA) annually). About 25 percent of college students report academic problems caused by drinking, including lower Figure 4  c  Average number of alcoholic drinks per week grades, poor performance on exams and papers, and missed by GPA. classes. Grade point average has also been found to be inversely related to the amount of alcohol consumed (see Source: Adapted from Core Institute. Figure 4). The problems associated with alcohol are directly related to the amount consumed. As shown in Table 5, the Table 5  c  Alcohol-Related Problems among College Students Problems All Students (%) Non-Binge Occasional Binge Frequent Binge Did something you regret 36.1 Drinkers (%) Drinkers (%) Drinkers (%) Missed a class 29.9 39.6 62.0 Drove after drinking 28.8 18.0 30.9 62.5 Forgot where you were or what you did 27.1 8.8 39.7 56.7 Argued with friends 22.5 27.2 54.0 Got behind in schoolwork 24.1 18.6 23.0 42.6 Engaged in unplanned sexual activities 21.6 10.0 26.0 46.3 Got hurt or injured 12.4  9.7 22.3 41.5 Damaged property 10.8  9.8 10.9 26.6 Had unprotected sex 10.3  7.9  8.9 22.7 Source: Wechsler et al.  3.9  9.8 20.4  2.3  3.7

Concept 20  c  The Use and Abuse of Alcohol   399 increase may be due, at least in part, to the greater number Some student groups have supported the movement, sug- of first-generation college students and nontraditional col- gesting that if they are old enough to fight in wars, they are lege students returning to college after spending time in the old enough to drink. On the other hand, the organization workforce. Mothers Against Drunk Driving (MADD) has argued that lowering the drinking age would lead to more car crashes. The college environment plays a key role in heavy In fact, alcohol-related traffic fatalities have decreased alcohol use among college students. Although many dramatically since the legal drinking age was raised to 21. more college students today are not of traditional college age There is also concern that allowing 18-year-olds to pos- (18 to 25) and/or work full or part time, college remains a sess alcohol legally will facilitate access to those who are period of transition from adolescence to adulthood for many. under the age of 18, and an earlier age of alcohol use is Because this period is characterized by fewer adult responsi- a well-known risk factor for later problems with alcohol. bilities, some have referred to it as “extended adolescence” The debate over the legal drinking age will no doubt con- or “emerging adulthood.” Regardless of the terminology, the tinue. As noted in this Concept, there are many factors to early 20s are clearly a period of heightened risk for engage- be considered. ment in risky behaviors, including alcohol and other drug use. It has been suggested that flexible schedules for college Drinking games place college students at high risk students contribute to this problem. In contrast to emerging for negative consequences. Drinking games are com- adults in the work sector, college students can often avoid mon on college campuses, but studies show that students morning classes and Friday classes to extend the weekend. who engage in drinking games reach In fact, a recent study found that the later students’ Friday dangerously high blood alcohol con- classes began, the more they drank on Thursday nights, with centrations and experience more nega- the heaviest drinking among those with no Friday classes. tive consequences. Younger students VIDEO 3 The authors argue that offering more Friday classes and requiring students to take them may help reduce alcohol use are more likely to play drinking games on college campuses. and experience more negative consequences. This is prob- ably due to the fact that younger drinkers have less toler- Some have argued that the legal drinking age of 21 ance and are therefore more impaired at comparable blood contributes to drinking problems in college. A large alcohol levels. group of university presidents joined forces to create the “Amethyst Initiative” to urge lawmakers to lower the drink- Mixing alcohol and energy drinks puts young people ing age from 21 to 18. Those leading the movement argue at risk. Alcoholic beverages with high caffeine levels (e.g., that current laws are routinely evaded and encourage dan- Loko and Joose) were popular in young drinkers when they gerous binge drinking on campus. The presidents indicate were introduced, but the U.S. Food and Drug Administra- that their movement is designed to stimulate public debate. tion banned their distribution after several teen deaths and emergency room visits associated with their consumption. HELP Health is available to Everyone Unfortunately, many young people mix alcohol with energy for a Lifetime, and it’s Personal drinks like Red Bull or Monster on their own, a combination Recent studies show that prevention programs designed that is associated with heavier drinking and more alcohol- to encourage communication about alcohol between par- related problems. One recent study found that those who ents and students are effective in reducing use and prob- consumed alcohol with energy drinks reported a stronger lems. Parents are given a workbook to help them discuss desire for more alcohol relative to those who drank alcohol alcohol use in college with their high school seniors and alone. Thus, it appears that mixing alcohol with caffeine are encouraged to communicate clear values and expec- may lead to heavier use. tations about alcohol use to their children. This may be a relatively cost-effective way to reduce heavy drinking and Female college students are at particularly high risk associated problems on college campuses. for negative behavioral consequences of drinking. Did your parents discuss alcohol use on campus with Women are at increased risk for a variety of acute negative you before you began college? Do you think such behavioral outcomes of drinking, though unprotected or a conversation is likely to affect a college student’s unwanted sexual behavior is perhaps the greatest concern. drinking behavior? Risks are particularly high for young women in situations where high blood alcohol levels are likely. For example, ACTIVITY women experience more negative consequences of drinking games because they drink at similar levels to men, leading to higher blood alcohol concentrations. Women are also at very high risk for negative consequences during spring break. In a recent online survey, 83 percent of women reported

400 Section 7  c  Avoiding Destructive Behaviors that spring break involved heavier than usual drinking, and Effective Approaches for Alcohol 74 percent said sexual activity was increased. Thirteen per- Prevention and Treatment cent of women said they had sex with more than one part- ner, and 10 percent said they regretted engaging in public or New approaches to preventing heavy drinking group sexual activity. among college students are showing promise. Efforts to prevent heavy drinking among college students have Misperceptions about peer attitudes and drinking traditionally focused on education. Unfortunately, a task force developed by the National Institute on Alcohol Abuse behavior contribute to heavy drinking in college. and Alcoholism (NIAAA) found that these approaches are Although increased attention to college drinking problems largely ineffective. Confrontational approaches do not work has led to increased education and prevention, rates of heavy well either, particularly with young people. Effective strat- use have changed little. One contributing factor may be that egies include motivational and skills-based approaches. attention to heavy drinking has led to the perception by col- These approaches encourage young people to examine how lege students that their peers are drinking more than they their drinking behavior affects their lives, and to consider actually are. Research has shown ways that changing their behavior might benefit them. that college students routinely over- Skills training focuses on teaching young people strategies estimate use by their peers and that to moderate their consumption or to maintain abstinence these misperceptions are associated VIDEO 4 in the face of social pressure to drink. Another promising approach that is increasingly used on college campuses with increases in drinking. In theory, addresses students’ misperceptions of drinking behavior students drink more to keep up with what they perceive to on campus. This approach focuses on the high percentage be the norm on campus. In addition to overestimating how of students who do not drink heavily. One study found that much alcohol their peers consume, college students appear 33.8 percent of college students did not report any alcohol to overestimate how much alcohol their peers want them use in the past 30 days. Those who did report drinking had to consume. This may be particularly true for women. A an average of 4.22 drinks over an average of 2.75  hours recent study found that 71 percent of women believed men the last time they “partied.” This amount of alcohol over wanted them to consume alcohol excessively, and 17 percent this time frame would result in relatively low levels of thought that men would find them more sexually attractive if intoxication. they had five or more drinks. In truth, the percentage of men who endorsed these beliefs was about half of what women perceived it to be. Much like colleges, the military confronts high rates The options for treating alcohol use disorders have of alcohol use and abuse. Young men (as a group) are at expanded in recent years. If you think you (or someone high risk for heavy drinking and related problems, and the you know) have a problem with alcohol, a number of options military is a major employer of this demographic (roughly are available. Self-help groups, such as Alcoholics Anony- 86 percent of active-duty military are male, and roughly mous (AA) and Rational Recovery, are widespread in the 67 percent are between the ages of 18 and 30). Given these United States. Treatment centers are also readily available. demographics, it is not surprising that active-duty military Most treatment centers focus on abstinence using a 12-step personnel report high levels of binge drinking. Unfortu- approach consistent with AA. Although this approach works nately rates increased from 35 to 47 percent between 1998 well for many, some are turned off by and 2008. This risk is exacerbated by the stress associated the strong religious component. For- with deployment and re-deployment. Rates of alcohol use tunately, a recent multisite clinical disorders have increased in the wake of recent conflicts, with trial showed that cognitive-behavioral one recent study reporting that roughly 15 percent of army VIDEO 5 soldiers returning from deployments in Iraq or Afghanistan met criteria for an alcohol use disorder. In addition, rates therapy and motivational enhance- of treatment seeking for alcohol problems among soldiers ment yield similar results to 12-step increased more than 50 percent during the first six years approaches. These approaches can often be implemented after the beginning of the war in Iraq. For many of these in less time and place more emphasis on personal control soldiers, alcohol may be used as a means to cope with the over behavior, features that may appeal to young adults in stresses of war or with symptoms of posttraumatic stress dis- particular. The medication naltrexone has also been shown order related to their experiences in the field. to help those trying to abstain from or reduce their alcohol consumption, providing yet another alternative or adjunct to behavioral treatment.

Concept 20  c  The Use and Abuse of Alcohol   401 Strategies for Action Take action to help prevent serious chronic consequences (e.g., alcohol use disorders). If alcohol-related harm in both yourself you drink, experts recommend no more than one drink per day and others. Excess alcohol consumption is associated with for women and no more than two drinks per day for men. Lab a number of acute negative consequences (e.g., alcohol poi- 20B provides an opportunity to evaluate your own behavior or soning, injuries, unsafe sex, driving accidents). The best way the behavior of a friend to determine if a problem may exist. to prevent these consequences is by keeping your BAC at a Additional information about safe levels of drinking is avail- safe level. Lab 20A provides a formula to estimate your BAC at able on the NIAAA website “Rethinking Drinking,” which was different levels of consumption over different periods of time. designed as a mechanism for evaluating alcohol use and risk Finding out how many drinks you can safely consume can help for the development of alcohol-related problems. The site also keep you out of harm’s way. provides resources for those who wish to change their drinking You can also take an active role in keeping your friends behavior. The site is specifically targeted toward young adults safe by being a responsible party host. Strategies for being a with the goal of reducing harm associated with heavy drinking. responsible host include: If you or one of your friends currently exceeds safe levels of • Encourage guests to bring a designated driver. consumption, take steps to change, such as: • Secure safe transportation for those who are intoxicated. • Have nonalcoholic beverages and food available. • Make a list of reasons to stop drinking or cut down. • Tactfully remove alcohol from overindulging guests. • Set a goal for yourself and make plans to meet it. • Close the bar an hour or two before the party ends. • Monitor your drinking—when, where, how much. • Identify situations that trigger strong urges to drink. The most important (first) step in preventing chronic alcohol • Spend less time in drinking settings (e.g., bars). problems is to determine if a problem exists. Moderate alco- • Drink slowly and practice drink-refusal skills. hol consumption is safe for many people and may even have • Alternate alcoholic and nonalcoholic drinks or water. some health benefits. However, many people who drink do so • Establish nondrinking days; offer to be a designated driver. beyond safe levels. Continued overconsumption can lead to • Don’t try to keep up with others; avoid drinking games. ACTIVITY Suggested Resources ∙ Daube, M. (2015). Alcohol’s evaporating health benefits. British and Readings Medical Journal, 350, h407. ∙ Institute of Medicine of the National Academies: Substance Use Disorders in the U.S. Armed Forces. The websites for the following sources can be accessed by searching ∙ Interagency Coordinating Committee on the Prevention of Under- online for the organization, program, or title listed. Specific scien- tific references are available at the end of this edition of Concepts of age Drinking: Stop Underage Drinking. ∙∙∙∙ Mayo Clinic: Alcohol Use: If You Drink, Keep It Moderate. Fitness and Wellness. NIAAA: Alcohol: A Women’s Health Issue. NIAAA: College Drinking—Changing the Culture. ∙∙∙∙∙ Amethyst Initiative: Rethinking the Drinking Age. NIAAA: Fact Sheet on Alcohol Use Disorder: A Comparison CDC: Alcohol and Public Health. Between DSM-IV and DSM-5 (pdf). CDC: Impaired Driving: Get the Facts. ∙ Today Health: Mixing Energy Drinks and Alcohol Can “Prime” CDC: Sobering Facts: Drunk Driving State Fact Sheets. You for a Binge. Center on Alcohol Marketing and Youth: Youth Exposure to Alcohol Advertising on Television, 2001–2009.



Lab 20A  Blood Alcohol Level Name Section Date Lab 20A Purpose: To learn to calculate your (or a friend’s) blood alcohol concentration (BAC). Procedures 1. Assume a drink is a 12-ounce can or bottle of 5 percent beer or a 5-ounce glass (a small glass) of 12 percent alcohol (wine), or a mixed drink with a 1½-ounce shot glass ( jigger) of 80 proof liquor. Case A: Assume you consumed two drinks within 40 minutes. Blood Alcohol Level Case B: Assume you consumed two drinks over a period of 1 hour and 20 minutes. Case C: Assume you had two six-packs of beer (12 cans) over 5 hours. Case D: Same as C, but, if you weigh less than 150 pounds, assume you weigh 50 pounds more than you now weigh, and, if you weigh more than 150 pounds, assume you weigh 50 pounds less. 2. Divide 3.8 by your weight in pounds to obtain your “BAC maximum per drink,” or refer to Table 4 in this Concept. You should obtain a number between .015 and .04 (based on one drink in 40 minutes). Use the formula below to determine BAC over time. [.01 (# min 40)] 40 Approximate BAC over time 5   (3.8 3 # of drinks)    2  3 2 (body weight) 3. After 40 minutes have passed, your body will begin eliminating alcohol from the bloodstream at the rate of about .01 percent for each additional 40 minutes. Multiply the number of drinks you’ve had by your “BAC maximum per drink” and subtract .01 percent from the number for each 40 minutes that have passed since you began drinking—but don’t count the first 40 minutes. Compute your BAC for cases A, B, C, and D. Example: Case A. Mary weighs 100 pounds.   3.8 3 2 5 7.6 5 .076% BAC 100 100 Case B. Mary takes 80 minutes. .076%  2   [.01 3 (80 2 40)]   5  .066% BAC 40 4. Record your results below by writing the formula and computing the BAC for each case. Results # of drinks)   ​ 5  _____ % BAC Case A   (3.8 3 lbs Case B ​ (3.8 3 # of drinks)    2   [.01 3 ( # min – 40)]   5 BAC (   ) 2 (   ) 5  _____% BAC lbs 40 Case C   (3.8 3 # of drinks)    2   [.01 3 ( # min – 40)]   5 BAC (   ) 2 (   ) 5  _____% BAC ​ lbs 40 Case D   (3.8 3 # of drinks)    2   [.01 3 ( # min – 40)]   5 BAC (   ) 2 (   ) 5  _____% BAC lbs 40 403

Lab 20A Would you (or your friend) be able to drive legally according to your state laws? Place an X over your answer. Case A Yes No Blood Alcohol Level Case B Yes No Case C Yes No Case D Yes No Conclusions and Implications:  In several sentences, discuss what you have learned from doing this activity. 404

Lab 20B  Perceptions about Alcohol Use Name Section Date Lab 20B Purpose:  To better understand perceptions about drinking behaviors. Procedures Perceptions about Alcohol Use 1. Think of a person you care about. Do not identify this person on this lab report. 2. Answer each of the questions below as honestly as possible, evaluating the behavior of the person you have identified. Calculate a total score and determine a rating (see Chart 1). 3. At another time, when you do not have to submit your results, you should answer the questions about yourself. 4. Answer the questions in the Conclusions and Implications section. Results Never Sometimes Frequently Too Often Add Score 1. How often does the person drink? 0 1 2 3 2. How often does the opcecrasosinonh?a ve six or 0 1 2 3 more drinks on one 3. How often do friends of the person drink? 0 1 2 3 4. How aofftteernshtaarstinthgetopedrrsinokn?b een unable to 0 1 2 3 stop 5. How often does the mpeorrsnoinngn?e ed a drink 0 1 2 3 to get started in the 6. How often pharesvtihoeuspeevrseonntsbaefetenr udnrianbkliengto? 0 1 2 3 remember 7. How often does twheithpderrisnokninmg?is s class or 0 1 2 3 work associated 8. pHeorwsoonfatel nprdoobelesmthseapsseorscoiantehdavweitshodcriainlkoinr g? 0 1 2 3 9. tHooowmoufctehn(odnoleysfothr et hpoesersownhodmenyyoduricnokninsgider 0 1 2 3 to drink too much)? C hart 1  Drinking Behavior Rating Scale Total Score Rating Score Rating 181 Alcohol abuse* 12–17 D rin king problem 8–11 ,8 Potential problem Low risk of problem *Professional help recommended. 405

Lab 20B Conclusions and Implications 1. In several sentences, discuss the drinking behavior of the person you identified. Do you think your ratings give an Perceptions about Alcohol Use accurate picture of the person? Do you think the person you rated has a problem with alcohol? 2. In several sentences, discuss the drinking behavior of the person’s friends. Do the friends promote drinking, or not? 3. In several sentences, discuss things you could do to help a friend or loved one solve a drinking problem. 406

The Use and Abuse Concept 21 of Other Drugs LEARNING OBJECTIVES After completing the study of this Concept, you will be able to: c List the six major classes of illicit drugs and their effects. c Describe the negative health, financial, and legal consequences of illicit drug use. c Identify biological, psychological, and social factors that contribute to illicit drug use and abuse. c Explain differences in prevalence of the various classes of drugs, including both illegal drugs and prescription drugs. c Describe long-term and recent trends in use of the different drug classes. c Identify signs of drug problems and available resources for addressing these problems. Illicit drug abuse has serious health consequences and enormous personal, social, and economic costs. Preventing onset of illicit drug use and providing adequate treatment to individuals with substance use disorders is a public health priority. 407

408 Section 7  c  Avoiding Destructive Behaviors Approximately 39 percent of college students reported swings, and confusion occur after prolonged use. Alcohol, using illegal drugs in the past year, up from a low of discussed in an earlier Concept, is the most widely used 29 percent in 1991 but far below the 56.2 percent who used depressant. illicit drugs in 1980. Of concern are rates of drug use among twelfth graders, which equal the rate of 39 percent for college Opiate narcotics include heroin, codeine, morphine, students and represent peak rates for any age group. Millions and methadone. Narcotics are smoked, injected, sniffed, of people are arrested each year for drug offenses—includ- or swallowed (see Table 2). Narcotics are often used clini- ing sale, distribution, and possession. This has a tremendous cally to treat pain; however, heroin has no legal medical cost to society. This Concept discusses drug use and abuse use in the United States and has a high rate of addiction. It (including Substance Use Disorders) and discusses both is three times stronger than other medicinal narcotics and use of illicit drugs and misuse of prescription drugs induces different physiological effects. Narcotics are all opium poppy derivatives or synthetics that emulate them. Classification of Illicit The narco- part of the word derives from the Greek word for and Prescription Drugs sleep, because of its sleep-inducing properties. Drugs can be classified in several ways, but the Every narcotic, legal or illegal, is a potential poison. A single dose can be fatal, although this is rare. Deaths related mood-altering, or psychoactive, drugs are the ones to narcotic abuse are typically caused by overdose, impuri- we hear about most. Psychoactive drugs can be classi- ties of the drug, or mixing of the drug with other depres- fied in six major groups: depressants, opiate narcotics, stim- sants, such as alcohol. The mixing of drugs in the same or ulants, hallucinogens, marijuana, and designer drugs. Drugs similar categories can produce a heightened physiological in the same group have similar effects. Narcotics, however, effect known as synergism, or the synergistic effect. The are actually depressants, but because the word narcotics is combined use makes drug taking far more dangerous. so widely used in law enforcement and in society in gen- eral, they are generally given their own category. Each of the Stimulants include cocaine and methamphetamine six categories of drugs is discussed in this Concept. Their as well as prescription drugs like Ritalin and Adderall. effects are classified as either physiological or psychologi- One of these stimulants—cocaine—comes in powder form cal (primarily affecting the body ver- (coke) and a rocklike form (crack). The timing and mag- sus affecting behavior). The effects of nitude of effects of cocaine vary depending on whether it is drugs can vary with each individual inhaled, injected, or smoked. Combining cocaine and alco- and with different doses. VIDEO 1 hol use leads to production of cocaethylene, which increases risk for overdose. Amphetamines and methamphetamines are Depressant drugs include alcohol, tranquilizers, and also classified as stimulants due to their effects on the central barbiturates. Depressants come in the form of pills, liq- nervous system. Stimulants are often included in diet pills to uids, and injectables (see Table 1). In small doses, they slow reduce appetite; others (e.g., Ritalin) are used clinically to treat heart rate and respiration. In larger doses, they act as a poi- attention-deficit/hyperactivity disorder (see Table 3). son and damage every organ system in the body. In large enough doses, they can dramatically depress heart rate and Crystal methamphetamine (also known as ice, meth, or respiration enough to cause death, if quick intervention is crystal) is a purified methamphetamine that also comes in not available. In terms of their effect on behavior, the user rock form or powder. As a powder, it is usually smoked in might at first feel stimulated, despite their depressant effects. a glass pipe or cigarette. It is a powerful stimulant, with an Depression, loss of coordination, drop in energy level, mood effect that lasts 8 to 30 hours. Much like crack cocaine, ice is a concentrated form of an already potent stimulant drug Table 1  c  Depressants (“Downers,” Sedatives) Examples Physiological Effects Psychological Effects • Tranquilizers (e.g., Valium, Xanax, • In large doses, act as a poison and damage • Feelings of relaxation and euphoria; meprobamate, sleeping pills, every organ system after prolonged use: depression, loss of methaqualone) are also called tranks, downers, or candy coordination, drop in energy level, mood •  Barbiturates (e.g., Mebaral, Nembutal) swings, confusion, euphoria • Quick sedation: vomiting; loss of motor • Amnesia and neurological control; combined with alcohol, can lead to coma and death

Concept 21  c  The Use and Abuse of Other Drugs   409 Table 2  c  Opiate Narcotics Examples Physiological Effects Psychological Effects • Codeine • Narcotics: blockage of pain, chronic constipation, • Narcotics (including heroin): euphoria and feeling • Morphine • Synthetic opiates (e.g., depressed respiration, redness and irritation of of pleasure; nontherapeutic doses may result in nostrils, nausea, lowered sexual drive, impaired mental distress, such as fear and nervousness; in Vicodin, Oxycontin) immune system heavy users, drowsiness and apathy may occur • Methadone • Heroin: blood clots, bacterial endocarditis, serum • Heroin (also called brown hepatitis, brain abscess, HIV infection (from sugar, junk, or smack) shared needles); in pregnant users, high risk of miscarriage, stillbirths, birth defects, toxemia, addicted babies Table 3  c  Stimulants Examples Physiological Effects Psychological Effects • Cocaine (also called coke, • Cocaine: sore throat, hoarseness, shortness of • Powder cocaine: initial rush of energy, feeling of blow, snow, or crack) breath (leads to bronchitis and emphysema), confidence; as it wears off: depression, moodiness, dilated pupils, “lights” seen around objects irritability, severe mental disorders • Crack: intense euphoria, then crushing depression, intense feeling of self-hate; as it wears off: depres- sion and sadness, intense anxiety about where to get more drugs, aggressiveness, paranoia • Amphetamines and powder • Excite central nervous system; increase blood • Initially, feeling of being invincible, alertness, methamphetamines (also pressure, respiration, and heart rate (sometimes excitement; with increased use: feeling of anxiety; resulting in convulsions and stroke); reduce called speed, uppers, or appetite; highly addictive; overdose is fatal; with long-term use: hallucinations, psychosis with increased use: dizziness, headaches, black beauties); diet and sleeplessness; with long-term use: progressive brain damage, malnutrition pep pills, Ritalin • Crystal methamphetamine • Extreme energy, sleeplessness, seizures, flushed • Euphoria, delusions of grandeur, feelings of (also called meth, crystal, skin, constricted pupils invincibility, physical aggression, paranoia, mood crank, or ice) swings, psychosis that is either smoked or injected. Ice also causes an intense gasoline, paints, paint thinner, lighter fluid, shoe polish, and “rush” or “flash,” which is experienced as highly pleasur- liquid wax; (2) aerosols, such as hair spray, air fresheners, able. Because the initial rush lasts for only a few minutes, insect spray, and spray paint; and (3) nitrites, such as nitrous users need to administer the drug frequently to maintain the oxide (laughing gas) and butyl nitrite (a liquid incense). effects. Tobacco, which contains the powerful stimulant nic- Table 4 describes the effects of hallucinogens and pysche- otine, is discussed in an earlier Concept. delics (drugs that cause hallucinations). Drugs that cause the user to have hallucinations are called hallucinogens, or psychedelics. PCP and LSD are Substance Use Disorder  The use of a drug to the extent that it common examples of hallucinogens but less-known drugs in impairs social, psychological, or physiological functioning. this category include mushrooms, or “shrooms,” which are Psychoactive Drug  Any drug that produces a temporary change chewed, and peyote cactus buttons, which have been used for in the physiological functions of the nervous system, affecting ceremonial purposes by some indigenous groups for centuries. mood, thoughts, feelings, or behavior. Synergistic Effect  The joint actions of two or more drugs that Inhalants are sometimes classified separately from other increase the effects of each. hallucinogens because their effects are so serious. They Hallucinations  Imaginary things seen, felt, or heard or things reach the brain in seconds, and the effect lasts only a few seen in a distorted way. minutes. There are three types: (1) solvents, such as glue,

410 Section 7  c  Avoiding Destructive Behaviors Table 4  c  Hallucinogens (Psychedelics) Examples Physiological Effects Psychological Effects • Lysergic acid diethylamide (LSD, also • Changes chromosomes and may result in birth • Vivid hallucinations, feelings of called acid, boomers, or cubes) defects of babies of users; bad trips, confusion, overlapping/merging of the senses, flashback expanded consciousness and mystical experiences, stimulated awareness and desire, confusion, flashback • Phencyclidine (PCP) • Accumulates in fat cells and may remain in body • Insensitivity to pain can lead to longer than most drugs; impaired immune system, death; euphoria, depersonalization, poor coordination, weight loss, speech problems, hallucinations, delirium, amnesia, tunnel heart and lung failure, irreversible brain damage, vision, loss of control, violent behavior convulsions, coma, death • Inhalants (solvents, aerosols, and • Slow reaction time, headache, nausea, vomiting, • Giddiness, overexcitement, less nitrites, also known as poppers, rush) seizure, brain damage, suffocation, heart attack, death, inhibition, feelings of being all-powerful; double vision, sensitivity to light, dizziness, loss of powerfulness soon fades and leaves coordination, weakness, numbness; irregular heartbeat, irritability liver and kidney failure, bone marrow damage Table 5  c  Marijuana (Subclass of Hallucinogens) Examples Physiological Effects Psychological Effects • Marijuana (containing • Long-term use: bronchitis, emphysema • May not hallucinate; pleasant, relaxed feeling; tetrahydrocannabinol, or THC) is also and lung cancer, bloodshot eyes, heart giddiness; self-preoccupation; less precise thinking; impaired task performance; inertia; with called pot, grass, weed, blunt, or herb disease, infertility, sexual dysfunction, prolonged use: may be withdrawn and apathetic, have anxiety reactions, paranoia; eventually, permanent memory loss (brain damage) decreased motivation and enthusiasm, reduced ability to absorb and integrate effectively, profoundly impaired scholastic performance • Synthetic cannabinoids (e.g., K2, Spice) • Rapid heart rate, vomiting, agitation, • Elevated mood, relaxation, altered perception, and cathinones (bath salts) confusion, high blood pressure, reduced anxiety, paranoia, hallucinations, panic attacks, blood supply to the heart, heart attack, delirium kidney failure, dehydration Marijuana is classified as a hallucinogenic, but its controlled. They change the molecular structure of an exist- effects are less dramatic than those of other drugs ing drug to create a new substance. Since new drugs are being in this class. The active ingredient in marijuana (delta- created all the time, their potential effects are often unknown. 9-tetrahydrocannabinol—THC) is technically a hallucino- gen (see Table 5). Marijuana use became widespread in the The Consequences of Drug Use 1960s and, despite decreased use over time, is still the most widely used illicit substance in the United States. Marijuana Drug use takes a human toll in terms of increased use leads to a range of experiences, which differ from person morbidity and mortality and lost productivity. Drug to person. Marijuana is generally smoked in a pipe, joint, or abuse leads to over 2.5 million emergency room visits annu- bong, although it can also be eaten and is also smoked in ally and is the leading cause of injury deaths in the United hollowed-out cigars called blunts. States, surpassing traffic-related fatalities for the first time in 2011. In 2013, there were nearly 44,000 drug-related Designer drugs, which are made in laboratories, deaths, greater than two times the rate in 1999. This does not have many of the same properties as the drugs they take into account the indirect effects of drug use on mortal- simulate, such as pain relievers, anesthetics, and ity, including deaths from accidents, homicides, and AIDS amphetamines. Designer drugs (see Table 6) are modifica- (acquired via intravenous drug use). Because of problems tions of illegal or restricted drugs made by chemists working with low productivity in the workplace, a large percentage illicitly to create street drugs that are not specifically listed as of American businesses now conduct employee drug tests.

Concept 21  c  The Use and Abuse of Other Drugs   411 Table 6  c  Designer Drugs Examples Physiological Effects Psychological Effects Date rape drugs Depression of the central nervous system, Negative mood states including depression incapacitation, coma, seizures, tremors, and anxiety; amnesia and delirium; insomnia • Rohypnol nausea, sweating, high blood pressure, and impaired motor function • Gamma hydroxybutyrate (GHB) is also called and potentially fatal respiratory problems Initial feelings of calm and euphoria may Georgia homeboy or liquid ecstasy be followed by exhaustion or psychological burnout; increased risk for psychosis and •  Ketamine (also called Special K) depression; cognitive impairment MDMA (3,4-methylenedioxymethamphetamine; Irregular heartbeat, intensified heart also called ecstasy, or X) problems, liver and brain damage, depletion of serotonin in the brain, muscle tension, and dry mouth Treatment (1.9%) A CLOSER LOOK Early death (8.3%) Public Health Implications of Marijuana Criminal justice Reduced Decriminalization (law productivity (27.1%) More than two dozen states now have medical mari- enforcement, juana laws, and more than a dozen have decriminalized private legal marijuana. In Colorado and Washington, possession of cases, property small amounts of marijuana is legal. Although it will take destruction, etc.) some time to determine the consequences of these legal changes, regulation will almost certainly be necessary as (58.7%) it has been for alcohol and tobacco. In particular, there is concern about the safety of food products containing mari- Social programs juana and driving under the influence. Between 2005 and and other costs (4.0%) 2011, rates of marijuana-related poisonings in young chil- dren increased by 30 percent in states that decriminalized Figure 1  c  The estimated cost of drug abuse (percentage marijuana, and the percentage of fatal traffic accidents in of total costs). Colorado that involved marijuana use more than doubled from 1994 to 2011. Source: U.S. Department of Justice National Drug Intelligence Center. Do you support laws that decriminalize marijuana? What Drug use also has significant economic costs. The eco- do you think are the biggest risks and benefits of this nomic costs of illicit drug abuse are estimated at approxi- approach? mately $193 billion a year. Approximately 20.3 million adults in the United States meet criteria for a substance use ACTIVITY disorder, but most of the national economic burden is not related to treatment (3 percent). More than half of the costs states have decriminalized marijuana, penalties for mari- are associated with drug-related crime. Figure 1 illustrates juana possession are still substantial in other states, and the proportion of societal costs result- all states tend to have more severe penalties for drugs like ing from factors such as law enforce- cocaine, heroin, and methamphetamine. Penalties for the ment expenditures, social programs, possession of small amounts are the least severe, with pen- and reduced productivity. VIDEO 2 alties for the sale or production of large amounts the most severe. In most states, the maximum jail time for posses- Drug use can lead to significant legal problems, sion ranges from 6 months to a year for marijuana and from resulting in jail time and substantial fines. State laws 1 to 7 years for cocaine, methamphetamine, and ecstasy. In regarding the possession and sale of illicit drugs vary con- addition, fines between $500 and $1,000 for marijuana and siderably, and penalties within states vary based on the between $5,000 and $25,000 for other illicit drugs are typi- amount of the drug, the type of drug, and the type of offense cal of most states. (possession, sales, or production). Although a number of

412 Section 7  c  Avoiding Destructive Behaviors Causes of Illicit Drug Abuse of administration also influences risk for addiction. For example, the likelihood of becoming addicted to metham- Drug use generally begins with cigarette smoking phetamine is much higher if it is smoked rather than inhaled and alcohol use. Of course, most people who smoke or as powder. drink will not go on to use illegal drugs, but it is rare for people who do not smoke or drink to use illegal drugs. The average age of first use of cigarettes, alcohol, and marijuana Psychological factors such as personality traits, is roughly 16 among those who report using prior to age attitudes, perceptions of risk, and expectations of 21. In general, the younger a person is when he or she starts benefits can influence drug use. Individuals with higher using drugs, including nicotine and alcohol, the more likely levels of sensation seeking and impulsivity have been shown that person is to use illegal drugs and become physically to be at increased risk for use of a range of illicit drugs. dependent on them. Those who believe drug use is acceptable and affiliate with others with similar views are also more likely to use drugs and to develop problems. These attitudes are influenced by Most experts agree that drug use and abuse are both parental and peer attitudes as well as the attitudes of the complex phenomena that must be understood within broader culture. Perceptions of risk are also a strong predic- a biopsychosocial model. The biopsychosocial model suggests that biological, psychological, and social factors tor of drug use. In fact, national studies have consistently found that shifts in perceptions of risk related to specific must be considered in understanding substance use and drugs precede changes in rates of use of those drugs. Much abuse. From this perspective, the potential for addiction like alcohol, those who believe drugs will have strong posi- depends on a host of factors, including genetic vulnerabil- tive effects are more likely to use and abuse them. This is ity, the type of drug used, the route particularly true for those who believe that drug use is an of administration, attitudes toward effective way to cope with stress. drug use, expectations regarding drug effects, peer use, and ease of access. VIDEO 3 Social factors and social norms have important effects on drug use. People who live in areas where drugs are readily available are at increased risk for both use and Genetics play a role in susceptibility to drug addiction. abuse. Another major influence on drug use in young people Research has suggested that genetic factors explain as much is the extent to which their social group engages in drug use. as 50 percent of alcohol and nicotine addiction, and the same Those who perceive that most of their peers use drugs are is likely true for other drugs of abuse. The effect of genetics likely to use drugs themselves. (and susceptibility to addiction) depends on how the drug is used and how it affects the brain. Some drugs act on receptors in the brain that are specific to that drug (e.g., cannabanoid receptors for marijuana; opioid recep- tors for heroin and prescrip- tion narcotics), whereas others act on more general neurotransmitters associated with reward (e.g., effects of cocaine and methamphet- amine on the dopamine system) and the regula- tion of mood and behavior (e.g., MDMA effects on the serotonin system). Because both the dopamine and opioid systems are directly related to the experience of reward, drugs like her- oin and cocaine that affect these systems are particu- larly addictive. The route Connecting with the right social group can help you adopt positive lifestyles and behaviors.

Concept 21  c  The Use and Abuse of Other Drugs   413 Prevalence and Consequences consequences, including impaired cognitive abilities and of Illicit Drug Abuse academic performance, increased risk of accidents and inju- ries, greater incidence of high-risk sexual behavior, and Use of most illicit substances has decreased in the increased risk for substance use disorders. Students who use drugs have less academic motivation and report lower past decade, but rates of use remain high among involvement in religion, community service, and extracur- adolescents and young adults. In the United States, rates of illicit drug use peaked in the 1970s followed by sharp ricular activities on campus. decreases during the 1980s (see Figure 2). Overall drug use Much like alcohol, both direct and indirect peer influences by adolescents spiked upward in the early 1990s, primarily are important predictors of use among college students. Stu- as a result of two- to threefold increases in marijuana use. dents with friends who use marijuana are more likely to use Rates of illicit drug use then began a steady but gradual it themselves. Misperceptions of normative behavior may decline during the first decade of the new century. Unfortu- also influence personal behavior. One study found that 98 nately, rates of illicit drug use in adolescents have increased percent of students incorrectly believed that the typical stu- 2.4 percent since 2007, representing a proportional increase dent on campus used marijuana at least once per year, despite of nearly 10 percent. Rates have increased even more sub- the fact that most of the students reported no personal use of stantially in young adults, from 32.5 to 36.3 percent. In marijuana. Although both direct and indirect peer influences contrast to other illicit drugs, misuse of prescription drugs may contribute to drug use, these same influences can also peaked later (2001) and rates remained high through 2007. deter use. One study found that peers Fortunately, rates of prescription drug misuse have declined exposed to a peer group with strong by nearly 20 percent since that time. Still, the current rate anti-drug attitudes were likely to con- of 13.9 percent makes prescription drugs the second most form to this norm. VIDEO 4 widely used drug class (not including alcohol and tobacco) The development of new drugs in young people, trailing only marijuana use. contributes to the maintenance of drug use in the Rates of illicit drug use among college students are United States. New drugs are always being manufactured, among the highest of any age group. High rates of and new ways of administering old drugs often lead to a drug use in college are associated with a host of negative resurgence in use. Designer drugs provide examples of new drugs, and crack cocaine and crystal methamphetamine are examples of 70 8th grade old drugs that became popular in new 60 10th grade forms. When these new drugs become 50 12th grade available, information about their College students benefits is generally spread immedi- ately by word of mouth. In contrast, Young adults the risks associated with use are often Percentage unknown until the drug has been used 40 for a number of years. This gives new drugs time to become popular before information that might deter their 30 use is available. Ecstasy and crystal methamphetamine are good exam- 20 ples of this phenomenon. Public cam- paigns by the National Institute on Drug Abuse and other agencies have 10 provided information about risks and have helped to curb levels of use rela- tively quickly. Thirty-day prevalence 1980 of ecstasy use in high school seniors 1982 decreased from 3.6 percent in 2000 to 1984 1 percent in 2005, and rates of crys- 1986 tal methamphetamine use decreased 11999808 from 1.2 percent in 2002 to .5 percent 1992 in 2009. Unfortunately, efforts to pro- 11999964 2222212000009000001090268408 2012 2014 Year tect the public are challenged by the Figure 2  c  Trends in annual prevalence of an illicit drug use index across five populations. Note: Use of “any illicit drugs” includes any use of marijuana, LSD, other hallucinogens, crack, other cocaine, or heroin, or any use that is not under a doctor’s orders of other opiates, stimulants, barbiturates, methaqualone (excluded since 1990), or tranquilizers. Source: National Institute on Drug Abuse.

414 Section 7  c  Avoiding Destructive Behaviors constant production of new designer drugs. Recent examples HELP Health is available to Everyone include synthetic cannabinoids and cathinones (bath salts). for a Lifetime, and it’s Personal These drugs emerged around 2010 and quickly led to a Patterns of use of specific drugs among young adults large number of calls to poison control centers. (See Table seem to go up and down in cycles, but overall rates 6 for a description of negative drug reactions.) The Drug remain relatively stable. For example, although rates of Enforcement Administration (DEA) acted swiftly to place prescription drug use have decreased substantially in the bans on these products, and annual rates of synthetic mari- past decade, marijuana use has increased. In addition, juana use subsequently decreased from 11.4 percent in 2011 new drugs are always emerging to replace those to which to 5.8 percent in 2014. Similarly, the use of bath salts has access has been restricted. decreased from 1.3 to .9 percent in recent years. In addition Do declines in use of specific drugs simply reflect to the emergence of new drugs, there is a tendency to forget exploration with new drugs? Which drugs should be about the negative consequences of existing drugs after rates targeted to reduce harms associated with illicit drug use? decrease—a phenomenon called generational forgetting. For example, after dramatic decreases in MDMA use fol- ACTIVITY lowing the peak in 2000, rates began to climb again, nearly doubling between 2005 and 2010. Marijuana is the most widely used (illicit) drug in the United States and is associated with a host of physical health and social consequences. In a national survey, over 20 million Americans, or roughly England Journal of Medicine outlines the many risks of 6 percent of people over the age of 12, reported the use marijuana use. With respect to health, chronic marijuana of marijuana in the past month (see Figure 3). Although use leads to many of the negative consequences associ- many believe it is a relatively safe drug, and some favor ated with cigarette smoking, including cardiovascular dis- decriminalization or legalization, a number of risks are ease and lung cancer. One study showed that marijuana associated with marijuana use. A recent review in the New use  also increases risk for stroke. Another study found that marijuana use leads to nearly a fivefold increase in acute risk for a heart attack, especially among those with existing cardiovascular risk. Marijuana 10 9.4% use is also associated with impaired cognitive 9 abilities. For example, adolescents who use mari- juana heavily have been shown to have deficits in attention, learning, and processing speed. There is 8 7.5% also direct evidence from neuroimaging studies for Percentage using per month 7 differences in brain function. In particular, areas of the brain associated with processing of emo- 6 tional information appear to be affected. These findings are cause for concern, given evidence for 5 increased risk of emotional problems among indi- 4 viduals who use marijuana. For example, a recent study found that marijuana use increased risk for experiencing panic attacks. 3 2.5% Although the debate is ongoing regarding 2 the addictive (physical dependence) potential of marijuana, it is clear that one can become psycho- 1 logically addicted to the drug. Psychological depen- 0 .6% .2% .2% .1% dence is characterized by craving for the drug and Psyc(hAlolthcIlleoirMcamiatrpbiijednruuetuaidngc)ssa continued use despite negative consequences. There MethampheCtoacmaiinnee is also emerging evidence that those who try to quit using marijuana experience withdrawal symptoms. Inhalants For example, a recent study found that smokers of Heroin marijuana experienced withdrawal symptoms that were quite similar to those of Figure 3  c  Illicit drug use among persons 12 and older, by drug tobacco smokers, including irritability, anxiety, and sleep (% per month). difficulties. VIDEO 5 Source: Substance Abuse and Mental Health Services Administration.

Concept 21  c  The Use and Abuse of Other Drugs   415 Stimulants, including cocaine and methamphetamine, drug-assisted assault or date-rape drugs. In addition to are the second most commonly used illicit drugs. incapacitating the user, these drugs lead to anterograde Cocaine and methamphetamine are both stimulant drugs, amnesia, or the inability to remember events that occur and they share a number of other characteristics. First, both after consumption. come in powder form as well as more concentrated crystal Inhalant use poses a serious risk to physical health, (ice) or rock (crack) forms. Crack cocaine was one of the including risk for sudden death. Those who use inhal- most abused drugs in the United States during the peak rates ants are at risk for what is known as “sudden sniffing death.” of use in the early to mid-1980s, and crystal methamphet- Sniffing inhalants can lead to irregular and rapid heart amine was at the center of the more recent but less dramatic rhythms that can cause heart failure and rapid death. This increase in illicit drug use in the early 1990s. Crack and ice can occur from a single episode of sniffing in an otherwise are highly addictive. Because of the intense, short-lived high healthy adolescent. associated with using these drugs, patterns of repeated use Misuse and abuse of over-the-counter (OTC) and develop quickly, leading to rapid development of depen- prescription drugs has become an increasing dence. Both drugs are also known to damage dopamine neu- problem. Prescription drugs are often used inappropri- rons in the brain and lead to a host of short- and long-term ately. Examples include using prescriptions written for other health consequences. Short-term effects that occur after people and using medicines for purposes other than as pre- the initial high include irritability, anxiety, and paranoia. scribed. Users may also obtain prescription drugs without In terms of long-term risk, cocaine and methamphetamine prescriptions via the Internet, though most people who mis- use lead to increased risk for stroke, respiratory problems use prescription drugs indicate that they obtain them for free (including respiratory failure), irregular heartbeat, heart from friends or family members. Many fail to recognize the attacks, and psychiatric symptoms. potential risks of prescription drug use, assuming that any- thing prescribed by a physician must be safe. The more com- Unique physical consequences of methamphetamine use monly abused prescription drugs among college students include poor complexion and tooth loss, which is costly and include Ritalin, Valium, Xanax, Percoset, Vicodin, and Oxy- extremely distressing. Ice has added risks associated with contin. Sometimes called “hillbilly heroin,” Oxycontin is a its production. Because some of the products used to pro- painkiller that has received much attention because of its duce meth (e.g., pseudoephedrine) have legitimate phar- misuse by celebrities and its link to many deaths nationwide. maceutical uses, policies have been put in place to monitor However, Vicodin is by far the most widely misused pre- their sale. If you go to your pharmacy to purchase an over- scription narcotic in the United States. Methadone use with- the-counter decongestant, you may be asked to provide out a prescription also appears to be increasing. Methadone identification and a signature. In addition, you may have to has been approved in the United States for the treatment of purchase your medication at the pharmacy even though it is opiate dependence (primarily heroin) since 1972, but it is an over-the-counter drug, and you may be limited to one or increasingly making its way into the hands of those with- two packages. out prescriptions. Although nonprescription use of metha- done has not been systematically tracked, methadone-related The continued use of designer drugs is a concern, overdoses have been. Recent data from the Centers for Dis- given strong evidence of their harmful effects. ease Control and Prevention (CDC) indicate a sevenfold Designer drugs include ecstasy (MDMA), Rohypnol, GHB, increase in methadone-related deaths in less than a decade. ketamine, DOM, DOB, and NEXUS. Ecstasy, a hallucino- With a street value of about $20 a pill, methadone is consid- gen, is inhaled, injected, or swallowed. The drug was ini- erably cheaper than many of the other prescription opiates, tially popular at all-night dance parties called raves, but its which may have led to its increased popularity. use quickly expanded beyond the club scene. Ecstasy alters brain levels of serotonin; negatively impacts memory; and Rates of misuse of ADHD drugs like Ritalin and Adder- affects the brain regions that regulate sleep, mood, and all are particularly high among young people, particularly learning. Recently, a more potent form of ecstasy sold in college students who often use the drugs in an effort to capsules or as powder has been a major concern in several enhance academic performance. The most recent national areas of the country. This type of ecstasy is often referred to data indicate that 11 percent of college students report using as “Molly.” The negative effects of ecstasy may last as long Adderall without a prescription in the past year. as 7 years. Dealers often pass off other drugs as ecstasy, and they are often even more dangerous. Generational Forgetting The tendency for individuals to forget about the risks of a particular drug over time, leading to a Rohypnol and GHB are predominately central ner- resurgence in its use. vous system depressants, like the other sedative drugs described previously. These drugs are odorless, colorless, and tasteless, so they can be added to food or beverages without the consumer detecting their presence. Because of these properties, Rohypnol and GHB are known as

416 Section 7  c  Avoiding Destructive Behaviors In the News New Federal Regulations Designed to Decrease Misuse of Prescription Narcotics Rates of prescription drug abuse have patients won’t be able to receive more than a 3-month supply increased dramatically in the past 20 years of these drugs, and manufacturers will have to increase security with prescription narcotics (pain killers) among the most com- and monitoring of their products. The hope is that the reclassifi- monly abused. Although Oxycontin has received considerable cation will decrease the very high rates of abuse of these drugs media attention, rates of Vicodin abuse are actually much higher. (roughly 6 percent in young adults). This is likely due, at least in part, to the fact that Oxycontin is clas- Do you think that the reclassification of these drugs will sified as a Schedule II narcotic, a more restrictive classification help decrease their use? Do you think these new regulations than Vicodin. That, however, is set to change as the U.S. Food are fair to those suffering from chronic pain who will have and Drug Administration has approved the reclassification of greater difficulty obtaining medication? products containing hydrocodone and other products like aspirin (e.g., Vicodin, Lortab) to Schedule II narcotics. As a result, ACTIVITY Overdoses from misuse of prescription drugs account drugs increased more than 132 percent. The majority of for the vast majority of drug overdoses in the United these ER visits involved use of prescription narcotics, which States. Of the more than 2.5 million emergency room visits showed a 183 percent increase from 2004 to 2011. The num- related to drug abuse each year, more than half involve non- ber of overdose deaths associated with use of prescription medical use of prescription drugs. Further, between 2004 narcotics tripled between 1999 and 2012. In fact, the recent and 2011, ER visits related to nonmedical use of prescription increases in drug overdoses associated with prescription nar- cotics are even more dramatic than the increases seen when TECHNOLOGY UPDATE heroin and crack cocaine were first introduced. Although rates are not as dramatic as for the prescription narcotics, ER Nasal Spray May Help Save Heroin Addicts visits related to nonprescription use of tranquilizers like Valium and Xanax Although rates of prescription drug abuse have been have also increased dramatically in decreasing, rates of heroin use have remained relatively recent years. VIDEO 6 stable and overdose rates have more than doubled. In response to the problem, police officers are beginning to Accidental misuse of prescription drugs is another carry naloxone—a nasal spray that helps reduce risk for common problem. Examples of unwitting misuse of drugs overdose among heroin users. Paramedics have admin- include taking a medicine twice, taking the wrong medicine istered naloxone in an injectable form for some time, but from unlabeled bottles, using outdated medicines, and tak- the nasal spray allows those without medical training to ing multiple medications that negatively interact with one safely administer the drug. In New Jersey alone, roughly another. Thus, it is important to understand the nature of 200 potentially fatal heroin overdoses were prevented in all the medications you are taking (including supplements, a 7-month period. Unfortunately, many people whose lives prescription drugs, and OTC drugs) and how they interact. are saved return to using heroin, making it critically impor- Women who are pregnant, are nursing, or want to get preg- tant that they receive treatment in addition to medical care nant should avoid drug use, including many prescription and detoxification. drugs. The most recent results of the National Pregnancy and Health Survey, conducted by the National Institute on Drug Do you think efforts to reduce access to prescription nar- Abuse (NIDA), estimated that 5.4 percent of the 4 million cotics are leading to increases in heroin use? If so, how women who give birth each year in the United States used do we combat prescription drug use without contributing illegal drugs while they were pregnant. Taking drugs during to the heroin epidemic? pregnancy can result in various conditions, including prema- ture separation of the placenta from the womb, fetal stroke, ACTIVITY miscarriage, birth defects, low birth weight babies, babies born addicted to substances, and postnatal risks, including SIDS and learning disabilities.

Concept 21  c  The Use and Abuse of Other Drugs   417 Strategies for Action The best way to avoid problems be able to help the person seek help from a referral source, associated with drug use is not to try such as an employee assistance program, a family or university illegal drugs and to be careful in the use of legal drugs. This physician or hospital, or your city or county health department. Concept clearly indicates that taking a drug for reasons other These sources help get the person into a treatment program or than managing your own good health increases the risk of tak- support group. Some of the better-known nationwide programs ing more drugs in the future. While most people avoid illegal include Alcoholics (or Narcotics or Cocaine) Anonymous and Al- drugs, almost everyone will take medication sometime in life. Anon Family Groups. Another option is to call the Substance Monitor the use of medications to be sure that you are using Abuse and Mental Health Services Administration (SAMHSA) them as directed and not with other medications that may result hotline and someone will direct you to help in your area. SAM- in dangerous synergistic effects. HSA also has a online treatment locator to help you find local Making responsible decisions about drugs is an important resources: life skill. To combat peer pressure, the ability to clearly and effectively say no is necessary. One effective strategy is to • SAMHSA Hotline (1-800-662-HELP) choose friends whose values support, rather than undermine, • SAMHSA Online Treatment Locator (https://findtreatment. your own. samhsa.gov/) People who have a problem with drugs typically will need help to develop skills and personal characteristics to quit using If you think a fellow student might have a problem with them. For people with a problem, the first step is recognizing illicit or prescription drugs, help is probably available within the that help is needed. In Lab 21A, you will have the opportunity counseling center at your school. Most colleges and universi- to evaluate the behavior of a friend or loved one to determine ties have information about available substance abuse services if the person needs help. People who need help need to talk to on their website. At a later time, it would be wise to answer the someone they can trust, perhaps a friend or relative. You may questions in Lab 21 for yourself rather than for a friend or loved one. This will allow you to determine if you need help. ACTIVITY Suggested Resources ∙ National Council on Patient Information and Education: “Get the and Readings Facts” Prescription Drug Use on College Campuses (pdf). ∙∙ NBC News: America’s Heroin Epidemic. The websites for the following sources can be accessed by searching New England Journal of Medicine: Adverse Health Effects of online for the organization, program, or title listed. Specific scientific Marijuana Use (pdf). references are available at the end of this edition of Concepts of ∙∙∙∙∙ NIDA: DrugFacts: Spice (“Synthetic Marijuana”). Fitness and Wellness. NIDA: DrugFacts: Synthetic Cathinones (“Bath Salts”). SAMHSA: www.samhsa.gov/treatment. ∙ American Public Health Association: As Marijuana Decriminal- USA Today: Narcotic Pain Pills to Face Tougher Regulations. ization Spreads, Public Health Prepares: Health Effects, Regula- U.S. Department of Justice National Drug Intelligence Center tions Examined. (2011). The Economic Impact of Illicit Drug Use on American Society. (pdf) ∙ CDC: Increases in Heroin Overdose Deaths: 28 States, 2010 to 2012. ∙ WebMD Substance Abuse and Addiction Help Center: Benzodiaz- ∙ CDC: Prescription Drug Overdose in the United States. epine Abuse.



Lab 21A  Use and Abuse of Other Drugs Name Section Date Lab 21A Purpose: To evaluate a friend or family member’s behavior and potential for becoming an abuser of drugs; if this report is Use and Abuse of Other Drugs submitted to an instructor, be sure not to identify by name the person you are evaluating Procedures  Answer these questions to determine if the person you are evaluating is an abuser of medications. Place an X over the answer that applies. A.  Prescription Drug Abuse Yes No 1. Does he/she take more medicine than prescribed per dosage? Yes No 2. Does he/she feel more nervous than ever when the medicine wears off? Yes No 3. Does he/she hoard medicine? Yes No 4. Does he/she hide the amount of medicine taken from friends, family, or his/her doctors? Yes No 5. Does he/she fail to provide his/her doctor with a complete list of medications he/she is taking from all sources (dentist, family physician, specialists)? The more questions to which you answered “yes,” the more likely he/she is a drug abuser. B.  Risk Factors for Becoming Addicted (Remember that alcohol is a drug, too.) Yes No 1. Have any members of his/her family ever abused drugs? Yes No 2. Was he/she abused as a child, or did he/she go through other trauma during childhood? Yes No 3. Is he/she now undergoing unusual stress or mental pain? Yes No 4. Does he/she have easy access to drugs? Yes No 5. Has he/she used or does he/she use drugs recreationally? Yes No 6. If he/she has used or now uses drugs recreationally, did or does he/she choose the fastest method of getting a hit? The more “yes” answers, the greater his/her risk of addiction. C.  Signs and Symptoms That a Problem with Drugs Exists (Remember that alcohol is a drug, too.) Yes No 1. Does he/she use drugs as an escape or to cope with a stressful situation? Yes No 2. Does he/she become depressed easily? Yes No 3. Does he/she use drugs the first thing in the morning? Yes No 4. Has he/she ever tried to quit and resumed using again? Yes No 5. Does he/she do things under the influence of a drug that he/she would not normally do? Yes No 6. Has he/she had any drug-related “close calls” with the police or any arrests? Yes No 7. Does he/she think a party or social gathering isn’t fun unless drugs are served/available? Yes No 8. Does he/she feel proud of an increased tolerance to drugs? 419

Yes No 9. Does he/she use drugs when alone? Lab 21A Yes No 10. Has or does he/she use a wide variety of drugs? Yes No 11. Is he/she constantly thinking about being high? Yes No 12. Does he/she avoid people or places that oppose usage? Yes No 13. Has his/her friends, family, teachers, or employer expressed concern about his/her use? Yes No 14. Is his/her usage causing him/her to neglect responsibilities? Use and Abuse of Other Drugs Yes No 15. Has he/she ever had blackouts or lack of memory of drug use or other events? Yes No 16. Has he/she stolen to get money for drugs? Yes No 17. Has he/she seriously considered that he/she might have a drug problem? The more “yes” answers, the more likely he/she is to have a serious problem with drugs. Results Yes No Yes No A. Does he/she abuse prescription drugs? (Questions A: 1–5) B. Is he/she at considerable risk for addiction? (Questions B: 1–6) C. Does he/she have a serious problem with drugs? Yes No (Questions C: 1–17) Conclusions and Implications: In several sentences, discuss a plan of action that could be taken by a person who has a problem with the misuse of over-the-counter drugs, prescription drugs, or illegal drugs. Discuss specific things you could do to help a person with a problem. At some point, you may want to answer the questions about yourself. 420

Preventing Sexually Concept 22 Transmitted Infections LEARNING OBJECTIVES After completing the study of this Concept, you will be able to: c Identify the most common sexually transmitted infections (STIs). c Define HIV and AIDS and indicate rates and trends in their prevalence. c Describe common modes of HIV transmission and the HIV replication process. c Understand the importance of testing and early intervention in preventing HIV/AIDS. c Describe symptoms and consequences of common STIs, including HPV, chlamydia, gonorrhea, and syphilis. c Identify less common STIs and their associated health risks. c Describe important factors contributing to increased risk for STIs. c Understand effective approaches to the prevention and treatment of STIs. Safe sex and sound information about sexually transmitted infections are important to health and wellness. 421

422 Section 7  c  Avoiding Destructive Behaviors The sexual experience is interpersonal and influences our actions and behaviors. It is basic to family life and fundamental to the reproduction of the human species. Approached responsibly, the human sexual experience con- tributes to wellness and quality of life in many ways. When approached irresponsibly, it can result in disease and per- sonal and interpersonal suffering. Learning and adopting safe sex practices are critical for avoiding unwanted preg- nancies and for reducing risks for various infections and diseases. This Concept provides information about the symptoms, causes, and treatments of various infections and diseases transmitted through sexual contact. The term sexually transmitted disease (STD) has been used to refer to these conditions, but the broader term of sexually transmitted infection (STI) is now more accepted. The term STI better reflects the fact that a period Shared interests can help build healthy relationships. of infection typically occurs prior to the emergence of any associated disease symptoms. HIV/AIDS is an example intentionally infect a partner with an STI, and another was of this, as one can be infected for many years before signs to break up a rival’s relationship. Thus, as stated previously, of disease begin to occur. In other cases, STIs never result sexual behavior can have both rewarding and costly effects. in identifiable disease symptoms. Human papillomavirus (HPV) is an Good physical health contributes to an active and example of this type of STI. Although satisfying sex life. Two population-based studies in the HPV can lead to cervical cancer in United States found that individuals who were in good or women, most women infected with VIDEO 1 excellent health were more likely to be sexually active. Among those who were sexually active, good health was HPV never experience disease symp- associated with greater interest in sex, more frequent sex, toms. Because STI better captures the range of outcomes, and a better-quality sex life. On average, being in good this term will be used throughout the remainder of the health increased the sexual life expectancy for men by 5 to Concept. 7 years and for women by 3 to 6 years. General Facts Unsafe sexual activity can result in disease, poor health, and much pain and suffering. Until the 1940s, The healthy sexual experience can contribute to STIs were a leading cause of death. The discovery of peni- wellness in many ways. All five wellness dimensions are involved in decisions concerning participation in, the cillin and other antibiotics, and improved public health practices, lowered the death rate from STIs, but they have meaningfulness of, and the long-term consequences of the remained a significant health problem. In 1991, STIs sexual experience. The healthy sexual experience requires sensitive and thoughtful consideration of the consequences. became one of the 10 leading causes of death in the United States, principally because of the high death rate from When approached responsibly, sexual behavior can enhance acquired immune deficiency syndrome (AIDS) caused by quality of life in important ways. This fact is evident in a recent study of the reasons that college students have sex. the human immunodeficiency virus (HIV). The develop- ment of more effective treatments has The study of over 1,500 college students identified 237 dif- reduced deaths from HIV/AIDS and ferent reasons for engaging in sexual behavior. Although women tended to report more intimacy reasons and men moved STIs off the top 10 list. VIDEO 3 tended to report more reasons related to physical pleasure, 20 of the top 25 reasons overlapped for men and women. The most common reasons across the full sample were love, HIV/AIDS pleasure, affection, romance, emotional closeness, arousal, excitement, adventure, experience, Of all the STIs, HIV/AIDS poses the greatest health connection, cele­bration, curiosity, threat to the world. About 50,000 people in the United States opportunity and the desire to please. are infected with HIV annually, with a total of over 1.2 million Although antisocial reasons for sexual VIDEO 2 people currently infected. Worldwide, the problem is even more profound, with roughly 2.1 million people infected each behavior were less common, they have year and a total of more than 35 million people currently liv- the potential for severe negative consequences. For example, ing with HIV. The problem of HIV/AIDS is particularly bad one of the very infrequently endorsed reasons for sex was to in sub-Saharan Africa, which accounts for roughly 70 percent

Concept 22  c  Preventing Sexually Transmitted Infections    423 of individuals living with HIV. Rates vary considerably across Incidence of HIV/AIDS is increasing disproportionately countries, with a high of 27 percent in Swaziland. Interna- in women and minorities. What was once thought to be a tional health agencies have been working to address the gap in disease of males, especially gay men, is now increasingly a awareness and the limited access to treatments in these parts female condition. Women now represent roughly one-fourth of the world. Fortunately, these efforts are starting to pay off, of those living with HIV in the United States and nearly with a 40 percent decrease in new HIV infections since 2001. half of the global cases of HIV. Ethnic minority groups in There are three mechanisms for most HIV the United States are also disproportionately affected, with transmission. The three primary mechanisms responsi- roughly 46 percent of new cases occurring among African ble for the transmission of HIV are sexual activity, contact Americans and another 23  percent occurring among His- with infected blood (needle sharing), and transmission from panics. This discrepancy is largest among women, with a an infected mother to her child. Among men in the United rate among African American women roughly 20 times that States, the greatest number of new cases result from men hav- of white women. ing sex with men, though a significant number of cases result from heterosexual sex. Among women, risk of transmission HIV attacks the immune system and can lead to AIDS. is most frequent in heterosexual sex. Worldwide, two-thirds A test of serostatus can indicate if a person is seropositive. of all AIDS cases are transmitted by heterosexual sex. When a person tests seropositive for HIV, it means that a blood test has indicated the presence of HIV in the body. More than 10 percent of new cases worldwide are the HIV invades the body’s immune system cells, even killing result of using contaminated needles to inject drugs. Trans- them, which damages the immune system and the body’s mission from infected mothers to their children used to ability to fight infections. HIV causes immune suppression account for roughly as many HIV infections as IV drug use; by directly invading and killing CD4 helper cells. When However, rates have decreased by more than 50 percent too many of these cells (also called T helper cells) are since 2001. The latter mode of transmission could be largely destroyed, the body cannot fight opportunistic infections prevented through the use of a specific drug (nevirapine) effectively. and with a cesarean delivery. When T cell counts are low and the viral load is high, While HIV can be transmitted in multiple ways, it is the immune system cannot function properly, thereby mak- important to understand that HIV is not transmitted through ing the seropositive person more susceptible to various the air or in saliva, sweat, or urine. It does not spread by hug- types of diseases and disorders. Antibodies in the blood that ging, sharing foods or beverages, or casual kissing. Contact with phones, silverware, or toilet seats does not cause the Sexually Transmitted Infection (STI)  An infection for which a spread of HIV. Although people who had blood transfusions primary method of transmission is sexual activity. before 1985 had an increased risk of HIV transmission, the Human Papillomavirus (HPV) A group of more than 150 safety of the blood supply has increased dramatically since related viruses that represents the most prevalent STI and a cause that time, resulting in extremely low rates of risk from trans- of both genital warts and cervical cancer. fusion. The routes of transmission of HIV in the United Acquired Immune Deficiency Syndrome (AIDS) An HIV- States are summarized in Figure 1. infected individual is said to have AIDS when he or she has devel- oped certain opportunistic infections (for example, pneumonia, 25% tuberculosis, yeast infections, or other infections) or when his or Heterosexual her CD4 cell count drops below 200. Human Immunodeficiency Virus (HIV) A virus that causes 63% a breakdown of the immune system in humans, resulting in the MSM body’s inability to fight infections. It is a precursor to AIDS. Serostatus  A blood test indicating the presence of antibodies 8% the immune system creates to fight disease. A seropositive status 3% IDU indicates that a person has antibodies to fight HIV and is HIV MSM- positive. IDU CD4 Helper Cells (T Helper Cells)  Cells that protect against Figure 1  c  Routes of transmission for HIV in the United infections and activate the body’s immune response. HIV kills States. these cells, so a high count usually means better health. Opportunistic Infections  Infections that typically do not affect Note: MSM = men who have sex with men; IDU = injection drug users; MSM- healthy people, but may lead to diseases in people whose immune IDU = both MSM and IDU. systems have been compromised. Source: Centers for Disease Control and Prevention (2015). Viral Load  The level of virus (HIV) in the blood. Antibodies  Proteins in the bloodstream that react to overcome bacterial and other agents that attack the body.

424 Section 7  c  Avoiding Destructive Behaviors A CLOSER LOOK HIV Prevention Drugs: Benefits and Risks use it daily, strict adherence appears to be needed for it to be effective. Some are concerned that individuals will not take it Although overall rates of new HIV infections have decreased consistently but will engage in higher-risk sexual behavior, in recent years, data from the CDC show that rates among leading to increased rather than decreased rates of HIV. men who have sex with men increased by roughly 15 percent between 2008 and 2013. A new HIV prevention drug, Truvada, Should safeguards be put in place to ensure that drugs such has shown great promise in reducing new infections, and public as Truvada are used as intended? If so, what restrictions or health agencies, including the CDC, have encouraged its use monitoring should occur? (in combination with condoms) for high-risk men who have sex with men. Although the drug is highly effective for those who ACTIVITY normally fight infections are ineffective in stopping HIV on a personal level. Increasing awareness of and education from invading the body. about these risks is important for national and international prevention. HIV comes in many forms, creating unique challenges Early detection is critical for controlling the spread of for treatment. There are two primary types of HIV (HIV1 AIDS. Unfortunately, the majority of adults in the United and HIV2). HIV2 appears to be less contagious and to have States have never been tested for HIV. Although rates have a longer latency between infection and disease, but the vast increased gradually over the past decade, only about half of majority of cases of AIDS are due to HIV1. There are four adults report having been tested for HIV. Further, the Centers groups of HIV1 (M, N, O, and P), with the M, or “Major,” for Disease Control and Prevention (CDC) estimates that type accounting for most cases. Within the M group, there about 14 percent of individuals with HIV are unaware that are at least nine different subtypes, though type B (predomi- they are infected and that roughly one-third are diagnosed nant in the United States and Europe) and types A and C so late that they develop AIDS within a year of their HIV (predominant in south and east Africa) account for the diagnosis. To facilitate early identification of HIV, the CDC majority of the global epidemic. in 2006 revised its guidelines for HIV screening in medical settings, suggesting that testing should be routine for every An individual has AIDS when he or she is infected with person over the age of 13. In 2009, the American College of HIV and develops opportunistic diseases because of impairment of the immune system. Examples of oppor- HELP Health is available to Everyone tunistic diseases associated with AIDS are pneumonia, for a Lifetime, and it’s Personal tuberculosis, Kaposi’s sarcoma, yeast infections, and cervi- cal cancer. Other symptoms include fatigue, swollen glands, Finding out your HIV status has never been easier. Mail-in rashes, weight loss, and loss of appetite. Once a person kits allow you to call for a result within 24 hours of receipt receives a diagnosis of AIDS, the diagnosis is maintained of your blood sample (from a simple finger prick), and even if the individual becomes nonsymptomatic. you are not required to identify yourself. You can also test yourself at home with a simple cheek swab, though rates The risk of acquiring HIV/AIDS is reduced if exposure of false negatives (a negative test despite HIV-positive to HIV and to the methods of transmission is avoided. status) are higher for this method. Visit AIDS.gov for more Experts from the National Institutes of Health (NIH) have information. concluded that HIV transmission could be reduced if leg- islative barriers to needle exchange programs were lifted, if Do you support the availability of these quick consumer greater emphasis were given to youth education programs health screens, or do they increase chances of about HIV/AIDS, if greater funding were available for the misdiagnosis? treatment of people who abuse drugs, and if educational efforts among high-risk populations were increased. World- ACTIVITY wide, the money expended on treatment far exceeds the amounts spent on prevention. Taking personal responsibil- ity for reducing risky behaviors is important for prevention

Concept 22  c  Preventing Sexually Transmitted Infections    425 Physicians joined the CDC, recommending that physicians There is no cure for AIDS, but treatments have encourage all of their patients to get tested for HIV, regard- improved. For those infected with HIV/AIDS, there is no less of their level of risk. known cure. However, treatments have been developed to Testing for HIV and other STIs can be either confidential suppress or slow the progress of the disease process. These or anonymous. When a test is confidential, there is a written treatments target various stages in the replication process of record of the test results, but there is also assurance that this the HIV virus. Figure 2 depicts the various steps in the rep- information will be kept private by the health-care provider. lication of the HIV virus. In the first step, the virus must An anonymous test is one for which there is no written record, enter T cells in the body (1). Once HIV enters these cells, and the results cannot be connected to a name or other iden- HIV RNA is translated into DNA through a process called tifiable information. Clinics throughout the country provide reverse transcription (2). Once the HIV RNA has been con- both confidential and anonymous (in most states) testing at verted, an enzyme called integrase facilitates the integration no cost. Self-testing kits can be purchased at drug stores and mailed to labs for analysis so the individual does not have to Kaposi’s Sarcoma  A type of cancer evidenced by purple sores see a health-care provider. The tests are noninvasive, requir- (tumors) on the skin. ing the use of a swab to collect cells from inside the mouth. HIV glycoprotein CD4 receptor HIV envelope CCR5 receptor HIV Virus -or- 1 HIV DNA 3 CXCR4 receptor Host DNA 4 2 HIV mRNA HIV protein HIV RNA T-Cell chain HIV proteins 5 6 Figure 2  c  HIV replication cycle. Source: Adapted from U.S. Department of Health and Human Services.

426 Section 7  c  Avoiding Destructive Behaviors of HIV DNA into the host DNA of the cell (3). The HIV combined with immediate ART for those infected with HIV. DNA is then able to generate new protein sequences (4) Using South Africa as a basis for calculations, the math- necessary to create new copies of the virus (5). In the final ematical model suggested that the incidence and mortality step (6), the HIV protein called protease separates the pro- associated with HIV could be reduced to 1 in 1,000 cases tein sequence into its components so that these proteins can within 10 years of full implementation. Current incidence combine to form new viruses. rates in South Africa are roughly 1 in 20. Although these are only theoretical models, trials of the test and treat approach Several medications are used in combination to target are currently under way in sub-Saharan Africa, so we will different stages in the progression of HIV infection. Fusion soon be able to compare these projections to real data. inhibitors are a class of drugs that operate in the first stage The search for a vaccine for HIV is well under way, of the process by interfering with the virus’s ability to enter though no vaccine is currently available. More than the host cell. Reverse transcriptase inhibitors disrupt reverse 100 vaccines have been tested in humans or animals, and transcription so that HIV RNA cannot be converted into many vaccines are currently undergoing clinical trials in the DNA or integrated into the DNA of the host cell. Finally, United States and abroad. Unfortunately, the search for an protease inhibitors interfere with the protease enzyme, AIDS vaccine took a serious blow when a clinical trial of a which prevents the HIV DNA from being separated into its promising vaccine developed by Merck was discontinued in components. This prevents the development of new viruses 2007 due to heightened risk of HIV among those receiving within the host cell. the vaccine. The authors of the study suggest that the failure may have been due to the adenovirus, which served as the A three-drug “cocktail” has been the most common treat- “shell” through which the vaccine was delivered. Many lost ment, but the FDA recently approved four different “once a hope for the successful development of a vaccine, at least in day” pills for treating HIV. Some evidence suggests that use the near future. of these single-pill treatments leads to better adherence and lower rates of hospitalization. On the down side, it can be More promising results emerged in September 2009, difficult to know which of the drugs is creating side effects when a U.S.-funded study conducted in Thailand found among those who experience them. Thus, individuals with a significant reduction in new cases of HIV among those HIV are encouraged to work closely with their physicians receiving a combination of two vaccines that had been to decide on the best drug or combination of drugs for their ineffective on their own. Presumably, the combination might particular circumstances. work better because one vaccine serves to prime the immune Early treatment dramatically reduces death rates. system, while the second serves to boost its response. Numerous studies have demonstrated the benefits of early The study showed that this combination (RV144) led to a treatment for HIV. Public health agencies have responded 31 percent reduction of new HIV cases for participants by promoting and encouraging greater access to treatment. receiving the vaccine relative to those receiving a placebo. Whereas the CDC used to recommend treatment only for Although reduced risk for infection was modest, further individuals with a CD4 count less than 350, they now rec- analyses of data from this trial have provided ideas about ommend treatment for all individuals with HIV, regardless the types of immune responses necessary for an HIV vac- of CD4 count. Similarly, the World Health Organization has cine to be effective. In 2013, another promising vaccine that moved from recommending treatment at a CD4 count less was designed to slow the progression of HIV among those than 200 to a CD4 count less than 500. They also recom- who became infected (HVTN 505) was found to be ineffec- mend treatment for all infected children under the age of 5, tive. Again, the hope is that lessons learned from the clinical all pregnant or nursing women, and all HIV-positive indi- trial will inform new and more effective approaches. Most viduals with an HIV-positive partner, regardless of CD4 recently, an NIH-sponsored trial (HVN 100) was launched in count. It is estimated that these new guidelines could save an South Africa. This trial uses an improved version of RV144 additional 3 million lives and prevent 3.5 million new cases that has been adapted to the strain of HIV most common in of HIV by 2025. South Africa. Results should be available in about 2 years. Early treatment with ART may also decrease rates of HIV transmission. Although antiretroviral treatment Common Sexually Transmitted (ART) does not eliminate the risk for HIV among partners Infections of individuals who are HIV positive, one study found over a 96 percent reduction in risk for infection among the sexual STIs infect about 20 million people in the United partners of individuals started on ART, relative to those who States each year. Although HIV is the deadliest of the did not begin ART. Combining the approaches of routine sexually transmitted infections, it is not among the most testing and early treatment may have a particularly dramatic common in the United States. Table 1 lists some of the most impact. A recent mathematical model of this approach, common STIs in terms of both incidence (new cases) and called “test and treat,” proposed universal voluntary testing

Concept 22  c  Preventing Sexually Transmitted Infections    427 Table 1  c  R ankings of Incidence and Prevalence of Syphilis rates are much lower, though recent increases are Common STIs cause for concern, particularly among men who have sex with men. Figure 3 provides a graphic depiction of the trends in STI rates over the past 40 years. Rank of Rank of Incidence Prevalence The human papillomavirus (HPV) is a very common STI (Number of (Number of STI in young people. An estimated 14 million people New Cases of People with become infected with HPV each year, making this the the Condition) Condition) most commonly transmitted STI. The virus is responsible Chlamydia 2 3 for the development of genital warts, but most people do Gonorrhea 4 4 not develop them and are therefore unaware that they are infected. Although the disease is asymptomatic in the short Hepatitis B 5 5 term, it leads to significantly increased risk for cervical can- Herpes 3 1 cer in women. In fact, HPV is the leading cause of cervical cancer. Two strains are particularly dangerous, accounting HPV 1 2 for approximately 70 percent of cases of cervical cancer. Federal guidelines initially recommended that all young Syphilis 6 6 girls (aged 11–12) be vaccinated, and the CDC now recom- Source: Cates et al. mends that all young boys be vaccinated as well. The CDC also recommends catch-up vaccinations between age 13 and the early 20s for those Rate per 100,000 500 AIDS who do not receive the vaccination in child- 450 Gonorrhea hood. Virginia and the District of Colum- 400 Syphilis bia have mandated vaccinations, and Texas 350 Chlamydia had a mandate by executive order that was 300 reversed by the state legislature. A num- 250 ber of other states provide vaccinations 200 at no cost or provide education programs 150 designed to increase vaccination rates. 100 Advocates argue that vaccinations save 50 lives, whereas opponents argue that pro- viding the vaccine will encourage casual 0 1976 1980 1984 1988 1992 1996 2000 2004 2006 2008 2010 2012 sexual behavior. Fortunately, these policies Year seem to be working as roughly 38 percent Figure 3  c  Trends in STI rates in the United States. of female adolescent are now fully vacci- nated, and rates of HPV in young women Source: Centers for Disease Control and Prevention decreased by more than half between 2003 and 2010. Unfortunately, rates in adoles- cent females have remained relatively stable over the past few years. Rates of vaccination among male adolescents are prevalence (cumulative number of cases). Although rates of much lower overall, though they have increased dramatically HPV have not been tracked by the CDC because the vast from roughly 1 percent in 2011 to 14 percent in 2013. It is majority of individuals with HPV are unaware that they important to note that the vaccine will not help those already are infected, it is estimated that over 50 percent of sexu- infected with HPV. However, routine Pap tests can identify ally active adults will be infected with HPV at some point the early cell changes associated with HPV and help prevent in their lifetime. Of the STIs that are tracked by the CDC, the development of cervical cancer. chlamydia has been the most commonly reported for the past two decades. With improved methods of screening and efforts by the Chlamydia is a common STI, but it is often difficult to detect. About 1.4 million new cases of chlamydia CDC and other agencies to increase screening, rates of iden- are reported in the United States each year. Chlamydia is tified cases have increased dramatically in the past 25 years known as the “silent” STI because about three-fourths of despite the fact that most experts believe that rates of infec- tion are not increasing. Gonorrhea was the most commonly reported STI until the early 1990s and is now the second most common. Rates of gonorrhea infection in the United Chlamydia  A bacterial infection, similar to gonorrhea, that States have decreased dramatically over the past 25 years. attacks the urinary tract and reproductive organs.