Substance Use and Abuse 179

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

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

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

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

Reducing Substance Use and Abuse Preventing Substance Use Quitting a Substance

Without Therapy Treatment Methods to Stop Substance Use and

Abuse Dealing With the Relapse Problem

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

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

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

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Chapter 7 / Substance Use and Abuse 163

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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164 Part III / Lifestyles to Enhance Health and Prevent Illness

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

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

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

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

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

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

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

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Chapter 7 / Substance Use and Abuse 165

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

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

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

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

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


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

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

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

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

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

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166 Part III / Lifestyles to Enhance Health and Prevent Illness

0 5

College plans: Complete 4 years

Lesser or no college plans

Grade 8

Smoking Status

Grade 10

Grade 12


Grade 8

Grade 10

Grade 12

Young adults (19–28 Years)

10 15 20


25 30 35 40

Daily 1 or more cigarettes

Daily pack or more

At least once in prior 30 days

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

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

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

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

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

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

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

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

Country Males Females Overall

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

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

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Chapter 7 / Substance Use and Abuse 167

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

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

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

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

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

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

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

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

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

• Had at least one parent who smoked.

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

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

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168 Part III / Lifestyles to Enhance Health and Prevent Illness


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

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


Comparative likelihood

Nonsusceptible, precontemplation

Susceptible, precontemplation

Susceptible, contemplation

S us

ce pt

ib ili

ty – st

ag e

co m

bi na

ti on


Susceptible, preparation

5 10

Figure 7-2 Comparative likelihood of nonsmoking teenagers becoming smokers within 2 years, depending on the teens’ combination of susceptibility and stage of change. Note that the nonsusceptible, precontemplation combination arbitrarily = 1 in the graph. (Data from Huang et al., 2005, Table 2.)

affect teenagers’ likelihood of becoming smokers in the future (Huang et al., 2005). Figure 7-2 presents the findings: susceptible teenagers are more and more likely to become smokers as their stages advance from precontemplation (not considering smoking) to contemplation (considering smoking) to preparation (intending to smoke). A susceptible teenager at the preparation stage is nearly 10 times more likely to start smoking within a couple of years than a nonsusceptible teen at the precontemplation stage.

• Were rebellious, thrill-seekers, and low in school motivation.

• Were receptive to tobacco advertisements, such as by naming a favorite one.

• Felt peer pressure to smoke, for example, reporting, ‘‘Others make fun of you if you don’t smoke,’’ and, ‘‘You have to smoke when you’re with friends who smoke.’’

• Held positive attitudes about smoking, such as, ‘‘Smok- ing is very enjoyable,’’ and, ‘‘Smoking can help people when they feel nervous or embarrassed.’’

• Did not believe smoking would harm their health, for instance, feeling, ‘‘Smoking is dangerous only to older people,’’ and, ‘‘Smoking is only bad for you if you have been smoking for many years.’’

• Believed they’d be able to quit smoking if they wanted.

Three other findings are important. First, part of the way smoking by family and friends promotes teenagers’ smoking is that it reduces the belief that smoking might harm the teens’ own health (Rodriguez, Romer, & Audrain-McGovern, 2007). Second, teenagers usually smoke in the presence of other people, especially peers, and smokers consume more cigarettes when in the company of someone who smokes at a high rate rather than a low rate (Antonuccio & Lichtenstein, 1980; Biglan et al., 1984). Third, feeling negative emotions, such as depression, increases people’s smoking (Fucito & Juliano, 2009; McCaffery et al., 2008).

Reinforcement is another important factor in con- tinuing to smoke. For many smokers, the taste of a cigarette provides positive reinforcement for smoking. Research has found that people who feel that the taste

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Chapter 7 / Substance Use and Abuse 169

of a cigarette is the main reason for smoking smoke less than other smokers when their cigarettes are altered to taste less pleasant (Leventhal & Cleary, 1980). Nega- tive reinforcement maintains smoking when people use the behavior as a means of coping with stress or other unpleasant emotional states (Baker et al., 2004). Smok- ing is also related to stress: the greater the stress, the more smokers smoke (Wills, 1986). And smokers report less anxiety and greater ability to express their opinions if they smoke during stressful social interactions than if they do not smoke (Gilbert & Spielberger, 1987). But even if smokers perform better and feel more relaxed in stress- ful situations when they are allowed to smoke than when they are not, they do not necessarily perform better or feel more relaxed than nonsmokers do (Schachter, 1980). Some findings suggest that smoking may reduce stress temporarily, but may increase it in the long run (Parrott, 1999). A study that tested this idea found support for it, but another did not (Orlando, Ellickson, & Jinnett, 2001; Wills, Sandy, & Yeager, 2002).

Biological factors are also involved in sustaining smoking behavior, probably by affecting the addictive effects of nicotine. The fact that adolescent smoking is strongly associated with parental and sibling smoking shows that smoking runs in families. Certainly part of this relationship results from social learning processes. But there are at least three biological routes. First, nicotine passed on by a smoking mother to her baby in pregnancy may make the child more susceptible to nicotine addiction (Kandel, Wu, & Davies, 1994). The second is heredity: genetics affect how likely people are to become smokers, how easily and strongly they become physically dependent on tobacco, and how able they are to quit (Lerman, Caporaso et al., 1999; Pomerleau et al., 1993). Third, researchers have found that an area of the brain, the insula, may control the desire to smoke: smokers who suffer a stroke with damage to that area instantly lose their desire to smoke (Naqvi et al., 2007).

The Role of Nicotine People become physically dependent on tobacco because of the chemical substances their bodies take in when they use it. A person who smokes a pack a day takes more than 50,000 puffs a year, with each puff delivering chemicals into the lungs and bloodstream (Pechacek et al., 1984; USDHHS, 1986b). These chemicals include car- bon monoxide, tars, and nicotine. Cigarette smoke has high concentrations of carbon monoxide, a gas that is readily absorbed by the bloodstream and rapidly affects the person’s physiological functioning, such as by reduc- ing the oxygen-carrying capacity of the blood. Tars exist as minute particles, suspended in smoke. Although tars

have important health effects, there is no evidence that they affect the desire to smoke. Nicotine is the addictive chemical in cigarette smoke and produces rapid and pow- erful physiological effects. Nicotine dependence does not necessarily take months or years to develop: a study found that some beginning smokers who had smoked infrequently experienced symptoms of dependence, such as craving (O’Loughlin et al., 2003).

Nicotine is a substance that occurs only in tobacco. When people smoke, alveoli in the lungs quickly absorb the nicotine and transmit it to the blood (Pechacek et al., 1984; Baker, Brandon, & Chassin, 2004). In a matter of seconds the blood carries the nicotine to the brain, where it leads to the release of various chemicals that activate both the central and sympathetic nervous systems, which arouse the body, increasing alertness, heart rate, and blood pressure. These and other consequences of nicotine form the basis for the positive and negative reinforcement effects of smoking. Then, while people smoke a cigarette, nicotine accumulates very rapidly in the blood. But it soon decreases through metabolism—in about 2 hours, half of the nicotine inhaled from a cigarette has decayed.

Biological explanations of people’s continued cigarette smoking have focused chiefly on the role of nicotine. One prominent explanation, called the nicotine regulation model, proposes that established smokers continue to smoke to maintain a certain level of nico- tine in their bodies and to avoid withdrawal symptoms. Stanley Schachter and his associates (1977) provided evidence for this model in an ingenious series of stud- ies with adult smokers. In one study, the researchers had subjects smoke low-nicotine cigarettes during one week and high-nicotine cigarettes during another week. As the model predicts, the subjects smoked more low- than high-nicotine cigarettes. This effect was especially strong for heavy smokers, who smoked 25% more of the low- than high-nicotine cigarettes. Consistent with these results, other researchers have found that peo- ple who regularly smoke ultralow-nicotine cigarettes do not consume less nicotine than those who smoke other cigarettes—ultralow smokers simply smoke more cigarettes (Maron & Fortmann, 1987).

Although the nicotine regulation model has received research support, there are reasons to think it provides only part of the explanation for people’s smoking behavior (Leventhal & Cleary, 1980). One reason is that most people who quit smoking continue to crave it, and many return to smoking, long after all the nicotine is gone from their bodies. Another reason is that some people smoke a few cigarettes a day for years and don’t increase their use—that is, they don’t show tolerance. These people usually don’t experience withdrawal symptoms

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170 Part III / Lifestyles to Enhance Health and Prevent Illness

but absorb as much nicotine from a cigarette as heavier smokers do (Shiffman et al., 1990; Shiffman et al., 1995). Why do these people continue to smoke? Each of the processes of addiction we considered earlier provides a cogent explanation. For instance, nicotine provides powerful reinforcement of smoking behavior soon after the first puff of a cigarette (Baker, Brandon, & Chassin, 2004; McGehee et al., 1995; Ray, Schnoll, & Lerman, 2009).

Researchers today generally recognize that a full explanation of the development and maintenance of smoking behavior involves the interplay of biological, psychological, and social factors (Shadel et al., 2000). An example of this interplay is seen in the finding that among depressed smokers, those with a specific gene rely more on smoking to cope than those without that gene (Lerman et al., 1998).

SMOKING AND HEALTH ‘‘Warning: The Surgeon General has determined that cigarette smoking is dangerous to your health,’’ states a cigarette pack sold in the United States. Current projections for deaths annually from smoking-related illnesses are 6 million in 2010 rising to 8 million by 2030 (Shafey et al., 2009). Smoking reduces people’s life expectancy by several years and impairs their quality of life in old age, and these effects worsen with heavier smoking (Strandberg et al., 2008). No other single behavior takes such a toll. To what extent do your odds of dying of lung cancer or heart disease increase if you smoke? Figure 7-3 shows that the odds increase greatly, especially for lung cancer. The more you smoke, the worse your odds become—and if you quit, your odds improve steadily, in about 15 years becoming similar to those of people who never smoked (Godtfredsen et al., 2002; LaCroix et al., 1991). Smoking and, specifically, nicotine also impair immune function (McAllister-Sistilli et al., 1998).

WEB ANIMATION: The Case of the Worried Smoker

Access: This interac- tive animation describes the symptoms and medical test results of a woman with a smoking-related illness.

Cancer In the late 1930s, two important studies were done that clearly linked smoking and cancer for the first time (Ashton & Stepney, 1982). One study presented

No Yes Smoke

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nt ag

e dy

in g

be fo

re a

ge 6


Figure 7-3 Probability of a 35-year-old man dying of lung cancer or heart disease before age 65 as a function of smoking heavily or not smoking. Data for women were less complete, but probably would reveal similar risk increases. (Data from Mattson, Pollack, & Cullen, 1987, p. 427.)

statistics showing that nonsmokers live longer than smokers. In the other study, researchers produced cancer in laboratory animals by administering cigarette tar. By producing cancer with experimental methods, these researchers demonstrated a causal link between cancer and a chemical in tobacco smoke and identified tar as a likely carcinogen, a substance that causes cancer. A few decades later the evidence was clear that tobacco tars and probably other byproducts of tobacco smoke cause cancer (Denissenko et al., 1996; USDHHS, 1986b).

Prospective research provides fairly strong evidence for a causal relationship because smokers and nonsmok- ers are identified and then followed over a long period of time to see if they develop cancer. Many large-scale prospective studies have linked smoking with cancers of various body sites, including the lung, mouth, esoph- agus, prostate, bladder, and kidney (Huncharek et al., 2010; Levy, 1985; Shopland & Burns, 1993). The last two may result because carcinogenic chemicals in tobacco smoke are absorbed into the blood and conveyed to the urine. Cancers of the mouth and esophagus can also

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Chapter 7 / Substance Use and Abuse 171

result from using smokeless tobacco—chewing tobacco or snuff (ACS, 2009; Severson, 1993). Thus, carcinogenic substances exist not only in smoke, but in tobacco itself.

In the 1930s, lung cancer in America was quite uncommon and much less prevalent than many other forms of cancer, such as cancer of the breast, stomach, and prostate (ACS, 2009). Deaths from lung cancer at that time occurred at an annual rate of about 5 per 100,000 people in the population, whereas mortality rates for breast and stomach cancer were more than five times that high. Over the years, the mortality rates for most forms of cancer have either declined or remained fairly constant, but not for lung cancer. The annual death rate for lung cancer rose sharply in the second half of the 20th century per 100,000 Americans—it is now about 54 (USBC, 2010); the corresponding rate in the European Union is nearly 38 (WHO/Europe, 2010). In the United States, the deadliest form of cancer is of the lung, claiming over 159,000 lives per year and being responsible for nearly three times more deaths than cancer of the colon or rectum, the second-most-deadly form (USBC, 2010).

The correspondence between the rises in lung cancer deaths and in smoking prevalence since the 1930s is quite striking (McGinnis, Shopland, & Brown, 1987; Shopland & Burns, 1993). The rate of mortality from lung cancer began to rise about 15 or 20 years after the rate of smoking started to rise, and these rates have paralleled each other ever since. During this time, the rates of smoking and of lung cancer were higher for males than for females, but

since the mid-1960s, important gender-related changes have occurred. Smoking has decreased among men and increased among women, thus narrowing the gender gap—and corresponding changes in incidence rates of lung cancer are now evident: since the mid-1980s, the rates declined steadily for men but rose and leveled off for women (ACS, 2009).

How does smoking harm the lungs? When smoke recurrently passes through the bronchial tubes, the lining of the tubes begins to react to the irritation by increasing the number of cells just below the surface. Then,

the fine, hairlike growths, or cilia, along the surface of the lining, whose function is to clear the lungs of foreign particles, begin to slow or stop their move- ment. In time, the cilia may disappear altogether, and as a consequence carcinogenic substances remain in contact with sensitive cells in the lining of the bronchi instead of being removed in the mucus … . At this stage, a smoker’s cough may develop. It is a feeble attempt by the body to clear the lungs of foreign par- ticles in the absence of functioning cilia. (La Place, 1984, p. 326)

Lung cancer usually originates in the bronchial tubes. In most cases, it probably develops because of the extensive contact of carcinogens with the bronchial lining.

Smoking is a major risk factor for all forms of cancer, but its role is more direct and powerful in lung cancer than in other cancers. People’s environments contain many other carcinogens, and smoking is not the only

cause of these diseases. (Go to .)

Healthy lung Smoker’s lung (cancerous tumor) Smoker’s lung (emphysema)

An advertisement by the American Cancer Society that may motivate people to avoid starting or to quit smoking. Reprinted by the permission of the American Cancer Society, Inc. from All rights reserved.

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172 Part III / Lifestyles to Enhance Health and Prevent Illness


Does Someone Else’s Smoking Affect Your Health? ‘‘What do you mean I can’t smoke in

this bar! It isn’t your business what I do to my body,’’ a patron said indignantly to a bartender. Some smokers have reacted strongly to smoking bans in public places. Why were these regulations introduced?

Excess tobacco smoke goes into the environment, either as sidestream smoke from the burning tip of the tobacco item or as exhaled smoke from smokers’ bodies. This excess smoke constitutes secondhand smoke that others consume (Eriksen, LeMaistre, & Newell, 1988). Breathing secondhand smoke is called passive smoking. In the mid-1980s, the United States Surgeon General issued a report on the effects of passive smoking that included three conclusions (USDHHS, 1986b, p.7):

1. Involuntary smoking is a cause of disease, including lung cancer, in nonsmokers.

2. Compared with the children of nonsmoking parents, children of parents who smoke have a higher fre- quency of respiratory infections, increased respiratory symptoms, and slightly smaller rates of increase in lung function as the lungs mature.

3. The simple separation of smokers and nonsmokers within the same air space may reduce, but does not

eliminate, the exposure of nonsmokers to environ- mental tobacco smoke.

Public places, such as worksites, have high levels of secondhand smoke when smoking is permitted (Hammond et al., 1995). Levels of secondhand smoke can be so high as to produce high nicotine levels in the blood of nonsmokers (Okoli, Kelly, & Hahn, 2007).

Evidence of the harmful effects of secondhand smoke is quite substantial. Studies of nonsmokers whose spouses smoked have generally found that passive smok- ers’ risk of lung cancer increases, sometimes doubling or tripling (Eriksen, LeMaistre, & Newell, 1988; USDHHS, 1986b). Studies have also found a higher risk of car- diovascular disease in nonsmoking spouses of smokers than nonsmokers (Humble et al., 1990), and exposure to secondhand smoke increases atherosclerosis (Howard et al., 1998; Penn & Snyder, 1993). What’s more, for people with existing cardiovascular conditions, such as angina, and respiratory problems, such as asthma and hay fever, environmental tobacco smoke can bring on attacks or aggravate acute symptoms (Eriksen, LeMaistre, & Newell, 1988). Increasingly, people are becoming aware of the health effects of secondhand smoke and making efforts to have smoke-free environments.

Cardiovascular Disease Cardiovascular disease—including coronary heart dis- ease (CHD) and stroke—is the leading cause of death worldwide (WHO, 2009). In the United States, it is respon- sible for over 34% of all deaths each year and claims more lives than cancer, accidents, and several other causes combined (USBC, 2010). When you point out these facts to smokers, some say, ‘‘Well you have to die of something.’’ Of course, that’s true—but when you will die and how disabled you will be before are the real issues. Cardio- vascular disease takes many lives early: for instance, one in six Americans it kills are under 65 years of age.

Many millions of Americans suffer from CHD and stroke. The risk of developing CHD is two to four times as high for smokers as for nonsmokers (AHA, 2010). And the more cigarettes people smoke, the greater the risk: a prospective study of smoking and CHD across 81/2 years found that the risk of developing heart disease was far higher for individuals who smoked more than a pack a day than those who smoked less (Rosenman et al., 1976). Two other points are important in the

link between smoking and CHD. First, the greater risks smoking conveys for CHD may be aggravated by stress. An experiment tested smokers in a stressful task and found that their stress-hormone and cardiovascular reactivity were higher if they had smoked recently (that is, they had not been deprived of smoking) than if they had not smoked for many hours (Robinson & Cinciripini, 2006). Since smoking usually increases when people are under stress, the resulting heightened reactivity raises their CHD risk. Second, smokers tend to have lifestyles that include other risk factors for CHD, such as being physically inactive (Castro et al., 1989).

How does smoking cause cardiovascular disease? The disease process appears to involve several effects that the nicotine and carbon monoxide in cigarette smoke have on cardiovascular functioning (USDHHS, 1986a). Nicotine constricts blood vessels and increases heart rate, cardiac output, and both systolic and diastolic blood pressure. Carbon monoxide reduces the availability of oxygen to the heart, which may cause damage and lead to atherosclerosis. Studies have found that the more

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Chapter 7 / Substance Use and Abuse 173

cigarettes people smoke per day, the greater their level of serum cholesterol and size of plaques on artery walls (Muscat et al., 1991; Tell et al., 1994). After stopping smoking, cardiovascular risk factors, such as cholesterol levels, improve markedly within 2 months (Eliasson et al., 2001), and the risk of heart attack or stroke declines greatly in the next few years (Kawachi et al., 1993; Negri et al., 1994).

Other Illnesses Smoking can lead to a variety of other illnesses— particularly emphysema and chronic bronchitis—which are classified together as chronic obstructive pulmonary disease (COPD) (ALA, 2010; Haas & Haas, 1990). People with COPD experience permanently reduced airflow, which is especially evident when they try to exhale with force. Over 80% of cases of COPD in the United States are related to smoking (ALA, 2010). As we saw earlier, recurrent smoking irritates and damages respiratory organs. Research has shown that more damage occurs from smoking high-tar than low-tar cigarettes and that regularly smoking nontobacco (marijuana) cigarettes also damages the respiratory system (Bloom et al., 1987; Paoletti et al., 1985). COPD can incapacitate its victims, often forcing relatively young individuals to retire from work. It causes 3 million deaths each year worldwide, particularly among its victims who smoke (WHO, 2010).

Smoking may also increase acute respiratory infec- tions. This has been shown in two ways. First, studies have found that children of smokers are more likely to develop pneumonia than are children of nonsmokers (USDHHS, 1986b). Second, when exposed to common cold viruses, smokers are much more likely to catch

cold than nonsmokers, probably because their immune functions are impaired (Cohen et al., 1993).


People’s use of alcoholic beverages has a very long history, beginning before the eras of ancient Egypt, Greece, and Rome, when using wine and beer was very common. Its popularity continued through the centuries and around the world—except in cultures that strongly prohibited its use, as in Islamic nations—and eventually reached America in the colonial period. Colonial Americans arrived with

the drinking habits and attitudes of the places they left behind. Liquor was viewed as a panacea; even the Puritan minister Cotton Mather called it ‘‘the good creature of God.’’ By all accounts, these people drank, and drank hard. (Critchlow, 1986, p. 752)

But the Puritans also realized that excessive drinking led to problems for society, so they condemned drunkenness as sinful and enforced laws against it.

Over the next two centuries, attitudes about alcohol changed in many cultures. In the United States, the temperance movement began in the 18th century and pressed for total abstinence from alcohol. By the mid- 1800s, the use of alcohol had diminished sharply and so had its reputation: many Americans at that time believed alcohol destroyed morals and created crime and degenerate behavior (Critchlow, 1986). These attitudes persisted and helped bring about Prohibition, beginning in 1920, when the production, transport, and sale of alcohol became unlawful. After the repeal of Prohibition,

Women in the temperance movement were very assertive, and some went to saloons to keep records of who bought drinks.

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174 Part III / Lifestyles to Enhance Health and Prevent Illness

the use of alcohol increased, of course, and attitudes about alcohol softened. Americans today believe alcohol has both good and bad effects. (Go to .)

WHO DRINKS, AND HOW MUCH? People’s attitudes about alcohol and its use are tied to their own characteristics and backgrounds, such as their age, gender, and sociocultural experiences.

Age, Gender, and Alcohol Use Age and gender affect people’s experience with drinking alcoholic beverages in most societies. One reason for gender differences in drinking is that females on average experience more intoxication than males from the same amount of alcohol. This is because, even when body size is the same, females metabolize alcohol less quickly than males (Tortora & Derrickson, 2009).

Drinking typically begins in adolescence, and some- times in childhood. In a survey of thousands of students across the United States, high school seniors’ answers indicated that 72% had consumed an alcoholic drink at some time in their lives, 43% had a drink in the last month, 46% had been drunk in the past year, and 25% had drunk five or more drinks in a row in the pre- ceding 2 weeks (Johnston et al., 2009). Males reported more drinking than females. About 32% of eighth graders claimed they’d had a drink in the past year. Although young people sometimes have alcohol at home with the

parents present, such as at special occasions, most teenage drinking occurs in different circumstances. Even when it is illegal for high school and college students to purchase alcohol and to drink without parental supervision, many do anyway. In adulthood, more males than females continue to drink (NCHS, 2009a). Although most young adult and middle-aged Americans drink, the prevalence is much lower in older groups.

Sociocultural Differences in Using Alcohol Alcohol use varies widely across cultures around the world. Per capita, Americans each year consume 2.3 gal- lons (9.77 liters) of ethanol—the alcohol in beer, wine, and spirits (NIAAA, 2009). Table 7.2 compares several countries on the amount of alcohol consumed per per- son and alcohol-related traffic accidents. Traditionally, countries were classified into two types of alcohol use: those that integrate alcohol into daily life, as in serving it with meals in Italy and France, and those that restrict its use, such as the United States and Scandinavian nations (Bloomfield et al., 2005). Daily drinking occurred more in the former, and intoxication in the latter. But these distinctions are disappearing.

In the United States, drinking patterns differ among its many ethnic groups. The percentage of adults who drink is higher for Whites than for other ethnic groups: Black, Hispanic, Asian, and Native Americans (NCHS, 2009b). And the percentage of adults who sometimes drink several drinks in a day is much higher for White,


What’s True about Drinking? Put a check mark in the space pre-

ceding each of the following statements you think is true.

Alcohol is a stimulant that energizes the body.

Having a few drinks enhances people’s perfor- mance during sex.

After drinking heavily, people usually sober up a lot when they need to, such as to drive home.

Most people drive better after having a few beers to relax them.

Drinking coffee, taking a cold shower, and getting fresh air help someone who is drunk to sober up.

People are more likely to get drunk if they switch drinks, such as from wine to beer, during an

evening rather than sticking with the same kind of drink.

Five 12-ounce glasses of beer won’t make some- one as tipsy as four mixed drinks, such as highballs.

People seldom get drunk if they have a full meal before drinking heavily.

People can cure a hangover by any of several methods.

Most people with drinking problems are either ‘‘skid row bums’’ or over 50 years of age.

Which statements did you think were true? They are wrong—all of the statements are false. (Based on Drinking Myths distributed by the U.S. Jaycees.)

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Chapter 7 / Substance Use and Abuse 175

Table 7.2 Per Capita Pure Alcohol (Ethanol) Consumption Annually and Alcohol-Related Traffic Accident Rate (per 100,000 Accidents) in Selected Countries

Consumption in Alcohol-Related Liters per Capita Traffic Accident

Country Ages 15 and Overa Rateb

Australia 9.02 na Brazil 5.76 na Canada 7.80 na China 5.20 na Germany 11.99 29.4 India 0.29 na Italy 8.02 5.1 Netherlands 9.68 12.8 Singapore 2.17 na South Africa 6.72 na Sweden 5.96 11.7 Turkey 1.37 28.2 United Kingdom 11.75 18.8

Note: The amount of pure alcohol per liter varies with the beverage: beer, wine, or spirits; na = data not available. Sources:a WHO, 2009, b WHO/Europe, 2010.

Hispanic, and Native Americans than for Black and Asian Americans. Some years ago, the percentage of adults who drank several drinks in a day was far higher for Native Americans than for all other groups, but their drinking has moderated.

Problem Drinking Figure 7-4 shows that nearly 64% of Americans age 18 and older drink alcohol at least occasionally. Most of these people are light-to-moderate drinkers, consuming fewer than, say, 60 drinks a month. Many people drink much more heavily, but not all of them meet the criteria for substance abuse we described earlier. One definition of heavy drinking is engaging in binge drinking—that is, consuming five or more drinks on a single occasion at least once in a 30-day period. Using this definition, the percentage of American current drinkers who drink heavily at least occasionally is about 10% for teenagers, 42% for 18- to 25-year-olds, and 22% for adults over 25 (USBC, 2010). In comparison, of European 15- and 16- year-olds, 43% reported having engaged in binge drinking in the past month, and 39% said they had been drunk in the past year (ESPAD, 2009). The next step toward alcohol abuse, called heavy use drinking, involves binge drinking five or more times in a month (Kring et al., 2010). Binge and heavy use drinking occur at very high levels on college campuses, especially among fraternity and sorority members (Courtney & Polich, 2009; SAMHSA, 2008). Of individuals who develop problems associated with drinking, most—but not all—do so within about

Regular drinkers 50.3%

Former drinkers 14.4%

Infrequent drinkers 13.6%

Lifetime abstainers


Figure 7-4 Proportions of American adults with four drinking statuses: regular drinkers (12 or more drinks in the past year), infrequent drinkers (more than 1, but fewer than 12 drinks, past year), former drinkers (no drinks, past year), and lifetime abstainers (fewer than 12 drinks ever). (Data from NCHS, 2009b, Table 27.)

5 years of starting to drink regularly (Sarason & Sarason, 1984).

How many drinkers meet the criteria for substance abuse? Estimates have been made on the basis of the proportion of individuals at a given time who had ever displayed the problem. This statistic, called the lifetime prevalence rate, indicates that over 17% of adults in the United States become alcohol abusers (Kring et al., 2010). People who abuse alcohol—or problem drinkers—drink heavily on a regular basis and suffer social and occupational impairments from it. Many of them frequently get drunk, drink alone or during the day, and drive under the influence. Although alcohol abuse is more common in males than females, it is most likely to develop between the ages of 18 and 25 for both sexes (McCrady, 1988; NIAAA, 2006). More than half of those who abuse alcohol are physically dependent on it, or addicted to it, and are classified as alcoholics. These people have developed a very high tolerance for alcohol and often have blackout periods or substantial memory losses; many experience delirium tremens when they stop drinking. Although alcoholics often drink the equivalent of a fifth of whiskey (about 25 ounces) a day, 8 ounces can sometimes be sufficient to produce addiction in humans (Davidson, 1985).

Who abuses alcohol? Many people have an image of the ‘‘typical’’ alcoholic as a scruffy looking, unemployed male derelict with no family or friends. But this image is

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176 Part III / Lifestyles to Enhance Health and Prevent Illness

Drinking and celebrating often occur together, and this association conveys the message that drinking is fun.

valid for only a small minority of people who abuse alcohol (Mayer, 1983; McCrady, 1988; NIAAA, 2006). Most problem drinkers are married, living with their families, and employed—and many are women. Although individuals from the lower social classes, especially homeless people, are at greater risk than those from higher classes for abusing alcohol, large numbers of problem drinkers come from the higher classes and hold high-status jobs. Problem drinking is very rare in childhood; its prevalence increases in adolescence, rises sharply in early adulthood, and gradually declines across ages thereafter (NIAAA, 2006). Alcohol abuse is a major social problem that affects substantial numbers of people from almost all segments of many societies around the world. (Go to .)

WHY PEOPLE USE AND ABUSE ALCOHOL In examining why people use and abuse alcohol, we need to consider why individuals start to drink in the first place. The chief reasons for starting to drink involve social and cultural factors, particularly the expectancies that form from watching other individuals enjoying themselves while drinking (Thirlaway & Upton, 2009; Wood, Vinson, & Sher, 2001). For example, the more teens see alcohol scenes in movies and ads on TV, the more they are likely to drink in the future (Dal Cin et al., 2009; Stacy et al., 2004). Underage drinking is more likely among teens who have high feelings of depression, believe their friends drink a lot, have low school grades, and have

parents who drink and provide little monitoring or rules against drinking (Fang, Schinke, & Cole, 2009). Children who are depressed, abused, or neglected are at risk for drinking heavily in adolescence and adulthood (Crum et al., 2008; Shin, Edwards, & Heeren, 2009).

Adolescents continue drinking partly for the same reasons they started, but these factors intensify, and new ones come into play. For one thing, the role of peers increases. Although teenagers often begin occasional drinking under their parents’ supervision, such as at celebrations, drinking increases with peers at parties or in cars. Figure 7-5 shows that the percentage of American adolescents who claim to have been drunk in the past month increases with year in school, and is higher for teens who do not plan to complete 4 years of college than for those who do. Individuals who start to drink on a regular basis in early adolescence are at heightened risk of drinking heavily in adulthood (Pitkänen, Lyyra, & Pulkkinen, 2005). In late adolescence and early adulthood, drinkers drink frequently and almost always socially, with friends at parties or in bars. The social aspect is important in two ways (McCarty, 1985; Thirlaway & Upton, 2009). First, in social drinking, modeling processes affect behavior—for example, people tend to adjust their drinking rates to match those of their companions. Second, drinking socially creates a subjective norm in individuals that the behavior is appropriate and desirable.

With continued drinking, the strength of the behavior increases through positive and negative reinforcement,

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Chapter 7 / Substance Use and Abuse 177


Do You Abuse Alcohol? Ask yourself the following questions

about your drinking:

• Do you usually have more than 14 drinks a week (assume a drink is one mixed drink with 11/4 ounces of alcohol, 12 ounces of beer, or the equivalent)?

• Do you often think about how or when you are going to drink again?

• Is your job or academic performance suffering from your drinking?

• Has your health declined since you started drinking a lot?

• Do family or friends mention your drinking to you?

• Do you sometimes stop and start drinking to ‘‘test’’ yourself?

• Have you been stopped for drunk driving in the past year?

If you answered ‘‘yes’’ to the first question, consider changing your drinking pattern. If you answered ‘‘yes’’ to any additional questions, consult your college’s counseling office for their advice or help. (Based on TSC, 1992, and USDHHS, 1995.)

0 Eighth

Complete 4 Years

College plans:

Complete less or none



P er

ce nt

d ru







Figure 7-5 Percent of American adolescents at different grades in school who claimed to have been drunk at least once in the past month, depending on their college plans: either to complete 4 years or to complete less or no college. The graph does not separate data for males and females because they are fairly similar. (Data from Johnston et al., 2009, Tables D–68 to D–70.)

and substance-related cues develop (Baker, Brandon, & Chassin, 2004; Cunningham, 1998; Thirlaway & Upton, 2009). Individuals may receive positive reinforcement for drinking if they like the taste of a drink or the feeling they get from it, or if they think they succeeded in business deals or social relationships as a consequence of drinking. Having reinforcing experiences with drinking increases their expectancies for desirable consequences when deciding to drink in the future (Adesso, 1985; Stacy, 1997). In the case of negative reinforcement—that is, the reduction of an unpleasant situation—we’ve seen that

people often use alcohol to reduce stress and unpleasant emotions. They may, for instance, drink to suppress their negative thoughts or feelings of anxiety in social situations (Gilles, Turk, & Fresco, 2006; Zack et al., 2006). But the effects of alcohol on negative emotions are not so simple. Although drinkers report that alcohol reduces tension and improves their mood, it seems to do so only with the first few drinks they consume in a series. After people consume many drinks, their anxiety and depression levels usually increase (Adesso, 1985; Davidson, 1985; Hull & Bond, 1986). In cases of severe trauma, such as witnessing terrorism, alcohol use may be heightened for a couple of years (DiMaggio, Galea, & Li, 2009).

Why can most people drink in moderation, but others become problem drinkers? We’ll consider four psychoso- cial differences between these people. First, compared to individuals who do not abuse alcohol, those who do are more likely to perceive fewer negative consequences for drinking (Hansen, Raynor, & Wolkenstein, 1991). Second, heavy drinkers tend to experience high levels of stress and live in environments that encourage drinking. For instance, adolescents who abuse alcohol are more likely to have experienced a major trauma, such as physical assault, and have family members who drink heavily (Kilpatrick et al., 2000). Third, heavy drinkers may form particularly strong substance-related cues: they develop heightened physiological reactions and positive feelings to alcohol-related stimuli, such as seeing or smelling liquor, especially when alcohol is available (Turkkan, McCaul, & Stitzer, 1989). Fourth, people who drink in moderation are more likely to use alcohol control strate- gies, such as avoiding situations where heavy drinking is likely (Sugarman & Carey, 2007).

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178 Part III / Lifestyles to Enhance Health and Prevent Illness

But a complete answer to why people become problem drinkers also includes developmental and biological factors. For instance,

• Heredity plays a much stronger role when the abuse begins before age 25 than after (Kranzler & Anton, 1994).

• People with a family history of alcoholism appear to develop a tolerance to alcohol, drinking increasing amounts to feel the same effects, more readily than other people (Morzorati et al., 2002).

• People with a specific gene pattern experience stronger cravings for alcohol after having a drink than other individuals do (Hutchinson et al., 2002).

• Some evidence suggests that people at high genetic risk for alcohol dependence find alcohol more rewarding each time they drink, but low-risk people do not (Newlin & Thompson, 1991).

Genetic factors seem to combine with psychosocial processes, especially conditioning, in the development

of drinking problems. (Go to .)

DRINKING AND HEALTH Drinking too much is linked to a wide range of health hazards for the drinker and for people he or she may harm. Drinkers can harm others in several ways. Pregnant women who drink more than two drinks a day place their babies at substantial risk for health problems, such as being born with low birth weight or fetal alcohol syndrome, which involves impaired nervous system development and cognitive and physical defects (Gray, Mukherjee, & Rutter, 2009; Wood, Vinson, & Sher, 2001). Drinking lesser amounts during pregnancy has been associated with impaired learning ability in the child. The safest advice to pregnant women is not to drink at all.

Drinking also increases the chance that individuals will harm themselves and others through accidents of various types, such as from unintentionally firing a gun

to having a mishap while boating or skiing (Taylor et al., 2008; Wood, Vinson, & Sher, 2001). Drunk driving is a major cause of death in the United States: over 17,600 traffic deaths each year are associated with alcohol use (NHTSA, 2008). Consuming alcohol impairs cognitive, perceptual, and motor performance for several hours, particularly the first 2 or 3 hours after drinks are consumed. The degree of impairment people experience can vary widely from one person to the next and depends on the rate of drinking and the person’s weight. Figure 7-6 gives the average impairment for driving—but for some individuals, one or two drinks may be too many to drive safely.

People’s judging how many drinks they can have before engaging in a dangerous activity can be difficult for a couple of reasons. First, many people have misconceptions about the effects of alcohol, such as believing that drinking on a full stomach prevents drunkenness, or thinking, ‘‘I’ll be OK as soon as I get behind the wheel.’’ A study found that students underestimated the impact that alcohol has 2 or 3 hours after drinking, thought that later drinks in a series have less impact than the first couple, and downplayed the effects of beer and wine relative to mixed drinks (Jaccard & Turrisi, 1987). Second, people tend to ‘‘super-size’’ a drink they make for themselves, and still count it as ‘‘a single drink,’’ especially if the glass is large (White et al., 2003). So if we try to gauge how intoxicated we’re becoming by counting drinks, we may underestimate the effect.

Long-term, heavy drinkers are at risk for developing several health problems (Thirlaway & Upton, 2009; Wood, Vinson, & Sher, 2001). One of the main risks is for a disease of the liver called cirrhosis. Heavy drinking over a long period can cause liver cells to die off and be replaced by permanent, nonfunctional scar tissue. When this scar tissue becomes extensive, the liver is less able to cleanse the blood and regulate its composition. Heavy drinking also presents other health risks: it has been linked to the


Drinking—Games People Play ‘‘Hey, let’s play Kings, Queens,’’ said

Julie, holding up a deck of playing cards at a party. She was referring to one of many drinking games; in this one, the players assign rules for the amount and type of alcoholic beverage they will drink when specific cards are played. The beverage can be hard liquor or soft, such as beer. Some drinking games involve team competition

or chugging (drinking a full container without pausing). Drinking games are very popular at American college campuses and lead some students to consume seven or more drinks and become quite intoxicated while playing (Zamboanga et al., 2006). Some students play these games weekly and drink at levels that suggest substance abuse.

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Chapter 7 / Substance Use and Abuse 179


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