Tobacco Documents Online

....~.._ ..~..~._~_.~..__..,, . _.__.. Substance Abuse October 1993 51422 4577 „

;FURHEALTH _POLICY, BRANDEIS UNIVERSCI'Y for THE ROBERT WOO[> JONNSC~N FOUNDATION PRINCEI'ON, NF.W JERSEY October 1993

511B5T11111E JIB115E: THE NATION'S NUMBER ONE HEALTH PROBLEM Key Indicators for Policy 1'rcy,,o ,'rl fip [V; i i r(' ri~ EOEZ HE~.\t:rii PM«:Y, BizANDr.is UN ivrhsrrY f'or Tr-1E. RoBE:K-r V'ooi) JOHNsoN YouhuAriC>N hRfNCE"!Y)N, NI:Av JERSF.Y C)ctober• 1993 ^ \'\~ ~ ~. ~,.~.c..~ ...~es. ....r..

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~ ~ TABLE OF COnTEnTS .•.•.•........••.....•.........•••... ACKIlOIULEDGEItlEI1TS ......................................................... 5 PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 DATR UOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 ~ ~ OUERUIEW: THE COIITEHT OF SUBSTAIICE ABUSE .................................... 0 ~.~ Use, Abuse and Dependence, 8 ~ ~ Historical 'Irends in Consumption and Policy, 9 ~ ~ All Segments of Society Affected, 14 Societal Costs of Substance Abuse, 15 ~ Taking Action, 17 ~ ~ Monitoring Change, 17 Further Reading, 18 ~ A ~ 7 SECTIOII 1: PRTTERIIS OF USE .................................................. 19 ~ ~ Perception of Risk, 20 ~ ~ Implications of Early Use, 22 ~ i '1rends in Heavy Use, 24 ~ I)emographic Differences in Heavy Use, 26 , ~ Attempts to Quit, 28 Further Reading, 30 SECTIOII 2: COIISEQUEIICES OF USE .............................................. 31 ~ ~ "lobacco I)eaths, 32 Alcohol I)eaths, 34 ~ : Illicit I)rug I)eaths, 36 ~ ~: Strains on the Nation's Health Care System, 38 ~; Eflects of Substance Abuse on Families, 40 + Relationship to Crime, 42 a ~ Workplace Burden, 44 Further Reading, 46 ~ SECTIOIl3:C0It1BATTIIIGTHEPROBLEm...•.....,•,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47 Public Attitudes, 48 Illicit I)rug Control, 50 ~ ~ Community Coalitions, 52 ~ ~ Alcohol and Cigarette 'laxes, 54 Restrictions on Alcohol Use, 56 0' ~ Restrictions on Smoking, 58 Alcohol and I)rug Abuse Treatment, 60 Smoking Cessation Programs, 62 Further Reading, 64 ~. 00 . . ConClUSlo11 ,- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 ~-~ 00 ~, IIIDEH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 ~ ~ ~ r `. .r SUBSTAACE ABUSE . _ . . .... ........:~. . _.. ,., .~ -,.~.;

ACHOtULED GErClEI1TS ~ ~ ~ : ~ J ~ J ~ ~ -~ ~ ~ J ~ .~ ~ ~ ~ ~ ~ J ~ : ~ i ~ : . '~ a ~ ~ ~ -~ ~ 3 : ~ 0 1. WOU1.I)1.IKF, to thank a num- ber of people who provided very helpful advice on aspects of this report, including the overall orga- nization and content, the list of indicators, and locating data sources. The following people served on our Advisory Board: James J. Collins, John S. Gustafson, Michael Klitzner, Patrick M. O'Malley, Peter Reuter, Nancy Rigotti, and Robin Room. Also help- ful were government officials who served in an ex-oflicio capacity on the Advisory Board: Zili Amsel, Ann Blanken, Richard Fuller, Gary A. Giovino, Thomas Harford, Gale Held, Jerome Jaffe, and James Kaple. Dorothy Rice provided special cost calculations, and data also were provided by Rosanna Coffey, Joseph C. Gfroerer, Thomas Novotny, and Fred Stinson. Additional reviewers from Brandeis University were Deborah Garnick, Jeffrey Prottas, and Arthur Webb. Each provided useful advice on the most recent data sources as well as on accu- rate interpretation of data. C.H., M.E.M., M.J.L. i : : I SUBSTAIICE BBUSE

PREFRCE I MI'ROVING THE HFAI:r'H and health care of the American people is the mission of "I'he Robert \Cood Johnson Foundation. As a national philanthropy, the Founda- tion supports projects that provide ser- vices, conduct research and training and aa range of other activities that we hope will have an impact beyond our grantees' efforts: New models of care are tested so that others may adopt the most promising ones; health care leaders are trained so that they may discover new approaches and, in turn, influence the next generation. Policymaking takes place on many levels, with the participation of many people-busi- ness and communitv leaders, legislators, health professionals, interest group representatives, and voters. All have a role to play. Through the publication of a series of policy-relevant reports, the Foundation hopes to strengthen the ability of those participants to play effec- tive roles in the decision-making process, by arming them with simple, yet critical indica- tors that quickly summarize the nation's progress regarding specific health pol icy issues. Tracked over time, these indicators also can serve as early.varning signals, alerting policymakers to future problem areas. SUBST9]CE BBBSE Each report in the current indicator series describes one of the four health policy areas chosen by the Foundation as major program goals for the 1990s: • assuring access to basic health care for all Americans; • improving the way services are organized and provided to people with chronic health conditions; . promoting health and preventing disease by reducing harm from substance abuse; and • seeking opportunities to help the nation address the problem of escalating medical costs. Once our authors constructed a conceptu- al framework to measure each area, indica- tors were selected based upon their policy- relevance, the availability of data, and their ability to highlight a specific point and con- tribute to an overall understanding of the area. We hope this report will serve as a helpful resource, and we encourage readers to share its information with others. If you have comments or stiggestions, we would like to hear from you, as we decide whether subsequent editions would be usefitl. Please tell us what you think. STF\'EN A. SCHROEt)ER, \1D President ( ( ( 0 ( ( ( (

k , BOU7' THF. TERMS USEI) IN THIS REPORT... The labels used in this report for population groups, risk groups, and health problems are those used by the original data sources. In some cases, these labels--ethnic and racial identities are a good example-reflect old val- ues. We adopted this approach, despite our desire to be sensitive to changing preferences, because of the lack of consensus about which terms are preferred and to avoid potential con- fusion when people go back to an original data source to learn more about an issue. CAU'I'IONARY NO'FF;S FOR I)ATA INTERPRF:- T,tTIOti... "I-his report presents data on trends in substance use, consequences, and inter- DATA I10TES vention efforts, as well as comparisons among subgroups of the population on these issues. In most cases, available information was not sufficient to test for statistical significance of differences between years or between sub- groups. Accordingly, caution should be exer- cised in comparing the magnitude of such differences. In addition, trend data are gen- erally drawn from cross-sectional surveys or other data that do not represent the experi- ence of the same individuals over time. Despite these cautionary notes, the consistency of long-term trends and evidence from several sources is supportive of the major conclusions discussed here about the magnitude of the substance abuse problem and progress made in combatting it. SA85TA11CE BBU5E

OUERUIEUI: THE COI1TEXT OF SUBSTAIICE ABUSE R S THE NUMBER one health problem in the country, substance abuse places a major burden on the nation's health care system and con- tributes to the high cost of health care. In fact, substance abuse-the problematic use of alcohoZ illicit drugs and tobacco-places an enor- mous burden on American society as a whole. It can harm health, family life, the economy and public safety, and it threatens many other aspects of life as well. Substance abuse aects all segments ofsociety but it disproportionate- ly affects disadvantaged groups and threatens the future ofyoung people. ........................................................................... •'1'here are more deaths, illnesses and dis- abilities from substance abuse than from any other preventable health condition. Of the two million U.S. deaths each year, more than one in four is attributable to alcohol, illicit drug or tobacco use. Many of these deaths and other losses could be reduced-if not eliminated-- by changing people's habits. Alcohol and illicit drug use can result in family violence and maltreatment of children, and the loss of a family member due to sub- stance abuse has lifelong ramifications. Passive smoking causes respiratory problems in chil- dren and adults. The workplace is affected as well. Alcohol and drug abusers are costlier, less productive employees. Millions of people are arrested for driving under the influence of alcohol or drugs and for other crimes related to alcohol and illicit drug use. The safety of many neighborhoods-and the people living and working in them-is threatened bv vio- lence associated with drug sales. Federal, state, and local governments, as well as private citizens' groups, have acted to counter the enormous societal impact of sub- stance abuse, but much remains to be done. A great deal of the harm associated with sub- stance abuse can be prevented with increased public awareness of the problem and concerted public action. One step in this direction is the spread of effective prevention programs throughout the country with widespread sup- port from community groups, business and private citizens. GSE, ABUSE ANC) DEPF.NDENCE...Many people who drink, take illicit drugs or smoke occa- sionally do not experience problems from using these substances (although it is possible to have a serious injury or even to die from a single episode of alcohol or drug use). How- ever, with heavier, more frequent consump- tion, they are more likely to experience prob- lems with health, family members and other people, school, work or the law. Substance abuse refers to patterns of use that result in 51422 4585 SUBSTAACE ABU5E • • : t „ ..., ~, ,. , . . _. , . -. - , ,. . ,- .

. : 0 ~ y y V ~ : i i V 1; i V health consequences or impairment in social, psychological, and occupational functioning. While substance abuse concerns problems in living, dependence involves compttlsive use, craving, and increased tolerance. Although it is not possible to predict who will develop problems under what circum- stances, in general, moree serious problems develop when people become dependent on alcohol, illicit drugs or tobacco. A person who is dependent on a substance has a great need for it--often in inc.reasing amounts-in spite of trying to cut back. The process of becom- ing dependent is complex and is related to a number of factors, including the addictive properties of the substance, family and peer influences, personality and existing psychi- atric disorders. Genetics also plays a role in alcohol addiction, and recent research sug- gests that it may play a role in tobacco addic- tion, as well. At this time, its role in addiction to illicit drugs is not clear. Once a person is dependent on a substance, abuse becomes a chronic, relapsing condition characteriz.ed by waves of abuse, decreased use, and abuse again. It is very difficult to quit or curtail use, and frequently more than one attempt is nceded--sometimes over a long period of time-before a person suc- cessfully quits or gets use ttnder control. The likelihood of relapse is high. This report presents measures of use, abuse and dependence to illustrate the magnitude of thC substance abuse problem. Although the focus is substance abuse-use that has result- ed in significant problems for the user-infor- mation also is presented about patterns of use and the populations at risk. HISTORICAL TRENDS IN CONSUMPTION & PoI,ICY...The use of alcohol, illicit drugs and cigarettes has fluctuated during this century in response to shifts in public tolerance and with various political and economic events. In recent times, smoking began to decrease in the mid- 1960s, drug use in the late 1970s and alcohol consumption in the mid-1980s. Many people attribute these decreases to: • increased awareness of the health risks posed by substance abuse; • more governmental involvement in preven- tion, intervention and treatment efforts; and • the development of grassroots efforts and community coalitions directed toward decreas- ing substance abuse and its negative impacts. Alcohol... Alcohol consumption in the United States has risen and fallen over time. It was high during war years-the Civil War, World War I and World War 11-and low following Prohibition and during the Depression. Consumption was the lowest in U.S. history -0.9 gallons of ethanol per person aged 14 and older-in 1934, as the Depression was at its peak, and highest at 2.8 gallons per capi- ta-around 1980, following a period in which niore than half the states lowered the legal drinking age to 18. SU9STAUCE ABUSE

Historically, alcohol consumption has been higher and was perhaps double current con- sumption in the late 1700s and early 1800s. It fell during the heyday of the temperance movement in the mid-1800s, but it began to rise again in the latter part of the 19th centu- ry (see Chart 1). The 1919 passage of a con- stitutional amendment that prohibited the manuftcture, transportation and sale of alco- hol--also known as Prohibition--decreased use again, at least legal use, and temporarily. I)uring this time, an underground alcohol industry flourished and drinking continued to some degree. The amendment was repealed in 1933 as concerns about lawlessness rose. 1)uring the past decade, alcohol consump- tion has declined. This coincided with rais- ing the minimum drinking age to 21 in all states to counter the alarmino number of fatal automobile crashes invoh-ing alcohol and teenagers. The decrease also is related to a shift in beverage preference. The consumption of distilled spirits, which has a high ethanol con- tent, decreased substantialhy over the past 1~ years; beer consumption remained relatively stable; and wine consumption increased slightly. Both beer and -,.ine have a lower ethanol content. These overall trends in cur- rent alcohol consumption mask many impor- tant differences in drinking patterns across the life course and among demographic groups. as described in this report. Chart 1. Trends in Alcohol Use Annual Per Capita Consumption in Gallons of Ethanol L 10 3.0 • 1.0 • 0.0 . 1850 1855 1860 1865 1870 1875 1880 1885 1890 1895 1900 1905 1910 191'> 1920 51422 4587 SuaSTencE N9u5E ~ , I

. Illicit drugs...The history of illicit drug use in the United States also is marked by shifts in public attitudes and policies, between tol- erance artd intolerance. During the late 1800s, laissez-frtireapproaches to the problem of drug use began to he supplanted by increasing gov- ernmental regulation as the medical profession and the public became aware of the addictive properties of certain drugs. At that time, cocaine and opiates, which were inexpensive and read- ily available, were used widely in medicines available over the counter. A series of legisla- tive acts and court cases during the first two decades of this century resulted in a decrease in cocaine and opiate use, and the nation's drug probleni diminished during the Depression and World War II. During the 1950s and 1960s, however, hero- in emerged as a problem in our cities, and use of a variety of illicit drugs grew among the general population in the 1970s, peaking in the late 1970s for most drugs. The 1960s arid 1970s also saw the development of modern treatment modalities, including methadone maintenance, therapeutic communities, and outpatient care. Illicit drug use decreased among most segments of the population during the 1980s and 1990s. To illustrate recent trends, selected histor- ical events are charted against recent mari- juana use among 18- to 25-year olds from 19-2 to 1992 and cocaine use among 18- to 25- ~ pp jy _f G L a'~•S Ca ~ ° D-0 «.o c ~ ~ ~ 1925 1930 1935 1940 1945 1950 1955 1960 • Neat 260" 2.01 1965 1970 1975 1980 1985 1990 2000 SUSrA11cE A9ASE Notes: Alcobol consumption is measured in gallons of ethanol (absolute alcohol) per person aged 15 and older prior to 1970 and 14 and older tbereafter. Sottrces.' National Institute on Alcobol Abuse and Alco- holisrn, Division ofBio- metry and Epidemiologv. Surveillance Report # 23, Apparent Per Capita Alcohol Consumption: National, State, and Regional Trends, 1977- 1990. December 1992. Table 1. p. 1G-17. 11 ,. ,- .;y

year olds from 1974 to 1992 (sec Chart 2). This age group has high rates of rnarijuana use. By 1979, 35 percent of 18- to 25-year olds report- ed being current marijuana users. This was a peak period not only for marijuana use among 18- to 25-year olds, but also for most drugs and for most age groups. Since then, marijuana use has decreased, and by 1992, about 11 percent of 18- to 25-year olds reported using marijua- na in the past month. There is continued con- cern over the impact of illicit drug use, espe- cially cocaine and its derivative, crack. Reported declines in frequent cocaine use since 1985 are not statistically significant. Federal drug poli- cy has emphasized law enforcement and interdic- tion to reduce the supply of illicit drugs, but Chart 2. Trends in Illicit Drug Use 1 Percent Marijuana and Cocaine Users Aged 18-25 30 20 ~ Percent Marijuana Users Aged 18-25 ~ Percent Cocaine Users Aged 18-25 10 . . 0 x 1972 1973 19"4 19?5 1976 1977 19-8 19-9 19811 SUB5TNIICE flBUSE recent trends show an increasino ia~terest in pre- vention and treatment as control measures. Tobacco...Tobacco is a part of this land's ear- liest history, predating the arrival of Colum- bus. Native Americans had long cultivated tobacco and used it in various forms, includ- ing cigars, cigarettes, che-,ving tobacco, and pipes. During the 17th centun; tobacco began as an important cash crop for North Carolina, and by 1864 it was a significant enough com- modity that a federal tax was imposed on cig- arettes to help finance the Civil '\t'ar. By the 1890s, cigarette machines.vere Ferfected that produced cigarettes in much greater volume than possible by hand. 51422 4589 0 r t f r r I

Cigarette consumption increased dramati- cally between 1900 and the mid-1960s, with small peaks and valleys paralleling historical events: It wa.s slightly higher during World War I and World War II, and lower during the I)epression years (see Chart 3). Consumption peaked in 1963, at 4,345 cigarettes per person aged 18 and older per year. (Smoking a pack of cigarettes a day amounts to about 7,500 cig- aretres a year.) The precipitating event in the decline since then was the 1964 Surgeon General's Report that definitively linked ciga- rette smoking to health problems. The tobacco industry has tried to reverse the downward trend in tobacco consumption. For example, filter cigarettes were heavily i 1982 1983 1984 1985 1986 1987 promoted during the 1950s, and low-tar cig- arettes were introduced in the 1960s. Smoke- less and perfumed cigarettes were introduced in the 1980s to attract new smokers and keep current smokers from quitting. The tobacco industry also has targeted minorities and women in their advertising. In spite of these efforts, consumption con- tinues to decline. The decreases, however, have not been uniform across all groups. The poor, the less-educated and minority groups have had smaller reductions in rates, and so have women in comparison to men. While the 1992 per capita consumption was the lowest since 1963-2,629 cigarettes a person a year-it is roughly the same as in the early 1940s. 0 ~ r ~ aa 1988 1989 1990 Year 2000 0 7.896 1991 1992 ~ 5UB5TAUCE ABU5E y Noter: Data for 1992 are prelintinary. Sources: Substance Abuse and Mental Health Services Administration, Office ofApplied Studies. National Household Sun,ey on Drug Abuse: Highlights 1991. Rockville, i1D: DIIHS Pub. No. (SmA) 9-3-19 9, 1993. Table A. 10. p. 78. Substance Abuse and Metual Health Services Administration, Office of Applied Studies. Preliminary Estimates from the 1992 National Household Survec on Drug Abuse. Advance Report No. 3. Rockville, MD: fune, 1993. 7able 7A, p. 44.

1 Al.l, SEGSIFNI'S OF SOCIETYAFFECTLD... No polr ulation group is immune to substance abuse and its effects. Men and wotnen and people of all ages, racial and ethnic groups and levels of education smoke, drink and use illicit drugs. In 1991, some 103 million Americans used alcohol in the past month, 46 million smoked, and almost 13 million used illicit drugs. There are, however, significant differences in sub- stance use among groups. Young adults, for example, are the group most likely to use alcohol, illicit drugs and tobacco, and many adolescents have already started. In terms of gender, men are more likely than women to use most substances, but they are particularly more likely to be heavy users of alcohol and to Chart 3. Trends in Cigarette Use Annual Per Capita Consumption of Cigarettes 5UBSTBUCE ABUSE be problem drinkers. Whites are more likely than blacks or Hispanics to drink, but they are no more like- ly to drink heavily. Native Americans, mean- while, are more apt to have problems with alco- hol. Illicit drug use disproportionately affects minority groups, with minority groups at an additional risk for a range of adverse conse- quences, because they are more likely to use these drugs intravenously. Level of education is increasingly recog- nized as an important correlate of substance use, with heavier use among those who are less well-educated. People with higher edu- cation levels are more likely to drink, but those with less education are more likely to 51422 4591 i f 0 I

&0`41arl 0 1945 Is drink heavily. Among less-educated people, smoking is more common and smoking ces- sation less likely. The impact of substance abuse is felt from earliest infancy through old age. Some infants are born already compromised through expo- sure to substances consumed by their moth- ers during pregnancy. Throughout childhood, boys and girls are affected in many ways by their parents' substance use, from neglect and abuse associated with alcohol and illicit drug abuse to chronic respiratory problems from environmental tobacco smoke. Adolescence is a period of experinientation with substance use, and teenagers are partic- ularly at risk for being involved in alcohol- and 1950 1955 1960 1965 1970 drug-related vehicle injuries. Because substance use is higher in young adulthood, men and women in this age group are more likely to experience problems associated with it. For example, workplace problems and family dis- ruption can develop during this time. But it is later in life that the long-term health effects from alcohol use and cigarettes are most appar- ent. A lifetime of drinking and smoking exacts a heavy toll in chronic health problems and premature death. SOC1E7'A1., COSTS OF SUBSTANCE ABUSE... The total economic cost of substance abuse on the U.S. economy each year is staggering, and at least one estimate is in excess of $238 1975 1980 1985 19901992 5UBSTBBCE BBUSE Notes: Data for 1992 are prelirrtinary. Sources: For 1900-1974: Tobacco Yearbook 1981. Col. Clem Cockrel. Bowling Green, h'Y. p.5 ,. For 1975-1981: US Department of Agriculture. Tobacco Situation and Outlook Report. Cotnmodity Economics Division, Economics Research Service. Rockville, .t1U: April 1985. T able ? p. 6. F'or 1982-1991: US Department of Agriculture. Tobacco Situation and Outlook Report. Commodity Economics Division, Economics Research Service. Rockville, .111): Apri11992. Table 2, p.4. For 1992: US Department of Agriculture. Tobacco Situation and Outlook Report. Commodity Economics Division. Economics Researcb Service. Rockuille. .11D: Apri1199_3. Table? p.v. ©

Notes: Aledi<<rl.• 1)irect e.ipenduures. Ilbress•. Present ra6re of lost productivity due to illness or mjuq,. 1)eatGs: 1'resettt mtlue of frrturc lost productivity due to prerrr,tture tleatA Other Releted (.osts: 1)iret•t--criutr•, ntotor vcl itle rnul es, et,: Ittdirect-c4i tints of frirne, ittrnr rnuion, etc. Special C.'ondiriorts: AI!)S attributable to drug eGuse. k'etal zih'ol,ol Syndrome. Sources: Ciupulilisbed dtat for 199o fio» t Uo,'otl,y P. Rice. Institute for Nealth and.-lgirtg, linirersity of Ctli/i)rnia at San Fran- cisco, CA 9-t1-r.i-061?. 9.4 billion. Although specific cost estimates vary across studies because of differences in under- lying assumptions and definitions, all show substantial economic costs. This is an enor- mous burden that affects all of societv-- people who abttse alcohol, illicit drugs or tobac- co, and those who do not. This cost includes the expense of treating substance abuse, the productivity losses caused by premature death and inability to perform usual activi- ties, and costs related to crime, destruction of property and other losses. Alcohol is the most costly abused substance, with the total bill to the nation estimated to be $99 billion in 1990. Using the same econont- ic model, the cost of drug abuse was $67 bil- lion, and preliminary estimates place the cost of smoking at $72 billion (see Chart 4). Each substance has different impacts on users and on society: The major burden of alcohol abuse relates to productivity losses as_rociated with illness and death; crime plays the major role in drug-relat- ed costs; and for smoking, the most significant losses are associated with premature deaths. The core costs of alcohol and illicit drug abuse (costs of medical expenses, illness and death) fall disproportionately on people ages 15 to 44. "1'his reflects their higher preva- lence of substance abuse problems and larger number of related deaths. The core costs for most other health conditions tend to be con- centrated in older age groups. Chart 4. Economic Costs of Substance Abuse,1990 4.8 Drug Abuse/7otal Cost 566.9 billion - Medical 16 Alcohol Abuse/Total Cost $98.6 billion - Illness - Deaths SIIBSTAl1CC ABU5B Smoking/Total Cost S-2.0 billion (pnliminarv estinwtt) - Other ~ Special Related Conditions 51422 4593 c c 4 c 4 . . t 4 4 d . ...,. . ... .. ..:..~._. __,_.w .._.,~..a __.. ..

TAKING AC:7ION... Substantial governmental and private cfforts are being directed toward combatting the nation's substance abuse prob- lem, and there is a clear mandate to do more. However, the sheer size of the alcohol and tobacco industries and their influence in the economy-national, state and local-impedes progress. With more than 100,000 manufac- turing employees, these industries have a com- bined payroll that is more than 1.5 times the nation's soft drink manufacturing industry. Retail sales for beer, wine and distilled spirits total S92 billion, and tobacco sales total $44 billion. To help promote these sales, alcohol and tobacco are among the most widely adver- tised products in the country. In 1990, $3.9 billion was spent on tobacco advertising and promotions. Moreover, even though per capi- ta consumption is down, profits for tobacco manufacturers increased from 7 cents per pack in 1981 to 35 cents in 1991. These numbers powerfully influence the mix of governmental policies toward substance abuse. Some policies regulate, tax and other- wise limit the distribution of these products, while others create tax write-offs for advertis- ing them. In addition, tobacco and alcohol advertising targets some of the very groups at which the public health community is aiming its health promotion eflorts. ntolrrl)RENG CHANGE... 'I'his report presents indicators that describe the nature and extent of substance use and abuse, associated conse- quences, and efforts to combat the problem. Throughout, descriptive findings are provid- ed as well as measures that document change over time. Observed increases and decreases in these indicators will help determine how suc- cessful efforts have been and where addition- al resources need to be targeted. Meanwhile, the U.S. Public Health Service has set objectives for decreases in the use of alcohol, illicit drugs, and tobacco as part of a major effort to increase the span of healthy life for Americans, reduce health disparities among population groups, and achieve access to pre- ventive services for all. The federal govern- ment's Healthy People 2000: National Health Promotion and Disease Prevention Objectives offers specific measurable targets across the life course and for many population groups. The indicators presented in this report were chosen after careful review of current knowl- edge about substance abuse and its impact. National data were emphasized, although the charts also trace the progress of important pop- ulation subgroups, such as youth. A number of the Healt{ry People 2000 objectives appear with- in the indicators in this report, as noted. Together, the year 2000 objectives and the indicators presented here provide a blueprint for action and a means of charting our nation's progress against substance abuse.

FURTHER READInG 18 USE, ABUSE AND DEPF.NDENCE U.S. National Institute on Drug Abuse. Drug Abuse and IDrrrgAbrtse Research. The Third "Ihennial Report to C,ongress from the Secretary, Department of Health and Human Services. Rockville, MD: D11HS Pub. No. (ADM) 91- 1704,1991. HISTORICAI. TRENI)S IN CONSUMPTION ANI) POLICY l.evine, I 1G. "'1'he Alcohol Problem in America: From 7cmperance to Alcoholism," British Journal ofAddiction, -9:109-119, 1984. Musto, DF. 7he Anaerican Disease: Origins of Narcotic Control New York: Otiford University Press, 1987. Musto, DF. "Opium, Cocaine and Marijuana in American History," Scierrri6cAraerican, July, 40-47, 1991. Slade, J. "The Tobacco Epidemic: Lessons From History," Jotn-nal of P.•,,z-hoactiue Drugs, 21 (3): 281-291, 1989. A1.L SI'.GMENTS OF SOCIE'Il' AFFECTED Clark, WD, Hilton, MF. (eds.). Alcohol in Anterica: Drinking Practices and Problems. Albany: State University of New York Press, 1991. 5BBSTAIICE BBUSE Substance Abuse and Mental Health Services Administration. Ot-tice of Applied Studies. National Household Srnz ey on DnegAbuse: Main Findings 1991. Rockville, MD: DIIHS Pub. No. (ADM) 93-1979, 1993. SOCIETAI. COSTS OF SUBSTANCE ABUSE Rice, DI', Kelman, S, Miller, LS, Dunmeyer, S. The Economic Costs ofAlcohol, and Drug Abuse and Mental Illness 1985. San Francisco: DHHS Pub. No. (ADM) 90-1694, 1990. TAKING ACTION Kleiman, MAR Against Excess: Drug Poliry for Results. New York: Basic Books, 1992. MONITORING CHANGE U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Full Report, with Commentary. Washington, DC: DHHS Pub. No. (I'HS) 91-50212, 1991. Ir

C PERCEPTIOIIOF RISK 0 R h(FRICANS INCRFASINGLYrecognireY that the use of alcohol, illicit drugs, and tobacco carries substantial health risks. And, as a result, substance use among many segments of the popu- lation has declined. Several factors contribute to this change in the perception ofpotential harm (Indicator la). C)ne is the success of intensive communitv- based and public information campaigns on the health haiards ofsubstance abuse. Another is a grcater societal commitment to healthy lifcstyles in t;eneral and increased disapproval of substance use. Itesearch suggests that at least two of these factors --- increased awareness of risks and disapproval of use - have led to a drop in marijuana use among youth. I)espite increases in the percent of youth perceiving great risk, the percent still }alls far below the objectives targeted by IIe<tlt{iy Peofile 2000. Not all substances are perceived as equally risky. Illicit drug use is viewed by people of all a,;es as much riskier than smoking or drink- ing, and regular or heavier use of drugs or alco- hol is seen as riskier than occasional or exper- imental use. '1'herc also are differences in S7B5TAtlCE ABUSE perception of risk by age (Indicator 1b). In general, older people are more likely than young people to think that substance use is risk:,: One exception is that most teenagers as well as peo- ple ages 35 and older think usin~ ma-ijuana regularly is risky. Cigarettes are the only substance that is per- ceived as increasingly risky with each succes- sive age group. Forty-eight percent of vouth think it is risky to smoke one or mor: packs a day, whereas 68 percent of people 15 and older believe it risky. The fact that so manv young people do not think smoking i~ risky, is especially important because youth is a period of experimentation. More information about the risks of smoking should be targeted specif- ically to teenagers. Americans also are worried about envi- ronmental tobacco smoke -- the exposure of nonsmokers to cigarette smoke in Feople's homes, at work and in public places. Accord- ing to a nationwide poll, three offoLr non- smokers at some point in their lives have lived with smokers, and nearly half are concerned that environmental smoke miaht cause seri- ous health problems for them. cn ~ ~ N tJ 4P U'I lD J . 4 .

IJ t-J l, iUh t ~f P l Thi b t Subst U l a ounq eop e n a. a ou ance se ,, ,-0 .(CM .................................................................................... ,J .J q J J Perce•nt of } ligh School Seniors who Rclieve SubsrMace Use is Very Risky 90"~ 80 ,0 60 50 30 1975 ® kegular Cocaine llse 1985 J ~ lb. iUhat Americans Think about Substance Use Percent of An)ericans who Believe Substance Use is Very Risky, 1991 J ......................................................................................... . +.~ -!Z 9u", - 80 70 60 50 40 I lea"' Alcohol Use 83.2 n Ileavy Cigarette Use 82.6 Regular Marijuana Use ~ 12 - 17 1'ears ® 18 - 25 Years ® 26 - 34 Years / '90 '91 '92 2000 ~ Ileavy Alcohol Use Heavy Smoking %A& 35 + Years UOTES ~' ............................. ~!50UACES'). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . la. l),et,r or1,•r- ee•nt,e,gcs o/'hi~G ±cImol s<'ttiot:, who sc•e .,rrdn ri4 ,. t f lim7rt /rultt smmk- iu,t; eu,uijrernr,r ra,Kre- Lrrly: t,rkiv coc,eitie reOLtrly; h,rt4u,t; fire a nrore rlrinks once atwic,' trrrkouulr nr seuok- iu(+ otr• or tuorc 1 1980 0 kegnlar Marijuana Use Parkr oFcigarettes per e1,ty. 1 b. Heetr'y nlrohal use is froe atrmre drnt,(r once o, twice n tt'ea'k. ke'Kteie tr m,n'ijrrvun ucr is s uo,l•ing nrarijte,enw r,guLtrly. 1-featry setrokiag is smoknlQ at<• or tnorr I"acks prr t1ay. I a. 7Ge (htioersity of A9idhk,m News and Information Seroice's, Press Kelease, April 9, 199,3. A ut Arbor tl/. 7rrble 6. 11). 1-:5 Suhstance Ahtar mtd h9e uwl Health Services Adntinistrrttiot, OJjiee ofApplied Studies. National Householcl Sun'c'v on I)rug Abuse: }Iighlights 1991. kockrille Ml). UNHS Pteb. No. (S'MA) 2i- 1979• 1193. Tt61eA- ?5• /z 9.3. SUSTaneE aeUSE

IrCIPLICRTIOrIS OF ERRLY USE 22 G1'. IS ONfE of the niost important factors defining the likelihood of using alcohol, illicit drugs and to- hacco. It also is related to suhsequcnt patterns of use and prohlerns asso- ciatecl with use. Young adults-people ages 18 to 25-are the group mostly likely to use alcohol or illicit drugs or engage in heavy alcohol use (Indicator 2). People ages 18 to 341 are the group most likely to smoke. Many young people hee,in to experirnent with alcohol, illicit drugs and tobacco at very early ages, although not all who try drugs oncc or twicc continue to usc them. By the 8th grade, 70 hercent of youth report having tried alco- hol, 101)ercent have tried marijuana and 2 per- cent cocaine, and 414 percent have smoked cig- arettes. By the 12th grade, about 88 percent have used alcohol, 37 percent have used mar- ijuana and 8 percent cocaine, and 63 percent have smoked cigarettes. C:Iearly, substance use Smoked in Past Month 3. Alcohol, Marijuana, and Ciqarette Use Amonq Eiqhth Graders,1991-1992 .................................................... si . 804u 70 69 70 60 50 40 30 20 10 0 FNcr'tricd t)runk at F.ver 'Iried Alcohol least Once Cigarettes ; tow t= 1991 5UB5TBIICE BBBSB t0 11 Ever Tried Marijuana begins early for many young people. (Indica- tors 3 and 4). Because cigarettes and alcohol usuallv are tried before illicit drugs such as rnarijuana, hallucinogens or cocaine, they often are referred to as "gateway drugs." However, many youth who use alcohol or cigarettes never try illegal drugs.l he age when young people first start using alcohol and illicit drugs is a powerfitl predictor of later alcohol and drug problems, especially if use begins before age 15. People who begin using alcohol or smoking when verv young are more likely to he heavy users of these substances later on. Problems related to alcohol and drug depen- dence tvpically begin to hc apparent by age 20. 7'his is an important time for young people, as they complete school, enter the work force and begin to get married and have families. For women, problerns with alcohol frequently occur larer-when thev are in their thirties. 3 i ti~~~ Smoked in Past Month t'X;9`~ 1992 7he Urriversiry of llif-bigrut :Vetes arul Irt`orntatiorl Sendi.-. 1'rr„ kelm~e, Aprii r~ 192;. t1nntArGor, -V'. 7ablt 1. f [ t f f f f r ,r>

~ 2. Preualence of Substance Use,1991 ~. ~ .................................................................................. J I'rtcc•nt of l.lscr, in I'atit Mttnth . a a a a .7. st, 40 30 20 10 0 a Alcnhnl 2.3 -.0 3.8 I leavy Alcohol Anp Illicit I)rug o. f 'je3,*~ 'r~ 0.5 ~_~. Marijuana Cocaine V& 12 - 1- Yc'.trs M 18 - 25 Years W 26 - 34 Years W 35 + Years 4. Early Experimentation,1991 Avcraz,c Agc of First llsc 13. 7 Cig.vettes 15.2 Alcohol ® 1 2 . 1.. Yc.rrs 15.6 Marijoana ® 18-251'e.trs 17.9 15.6 14.2 17.0 Inhalartts Cocaine I lallucinogens --- Year 2000 Objective, People 12-17 Years SOUACC5_3 ................................................................... 2. 1 '~ Nrtinndl hnti- trur on 1 b ru,t Al,rrcr. Natinu•tl I Iousrh(lld tiurvc\ uii I )rul; i\huw: Prrpulation f.~tint.tcc•s 19~)1. Rord•, illr. .tfn. 1~1 ffL` I'lrl,. ,A'n. L II htf) 91- l,ti',~". .'- Ap. p. .'S, I;tGlr i ; I. p.l:rllr p. si, aud 7l1G1r l~t A p. 'll. l %.S' •Sttlist.uh'r' Abuse rool itlr'wa/ IlntltG Srn,ire•s; ltkiuisna- 1101f, 0/fi(i' of Alyrliecl Strrdirs. National I [ouschold Survey on l)rul; t\husc•: Higltlil;hts l,'rl, kt illr•, n ln. f>ffffs Pub. Nn. (,ti,llrl))i-19'9, 199-i. 7 tll .I-'.'. Ir. 711. `ul wnrrr• Ab,r~r rmcl.llr•IttLtl /ltaltb Serviec•s flcbniu,tmtion, C)Jfite of 'Aplilied Strrclirs. National I lousehold Survey on I)rug Ahusc•: lllain find- ing; 1991. 2ockr'ille, ,t11,. !)iffLS PrrG. No. (.1;1f.1) 9.3-19Rn. 19J3. 7"ahlc• fo.5, p. t ;?. 5UB5TAUCE ABU5E Cigarettes Year 2000 Oh)ective --- 1'eople 18-25 Years 2

TREnDS II1 HERVY USE R lFIRSI' GI.ANCF., the statistics look promising: The overall use of ciga- rettes, alcohol and illicit drugs atnong most segments of the population has declined in recent years. However, the number of heavy, frequent users has remained more stable. }leavy smoking is often defined as smoking a. pack or more of cigarettes per day; heavy drinking usually means consuming five or more drinks per occa- sion on five or more days in the past 30 days; and heavy drug use may be considercd to be daily or weekly use. '1b indicate how much heavy drinkers actu- ally consume, half of the alcohol consumed in this c.ountry is accounted for by the 10 percent of the population who drink the most heav- il,y. Heavy drinking has decreased in recent years, frotn 6.5 percent of the population age 12 and older in 1985 to 5.3 percent in 1991 (table). Nevertheless, heavy drinking among high school seniors and college students is still of concern and is one of the 1-lenlthy I'eople 2000 targets for reduction. '1'he decrease in people using illicit drugs since the late 1970s has been even more dra- matic At that time, almost 40 percent of high school seniors were using drugs. In 1992, in contrast, 14 percent of the senior cla,cs report- ed using drugs. For people ages 18 to 25-the age group with the highest rates of illicit drug use-marijuana use peaked at 35 percent in 19-9 and fell to 13 percent in T,)91. Cocaine use among this age group al.o peaked in 19-9 at nine percent and dropped to two percent in 1991. Between 1985 and 1991, the number of peo- ple who reported being frequent cocaine users (once a week or more) also decreased, but the decline was not statistically siQr,ificant (Indi- cator 5). Heavv dru- use is a p:;.rticularlv dif ficult problem in many urban areac svhere hard core users become concentrated and drug- related crime flourishes. Cigarette use also has decre3sed over the past decades - specifically since ihe 1964 pub- lication of the Surgeon General's report on the health effects of smoking. The proportion of the adult population who smc~ke<i decreased from 42 percent in 1965 to 26 percent in 1991. I)espite this overall decline in smokers, the proportion of heavy smokers---those who smoke 25 or tnore cigarettes a dav-has not changed much. In 1991, 15 perce-nt of the pop- ulation, or 56 percent of smok.r. srnoked a pack or more per day. ~" rA»>> ~;~ ................................ . ................... . . . . . . 24 '1'Ht:NllS IN ALC01io1. USF ll S. ttOUSF.IioLD MIPUTATION 1985 1988 Auy alroGol u.cr in pnrt mmnth 59.1°0 5_3.-f4o FG•'rry alcohnl tisr in Past rnrot:tG G.5 4.9 SBBSTA<IEE ABUSE ( 'S ~.::::: i„stitutr 1990 1991 oit r ~ .:'SCe. 59._'On 50.9^n Nac.clnai i {ousehold Sur.;ro^ Dru~ 5.0 5. 3 (1hca. ; ~ -1991. 51422 4°01 e 4 I I

J 5. Trends in Cacaine Use ,. ~ .................................................................................. a .J a Nunilxr t,/ Users J A7l)'tYC'dflh• tlSt' is dt least .~ o71Ce UI t~rr•Ir,1St yt'rU'. ..~ 1/edtry rmaine lrse k onr•e . a u eek or luore in tr!,r, . 7 ~ P,1;t 1•e,M . . 7 12,000 11,000 10,000 - 9,000 8,000 _ 7,000 - 6,000 5,000 4,000 3,000 2,000 - 1,000 - 0 12,200 ~ 198i Any Cocaine Use ~ 1988 ~ 1990 Heavy Cocaine Use Immmom 1991 ROTES ................. SUURCES':.......................................... C froererJCr-rnd BroeGky DrugAbuse. National tn ~ •11l ). 1•reqrretrt Cocaine Household Survey on N Users and 77 eir Use of I)rug Abuse: Population N 7'rertturerrt. American Nstintates 1990. rP /ournal of Public Rockville, ;SlU. !)HIIS ~ B I Ir.tlth, ['ol. 8.i, No. 8, I'ub. No. (ADhI) 91- N 1-7g. 1, p 1150, 199.3. l73?, 1991. 7rlble Z0-rl, C'S Nntiourtl hrstitnte on P. ! l l. 5UB5TBqCE RBUSE 25

DErCIOGRRPHIC DIFFEREIICES In HEAUY USE ........................................................................... D 26 IFFF.RENT POPUTATION GROUPS dif- fer in their rates of heavy use of tobacco, alcohol, and illicit drugs. These vari- ations are most apparent by race and ethnicity, gender, and education. White high school seniors are most likely and blacks least likely to be heavy smokers and drinkers; Hispanics fall in between (Indicator 6). Blacks have met the Healthy People 2000 objective for a reduction of heavy drinking. Although heavy smoking and drinking have decreased among all racial and ethnic groups, the decreases in heavy smoking among black youth have been particularly dramatic. Blacks have continued to decrease their smoking while the rates of other groups have stabilized. Among racial and ethnic groups, young Native Amer- ican males tend to be heavier smokers andd drinkers. Recent studies show that about 48 percent of male Native American and white high school seniors drank heavily, compared with 45 percent of Mexican-Americans, 24 percent of blacks, and 19 percent of Asian- Americans; some 18 percertt of male Native American high school seniors smoked 1/2 pack or more a day, compared with 12 percent of whites, five percent of Mexican-Americans, SUBSTAIICE ABUSE and 4 percent of Asian-Americans. There also are differences in sub_caance use by gender, but these patterns are in flux. Since the mid-1970s, male high school seniors have been more likely than females to use marijuana or alcohol daily; but now the gap berueen the sexes is narrowing. Meanwhile, for most of this period, female high school sen:ors have been more likely than males to smoke daily, but trends are changing here, too, and now more high school males smoke daih• tlyi females. Among people of all ages, males are more than three times as likely as females to be heavy drinkers and somewhat more likeh- :o smoke a pack or more of cigarettes per day. Males also are more than twice as likely as females to use marijuana once a week or more, but males and females are equally likely to be weekly cocaine users. Where people live and their educational level also relate to substance use. Hessv alco- hol use is more common among pecvle living in metropolitan areas and amono t,ose with less than a college degree. Heavy sn:okers are more likely to live in nonmetropolaan areas and to be less educated-having a h:-_h school diploma or less. 4 . . .. .. .. . ''1 ~ .. .. .

6. HeaUg Alcohol and Dailg Cigarette Use Among Young People ,a L ~Fl \a . Percent oFI ligh School Seniors Who are }leavy Users 45°i, 40 35 30 25 20 15 - ]0 1980 ~~ Alcohol/ ~ Alcohol/ Black White 1985 m Alcohol/ - Cigarette/ Hispanic Black '90 '91 '92 2000 . Cigarette/ - Cigarette/ White Hispanic flDTES .3.~ ................ SDURCES)1l ......................................... Laclt poitu plotted is the „rnr,r oftbe,/'a-ified year mid tbc• pret,ious yenr. Ylispanic"is deritvd flonr se~-raf,ort. °f/edty nlroGol use"!s fitle or more driuks in a rore iu the p,tu two rreeks. (1,4 National Institute on DrugAbuse. Smoking, I)rinking, and Illicit I)rug Use Among American Secondary School Students, Col- lege Students, and Young Adults, 1975- 1991. Volume l: Sec- ondary School Students. Rockui!!e, MD. N711 Pub. No. 23-3-fRO. 1992. Figttre 17b, p.111. Unpublished dnta frorn the LIS National htsti- tute on Drug Abuse, High Sc{ ool Senior Sur- vey, 1992. SABSTAACE ABUSE z7

ATTEmPTS TO QUIT zs ANY PEOPLE WHO smoke, drink or use drugs have experienced some kind of problem related to use and have tried to stop. Because quitting use of any of these substances is hard, the relapse rate is high, and some people have to try numerous times before they are successful. Depcnding on personal characteristics and the substance being used, some users become dependent or need larger amounts to achieve the same ef}ect. Other symptoms of dependence are daily use for two or more weeks, feeling a need for the substance, trying to cut down and withdrawal symptoms. One-third of peo- ple who used alcohol, marijuana, or cocaine experienced one or more of these symptoms. In f<tct, cigarettes are most likely to induce depen- dence, and 82 percent of those who smoked in the past year report having these symptoms. CIGARETrI'. SMOKING QUITTING CONTINUUM 1. (.}rrreut smokers :rbo had never tried to quit To break the smoking habit, mam, people try to quit or cut back on their own. The typ- ical smoker who becomes a confirmed former smoker usually has tried three or four times before being successful. More than 44 million Americans have quit smoking, and almost half of all living adults in the United States who ever smoked have quit. The percentage of smokers who quit increased dramatically after the release of the ] 96-i Surgeon General's report that documented the negative health effects of smoking (Indi- cator 7). The percent of people who ever smoked who now are former smokers is higher among the elderly than other age groups, among men than women, among whites than blacks and among college graduates than those with less education. Despite the increase in the per- centage who have quit, about 46 million Amer- icans still smoke cioarettes. I'erceur of People 20+ lFbo Hare Ever Smoked, 198' 2. Cut7eut smokers who liad tried to quit but not irrpast year 3. Current smokers wbo bad quit for 1-6 days in Past year 4. Curreut smokers u,bo had quit fitr 7 or more days in past year 5. 1'ormer stuokers who had quit tvit{iitt past 3 months 6 Ionaer smokers who had been afistineut for 3-12 months 7. Fornter smokers udio had been alistinent for 1-5 years 8. f•ormer smokers tobo had quit nrore than 5 years earlier SUBSTAACE ABUSE 1900 C S Ceuters for Disease Coutrol. The Health Benefits of Smoking Cessation. Ror.kuille, AID. DHHS Pub. A'o. (CDC) 20 90-3416, 1990. 7able 2, - p. 589. S 2 -3 10 -'1 P I 0

I ~ 7. Smokers tUho Haue Quit ~.~. ~ ............................................... ..................................... J a a ~ a . s0'o - Percent of People 20+ Who Ever Smoked Who Now Have Quit soa~c~s~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1965-1987 data: US Cruter; fir Disease Control. The I lealth Benefits of Smoking Cessation. Roikoille, MTI. Uh'HS Pub. No. (CUC) 90-s•f16, 1990. 7rtble 3, p. 592. Adults, US 1990. 1990 data: US Cettters Volume 41, No. 20. for Disease Control. Atlanta, GA. Morbidity and Mor- May, 1992. p. 355 tality Weekly Report, Cigarette Smoking Among SusSrAEE AsuSE 29

FURTHER RERDIIIG 30 1'I RCEP77ON OF RISK flachman, JG, Johnston. LD, O'Malley, I; Humphrev, RN. "Explaining the Recent De- cline in Marijuana Use: Differentiating the Ettects of Perceived Risks, Disapproval, and General I.ifestyle Factors." Jouruvl ofHectltli aud Socicrl Bchavior, 29 (\ farch): 92-112, 1988. IMPI.ICATIONS OF EARLY USE Christie, KA, Burke, JD, Regier, DA, Rae, I)S, Bovd, JH, I.ocke, BZ. "Epiderniologic Evidence for I?:uly Onset of iliental Disorders and Higher Risk of I)rug Abuse in loung Adults." Aruer- ican Jourunl of 'Psychiatj3; 145: 9-1-97>, 1988. TRFNllS IN HE:AVY USE Gfroerer, JC,13rodsky, Mi). "Frequent Cocaine Users and Their Use of Treatment." American Jorr~7talofl'rrhlicHecrlth, 83(8): 1149-1154, 1993. SuBS'3!1cE RBU5E DEMOGRAPHIC DIFFERENCES IN HEAVY USE Bachrnan, IG, Wallace, JM, O'Malley, P\I, Johnston, I.D, Kurth, CL, Neighbors, HW"Racial/Ethnic Differences In Sn)oking, Drinking and Illicit Drug Use Among American High School Seniors, 1976-1989." Arnerican Jourjtcrl ofPuhlic Health, 81(3): 37?- 377, 1991. ATI'EMPTS TO QUIT U.S. Centers for Disease Control. The Healtli Benefits ofSmo,(iug Cesation. Rockville, \1D.: DHHS Pub. No. (CDC) 90-S416, 1990. Schelling, 7 C. "Addictive Drugs: The Ciga- rette Experience." Science, 255: 430-433, 1992.

ZZ ~ ; ECTIOII2: a`COIISEQUEIICES OF USE FAST FACTS 1. ~ ............... ............ . ............................ .. • iriilltnri;Arjlcricatu die f •oni ~lcohol; %tI dr ugs;'' r><ak~ng substance <ibuse the;single cause ofdeath in the coun :dying f -om alcohol-related eduses loses, on average, ~ erson . S7~y .. .~. .~ ,,. .,... the G ea~rs o normal li e's dru' =relr~te ca d uses, ovcr'37' f~ f pan; g ~Y ZZ rs;`and,smoking-related causes, about 20 years.: ~death among substance abusers. P-AIDS,arrtong injecting drug users is the fastestgrowing cause of percen,t of all ge„Yteral,hospital.patients are there because of tSubstance abuse drives up health care costs. Between 25 and 40 complications related to alcoholism. P-Nearly one.ddultin five lived with analcoholic or problem drinker as a child. P~At least half of all people arrested for major crimes-including < homicide, th of their arrest ;`and assault-were using illicit drugs at the time

TDBACCO DEATHS .................................. 32 IGARF I'TE SMOKING ACCOUNTS for nearly 419,000 deaths a year--20 per- cent of all U.S. deaths (Indicator 8a). More than 3.6 millionvears of life.vould have been saved if ever.- person who died in just one year from cigarette smoking had lived until average life expectancy. Nearly all deaths associated with smoking result from a smoking habit acquired early in life. Cigarette smoking has long, been known to cause cancer, and nearly 90 percent of lung cancer deaths result from smoking. Lung can- cer rates, always high among! men, have risen among both men and women in the last few decades (Indicator 8b). Lung cancer deaths now surpass deaths from all other kinds of can- cer-exceeding prostate cancer in men and breast cancer in women. While lung cancer rates are a good marker for long-term use of tobacco, lung cancer accounts for only one-quaiter of all deaths attributed to smoking. Smoking also is a ma- SBBSTABCE ABUSE jor contributor in deaths from coronary heart disease, chronic bronchitis and emphysema, and cancers of the pancreas, trachea, bronchus, and larynx. Further, smoking during pregnancy is associated %vith fetal and infant deaths. In fact, smokinc is probably the most important modifiable cause of poor pregnancy outcome, according to the U.S. Surgeon General. Most deaths associated with smoking occur amon~, the smokers themselves, but exposure to environmental tobacco smoke also is an acknowledged health ha7ard and each year results in about 3,000 deaths among nonsmok- ers from cancer and other causes. Many peo- ple are exposed to tobacco smoke in the work- place, as well as at home from family members who smoke, and more than half of nonsmok- ers working in companies with minimal smok- ing restrictions say others smoking causes them at least some discomfort. With the increase in smoke-free.vorkplaces, second-hand smoke ex- posure-at least at work--is likely to decline. c 4 N N 4P \_ al m lD

!~ ~ J a 8a. Deaths from Smol4inq and Alcohol Use: Total .0.0 .................................................................................. J Total Deaths J Lung 116.920 Smoking Dcaths 1990 Alcohol [)caths 1989 A~ I I I I J 0 100,000 200,000 300,000 400,000 J , 8b. Deaths from Lung Cancer a 1980 k Alcohol Indirect Cause . a ................................................................................ .. . .. Age-Adjusted Lung Cancer I)eaths Per 100,000 People -Z . 90 80 70 60 50 40 30 20 10 0 1950 1 1960 White Male Itrug crtrtcrrs and other smoking d<•dtGs are esti- ruates of deaths where mmklttg is mt attrifitrt- alile fittor, includitt,K atrdioiwsrrtlvr and rcreGrotrtsrttl.n• dise,tses. 8b. Awtlysis of Nttional L'ital Statls- tirs Systrut. fttug otn- cer rrfers to all respirn- trny certcers. 1 1970 Black White Male ~ Fentale 8a. Smoking: US O/jice on Smokirt; and Health. 1990 SA.iLt/f•'C Alortality fistineates. Morbidity and \lortal- ity Weekly Report, fortbcomittg. AlcoGol: Stinson fS, DttfourrLIC, Stef}ius R, and UeB tkry SF. f% i- clerrtioloyic Bulletin 3?: Alcolml-Relnted afortal- 500,000 '87 ~ ~ I '85 , ''89 '86 '88 Black Female ity, 1979-1989. Alcohol Health and Research World, fortbcotrtittg. 8b. US National Cert- ter for Health Statistics. Health, United States, 1991 and Prevention Profile. Hyatuoille, ,111): I)HHSPuh. No. (1111S)92-1 232. 1992. 7rtfilr 3G, p. 169-170. 2000 SUBSTAACE ABU5E Cancer All Other Smoking- Related Causes Alcohol Direct Cause [Year 2000 - 42 ] 301,770 19.594 88.864 ~... ,~ ~, ®t~

ALCOHOL DEATHS 34 LCOIIOL IS A major cause of pre- mature death in the United States (In- dicator 8c). On average, people dy- ing from alcohol-related causes lose 26 years from their normal life expectancy. The ninth leading cause of death-liver disease-is largely preventable, because nearly half of all cirrhosis deaths are due to alcohol. Cirrhosis deaths are a marker of long-term alcohol use and accordingly are more preva- lent antong people in middle age and older. Since 1974, death rates for alcohol-related liver cirrhosis dropped 26 percent. This trend reflects the overall decline in alcohol con- sumption as well as an increase in the number of people recovering from heavy drinking be- cause of treatment, health education programs, and other interventions. Alcohol-related motor vehicle fatalities also continue to decline (Indicator 8d), and the death rate is now lower than the public health objective stated in Healthy People 2000. Between 1990 and 1991, the number of alco- hol-related traffic fatalities dropped 10 percent, with the greatest decrease among young dri- vers ages 15 to 20. Still, traffic crashes remain the single greatest cause of death among SUBSTBBCE RBUSE America's youth and voung adulus, and almost half of all traffic fatalities are alaohol-related. The recent decline in alcoho7l-related traf- fic fatalities may be due to dec7ines in both chronic use and inappropriate us: among even casual drinkers, particularly young people. Fed- eral requirements to restrict access to alcohol for those under age 21 and legisl3tion in some states to lower the allowable blood alcohol con- centration for young people m:a~~ in part ex- plain the decline. Diverse efforts under way in communities across the countr.--including prompt license suspension, soitirietv police checks, zero tolerance for underage drivers, and public education-such as "designated driver" programs-also may have had an impact on alcohol-impaired driving. Evidence links drinking and deaths from falls, fires and burns, and drowrnino. Falls are the second leading cause of fatal injuries, and fires and burns are the fourth leading cause. Various studies estimate that bens-een 17 and 53 percent of falls are alcohol-related, and be- tween 48 and 64 percent of people dying in fires had blood alcohol levels indicating in- toxication. One common cause of hre among intoxicated people is falling asle,p or passing out with a lit cigarette. tn ~ ~ A ~ ~ ",+`f` u ~cg~xp~L y'9 ;CYY{ 'x°1?~ ` 9 4 ti !

~.~...............m...~~.... J J ~ Bc. Deaths from Alcohol Use ouer Time •_, , -S Age-Adjusted Alcohol-Rclated Deaths Per 100,000 People 140 120 100 80 J J 60 40 20 0 1979 i '80 '81 '82 '83 1w White ~ Black Male Male 1 1 '84 '85 ~ White Female Bd. Deaths from Alcohol-Related Traffic Injuries '86 '87 ~ Black Female '88 1 1989 1991 - - 41 s°/c 1990 ~I 4c) ~ a ( 1989 49 L°lo a 1988 ~ 50 2°l0 ' Alcohol a 1987 5~ A°lu F Related 1986 52:L°/o a ~ 1985 518°!0 $ •sr . Not Alcohol If Related .7 1984 a 1983 ~0 5L 5v414 ~ 1982 ~ 1 I 1 1 1 a . a . 0 10,000 20,000 30,000 40,000 50,000 ......................................... 8d. 7nt~ic fntallties mr nrunber ofdeatl s froAm t7ashes in lO1Rc{J at least orie pet,on dies witbin 30 days oJ' the enub. Natiattal l/iKGuay 7raflir Sr f •ty .-idntinistrrnion difines a fatality or frttal crash a.c alcohol- rektted ifeitber a dri- ver or a nonntotorist (usually a pedestrian) had a blood alcohol concentration of 0.0145 or nGoe~e. ~................ .............. 8c. Stinson FS, Dtt- 8d. US Department tn four MC Steffens R of Trrmsportation F+ , , and DeBakey SF. , ~ National Highway M Epidemiologic Bttl- TYQfltc Slt'ftv N letin 32: Alcohol- Adrninistratiat. tT Rehtted Mortality, FARS Fatal Accident N 1979-1989. Reporting System, N Alcohol Health and Annual Report, 1992 Research World, forthcoming. forthcoming. SUBSTAUCE ABUSE 35 , ~ ~

ILLICIT DRUG DERTHS 36, D RUG-RELA"I F.I) I)F.ATI IS are itureas- ing--particularly among men, and even more so among black men. The number of peoplee dying from condi- tions directly identified with illicit drugs in vital statistics reports (e.g., over- dose) is more than one-half the number of deaths from conditions directly identified with alcohol. "1'hese drug deaths are rising (Indi- cator 8e). Adding in AIDS deaths aniong injec.ting drug users substantially increases the number. Iteported deaths directly related to druOs are gross underestimates of the mortality toll from illicit drugs since they exclude deaths from associated diseases, such as hepatitis or TB, and all other causes where illicit drugs contributed to death, such as homicides, falls and motor vehicle crashes. Medical examiner data from 1990 indicate that about one-third of all drug deaths involve illicit drugs as a contributing factor, but not the direct cause of death. I)eaths from drug causes often involve a Iethal combination of two or more illicit drugs or drugs combined with alcohol. I leroin or cocaine is involved in two-thirds of drug deaths. Nearly 40 percent of illicit drug deaths are among adults between 30 and 39 years old, an age group that has high rates of many SBBSTBnCE BBBSE chronic problems due to drug abuse. Over- all, rates are higher for men than for women, and for blacks than for .%-hites (Indicator 8f). Black men are more than twice as likely as white men to die from the direct effects of illicit drugs, and black women are nearly twice as likely as white women to die from drug use. Between 1979 and 1989. the rate for black men rose 133 percent, compared to a>0 per- cent increase for white men and black women, while rates among white women actually dropped. Only the rate for.vhite women falls below that targeted by He.riri?y People?000. The fastest growing cause of all illicit drug-related deaths is AII)S. More than 33 percent of new AIDS cases occur among inject- ing drug users or people having sexual con- tact with them. In 19S-i-the first year AIDS deaths were tallied reliabl.--989 AIDS deaths occurred among injecting dru~ users and their sexual partners. By 19S9. these two groups accounted for 7,700 AIDS deaths. Even non-users can be victims of a drug- related death-for example. people killed in drug-related violence or motor vehicle crash- es related to illicit dntg use. or the sexual part- ners of HIV-infected dru; users. The number of these deaths is not fullv known, but clearly a significant cost imposed upon American society by illicit drug abuse. Ln ~ ~rh N N bP Q) i--~ w k* <c

~ 8e. Alcohol and Illicit Drug Deaths Ouer Time ~~ ........... ................................... :.................................... J 20,000 19.810 J - J 15,000 J J 10,000 10.710 J .OON- 7,?03 J 5,000 J J 0 i I I 197'9 '80 '81 '82 '83 ..a~" '84 '85 '86 '87 '88 1989 J J J ~ Drug: I)irect Deaths - Alcohol: Direct Deaths ~ Drug-Associated AIDS J z 8f. Deaths DirectlU Caused bU Illicit Drugs Age-Adjusted I)caths Per 100,000 People , l 14 ;M1 . 12 Total Deaths: ~ ~ 10,710 / 10 a ~ 8 ~ 6 ~ ~ till a a 7 .15 4 2 _40mma-mb, 0 i 19,9 '80 '81 '82 ~~ Year 2000 ~ 3.0] I t ~ I '83 '8 4 '85 '86 '87 '88 '89 2000 hite Black White Black _ \~' h i teA1ale _ Male ~ Female ~ Fetnale 8c. iik'olml-dirrc't mtcl rG u,K-rlirrt7 rlcatls rtre i7NrFerCdtire 1R'(ltrrse thcy e..-rbrdr crc irlents, lmnric'idrs, nnd otl c•r r1rrr,rr rCLrtc'd to ctlrohol or i/li<it r/ncg 1tiP liut not rlirectl_y carrced by thr u. .............................................. 8c. Alcohol mul l )rrrgs: AIUS: U,4 National tn ~ 1LS Ncrtiouctl Cettter f r Lenter for Health Sta- Ad- HealtG Statistics ti;tirs. I iealth, United N . N vance Report of Final States, 1991 and I're- Mortalit,v Statistics, vention Profile, 1992. ~ 1989. Monthly Vital Sf. i'S Ndtioral Center ~ Statistics keport, Vol. f r Hectltb Statistics. -ao, No. 8, Supplement See 8e, f r'at citation. 2, 1992. SUBSTBBCE BBUSE 3 ~..n_._

STRAInS CI1 THE IIRTISII' S HERLTH CARE SYSTEm ..................................................................................... HEN USrD FoR long periods of time, tobacco, alcohol and illicit drugs can impair most major organ systems. As exam- ples, tobacco and alcohol use are major risk factors for diseases of the heart and blood vessels; and tobacco use also leads to chronic bronchitis and emphysema, cancers and infections, and pregnancy com- plications. Other risky behaviors associated with alcohol and illicit drug use increase the risk of acquiring the human immunode6ciencv virus (HIV). Using these substances during pregnancy can lead to a lifetime of disability• for the offspring. "I'hus, substance abuse adds considerably to the nation's total health care bill. These costs are for treating a host of illnesses and injuries associatcd with smoking, drinking and using illicit drugs, arid include services given in physician's offices, hospitals, emergency rooms and other treatment facilities. In any given year, a smoker uses more medical care than a person who has never smoked, and when heavy smokers are hospi- talized, they stay 25 percent longer than do nonsmokers. Likewise, problem drinkers av- erage four times as niany days in the hospital as nondrinkers, mostly because of drinking- related injuries. Studies show that as much as 38 SUBSTAtICE ABUSE 40 percent of all patients in general hospitals are there because of complications related to alcoholism. Illicit drug users-particularly peo- ple using cocaine or heroin-make more than 370,000 visits to costly emergency rooms each year, and since both alcohol and drug use may result in serious injur}; people using these substances disproportionately need care in high-cost trauma treatment centers. Most of the health care costs attributed to alcohol and illicit drug abuse are for treat- ment in general or short-stay hospitals, includ- ing their intensive care units (ICUs) (Indicator 9). About 28 percent of all ICU admissions and nearly 40 percent of all ICC costs at one major hospital were attributed to substance abuse. People who smoked were more frequently admitted to the ICU than were alcohol or dnro users arid incurred higher ICU costs. Specialized treatment centers also play their part in substance abusers' care. These include both residential and outpatient treatment cen- ters. Care in specialty alcohol treatment cen- ters costs more than $3 billion a year and in drug treatment centers nearh• S900 million. Nursing homes deliver services for smokers and drinkers debilitated by chronic health prob- lems, and more than 10 percent of all the mn1- ical costs associated with tobacco and alcohol come from nursing home care. Ic (D K IF E

1N ~-„ Short-Stay Ilospitals J J ' 9. Direct Health Care Costs of Hlcohol and Drug Abuse,1990 ~ a C .............................................. ....................................... ~ J J J J J J J J J J J J J J J J a ~ J J .~ .l ' ~ ~ Z 1 ~ Z ~ .7 Z .7 Z ~ ~ ~ ~ ~ ~ 4 15 7 a a a Support ~'~'%R~ ~lil/ Costs ~ ooicc-14asctl Physicians . Other Professional Services 4P Nursing Ilontcs 3 1 2 3 ~ Specialized Trcatmcnt Ccntcrs 7 7 esc cosu are based orr socioecarmmic indexes applied to 1985 estimates. (Viee-fieued pbysic latt costs include visits to p,ycGiatrisu. Otlier profe•ssionerl senviccs inc4rrlr: psycbolo~ists, socirtl workers, nurses, physi- cal and occupational therapists, pharma- cists, techtmlogists, ared otl ers. Support costs reGrted to alcohol and drugs include e:.peuditures sir,'.;,t.J.:,.-.~~~ ~ „. , 8 59% Drug Abuse $3.2 billion for research, training Unpublished data for costs for doctors, nurses, arrd program admirtistrators and primate irtsurauce for alco<iol and drug disorders. t 99o froru Dorothy P. Rice. hutirure for Health arrd Aging. Universit), of Califor- tria at San Francisco, CA 941=13-0G12. SUBSTAACE ABUSE 44% Alcohol Abuse $10.5 billion 39

EFFECTS OF SUBSTAIICE ABUSE 071 FAmILIES 5 URSI'ANCk? ABUSF. PLACFS tremendous psychological and financial burdens on f:tmilies. Nearly 20 percent of men and more than 25 percent of women say that drinking has been a cause of trouble in their family. As high as these figures are, the prevalence of substance abuse and fimily problems is no doubt seriously under- reported (Indicator ]0). Problem drinking can affect a family in many ways, even causing its break-up. More than one-third of women who are separated or divorced were married at one time to a problem drinker or alcoholic. Families with problem drinkers experience a host of social problems, such as violence between spouses, child abuse and a higher likelihood of raising children--particularly boys-- who themselves become problem drinkers. Almost one-fifth of adults say that they lived with a problem drinker or an alcoholic when they were children. Children in alcoholic families exhibit emotional and adjustment difficulties. These problems include aggressive behavior, diffi- culties with peers, conduct problems, bouts of hyperactivity and poor school adjustment. In addition, these youngsters miss school more often and have niore physical ailments and serious injuries than do children raised in non- alcoholic homes. Children whose parents smoke also have more health problems associated with tobacco smoke, such as respiratory in- fections and decreased pulmonary function and lung growth. Reports of child neglect and abuse have increased rapidly in recent years, and many such incidents are believed to be directly re- lated to illicit drug-and possibly alcohol- use among parents. In New York, crack is blamed for the threefold increase in the city's child abuse and neglect cases in the late 1980s. Another impact of substance use on fami- lies is the financial drain. The costs of smok- ing and drinking can be high (Indicator 11). These costs are calculated for all households, not just those with smokers and drinkers; $800 to $900 a year could be spent on four six-packs of beer a week, and a two-pack-a-day smoker could spend over $1,300 a year on cigarettes. If the impact of cocaine use and other illicit drugs were calculated, its effects on a family budget would be staggering. , I 4 c 4-0 ` 09 40 SUBSTNIICE NBUSE . - , .._ ... - . -A. ~. ~ ..,, .. ...,r

I 10. People with Rlcoholics or Problem Drinkers in the Familg,19S8 ~ .............................................;..,.................................. Pcrccnt of Adults Lived With as a Child Fver Marriea ~Ib Any Family Exposure J Q 0 1 20% 1 30% 11. Annual Household Expenses for Alcohol and Tobacco,1991 a .. ........................................................................................ a J J Avcragc Per Family llusband- Wife Families with Children Alcohol " Groceries ~ COS7' OF 'I'WO-PACK-A-DAY SMOKER FOR ONE YEAR =$1,300 1 COST OF FOUR SIX-PACKS A WEEK FOR ONE YEAR =$800-900 0 10. Srboeuborn Ci9. F.x- posure to Alcoholism in the I :intilv. Acl- vartce data from vital and bealth statistics, Natiou<rl Center for /lealtb Statisticr No. 205, Sq,tembtr,i0, I'l9/. T,61e 1, 1 $2,000 p. 9, "I'able 2, p.10, and 7able 4, p.1z. 11. US Department of Labor, Bureau of f I tbor Statistics. Con- surner Expenditures in 1991. Wirsbittgtou, DC: uscr0iaz-ss51 76921, 1992. 40% 1 1 $3,000 1 50% $4,000 SUBSTAACE ABUSE 41

RELATIOnSHIP TO CRIME ~ 42 T I IH L1NK BF: CWF.F.N alcohol or illicit drug use and crime is visible every day in courtrooms, jails, and prisons across the country. Many offenders were «nder the influence of drugs, or alcohol, or both when they committed their crime. Others illegally sold them. In 1990, more than 1 niillion arrests were made for drug oflcnses (sales/manufacturing and possession) and moree than 3 million for alcohol offenses (driving under the influence, liquor law vio- lations, drunkenness, and disorderly conduct). Illicit drugs and alcohol are partners in many violent crimes as well. At least half of the people arrested for major crimes such as homicide, theft, and assault were using illicit drugs around the time of their arrest (Indica- tor 12), and about half the people in state pris-ons for committing violent crimes report they were under the influence of alcohol or drugs at the time of their offense. SUBSTBIICE BBASE Alcohol is more likely to be involved in crimes against people than property. In about one-half to two-thirds of homicides and seri- ous assaults, alcohol is present in either the offender, the victim, or both. Women make up a small proportion of inmates (9 percent in jails and 4 percent in state prisons), but illicit drugs figure impor- tantly in their incarceration. Among convict- ed jail inmates in 1989, for example, females were more likely than males to have ever used these drugs (84 percent vs. 77 percent), to have used them daily in the month before their current offense (40 percent vs. 29 percent), and to have been under their influence at the time of the offense (31 percent vs. 17 percent). In contrast, males were about twice as likely as females to have been under the influence of alcohol at the time of their offense (44 per- cent vs. 21 percent). c. _ . . r . . . . . . 4 49 . .

„~,~~ ~ . ~... .._ ,_..,,... ~~ 12. Arrestees TestinQ Positiue for Illicit Drugs,1991 i.a. ~ : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... I J Drug Sale/ I ~ Possession 1JI h'~ 1 1lon,icide IJ ~ Men . ,~ arcen / t q - . I ~ 7'heft ~ ~ ` Women l`~+I I ` Prostitution I h~ ~ 1 Assault '3 i i 14 1 20% 0 7estirrg usitrg urinalysis is daie /nr c ocnine, npi- vtrs, » tvrijtmna, 1'CI'. nietbndorre, beuzodr- azrl,irres, metbaqurtlaee. propo.xypbene, barbitu- I 30°,6 1 40% I I I 1 1 50% 60% 70% 80% 90% rates, attd arrtplieta- US Department ofJus- mirtes. Data are collect- tice, National Institute ed in 24 cities on per- ofJrrsrice. 1991 Drug sons arrested during a Use Forecasting An- specific two- week time nual Report. Washing- period ton, DC: NCJ-136043. 199 i. p. 21. SUB5TAUCE BBU5E ~ L,0

IUORKPLRCE BURDEn t n1PloYnnNT S I ATUS oF 111 ICrr t)ItIIG USl.ItS, 1991  Fntploycd Ftdl-Time 0 Fmploycd 1'art-'1'imc / l)nrmployed  Other Notes: A "Cklro "inrluiles people ml"a are n•tirrdl rG.cablctl, hn)uennrkrrs, mtd ttudr)ur. Souncas: A US A~rtiaial hrstrtrrtr ar /huQAGrue. National Housrhold Survrv on 1)rul; AIwW. 1'rr•sr Re- lrrrsr, l)ece)uba•r /9, 1 J9/. 44 EL SIGNIFI(:AN7'AMOUNT OF substance use takes place among the American work force, and son)e of this use occurs at work. One-third of full- time workers are smokers, about two-thirds report that they consumed alcohol in the past month, and about 15 percent say they used illicit drugs during the past year. Smoking is a costly burden for employers. In addition to health care costs for the smok- ers, smoking poses health hazards to non- smokers at work and increases the risk of workplace fires and product contamination, as well as thee cost of facility cleaning and ventilation. F.ach year employers may pay thousands of dollars per sn)oker to cover these costs. Smoking is most common among workers who earn less than $10,000 a year. The more people earn, the less likely they are to smoke. Smoking also is more common among certain occupations, including handlers/cleaners, protective service workers, transportation/ma- terial niovers and machinists, and it is more hazardous in certain chemical industries where tobacco smokee can interact with occupation- al exposures and exacerbate health risks. Illicit drug and alcohol use also are costly to employers. Ilealth insurance costs for SABSTFIICE ABUSE employees with alcohol problems are about twice those of other employees. In addition, there are the costs of related workplace in- juries-including those in company-owned vehicles-higher employee turnover and lost productivity. -Iwo-thirds of drug users work fitll or part-time (chartlet). Some 2- per- cent of full-time employed illicit drug users report that in the past 30 days they had missed work due to illness or injury, and 18 percent had simply skipped work (Indicator 13). Fifteen percent of illicit drug users and 6 percent of heavy alcohol users say the' N- had actually gone to work high or a little drunk in the past year. During the year before em- ployees begin drug or alcohol treatment. two out of five report that they worked under the influence at least once a week. Since evidence shows that treatment can reduce job-related problems and result in abstinence, many employers sponsor emF1o.-- ee assistance programs (EAPs), conduct drut- testing, or have policies or procedures to de- tect substance use and promote early treat- ment. Nationally, at least 30 percent of em- ployees have access to an EAP, and 20 per- cent work in firms with a drug testing gram. Workplace smoking cessation pro~rams are increasingly popular as well. Ln N tJ N a) N .-y~.5. i. 1;X c < c < I t t l l.

-~ , ~~ 13. Alcohol and Drug Users HaUe Problems tUorking,1991 ............................................ ..................................... Full-Tin)e f•:n)ployees with Problems Missed Work Due to llanguver (Past 12 Months) I ligh or I)runk At Work (1'ast 12 Montlts) Missed \t'ork 1)ue to Illness/ Injury (Past 30 1)ays) Skip4red Vork (Past 30 1)ays) 0 70- Heary alroGol users an'e p"rple wbo dratrk fire or tn ,rr rhvuks per ocra,ioar oll /!l'e ol' lllolY rll7Ys in tGepast."0r(tys. (.irrreut rlrrT rrSett m'e people who rr.<ed auy illicit rG tr.Ks in ~~r7•':'r~A~"1? ~.. ,;u* xs the past tuatth. Prtst users are those who used mt illirit dnrg or nlrohol ire tlre past. but wl o are not eru-ra'rtt rlrtrg or beavy alcoho/ users. UnpublisGerd data frotr the 1991 National I lousehold S'urvey on Drug Abuse. ( :S Substancz.-1 brue mu! Ale ual Hea/tb Services Arlotini;tratiort, Ofjire of AppGed Studies. 30°o 5UBSTRRCE RBU5E ~ Heavy Alcohol User ~ Current Drug User Past User 15°/0 2040 25% 4= 45

FURTHER READIIIG 40 TOBACCO DEATHS U.S. Centers for Disease Control. Reducing the Health Consequences of Smoking: 25 Years of I'rogress. Rockville, MD: DHHS Pub. No. (CDC) 89-8411, 1989. ALCOHOL DEATHS U.S. Centers for Disease Control. Alcohol- Related Mortality and Years of Potential Life Lost-United States, 1987. Morbidity andMor- tality Weekly Report 39 (11): 173-177, 1990. U.S. Centers for Disease Control. Factors Potentially Associated with Reductions in Alcohol-Related 7 raffic Fatalities-United State.s, 1990 and 1991. Morbidity and Mortal- rty Weekly Report 41(48): 893-899, 1992. ILLICIT DRUG DEATHS U.S. National Institute on Drug Abuse. Annual Medical Examiner Data 1990. Data from the Drug Abuse Warning Network (I)AWN) Statistical Series. Series 1, Number 10-B. Rockville, MD: US DHHS Pub. No. (ADM) 91-1840, 1991. STRAINS ON THE NATION'S HFAI:I'I1 CARE SYSTEM Blose, JO, Holder, HI). Injury-Related Med- ical Care Utilization in a Problem-Drinking Population. AmericanJournal ofPublic Health, 81 (12): 1571-1575, 1991. Hodgson, 7'A. Cigarette Smoking and Life- time Medical Expenditures. TheMilbank Qtutr- terly70 (1): 81-125, 1992. 5ABSTAACE ABA5E EFFECTS OF SUBSTANCE ABUSE ON FAMILIES Bijur, PE, Kerzon, M, Overpeck, MD, Scheidt, PC. Parental Alcohol Use, Problem Drinking, and Children's Injuries. Journal of the American Medical Association 267 (23): 3166-3171, 1992. Schoenborn, CA. Exposure to Alcoholism in the Family: United States, 1988. Advance Data from Vital and Health Statistics of the Nation- al Center for Health Statistics. 205: September 30, 1991. RELATIONSHIP TO CRIME U.S. Bureau of Justice Statistics. Drugs, Crime and the Justice System: A National Report from the Bureau ofJustice Statistics. Washington, DC: NCJ-133652, 1992. WORKPLACE BURDEN U.S. Bureau of Labor Statistics. Survey ofEm- ployerAntidrugPrograms. Washington, DC: US Department of Labor, Bureau of Labor Sta- tistics, Report 760, 1989. Moore, KA. The High Cost of Smoking. Busi- ness and Health Special Report: A Look at Smok- ingin the Workplaee. pp. 9-11, 1993.

PUBLIC ATTITUDES P UBLIC INTOLERANCE OF substance abuse is growing among Americans, and for more than a decade the pub- lic has looked more favorably on restricting the use of cigarettes, alco- hol, and illicit drugs. This shift in attitudes is related in pan to a rising awareness of the health impacts of substance abuse and to a greater health consciousness. Another factor is the association among alcohol, illicit drugs, and the nation's concern about crime. Attitudes about smoking and drinking can vary depending on whether the use takes place in public or in private. In 1992, 54 per- cent of high school seniors thought getting drunk in public should be prohibited, while only 24 percent thought people should be prohibited from getting drunk in private (Indicator 14). About two-thirds of Ameri- cans favor restricting the use of cigarettes in various public places, including hotels, restau- rants, and the workplace, and more than 40 percent support a total ban on smoking in public places. The public also supports stringent sanctions against driving while intoxicated and, accord- ing to a national poll, would like to see tougher enforcement of drinking-age laws (64 percent), 5UB5TAtICE ABUSE b expanded use of police checkpoints to catch drunk drivers (79 percent), automatic license suspensions for the first offense (89 percent), and automatic confiscation of plates for the second offense (89 percent). Attitudes about how to deal with illicit drug abuse are mixed. Some people see it as a law enforcement problem, which should be dealt with through arrests or border control. Others view it as a health problem, best han- dled through prevention, early intervention, and treatment. In response to a question about the most important government activity to address the drug problem, one public opinion poll found that 40 percent ofAmericans favored teaching young people about the dangers of drugs, while another 51 percent favored stop- ping the drug flow from other countries or arresting pushers or users. Another poll showed that 57 percent of the adult population favored using treatment programs to help drug users while 33 percent favored punishing them. There is one area of agreement: For the last decade, the public has consistently thought that we spend too little on treatment. At least three-quarters of the public support using cig- arette and alcohol taxes to pay for a bigger fed- eral anti-drug program. (

U ~~ 14. High School Seniors' Rttitudes Toward Restrictions on Use ~.;..~ ................................................................................... Percent Who Favor Prohibition of... 80% 75 70 65 60 20 .~ 15 a 7 10 a ~% 5 .7 0 . ~ 1975 . ' Smoking Marijuana In Private . ' ~ .y I= 4 US Nntiourrl Institute on I)rup-ibuse. llrug Use Among American High School Seniors, College Students and Young Adults, 1975- 1991. 1'ol.l. NIH Pub. No. 93-3a80, 1992. 7nble?t, p. vt. 1980 1985 I 1990 I 1991 I 1992 ~ Smoking Marijuana In Public Getting Drunk In Private ~ Getting Drunk In Public Unpublrshed data from the US National Insti- tute on Drug Abuse High School Senior Survey, 1992.

4 ILLICIT DRUG COIITROL T HE'I'WO MAJOR strategies to control illegal drug use are: reducing the illicit drug supply and reducing Americans' demand for drugs. Supply-reduction strategies seek to curtail the supply of drugs through intercepting and seizing illegal drug shipments (interdiction), breaking up street market dealing, and other traditional law enforcement activities. Demand-reduction strategies aim to decrease the number of peo- ple who want to use illicit drugs, primarily through prevention, early intervention, andd treatment services. More money and effort traditionally have gone into supply reduction than demand re- duction. Out of the total 1994 federal drug control budget of $13 billion, international and domestic law enforcement accounted for almost two-thirds, or $8.2 billion (Indicators 15a and 15b). The largest expenditures were for curtailing the imports of drugs (through interdiction, investigations and intelligence, and international efforts), followed by prose- cution and corrections. Anorher major federal supply reduction activity is to intercept and seize drugs at the borders, and thwart use of air, land, and maritime routes for drug smug- gling. Each year for the past several years, the U.S. Customs Service has made about 19,000 seizures with a retail value in excess of $12 billion. To achieve these seizures, the federal government has made major investments in interdiction equipment, including advanced communication and detection systems. Despite spending $14 billion on interdiction over the last 10 vears, the flow of illicit drugs into the United States has not slowed, and the .vorldwide production of cocaine, opium, and other drugs continues to increase. Intensi6ed enforcement has not reduced the number of dnlg dealers or dru~ related deaths and has had only limited success in raising drug prices. State and local law enforcement agencies make more than -60,000 arrests for drug law violations a year. Of the total arrests in 1990, 68 percent were for possession and 32 per- cent for sales and manufacturing of illegal drugs. In recent years, the proportion of arrests has decreased for possession of drugs and increased for sales and manufacturing. DRUG OFF@NI>FR.S IN PRISON Federal data: 7he ington, I)C 1979-80 1991 Mhite House. National 133G52, 1991 State Prisons 17,572 150,000 Drug Control Strat- egy. lC'ashittqto>t. DC State 1991 drtt: US Department offtutice. f-ederal Prisons 4 749 30.-I98 USGPO, 1992. Survey of Swte Prison , State 1979 tdata: ( S Department ofJu.;:cr. Drugs, Crime, and the Inmates, 1991. lFSulr ington, DC.• .\'CJ- 1369-19, 19.9-3 Justice System. A':cb- i i t 0 r

AL ' ~ 3 j3 15a. Federal Drug Control Budget ouerTime i .0 ..0 ............................................. .................................... ; ~ in • cinioit I J $15.0 IJ I 12.5 I J 10.0 I ~ 7.5 5.0 la I = !~I 2.5 0 rr,awwwwwl 1981 1982 1983 1984 1985 1986 1987 I 1988 1989 .... Total Adjusted to 1981 Dollars 1990 1991 1992 1993 1994 (Rrquerter/j ~ a 15b. Federal Drug Control Budget Requested for 1994 ' 1 ~ la ~ a asa Rcu la 1 r 1 = 11 0 1 ype of Activity M'Yrevent ion OW. Research & Development - International 4w Other law Enforcement - prosecution - & Corrections - -Interdiction - ]nvestigations & Intelligence - "freatment 12 21 % 1 ........................................................................... 15 a. & 156. (LS Ofliee of hlarrvgenient and RudQet, l::veetrti ve Oflice o/'tLe Precidetrt. Federal I )rug Control 1'ro- granu: Budget Sum- rnary Fiscal Year 1994. lK4rsl iugtwt, UCr April ? 3, 199.31 p.145-198. SUBSTRRCE RBASE

COU1mUI1ITY COALITIOnS 52 OMMUNITIFS ACROSS THE country are responding to the impact of substance abuse in their neighborhoods by form- ing broad-based coalitions to fight back. The focus of most coalitions is on alcohol and illicit drugs, perhaps because the problems associated with them are so dramatic and obvious (Indicator 16). The fed- eral Center for Substance Abuse Prevention has helped more than 250 communities set up "Partnerships" to reduce local problems from substance abuse. Coalitions exist in sev- eral thousand other communities, as well. Much coalition activity focuses on pre- vention arid early intervention for young peo- ple (table). Early intervention can reach peo-. ple in the beginning stages of use and help them stop before serious problems develop. In some cases, intervention begins at the time of an arrest or in a youth detention facility. Early intervention programs-such as coun- seling, screening, and referrals to treatment-- usually involve both the adolescent in trouble as well ac the family. Prevention and early inter- vention activities include education on the consequences and risks of use and on giving people---partictllarly those at risk, such as chil- dren of substance abusers, the homeless, and school dropouts-the self-esteem and skills to avoid use. Schools are involved in almost all of the community coalitions. In addition to educat- ing students about the physical effects of substance use, schools can provide drug-free environments and activities that are alterna- tives to substance use. For example, many schools hold alcohol-free parties after proms and other school-sponsored events. Schools also have programs to educate parents about the pressures on their children to drink and use illicit drugs and how they can mitigate them. A consistent no-use message from parents helps young people avoid drugs and alcohol. Other community work includes media campaigns such as those against drinking and driving sponsored by Students Against Driving Drunk (SADD) or the Partnership for a Drug-Free America's campaign depicting illicit drug use as risky to people, business, and the community. Messages such as "Friends don't let friends drive drunk" have become highly visible, and many beer companies have added a responsible drinking component to their advertising. COMMUNITY COALITIONS REPORTING ExTENSIVE PROGRAM ACTIVI7Y, 1992 Join Togetber: A N i l R I'revention finrly huerrenuion 1'Gnuaing ofSlstenrwide 1'rogntm Impaired I)riving Program 7 renhnent.;-lftereare AleoGol/Drue Relnted Health AlcohoUl)nrg Relnted Crinre 6496 36 33 32 32 27 26 esorrree for at ona Communities Fighting Substance Abuse. A National Study of Community-Based Anti-Drug and Alco- hol Activity in Amer- ica, Boston, hL-1. 199'. Figure I, p. 8. SuBSrNnCE a9A5E 51422 4629 0

.~ ~~ 16. Substances Targeted bg Coalitions, 1992 a i a. e .............................................:...................................... .. ~.~ la la la fa a a a ~ ~ a w/a .a a a t.7 ~ ' ~ ~ Percent of Community Coalitions Addressing Various Substances 70% 60 50 40 30 20 10 0 Alcohol Use Size of Less than Cornuuunity 11111111 10,000 Join 7bgether: A National Resonrcz for Conuitrmities jigluing Subsmteee Abuse. A National Study of Community-Rased Anti- I )rug and Alcohol Activ- ity in America. Boston, AIA. /927. I ieure 1, p. 8. Illicit Drug Use Tobacco Use 10,000- 50,000- 100,000- More than ~ 50,000 ~ 100,000 ~~ 500,000 ~~ 500,000 SUASTAACE AAUSE

ALCOHOL AnD CIGARETTE TA}f ES 54 T FIF. BILLIONS OF dollars collected each year in tobacco and alcohol taxes gen- erate substantial revenue for govern- nerit-and help pay for substance abuse prevention and treatment. These taxes also discourage consumption, especially among teenagers. Just one year after California raised its cigarette tax 25 cents in 1989-earmarking some of it for anti-smoking campaigns-per capita consumption declined 9 percent. Re- searchers estimate that a 50--cent tax increase would result in 2.5 million fewer smokers. In fiscal year 1992, federal excise taxes on tobacco generated more than $5 billion in revenue and state excise taxes, $6 billion. An additional $1.6 billion in revenue came from state sales taxes on tobacco. Yet, cigarette taxes in the United States are lower than in many other countries (table). Moreover, while there have been three federal excise tax in- creases on cigarettes since 1983, taxes as a percent of the average retail price for a pack have declined dramatically--from 47 percent in 1970 to only 30 percent in 1993, while I tobacco company profits rose sharp}v Federal alcohol taxes brought in nearly $5.7 billion in government revenue in 1989, but these taxes have been raised only twice on beer and wine and three times on spirits since 1951. If the federal tax on liquor had been adjusted for inflation from 1951 on, a bottle of scotch today would cost an additional $5.50. State and local alcohol taxes brought in more than $7 billion in 1987. State alcohol and tobacco tax rates vary widely (Indicators 17 and 18), and the two often are not related. Wis- consin, for example, has a heavy cigarette tax and a low beer tax. Do these taxes pay for the burden that cig- arettes and alcohol inflict on societv? Econo- mists compared total tobacco and alcohol taxes paid in the late 1980s with the total costs these products imposed upon society- including injuries, medical care, and disabil- ity: Cigarette taxes covered societal costs, but alcohol taxes did not. The societal cost of alco- hol was more than double alcohol tax revenues. f 6 CIGARE I"It TAxFS: IPnFJiNA77ONAt. COMPARISONS Broum LR and Kane H. enntar(, Frrrni e Lndia United J+'l ,gdom Brazil Gernuany Tax as a pereenu ofprice 85 iG 75 75 74 72 More Countries Raising Cigarette 7iu•es to Cut Health Care Costs. Worldwatch Institute Vital Signs Brief #7. May 26, /993. Adapted from Table 1. t d k I Crmada Japan 69 60 tn ~ ~ Thail.rnd Unrted S:.rres 54 :30 N N 1 SUB51aIICE BBASE ! r

17. State Cigarette Excise Taxes 18. State Beer Excise Taxes Taxes Per Gallon, April 1992 ~ }lighest States _ SCCont}- }lighest _ Middle States - Second- I owest - IAWeSt States L= ® ® . - ® ® Ia.v< ~ ~. -' l1A!V. I,YII-11.Sai , 'I ! S\IS L,.~\I li~ ® ® ® 6bb'll r ®  ® ® ® ® ® SU !'P J ' A71 !II. NF 21a I ® ® ® r ® ................................................................... 17. 7he 7oGacro lusti- tute. -l ax Burden on --obacco: Hisrorical Compilation. l/ol. 27. lk~it;liirJgtorr, hC, 199.3. p. viii. 18. Researeb Institute ofAmerica, Inc. State and l.ocal Taxes: All States Tax Guide. Neu! York, NY, 1992. p. 271. SUBSTAACE AAUSE .~...,:,,:..:,. K_ ...... = 1

RESTRICTIOIIS On ALCOHOL USE 1:1'IIOUGH ALCOHOL IS a legal sub- stance, many federal, state, and local regulations restrict its use. Certain activities related to alco- hol use are against local laws, such as driving while under the influence (DUI), public drunkenness, disorderly conduct and liquor law violations (Indicator 19a). The num- ber of arrests for alcohol offenses peaked in the early 1980s, with about 3.7 million annu- ally (Indicator 19b). In 1990, there were 3.22 million such arrests. Fluctuations may be explained in part by changes in state and local laws or enforcement practices. DUls have increased steadily as a fraction of all alcohol-related arrests, from just over one-third in 1981 to 43 percent in 1991. In most states, DUI offenders will have their driver's licenses revoked or suspended for a period of time. Some states require them to participate in an alcohol education, treatment or counseling program before their licenses can be reinstated. The determination of DUI usually is based on either a specified blood SUBSTAUCE ABUSE alcohol concentration (BAC) or a sobriety test. In most states, it is illegal to drive with a blood alcohol level at or above 0.10 percent. The HealthyPeople2000objective is to reduce the legal BAC level for drivers ages 21 and older to 0.04 percent and for younger drivers to 0.00 percent. Alcohol in any quantity is a risk factor for young drivers, and nearly 40 percent of 16- to 19-year old drivers in alcohol-involved fatal crashes had BAC levels under 0.10 percent. States with lower legal BAC levels for drivers under age 21 have seen significant decreases in traffic fatalities among young people. All states already restrict access to alcohol to anyone under age 21, but enforcement is uneven. Many states hold the sellers or servers of alcohol partly liable for alcohol's conse- quences-for example, if they sell to an intox- icated person who is subsequently involved in a traffic crash. These laws have increased bartenders' awareness about alcohol intoxica- tion and boosted participation in server training programs. W W V

19a. Tqpes of Arrests for Alcohol Offenses,1991 1)isorderly A;onduct ftJ )ru nkenness 4.iquor Law iolation ~~I hiving Under ~~Tihe 1nfluence 43% ~.. I ` 4WAVagranry I "vh1 l a 19b. Arrests for Alcohol Offenses Ouer Time 15 ~ 3 ....................................................................................... fa ~ ~ ~ ~ ~ ~ „' a a . ~ .7 ~ I .d ~ ~ ~ Is in niillro.n 4.0 3.5 3.0 2.5 2.0 I 1972 1 1975 1 1980 19a. 'Y)riving under involved. Alcohol the influence"includes offenses include dri- inipairntent due to ving under the influ- alcohol or a,ry type t f ence, liquor law viola- dntg. tions, disorderly 19b. Conservative conduct, and estimates ofalrohol vagranry. 1991 data arrests because arrests are incomplete at this are classified under the reporting date and are prinrary of~nse, not not shown here. whether alcohol was 1 1985 1990 19a. US Department 19b. US Deparnnent ofJtutice, Bureau of ofJustice, Bureau of tn Justice Statistics. Justice Statistics. r Crime in the United Sourcebook of N N States 1991. Wash- Criminal Justice l~ ington, DC, 1992. k Statistics 1991. am T able 38, p. 223. Washington, DC.• W U.4GPO, 1992. Table 4.28, p. 468. SUBSTBIICE BBUS£ 1 M r= hu, M. ~ ~

RESTRICTIOnS OI1 SrCIOKInG .................................................... UMEROUS RI:GUTATIONS CONTROL the sale, marketing, and use of tobacco products. Cigarette advertising on tele- vision and radio, for example, was dis- continued more than two decades ago, and several states restrict cigarette advertising on state or local government property, includ- ing buses, transit stations, and sports facilities. Almost every state prohibits the sale of cig- arettes to underage youth. In nearly all states the minimum age of sale is 18. These laws, however, are inadequately enforced. A 1989 national survey reported that there were 2.6 million current smokers ages 12 to 17, and over half said they usually buy their own cigarettes. While this practice was most common (66.6 percent) among 16- and 17-year old smokers, nearly half of younger smokers also were able to buy their own cigarettes. Underage smokers buy cigarettes more often in smaller stores (Indicator 20). About 20 per- cent of smokers ages 12 to 15 purchase ciga- rettes from vending machines, compared to 12 percent of older teens. Some locales have ordinances requiring a locking device on cig- arette vending machines, which retailers are supposed to release at the time of purchase and presumably question the age of the purchaser, but many merchants do not comply. Minors still buy cigarettes from locked machines nearly half the times they try. Colorado and several municipalities in other states have banned cig- arette vending machines, and more than a dozen states restrict the placement of machines so that purchases can be monitored. Smoking bans-partial or total restrictions on public smoking-have been adopted by 46 states, the District of Columbia and about 500 municipalities. These laws range from pro- hibiting smoking in some settings, such as school buses or elevators, to comprehensive clean indoor air laws that limit or ban smok- ing in public buildings, restaurants, education and health facilities, retail stores and private worksites. The states with few or no restric- tions are concentrated in the South, and those with the most extensive restrictions are in the East and North Central states (Indicator 21). The intent of these clean indoor air laws is to reduce discomfort and health hazards among nonsmokers, but they also may encourage smokers to quit. A Healthy People 2000 pub- lic health objective is to enact comprehensive clean indoor air laws in all 50 states. w ~ N tJ

I V-~ ~~ 20. iLfhere Teen Smokers Purchase Cigarettes,1989 9090 80 70 60 50 40 30 20 10 0 Age 12-15 Iarge Store Age 16-17 Small Store ~~ 21. State Restrictions on Smoking in Public Places,1992 .; ....................................................................................... i ~ I~1 WW ................................................................................. 4W, No Restrictions (5 States) - Minimal (22 States) - Moderate Vending Machine (20 States) - Extensive (3 States) _ Comprehensive (0 States) 21. Alinintal-Sonte areas have written sntokittg poliry requirements but no minimums are man- dated or that desig- ttated smoking areas are required in some public pGues. Mod- erate: Likely to bans at least in include a fe•w bans bttildrngs with possi- and many manda- bly some designated tory designated areas. areas where all agree Must have restric- that smoking can be tions in most cate- permitted. Cornpre- gories to achieve this hensive: Bans in designation. Exten- almost all areas. sive: Would include Healthy People 2000 Objective: 50 states will have no smoking in public places laws by year 2000 20. US Centets for Dis- ease Control. Morbidity and Mortality Weekly Report. I/ol. 41, No. 27. July 10, 1992. 21. Coalition on Srrrok- ing or Health. State Legislated Actions on Tobacco Issues. Wash- ington, DC. 1992. SUBSTAACE ABASE

ALCOHOL AI1D DRUG ABUSE TREATn1EI1T ORE TtIAN 18 MILLION people who use alcohol and 5 million who use illicit drugs are in need in of substance abuse treatment. "Need" is determined by con- sumption patterns and the seriousness of the associated consequences. Overall, less than one- fourth of those needing treatment get it-either due to lack of available space or funding, or because users don't admit they do need it. Most of the funding for specialry drug and alcohol treatment facilities comes from fed- eral block grants and state and local govern- ment funds. Private insurance, Medicaid, and other public insurance programs contribute less than a third of the total funding. In vir- tually all other areas of medical care, insur- ance pays the lion's share. Substance abuse treatment is effective for many people and can decrease the use of alco- hol and drugs and increase employment. For some people, brief interventions can be effective, while others require more intensive services and sometimes multiple rounds of treatment. The key to effective treatment is to match individual clients with the interven- tion most appropriate for them-something too rarely done. On any given day, more than 800,000 clients receive alcohol and/or drug treatment in a spe- cialized substance abuse treatment program (Indicator 22a). In 1991, most clients-82 per- cent-were outpatients. Only 8 percent -were in long-term residential programs or therapeutic communities. After alcohol, the primary drug of abuse for people in treatment is cocaine or its derivative, crack, followed by heroin and other opiates (Indicator 22b). Polydrug use is common among people in treatment. Alcohol and drug treatment services also are provided by family practitioners, internists, psychiatrists, and other medical specialists and in emergency rooms. Physicians in these settings can provide early intervention and refer patients to specialized treatment facili- ties when necessary. The criminal justice system also renders ako- hol and drug abuse treatment. Many people enter community treatment as a condition imposed by the court or criminal justice system, including DUI arrestees. However, less than 10 percent of people in prison receive substance abuse treatment-far fewer than the proportion of offenders with alcohol and drug problemc. Self-help groups such as Alcoholics Anonv- mous and Narcotics Anonymous are part of the recovery process for many individuals with substance abuse problems. Due partially to the philosophy of the groups to preserve partici- pants' anonymity, accurate counts of current or former members or their current status are not available. 0

r 22a. Clients in Alcohol or Drug SpecialtU Treatment,1991 ................................... S , 9 - J~ong--I'erm ~ Residential rort-7 erm - 17 sidential --}.lospital ~[npatient - "Detoxification - antensive - butpatient - t()ther ~utpatient 7.5 22b. Principal Drug Used bg Clients in 5pecialtV Treatment,1990 40 , Nlarijuana - -lleroin, Other Opiates - Crack or Cocaine Other r_.:: ur.~._-- ~!~I,~~~ 22a. Clients in treatmeut on Sep- te,uber 30, 1991. Forty f rr perceut of clieut were in treat- meut f r rtlc obolisrd, 29 percent for drug abuse, and 2G per- ceut for liotb. Ajii tljW 22h. Treatnrentiu frtcilities that o ffrred drug only and com- bined drug and alcohol treanueut. 22a. US Substartce Abuse antd Mental Nealtb Services Administration, Office ofApplied Studies. Highlights from the 1991 National Drug and Alcoholism Treat- ment Unit Survey. Rockville, MD. 1992. Talile 3, p. 9. 22b. US National Institute on Drug Abuse. 1990 Drug Services Research Survey. Phase I Final Report: Non-Correc- tional Facilities. frtstitute for Healtli Policy, Brandeis Uui- versity. Waltbam, MA. 1993. Table 33. SUBSTBUCE RBUSE

SrClOKII1G CESSATIOII PROGRRrCIS .......................................................... 'I' SOME POINT in their lives, the majority of the 46 million adults in the United States who smoke have wanted to quit. Quitting is difficult, and most smokers initially try to quit on their own but are rarely successful. 'I'he most effective way to get people to stop smoking and prevent relapse seems to be to employ multiple interventions and provide continuous reinforcement. The two basic types of smoking cessation methods are: self-help strategies and assisted strategies. The majority of successful quitters (90 percent) have used self-help techniques, such as quitting abruptly ("cold turkey') or relying on how-to manuals or over-the-coun- ter drugs. One-year abstinence rates for peo- ple using self-help methods range from 8 to 25 percent. Assisted strategies include smok- ing cessation clinics, hypnosis, acupuncture, nicotine patches and other methods involv- ing counselors, physicians, or other health care providers. The cessation rates for people using these strategies are somewhat higher and range from 20 to 40 percent. Nicotine patches are a particularly popular method, with sales top- ping $880 million in 1992. Smoking cessation programs are promoted in many worksites. About two-thirds ofAmer- ican companies and most state health depart- ments offer smoking cessation programs to their employees. The most common work- [,tnk?_?:'Ik.. .. r.Z..~.. w._._?49 v: Mf.*~i~;i d..,t§.,:-b'"'rp~:~- .. place programs are educational-based, such as providing quit-smoking literature and em- ployee wellness programs (Indicator 23). About one-third of employers sponsor in-house pro- grams to quit smoking or reimburse workers for participating in such programs. Based on company assessments, the most effective pro- grams are cash rewards to workers who quit, employee wellness programs and reimburse- ment for participation in outside programs. An important component of many effective smoking cessation programs is a physician who can provide face-to-face advice, set target quit- dates, reinforce smoking cessation and moni- tor nicotine replacement in conjunction with behavioral interventions. Counseling by doc- tors, dentists and other health care providers can be instrumental in getting people to quit smoking, or to never smoke at all. Neverthe- less, only 47 percent of current male smokers and 54 percent of current female smokers recall that they were ever advised to quit by a physi- cian (Indicator 24). While this is a significant increase since 1966, when only 17 percent of smokers recalled being advised to quit, physi- cians need to counsel all their tobacco-using patients-partictilarly people in hig,6-risk groups, such as pregnant women and adolescents. A Healthy People 2000 public health objective is to have 75 percent of primary care and oral health care providers routinelv counsel their patients who smoke to quit. 9

23. iPorkplace measures to Encourage iUorkers to Quit Smoking Percent of Workplaces that `I'ried Measures 5090 45 40 35 30 25 20 15 10 5 0 Qu i t- Smoking Litcrature I f:mployee Wellness Program Sponsored Events In-Ilouse In-House Reimbursed Cash Award Lower Non-Cash on off for Outside for Workers Insurance Reward Company Company Program Who Quit Rates for for Workers Time Time Nonsmokers Who Quit ; a 24. Doctors Fail to Aduise Patients to Quit ;. ~ ........................................................................................ ~ a I ercent of Smokers 21 and Older Who Recall Being Advised by Doctor to Quit SSui _ ~u 50 45 40 35 1966 1976 1987 ~ Male ~, Female 24. 1)ate for 19G6 rront 23. 77ie Bureau of 24. US Centers for Dis- Adult Clse of 7obaero Nntiorcnl Af fairs, Inc. ease Control. The , N Survey. l)ata for 1976 SI IRM-RNA Survey Health Benefits of N aand 198,' fiant No. 55, Smoking in the Smoking Cessation. N National Hertlth lnter- Workplace: 1991. E3ul- Rorkoille, MD: DHfIS N vieco Survey. letin to Management: Pub. No. (CDC) 9o- m RNA Policy and Prac- 8416, 1990. Tnble 7, tice Series. Yol. 42, No. p. Glo. m 3-i-Part 11. Auqust 19, 1991. Tcrble 10, p. 14. SUBST8t1CE RBUSE 63

FURTHER RERDInG PUBLIC AT77TUDFS Maguire, K, Flanagan, TJ (eds.). Sourcebook of CrirnittalJustzceStatistics, 1991. U.S. Department of )ustice, Bureau of Justice Statistics. Wash- ington, I)C: USGPO NCJ-137369, 1992. DRUG CONTROL Reuter, P Hawks Ascendant: The Punitive Trend of American Drug Policy. .Daedalus:.journal of the American Academy ofArts and Sciences. Summer, 121(3):15-22, 1992. PRFVEN77ON AND F.ARLY INTERVENTION Klitzner, M, Fisher, D, Stewart, K, Gilbert, S. E,arly Intervention for Adolescents. Pacific Institute for Research and Evaluation. Prince- ton, NJ: The Robert Wood Johnson Founda- tion, 1992. Join'Jogether: A National Resource for Com- munities Fighting Substance Abuse. A National Study of Community-Based Anti-Drug and Alco- hol Activity in America. Boston, MA: 1992. AI.COHOL AND CIGARF.TTE TAXES Flewelling, RL, Kenney, E, Elder, JP, Pierce, J, Johnson, M, Bal, PG. First Year Impact of the 1989 California Cigarette Tax Increase on Cig- arette Consumption. American.Journal ofPub- lic Health, 82 (6): 867-869, 1992. Manning, WG, Keeler EB, Newhouse JP, Sloss, EM, Wasserman, J. The Costs ofPoor Health Habits. Cambridge, MA: Harvard University Press, 1991. RESTRICTIONS ON ALCOHOL USE National Institute on Alcohol Abuse and Alco- holism. Alcohol and Health. Seventh Special Report to the U.S. Congress. DHHS Pub. No. (ADM) 90-1656, 1990. RESTRICTIONS ON SMOIQNG U.S. Centers for Disease Control. Reducing the Health Consequences of Smoking: 25 Years of 13ngress. Rockville, MD: DHHS Pub. No. (CDC) 89-8411, 1989. ALCOHOL AND DRUG ABUSE TREATMENT Gerstein, DR, Harwood, HJ (eds.). Treating Drug Problems. Volume I. I nstitute of Medicine, Committee for the Substance Abuse Coverage Study/Division of Health Care Services. Wash- ington, DC: National Academy Press, 1990. Institute of Medicine. Broadening the Base of Treatment forAlcohol Problenu: Report ofa Study by a Committee of the Institute of Medicine, Division ofMental Health and Behavioml Med- icine. Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse. Washington, DC: National Academy Press, 1990. SMOIQNG CESSATION U.S. Centers for Disease Control. The Health Benefits of Smoking Cessation. Rockville, MD: DHHS Pub. No. (CDC) 90-S416. 1990.

UBS'1'ANCE AIiUSF;: The Nation's Num- ber One Health Problem documents the devastating impact that smoking, alcohol abuse, and illicit drug use have on our society. Millions of Amer- icans arid their families are affected-young and old, men and women, rich and poor, and rural, suburban, and urban residents. Substance abuse causes illness, death, injur- ics, school problems, family break-up, and crime. It strains our health care system, as well as our education, social service, and criminal justice systems. It saddles our economy with a tremendous, unnecessary burden. Many trends are disturbing. Although over- all consumption is down, frequent heavy use is relatively unchanged. Mortality related to substance abuse remains high and is increas- ing dramatically for drug-related AIDS deaths. COIICLUS1011 Drug-related crime continues to grow. Fortunately, some positive signs are evident. For example, awareness of the health risks associated with substance abuse is increasing, and the public is growing more intolerant of abuse. Overall use of tobacco, alcohol, and illicit drugs is down. Motor vehicle fatalities involving alcohol are decreasing. As a nation we seem to be doing better in combatting the problem of substance abuse. At least some prevention, intervention, and treatment activities are in place in most com- munities across the country. These activities are increasing, as more people become com- mitted to fighting substance abuse in their community, their city, their state, and their country. The trends noted in this report will provide benchmarks for assessing the impact of their efforts. SUASTAACE AEUSE 474 65

IIIUEN Note: 1'age nuntben for tables and cbans are ita6'ciud,• indirators are bold page numbers. Adole.ccents, 14, 15, 19, 21, 22, 22, 23, 48 Advertising, 13, 17, 52, 58 Age and alcohol, 10, 14, 19, 22, 22, 23, 24, 26, 27, 34, 48, 54 and heavy use, 26, 27 and illicit drugs, 11, 12-13, 14, 19, 22, 23, 24, 36 and perception of risk, 20, 21 and societal costs of abuse, 16 and tobacco use, 14, 19, 20, 22, 23, 26, 27, 47, 58, 59 See also Adolescents; Early use; Young adults All)S,31,36,37,38,65 Alcohol advertising about, 17, 52 and age, 10, 14, 19, 22, 22, 23, 24, 26, 27, 34, 48, 54 comnrunity ef}orts concerning use of, 34, 52, 52, 53 consumption of, 9-10, 10, 11, 17, 34, 47, 65 and crime, 8, 42, 47, 52, 56, 57 dc•aths front, 8, 15, 16, 31, 33, 34, 35, 37 driving under the influence of, 8, 10, 15, 34, 35, 47, 48, 52,56 early use of, 19, 22, 22, 23 econontic/societal costs of use of, 15-16, 16, 39, 40, 44, 54 and educational level, 14 and ethnicity, 26 f.uuily effects of, 31, 40, 41 and gender, 14, 19, 22, 26, 42 and government policy, 10, 11, 34 and the health care system, 31, 38, 39 and health issues, 15, 16, 31, 33, 34, 38, 52 heavy use of, 19, 20, 21, 22, 23, 24, 24, 27, 45 and intervention, 34, 60 and perception of risk, 20, 21 and public attitudes/awareness, 48, 49, 56 and quitting, 28 and race, 14, 26 restrictions on use of, 9, 10, 34, 48, 56, 57 taxes on, 47, 48, 54, 55 and trc•atment, 47, 60, 61 trends concerning, 9-10, 10-11, 19, 24, 24, 65 in the workplace, 8, 44, 45 and Year 2000 objectives, 23, 24, 27, 34, 56 Arrests. SeeC:rime Asian-Americans, 26 ( ( ( . ~ ~ ~ ~ Blacks, 14, 26, 27, 33, 35, 36, 37 See alto Race ( Children ~ consequences of substance abuse on 14-15 31 40 , , . ~ See also Adolescents Cigarettes ~ and age, 22, 23 t consumption of, 12-13, 14-15, 54 ( deaths from, 31 ( early use of, 22, 22, 23 heavy use of, 21, 24, 27 ( and perception of risk, 20, 21 ~ quitting, 28, 28 1 restrictions on use of, 59 taxes on, 47, 48, 54, 54, 55 4 trends concerning, 12-13, 14-15, 24, 27 4 See also Tobacco ~ Cocaine I and age, 11, 19, 22, 23, 24 deaths from, 36 ! early use of, 22, 23 1 and gender, 26 ! and the health care system, 38 heavy use of, 24, 25 and perception of risk, 21 ! treatment for, 60, 61 t trends concerning, 11, 12, 12-13, 24, 25 and Year 2000 objectives, 23 t Community efforts, 8, 9, 20, 34, 52, 52 53, 65 ( Crack 12 60 61 , , , t Crime ! and alcohol, 8, 42, 47, 52, 56, 57 and gender, 42 ( and illicit drugs, 8, 16, 24, 31, 42, 43, 47, 50, 52.65 ( and societal costs of abuse, 15, 16 ( Deaths alcohol-related, 8, 15, 16, 31, 33, 34, 35, 36, 37 l illicit drug-related, 8, 31, 36, 37, 65 4 tobacco-related, 8, 15, 16, 31, 32, 33 trends concerning substance abuse-related, 65 Driving and alcohol, 8, 10, 15, 34, 35, 47, 48, 52, 56 and illicit drugs, 8, 15, 36 Drugs. See Illicit drugs; specific drug Early use, 14, 19, 22, 22, 23, 477 , See abo Adolescents; Young adults Education, about substance abuse, 34, 48, 62, 63 Educational level, 13, 14, 26

ii;'tLj: .. Hmployee assistance programs (I:APs), 44, 62, 63 Environniental smoke deaths from, 32 and health issues, 8, 15, 32 and restrictions on tobacco, 58, 59 in the workplace, 8, 20, 44 Nthnicity, 14, 26, 27 Family, effects on the, 8, 15, 31, 32, 40, 41, 65 Foreign countries, tobacco taxes in, 54, 54 Gender and alcohol, 14, 19, 22, 26, 422 and early use, 22 and heasy use, 19, 26 and illicit drugs, 19, 26, 36, 37, 42 and tobacco, 13, 26, 33, 63 Government policy/involvement and alcohol, 10, 11, 34 and illicit drugs, 12, 12-13, 48, 50, 51 induary pressures on, 17 public attitudes about, 48 and rreatment, 9, 48, 51 and trends in substance abuse, 9, 10, 11, 12 See alto Taxes; rpeeific type ofruGrtanee abuse I lealth care system, strains on the, 31, 38, 39, 65 llealtlry 1'eople 2000: NNational Health Proraotiou and Disease 1'reventiou Objectives (U.S. Public Ilealth Service). SeeYear 2000 objectives Ileasy use of alcohol, 19, 20, 21, 22, 23, 24, 24, 27, 45 consequences of, 8 demographic diflerences in, 26, 27 of illicit drugs, 19, 24, 25 and perception of risk, 19, 20, 21 of tobacco, 20, 21, 22, 24, 26, 27 trends concerning, 19, 24, 24, 65 1 Icruin, 11, 36, 38, 60, 61 l lispanics, 14, 26, 27 l 11 V. See AlDS I lospitali.:uion, 31, 38, 39, 61 Illicit drugs and age, 1 I, 12-13, 14, 19, 22, 23, 24, 36 and .\I1)S, 31, 36, 37, 38, 65 and community coalitirnts, 52, 52, 53 and crime, 8, 16, 24, 31, 42, 43, 47, 50, 52, 65 deaths from, 8, 31, 36, 37, 65 driving under the inFluence of, 8, 15, 36 early use of, 19, 22, 22, 23 economic/societal costs of use of, 16, 16, 36, 39, 40, 44 family effects of, 8, 14-15, 40 and gender, 19, 26, 36, 37, 42 and government policy/involvement, 12, 12-13, 48, 50, 51 and the health care system, 38, 39 and health issues, 16, 36, 38, 52 heavy use of, 19, 24, 25 and intervention, 50, 60 and perception of risk, 20, 21 and pregnancy, 38 and prevention, 12, 51 prisons, 47, 50, 50, 60 public attitudes about, 11, 48, 49 and quitting, 28 and race/minorities, 14, 36, 37 treatment for use of, 11, 12, 47, 50, 51, 60, 61 trends concerning, 11-12, 12-13, 19, 65 and the workplace, 8, 44, 44, 45 and Year 2000 objectives, 20, 23, 36 See also specific drug Income level, and tobacco abuse, 13, 14 Infants, and the consequences of substance abuse, 15, 32, 38,40 Interdiction, 50, 51 Intervention, 9, 34, 50, 52, 52, 60, 62, 65 Marijuana and age, 11-12, 12-13, 19, 20, 22, 23, 24 early use of, 22, 23 and gcnder, 19, 26 heavy use of, 24, 26 and perception of risk, 20, 21 public attitudes about, 49 treatment for, 61 trends concerning, 11-12, 12-13, 24 and Year 2000 objectives, 20, 23 Native Americans, 14, 26 Nursing home care, 38, 39 Opiates, 11, 60, 61 Outpatient care, 11, 61 Partnership for a Drug-Free America, 52 Physicians, 39, 62, 63 Pregnancy, 15, 32, 38 Prevention and communirv efforts, 8, 52, 52 and illicit drugs, 12, 51 trends concerning, 65 Prisons, substance abuse and, 47, 50, 50, 60 Public attitudes/asvareness, 8, 9, 11, 20, 47, 48, 49, 56, 65 SUBSTAACE ABUSE 67 , x~r~

68 Quitting and alcohol, 28 and illicit drugs, 28 and relapses, 9, 19, 28, 62 smoking, 28, 28, 29, 44, 47, 62, 63 Sa alwTreatment Racc/minorities, 13, 14, 26, 27, 33, 35, 36, 37 Risks, perceptions about, 19, 20, 21 Smoking bans, 58, 59 Smoking cessation progranu, 44, 62, 63 Smoking. SeeTobacco Spccialixcd treatment centers, 38, 39, 60, 61 Surgeon General's reports, 13, 24, 32 Taxes on alcohol, 47, 48, 54, 55 comparison with other countries of, 54, 54 on tobacco, 12, 47, 48, 54, 54, 55 and treatntent, 54 Teenagers. See Adolescents; Early use; Young adults Therapeutic communities, 11, 60 Tobacco advertising about, 13, 17, 58 and age, 14, 19, 20, 22, 23, 26, 27, 47, 58, 59 and contmunity coalitions, 52, 53 consumption of, 12-13, 14-15. 17, 47, 65 deaths from, 8, 15, 16, 31, 32, 33 early use of, 13, 19, 22, 22, 23, 47 economic/societal costs of use of, 16, 16, 40, 41, 44, 54 education about, 62, 63 and educational level, 13, 14, 26 family e(}ects of, 32, 40, 41 and gender, 13, 26, 33, 63 and the health care system, 38 and health issues, 8, 15, 20, 24, 32, 33, 38, 62, 63 heavy use of, 21, 22, 24, 27 and income level, 13 and in« rventions, 62 lobbies for, 16-17 and perception of risk, 20, 21 and public attitudes/awareness, 48, 49 and quitting, 28, 28, 29, 44, 47, 62, 63 and race/minoritics, 13, 26, 33 restrictions on use of, 47, 48, 49, 58, 59 and the Surgeon General's reports, 1:3, 24, 32 taxes on, 12, 47, 48, 54, 54, 55 trends concerning, 9, 12-13, 14-15, 19, 24, 65 in the workplace, 32, 44, 48, 52, 58, 62, 63 artd Year 2000 objectives, 58, 62 5UBSTAt1CE BBB5E See aGo Cigarettes; Environmental smoke Tobacco industry, 13, 16-17, 58 Treatment and alcohol, 47, 60, 61 and community coalitions, 52 and governmental involvement, 9, 48, 51 and illicit drugs, 11, 12, 47, 50, 51, 60, 61 numbers of people receiving, 60, 61 public attitudes about, 48 and taxes, 54 trends concerning, 65 types of, 11, 60, 61 and the workplace, 44 Whites, 14, 26, 27, 33. See also Race Workplace and alcohol, 8, 44, 45 and illicit drugs, 8, 44, 91 45 restrictions in the, 48 tobacco in the, 32, 44, 48, 52, 62, 63 and treatment, 44 Year 2000 objectives and alcohol, 23, 24, 27, 34, 56 and illicit drugs, 20, 23, 36 purpose of, 17 and tobacco, 58, 62 Young adults and alcohol, 10, 22, 22, 23, 24, 26, 27, 34, 48, 56 attitudes of, 48, 49 and extent of substance abuse, 14 and heavy use, 22, 23, 26 and illicit drugs, 11-12, 12-13, 15, 20, 22, 23, 24 and perception of risk, 19, 20, 21 and tobacco, 20, 23, 26, 58 See alao Early use • 1 ~ C

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R SummarU ...................................................................................... IGARETTES, ALCOHOL ABUSE and the use of illicit drugs are responsible for destroying families, crippling U.S. businesses, terrorizing entire neighborhoods, and choking the education, criminal justice and social service systems. Substance abuse is a problem in all segments of society. No population group is immune to substance abuse and its effects. Furthermore, the costs of substance abuse to the health care system frustrate any attempt to curb health care costs. Of the $238 billion the nation spends each year on substance abuse, $34 billion is spent on unnecessary health care. A heavy smoker will stay 25 percent longer when hospitalized than a nonsmoker, a problem drinker four times as long as a nondrinker. Without a reduction in 3ubstance abuse, health care costs cannot be curtailed effectively. This special report, "Substance Abuse: The Nation's Number One Health Problem," documents for the first time in a single volume the devastating impact of substance abuse on American society. (The page numbers referenced in the following material refer to the main text.) The toll of substance abuse can be measured in liues ...................................................................................... Each year, there are more deaths and disabilities from substance abuse than from any other preventable cause. Of the two million U.S. deaths each year, one in four is attrib- utable to alcohol, illicit drug or tobacco use. •More than 400,000 people die due to tobacco (page 33); • 100,000 people die as a result of alcohol (page 33); •Illicit drug abuse and related AIDS deaths account for at least 19,000 deaths (page 37). A half-million substance abuse deaths VearlU Substance abuse deaths as a percentage of all deaths 520,000 deaths due to substance abuse 1,630,000 deaths due to all -f- ~ 1 --.Oslo 11 Ln other causes I \ / ~ N N ~ a) Source: Indicator 8, (paga 32-37) 1

Substance abuse takes its toll in dollars, consuming ouer $238 billion annuallU ...................................................................................... • Every man, woman, and child in America pays nearly $1,000 annually to cover the costs of unnecessary health care, extra law enforcement, auto accidents, crime and lost productivity resulting from substance abuse. Wasted dollars I'er person cost of substance abuse Sourrt: Overvitu, (page 16) Pw 2

Substance abuse erodes worker productiuitU I ...................................................................................... • One out of three Americans in the workforce smokes, 8 percent drink alcohol daily, and 15 percent have used illicit drugs in the past year (page 44). • Most illicit drug users are employed (page 44). most illicit drug users are emploged Employment status of (past year) illicit drug users, 1991 Note: "Other"inrludes retired, disabled, hornernaker, and students. Source: (Page 44) 3

Illicit drugs and alcohol are partners in crime • One-half to two-thirds of homicides and serious assaults involve alcohol (page 42). • About half of men arrested for homicide and assault test positive for illicit drugs (page 42). Half of male arrestees test positiue for illicit drugs Percent of male arrestees testing positive for any drug at time of arrest, 1991 Source: Indicator 12 (page 43) 4

Substance abuse rips apart families .......................................................... • One out of four Americans experiences family problems related to alcohol abuse (page 40). • Alcohol abuse plays a part in one out of three failed marriages (page 40). Alcohol is a cause of familU problems One in four Americans say alcohol has been a cause of trouble in their family Sourcr: (Page 90) 5

Four Sources of optimism Source #l. Though heaq use of some substances is unchanged, substantial decreases haue occurred among casual users ............................................................................. • Cocaine use is down among casual users, but steady among heavy users (page 25); • Cigarette smoking overall has declined dramatically-from 42 percent of the popula- tion in 1965 to 26 percent in 1991. Again, rates of heavy smoking have not changed much (page 24); • Since 1988, the number of heavy drinkers has declined somewhat (page 24), and many fewer auto deaths are attributable to drunk driving (page 35). Casual cocaine use is down marhedlV Number of users (number in thousands) A. Heavy Cocaine Use Source: Indicator 5 (page 25) 6

Smoking's sharp declines leuel off in 1990 Percent of the U.S. population that smokes 1965 42% ® 1974 37% ~V, 1980 33% 61 1985 30% ® ® 1990 26% 1991 26% Source: National Ilea/th Interview Survrys 1974-1991. Data compiled by the CDC Office on Smoking and Health; 1965 data from page 24. Deaths from drunk driuing haue fallen substantiallg Percent of traAic injury deaths related to alcohol Source: National Highway Transportation Safety Administration ~

Source *2. R great mang Americans want treatment for their substance abuse problems ...................................................................................... • 800,000 people each day receive services in a special alcohol or drug program (page 60). • Nevertheless, only about one-fourth of those needing alcohol and drug treatment get it (page 60). Unmet need for alcohol and drug treatment Percent of those needing alcohol and drug treatment Source: (page 60) • Most smokers make multiple attempts to quit, yet few succeed on their first try. m ~ ~ N N 20% have never ,P tried to quit m u, N Sourrr. (page 28) ~ 0

Source 9. The American people increasinglU recognize the risks of substance abuse and want public action .......................................................................... • Major media campaigns have raised awareness and contributed to a shift in public attitudes (page 48); • 64 percent of Americans want tougher enforcement of drinking-age laws (page 48); • nearly 90 percent want tougher sanctions on people who drive drunk (page 48); • substantial efforts are under way in schools and workplaces to combat substance abuse-with some success. At least 30 percent of U.S. workers have access to an Employee Assistance Program, and 20 percent work in firms with drug testing pro- grams (page 44). Americans recognize substance abuse risks Percent of adults 35+ who think heavy use is very risky 71 Source: National Household Survey on Drug Abuse, 1991 i11iohul: 6/i(N) 7A Source N. And, Americans are taking action themselues • More than 2,000 communities have launched community-wide coalitions dealing with the problems of tobacco, alcohol, and illicit drugs (page 52). 9

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Help For Communities Fighting Substance Abuse f rom Join Together: 51422 4655 These two reports and their accompanying community action guides offer national policy recommendations and action steps for communities• r--~ Save Lives! F7~ ~ Recommendations L-J to Reduce Underage Drinking Health Reform for Communities: Recommendations on F'inancing Substance Abuse Services NAME: ORGANIZATION: ADDRESS: TITLE: Yes - - Please add me to your mailing list. Join Together is a Robert Wood Johnson Foundation-funded program helping communities be more successful in fighting alcohol and drugs.