Substance Misuse: What Have We Learned?

H. Stanton
Substance Misuse: What Have We Learned?
John Stuart Mill to have been
anv people consider
of the
state’ in which
an
opponent
The age at which young people start experimenting
smoking appears to have become somewhat younger
over the last few years.&dquo; Of particular concern is the fact that
more young women than young men are smoking in a
number of countries. A former US Secretary of Health
recently said. &dquo;Women bat,e come a long ll’a)’ ouer tbe past
20 years, but in substance abuse arzd addiction, it,oiiieii
have come the wrong u~alc’r
Current evidence of the factors that influence the
uptake of smoking among young people points to the
factors shown in table 1.
with
’nanny
politicians, bureaucrats and do-gooders try to take
responsibility for the health outcomes of others.
However J.S. Mill also said that &dquo;If either a public
W
i. V
officer or any one else saw a person attenzpting to cross a
bridge which had been ascertained to be unsafe, and
there was no time to warn him of his danger, they might
seize him and turn him back, without any real
infringement of his liberty.For liberty consists in doing
what one desires, and be does not desire to fall into the
river.&dquo; Mill, therefore provided a rationale for action to
prevent substance misuse - harm minimisation.
The two drugs of greatest concern in most Pacific
countries are tobacco and alcohol, with smoking being a
Table 1
Substance Misuse
public health problem that generally outweighs AIDS, motor
vehicle accidents, personal injury and suicide, and other
illicit drug use combined in terms of its impact on morbidity
and mortality. Tobacco is predicted to create by far the
greatest global burden of disease by the year 20252
In the last decade there have been substantial changes
in the consumption of tobacco and alcohol in many
countries in Oceania.~ Some countries report
increase in the consumption of cigarettes in
Changes of this magnitude do
not come about
a
10- fold
a
decade.
chance.
by
They are a direct consequence of a heavy investment in
advertising and promotional schemes by the transnational
corporations that control the production and marketing of
cigarettes.
The
Interventions to Reduce Harm
Associated With Substance
Misuse
Changing Pacific
Youth drug abuse is rising in Fiji., The bottom line
be that even with continued work to address
substance abuse by young people happening steadily over
the next coming years, it will be a slow process - and it will
probably get worse before it gets better.’ Many of the
problems facing youth in the Pacific stem from the
breakdown of traditional family and community systems,
from urbanisation and the advent of nuclear families, the
weakening of the power of traditional leaders, the loss of
the influence of the church, poor socialisation techniques
or the too easy flow of alcohol. All stem from changes
induced by colonialism and the capitalist economy’
seems to
During the 1960s and 1970s Australia, the United
States, and many other industrialised countries, devoted
much time and effort to health education that focussed on
improving people’s knowledge of the biological and
physiological risks associated with drug use, and on giving
basic information aboug ways to avoid drug abuse. While
some of this effort was ineffective. it nonetheless provided
a foundation for many of the later strategies that were
developed.
The Ottawa Charter, published in 1986. emphasised
the need for a range of strategies to address public health
issues, including the development of healthy public policy.
Current Understanding of the Reasons for
Substance Misuse Among Young People
action
to
improve people’s personal knowledge
and skills.
enhanced community action and the creation of supportive
environments. In addition. the Ottawa Charter pointed to
the need for a reorientation of health services to take up a
more active role in promoting health.
Young people start drug use or misuse for a misxture of
different reasons. Some of the factors known to influence
the uptake of smoking are outlined below. Similar factors
can be applied to alcohol and other drugs.
37
m
To date. the
comprehensive approach to health
promotion proposed by the Ottawa Charter appear to have
had little impact on actions in the Pacific to reduce the harm
Peter Evans posits that development is governed by a
&dquo;triple alliance&dquo; of local elites, the state, and multinational
corporations. Although these are not the only actors in the
development drama, they play central roles. A study of any
associated with tobacco and alcohol use and abuse.
In many Pacific countries, however, literacy in general
aspect of development that neglects one of these three will
and health literacy in particular, remain significant
problems. In many countries, a large proportion of the
population has limited education and literacy. Health
literacy in relation to drug use and abuse is also limited.
However, of greater concern is that there appear to be many
barriers to changing the economic and social environments
in Pacific countries to support action to reduce the harm
associated with drug use and abuse.
The marketing of tobacco and alcohol is now global,
with the international giants of alcohol and tobacco
be weakened by that ornission.1
Evidence of
Strategies That Work
There are some advantages to state-run monopolies for
alcohol and tobacco in individual countries, especially in
relation to their potential impact on public health.’ State-run
monopolies rarely pursue aggressive marketing and
promotion strategies, and are much more open in sharing
information because it is publicly owned. The removal of
national monopolies on tobacco has led to increased
marketing and promotion in many countries of Asia and
Eastern Europe. We need to &dquo;Think globally and act
production marketing their products more agressively,
particularly in countries where no controls exist. However,
despite the globalisation of the problem, many educators
and policy makers often think only in local terms.
In many countries the interests of rich and powerful
families, holding large investments in alcohol, tobacco and
other drugs remain paramount. Such a situation undermines
globally and think locally and advocate locally&dquo; if we are
to curtail this global push.
the attempts of government and non-government
organisations to reform policy and to intervene effectively
to reduce the harm associated with substance misuse.
Examples of the ways in which these interests impede
progress are in Indonesia, where kretek cigarettes rely on
the clove industry, which is controlled by the leading family.
In the Philippines the mogul Lucio Tan who owns Fortune
Tobacco has been able to influence judicial decisions,
remove tax liability and receive World Bank support for
development and modernisation of the Manilla tobacco
Educators and policy makers need to use the most
effective methods of intervention to reduce the harm
associated with substance misuse. Knowledge is needed of
the social, economic, political and policy processes in each
country and of ways to influence these structures. This is
often an art rather than science. A combination of advocacy
with education and promotion of healthy personal
behaviours is most desirable. Perhaps the best test of
effectiveness is the scream test. &dquo;If the industry were
targeting screams, we know that our strategies are being
processing plant.
The tobacco and alcohol industries have an ability to
health promotion efforts a thousand dollars to
one. In 1995, Vietnam imported cigarettes worth US $
100 million and spent US $ 10,000 on smoking and other
health promotion activities. In the Pacific (as elsewhere in
the world) financial incentives provided by tobacco and
alcohol manufacturers for colleagues, friends and country
leaders often influence critical policy decisions. Some
industries use blackmail, deceit, and illegal measures to
effective.&dquo;’~
It is important to look at both high risk and population
based strategies. In connection with alcohol, Nostrom&dquo;
points out that in Sweden lowering the risk to half from
misuse of alcohol could be achieved by a 25 percent
decrease in overall consumption or a 36 percent decrease
among the heavy drinkers. For tobacco there is no safe level
of use and the aim must be to reduce use by all legal
measures to the lowest possible level.
A brief review of the most effective strategies shows
the following:
Legislation is an effective tool
Legislation is a key to change. 12 Effective legislation
requires advocacy to implement.‘e When implemented,
legislation reinforces, supports and encourages change.
Where there is planned legislative change, social and
personal behaviours often change markedly. For example,
increasing global compliance with smoke-free air travel,
with smoke-free environments at work and in public
transport has led to smoking becoming socially
unacceptable, and a reduction in consumption. All
countries need to implement such policies. Random breath
outspend
change, especially legislative change.
Many Pacific countries have established local
breweries. SP Brewery in Papua New Guinea, Solbrew in
the Solomon Islands, and Fiji Bitter all hug their markets.
The global trend is confirmed by Fosters, Four X and
oppose
Heineken cans on distant beaches.
Hacker pointed out that viewing the behaviour of
transnational alcohol companies simply as another issue for
national alcohol programmes and policies to address is naive
and an anah-ticallv faulty stance: naive, because without
understanding how and why transnationals act in the
context of developing economies, it is very difficult to
fashion effective policies to regulate that behaviour;
analytically faulty because it assumes that transnationals are
not themselves actors in the shaping of national alcohol
policies. In this instance. alcohol is not different from other
commodities.8
testing for drivers has reduced the incidence of drunk
driving
crashes.
38
and
mortality
and
morbidity
from road traffic
Price and taxes influence both use and uptake.
There is a demand reduction effect by increasing
price. This can be either through taxes or as a result of
industry action. In reality the industries rarely raise prices
because they know of its effect in lowering consumption.
For a 10 percent increase in price, consumption decreases
between 2 and 10 percent, depending, to a large extent, on
the level of disposable income available.&dquo;I&dquo;
People who start smoking later in life, smoke for a
shorter period and have later onset of disease. In addition
the severity of the disease is lessened. The longer smoking
uptake can be delayed, the greater health benefit will result
to both individuals and society.
Information and education alone is never sufficient.
Where the focus is on education and community
projects such as World No Tobacco Day, the achievements
minimal. Effective education requires supporting
legislation. Effective community education is targeted,
culturally appropriate and uses clearly defined messages.
are
) Technology and education
In many countries, culturally diverse groups. often
with low levels of literacy live in poverty on the edges of
cities or in community groupings. Structural changes are
needed to alleviate these situations. but basic health
information and education can assist. Such messages are
often best communicated in the form of a story, picture or
drama. For the messages to be understood and applied the
structure and format needs to be evaluated.=&dquo;
This brief review has focused on the two major drugs
of alcohol and tobacco. But there are other drugs causing
concern within the Pacific including cannabis, kava, betel
nut and psychostimulants such as ecstasy. While accurate
information on prevalence of use is unavailable, cannabis
appears to be widely used. The use of kava, and betel nut is
linked with cultural influences that are slow to change. In
the Solomon Islands approximately 40-50 cases of oral
cancer a year occur due to betel chewing.
Conclusions
Some states in Australia and the United States have
achieved good results with their use of hypothecated tax to
’buy out’ sponsorship of sporting, arts and cultural events,
and to support a range of community-based smoking
prevention activities. California has used counteradvertising very effectively and has achieved a stated
smoking prevalence of 15.5 percent. 15 One powerful
counter advertisement used in California showed the seven
top tobacco executives giving evidence before the Senate
enquiry. The executives under oath were seen holding up
their hands and repeating in parrot-like fashion, &dquo;I do not
believe that nicotine is addictive.&dquo; This misrepresentation
by the executives of the tobacco industry, further destroyed
their credibility. The tobacco industry through its own
research knew for 30 years the addictive nature of nicotine,
the cancer producing effect of tobacco tars and the impact
of passive smoking.16 ’- These facts were kept from the
public by industry deceit, threat, litigation11 and public
relations and only revealed in recent years. 1-
People have, and no doubt always will, misuse drugs,
reduce the harm, and educate effectively to
ensure better lives for all. &dquo;The potential to (cheanically)
alter consciousness will always exist. However, I would
but
we can
like to commend the sober mind to you. It can achieve
that which is inconceivable. It can transport you to the
Virginias and the Carolinas, yes, to tlae shores
of the
Western sea, and beyond to its own Antipodes. &dquo;’-’
There is need for us as educators, advocates and policy
makers to look at the values, goals and visions that society
is seeking to create. &dquo;Never doubt that a small group of
thoughtful, comniitted citizens can change the world.
Indeed it is the only thing that ever has.&dquo;~’- It is encouraging
to remember in the David and Goliath struggle who
ultimately won!
References
Effective use of the mass media is possible.
1 - Mill J.S. On
places in the Pacific, radio is still the most
effective medium, although video and TV are now
becoming widely available. There are examples of effective
A. The global burden of disease.
Harvard School of Public Health for World Health
Organization and the World Bank; 1996.
In many
2-
advertisements used in some industrialised countries that
may be useful in the Pacific.
3 - Marshall M. The second fatal impact: cigarette smoking,
chronic disease, and the epidemiological transition in
Oceania. Social Science and Medicine 1991; 33: 1327-42.
There are other structural, cultural and personal
issues. Many of these are well known, and include:
Accessibility and location
Labelling and health warnings
Night spots, black markets, and gambling
4 - Tuvuki V Youth
Binge drinking
Cultural differences and the needs of
Times. November
alcohol and other drugs in the Pacific.
United Nations International Children’s Fund. Pacific
Island’s Montbly
July 1996.
-
-
drug abuse rises. Fiji
28, 1996. p.4.
5 - Mielke J. Youth,
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liberty.
Murray C., Lopez
indigenous
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populations
adolescent smoking:
a
review of options. Health Education
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Painter K. Teen girls as likely to drink. use drugs as boys.
Wall June
Street Journal 6. 1996. p. B12.
While we know some of the intervention strategies
that have succeeded elsewhere, there is still much to be
learned about the way in which change is effected. ’9
39
D. Multinational alcohol companies in
countries.
developing
Proceedings of the 3-th
International Congress on Alcobol and Drug Dependence.
Lausanne: ICAA; 1996.
8 -
Jernigan
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education: what we know and what we don’t. Healtb
Education Quarterly 1995; 22: 273-89.
11 - Norstrom T. Prevention strategies and alcohol
policy.
Addiction, 1995; 515-524.
12 - Piha T. Fifteen years’ experience of comprehensive
tobacco control legislation. Tobacco Control 1992; 1: 239-
240.
Chapman S., Lupton D. The fight for public health:
principles and practice of media advocacy. London: BMJ
Publishing; 1994.
14 - Townsend J. Price and consumption of tobacco. British
Medical Bulletin 1996; 52: 132-142.
15 - Scarcnet News Report. Atlanta: Centers for Disease
13 -
Control: Associated Press News. November 7;
1996.
16 - Glantz S., Barnes D., Bero L., Hanauer P, Slade J.
Looking through
a
keyhole
at
the tobacco
industry:
the
Brown and Williamson documents. Journal of the
American Medical Association, 1995; 274: 219-224.
1
- Glantz S., Slade J., Bero L., Hanauer P., Barnes D. The
cigarette papers. San Francisco: University of California
Press; 1996.
Kluger R. Ashes to asbes: America’s bundred-year
cigarette war, the public health and the unabashed
triumpb of Philip Morris. New York: Knopf; 1996.
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J., Goodman R., Jorgensen C. Health education intervention
18 -
strategies: recommendations for future research. Health
Quarterly 1995; 22: 307-28.
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Education
educational materials: model and instrument development.
Patient Education and Counseling 1991; 18: 253-63.
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medicine leaves behind a lifetime of ground-breaking work.
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1.
22 - Mead M.
Dr Harley Stanton, Associate Director, Adventist Health
Department, South Pacific, Chairman UICC Tobacco and
Cancer Program South Asia-Western Pacific, 148 Fox
Valley Road, Wabroonga, NSW 2076, Australia.
Tel: 61 2 9847 3333; Fax: 612 9489 0943
RESUME
Qu’avons-nous appris sur les toxicomanies ?
Les recherches actuelles identifient une s6rie de facteurs
qui poussent les jeunes a fumer : les facteurs personnels
comme une faible estime de soi, une connaissance limit6e
des risques et la curiosit6 ; des facteurs socioculturels
comme Ie stress familial, 1’influence des pairs et 1’influence
de normes non exprim6es ainsi que des facteurs
environnementaux comme la disponibilit6, le prix et la
publicite du tabac.
Un bref examen des strategies les plus efficaces d6montre
que la legislation constitue un outil efficace ; que les prix
et les taxes influent sur la consommation et 1’initiation ;
que 1’information et 1’education a elles seules ne seront
jamais suffisantes et qu’il est possible d’utiliser les m6dias
efficacement. Mais, bien que 1’on connaisse certaines des
strategies d’intervention qui ont fait la preuve de leur
efficacit6, il reste encore beaucoup a apprendre sur la
facon dont les changements s’operent. Certaines personnes
font. et feront sans doute toujours un mauvais usage des
drogues, mais il est possible de reduire le danger et
d’6duquer efficacement la population pour assurer une
meilleure vie pour tous. En tant qu’6ducateurs,
intervenants et d6cideurs nous devons examiner les
valeurs, buts et visions que la societe cherche a creer.
tabagisme et I’alcoolisme constituent deux preoccupations majeures et grandissantes
dans le Pacifique occidental sud. On pr6voit du reste que le tabac sera la principale
cause des maladies a 1’echelle mondiale d’ici I’an 2025.
L’article identifie quelques-uns des principaux obstacles a une intervention efficace qui
reduirait la frequence et la predominance des toxicomanies dans le Pacifique occidental
sud. Le texte passe en revue les strategies qui se sont r6v~l~es efficaces pour minimiser
les effets nefastes associ6s aux toxicomanies, et releve certains problemes specifiques à
cette partie du monde qui doivent etre abord~s.
Plusieurs changements importants se sont produits au cours de la derniere d6cennie en
matiere de consommation de tabac et d’alcool dans plusieurs pays en Oceanic. La
consommation de cigaretts a d~cupl6 au cours des dix dernieres annees dans certains
pays. Des changements de cette ampleur n’arrivent pas par hasard. Ils sont la
consequence directe d’investissements publicitaires consid~rables, et de promotions en
tous genres, mis en place par les compagnies multi-nationales qui contr6lent la
production et la mise sur le marche des cigarettes.
La toxicomanie chez les jeunes est en hausse a Fiji. Malgré les efforts de lutte contre la
toxicomanie chez les jeunes - un processus long terme qui se poursuivra au cours des
prochaines annees - la situation va s’aggraver avant de s’ameliorer. Plusieurs problemes
auxquels les jeunes du Pacifique doivent faire face proviennent de 1’eclatement du
svsteme traditionnel des structures familiale et communautaire. de 1’urbanisation et de
1’avenement des families nucléaires. de l’affaiblissement du pouvoir des « leaders
communautaires traditionnels, de la perte d’intluence de 1’6glise, de la faiblesse des
techniques de socialisation ou de la circulation trop aisee de I’alcool. Tous ces facteurs
sont la consequence des changements introduits par le colonialisme et 1’economie
Le
»
’
capitaliste.
40