Ch #13 Substance Abuse

Introduction

A drug is any substance other than food taken to affect body processes. The development of medical drugs has been one of modern society's greatest advances. Drugs prevent or cure diseases, alleviate pain, treat a variety of conditions, and perform many other functions. Recreational drugs—or drugs taken for pleasure—such as alcohol and caffeine, can provide relief or enjoyment when used in moderation, and their use has become an important part of many cultures.

Alcohol of Informed Decision Making

For women who choose to drink, drinking in a responsible manner can improve their health. Drinking to excess has numerous direct eifects on health. Excessive drinking also indirectly increases the risk of death, injury, or trauma through drunk driving and potential sexual assault. For those with a propensity toward excessive drinking, it is important to set a limit and stick to it. For most women, drinking no more than one drink a day may provide some health benefits; drinking beyond this level on a regular basis may cause serious harm. It is also critical to have healthy coping strategies to avoid turning to alcohol when upset or depressed. Alcohol neither fixes a problem nor provides an escape. When drinking becomes the primary focus of an activity, a significant risk for serious long term alcohol problems arises. Communication skills are an important component of responsible drinking. Learning to say, "No thanks, I've had enough," is an important step in exercising personal power and control over drinking behavior. Pacing alcohol consumption is important as well. Drinking a week's worth of alcohol on a Friday night is not the same as moderately paced drinking throughout the week. Alcoholic beverages are not good or wise thirst quenchers, as alcohol increases dehydration. Food should be consumed before drinking, so it is a good idea to eat something before going to a party or meeting someone for a drink. Helping others to drink in moderation is also a personal responsibility issue. It is not wise to push drinks or refill empty glasses quickly. Food helps to slow the absorption of alcohol and should be encouraged first, particularly if guests have not eaten for a while. Nonalcoholic beverages should always be available alongside alcoholic ones. Perhaps the most important responsibilities are never to serve alcohol to a guest who seems intoxicated and never to permit an intoxicated person to operate a vehicle. Assuming responsibility includes making contingency plans for intoxication. The early identification of designated drivers helps ensure safe transportation home for guests. If intoxication occurs despite efforts to prevent it, assume responsibility for the health and safety of guests by providing transportation home or overnight accommodations. Women should stay With their female friends who appear overly intoxicated and be aware of men who may try to take advantage of an intoxicated woman. Stay with the person if he or she is vomiting. If the person is lying down, turn his or her head to the side and protect the person from swallowing the vomit. Monitor the person's breathing status. If there are any signs of unconsciousness or respiratory problems, seek immediate medical attention. Remember that the only thing that sobers a drunk person is time. (See Table 13.8.)

Epidemiological Trends and Issues of Tobacco

Native Americans first cultivated and smoked tobacco in North America thousands of years ago. Tobacco became popular in Europe about 450 years ago, when Spanish explorers brought it to their colonies and Europe from the New World. Tobacco became an accepted component of early colonial life. though its use was largely limited to men. Through the next century, tobacco was also snuffed (inhaled), dipped, and chewed. Cigarette smoking gradually increased in popularity throughout the 19th century. During this time, a few doctors noted that tobacco seemed to cause a number of diseases, but this information was not widely spread or believed. Most people believed that tobacco use either posed no harm or actually improved health. Over the course of the 1800s, a series of technological additions to cigarettes enhanced the ease of inhalation and modified their flavor and aroma. The 1920s were a critical period of change for women, characterized by new social and cultural patterns, a constitutional ability to vote, and a push for greater rights and emancipation. In an extremely effective series of advertising campaigns, the tobacco industry took advantage of this women's rights movement. Cigarette companies marketed smoking as a symbol of rebellion, romance, and emancipation for women—women could now smoke cigarettes alongside men as well as vote. Women began to smoke openly in public settings, and female cigarette smoking prevalence rates rose from 2% in 1930 to 34% in 1965 . Just over one in six women (17.3currently smoke in the United States. While this number represents tremendous progress—current smoking rates are half of what they were 50 years ago—this decline has not affected all groups of women equally. Large disparities exist based on race, ethnicity, and other factors (see Table 13.1 and Figure 13.2). Among adult women in the United States, smoking rates are by far the highest among people of Native American descent (36 This is twice the national average, and nine times the smoking rate of Asian Americans, the racial group least likely to smoke. After Native Americans, the ethnic and racial groups most likely to smoke are people of mixed race, Whites, African Americans, and Hispanics. Smoking also varies by education and poverty level, with higher rates of smoking corresponding to lower levels of education and incomes below the poverty level. Even though tobacco use is illegal for people under the age of 18, many teenagers and adolescents have tried tobacco. This tobacco use often becomes a lifelong habit. Almost one—half (46 of all high school students have tried smoking, establishing a pattern for becoming smokers as adults. About one in five (19 of female high school students reported smoking in the past month, slightly less than the smoking rate among male high school students (20. White high school students are most likely to smoke, followed by Hispanic and Black high school students (Figure 13.2). Water pipes, also known as hookahs, have become popular among some adolescents, college students, and young professionals An old custom among some cultures in the Middle East, hookahs can now be found in fashionable clubs, restaurants, and cafes in many cities. Hookah smoking appears to be just as harmful as cigarette smoking. In fact, it may be even more dangerous because the water pipe is used over a longer period of time than smoking a cigarette (about 40 to 45 minutes compared to 5 to 10 minutes). This longer period of inhalation and exposure may lead a smoker to inhale as much smoke as consuming 10 or more cigarettes during a single hookah session.

Quitting Smoking

Quitting smoking is often the most significant personal behavior that a person can undertake to improve one's health. Some health benefits of quitting begin shortly after the last cigarette. After a few weeks, a person's lungs and circulatory system improve; coughing and shortness of breath usually decline within a few months. The risk for cardiovascular disease and cancer also drops over time. A year after quitting, a person's risk of coronary heart disease falls by 50%. A person's risk of mouth, throat, and lung cancers also usually fall by 50% within 5 to 10 years. A person will experience greater benefits the earlier she or he quits, but quitting at any age improves health in many ways, Quitting smoking is not an easy process. Some people are able to quit on their first attempt, others are able to quit after several efforts, and some people are never able to quit. Typically, only about 8% to 10% of smokers who attempt to quit on their own are successful on any given attempt. The most difficult period is usually the first 3 months, When a person's physical and psychological addiction to tobacco is the strongest. After that period, some people have an easy time staying away from smoking, while Others continue to feel cigarette cravings for years. Some people decide to quit by going "cold turkey," or making a sudden, decisive break from cigarettes. Some people find that they are able to go cold turkey if they do it one day at a time. They promise themselves to be smoke free for 24 hours; at the end of that day, they reaflirm their commitment to another smoke—free day. Another approach involves gradually reducing the amount of nicotine the body receives. A person can do this either by reducing the number of cigarettes he or she smokes, or by switching from smoking to an alternate form of nicotine, such as nicotine replacement therapy (NRT) or electronic cigarettes, and then gradually reducing their use. Some smokers are able to quit by enlisting the help of other people. Counseling can help smokers identify their motivations for smoking and "triggers" that make them more likely to smoke. Support groups, conducted either online or in person, can help a person meet with and get sympathy, advice, and help from other people trying to quit, A person's own friends and family can be a valuable source of assistance by providing sympathy and gently but persistently encouraging them to continue their efforts to quit. Various forms of treatment are also available to help people quit tobacco use. Nicotine replacement therapy Typically, only about 8% to 10% of smokers who attempt to quit on their own are successful on any given attempt. The most difficult period is usually the first 3 months, When a person's physical and psychological addiction to tobacco is the strongest. After that period, some people have an easy time staying away from smoking, while Others continue to feel cigarette cravings for years. Some people decide to quit by going "cold turkey," or making a sudden, decisive break from cigarettes. Some people find that they are able to go cold turkey if they do it one day at a time. They promise themselves to be smoke free for 24 hours; at the end of that day, they reaflirm their commitment to another smoke—free day. Another approach involves gradually reducing the amount of nicotine the body receives. A person can do this either by reducing the number of cigarettes he or she smokes, or by switching from smoking to an alternate form of nicotine, such as nicotine replacement therapy (NRT) or electronic cigarettes, and then gradually reducing their use. Some smokers are able to quit by enlisting the help of other people. Counseling can help smokers identify their motivations for smoking and "triggers" that make them more likely to smoke. Support groups, conducted either online or in person, can help a person meet with and get sympathy, advice, and help from other people trying to quit, A person's own friends and family can be a valuable source of assistance by providing sympathy and gently but persistently encouraging them to continue their efforts to quit. Various forms of treatment are also available to help people quit tobacco use. Nicotine replacement therapy allows a person to gradually reduce feelings of withdrawal by providing an alternate source of nicotine. It is available as a patch, gum, lozenge, spray, or inhaler. Although these forms all provide the same drug, they differ in the Speed in which it is delivered. The nicotine patch provides a slow, steady dose of nicotine that lasts all day. Kept in the mouth, nicotine gum and lozenges may take about 30 minutes to take effect. Nicotine sprays (sprayed into the nose like some allergy medicines) and inhalers provide a Strong, short-lasting dose of nicotine within a few minutes. Studies have found that NRT improves a person's chances of quitting by 50% to 70% for the first 3 to 6 months. However, the long—term effectiveness of NRT—whether they help people quit tobacco for good—is still unknown. The FDA has also approved two medications to help people quit smoking: bupropion (Zyban) and varenicline (Chantix). Both of these medications appear to reduce cravings for tobacco and to block the pleasurable effects nicotine has within the brain. After taking these medications for a few weeks, a person who does smoke a cigarette may feel little or no enjoyment from the experience. Both of these medications are about as effective as NRT in helping people to quit; like NRT, there are still questions as to their long-term efficacy. A small percentage of people who take varenicline may experience disturbing psychological symptoms, ranging from changes in mood, to altered dreams and thoughts of violence or suicide; women who experience any of these symptoms should contact their healthcare providers immediately. allows a person to gradually reduce feelings of withdrawal by providing an alternate source of nicotine. It is available as a patch, gum, lozenge, spray, or inhaler. Although these forms all provide the same drug, they differ in the Speed in which it is delivered. The nicotine patch provides a slow, steady dose of nicotine that lasts all day. Kept in the mouth, nicotine gum and lozenges may take about 30 minutes to take effect. Nicotine sprays (sprayed into the nose like some allergy medicines) and inhalers provide a Strong, short-lasting dose of nicotine within a few minutes. Studies have found that NRT improves a person's chances of quitting by 50% to 70% for the first 3 to 6 months. However, the long—term effectiveness of NRT—whether they help people quit tobacco for good—is still unknown. The FDA has also approved two medications to help people quit smoking: bupropion (Zyban) and varenicline (Chantix). Both of these medications appear to reduce cravings for tobacco and to block the pleasurable effects nicotine has within the brain. After taking these medications for a few weeks, a person who does smoke a cigarette may feel little or no enjoyment from the experience. Both of these medications are about as effective as NRT in helping people to quit; like NRT, there are still questions as to their long-term efficacy. A small percentage of people who take varenicline may experience disturbing psychological symptoms, ranging from changes in mood, to altered dreams and thoughts of violence or suicide; women who experience any of these symptoms should contact their healthcare providers immediately. Typically, only about 8% to 10% of smokers who attempt to quit on their own are successful on any given attempt. The most difficult period is usually the first 3 months, When a person's physical and psychological addiction to tobacco is the strongest. After that period, some people have an easy time staying away from smoking, while Others continue to feel cigarette cravings for years. Some people decide to quit by going "cold turkey," or making a sudden, decisive break from cigarettes. Some people find that they are able to go cold turkey if they do it one day at a time. They promise themselves to be smoke free for 24 hours; at the end of that day, they reaflirm their commitment to another smoke—free day. Another approach involves gradually reducing the amount of nicotine the body receives. A person can do this either by reducing the number of cigarettes he or she smokes, or by switching from smoking to an alternate form of nicotine, such as nicotine replacement therapy (NRT) or electronic cigarettes, and then gradually reducing their use. Some smokers are able to quit by enlisting the help of other people. Counseling can help smokers identify their motivations for smoking and "triggers" that make them more likely to smoke. Support groups, conducted either online or in person, can help a person meet with and get sympathy, advice, and help from other people trying to quit, A person's own friends and family can be a valuable source of assistance by providing sympathy and gently but persistently encouraging them to continue their efforts to quit. Various forms of treatment are also available to help people quit tobacco use. Nicotine replacement therapy allows a person to gradually reduce feelings of withdrawal by providing an alternate source of nicotine. It is available as a patch, gum, lozenge, spray, or inhaler. Although these forms all provide the same drug, they differ in the Speed in which it is delivered. The nicotine patch provides a slow, steady dose of nicotine that lasts all day. Kept in the mouth, nicotine gum and lozenges may take about 30 minutes to take effect. Nicotine sprays (sprayed into the nose like some allergy medicines) and inhalers provide a Strong, short-lasting dose of nicotine within a few minutes. Studies have found that NRT improves a person's chances of quitting by 50% to 70% for the first 3 to 6 months. However, the long—term effectiveness of NRT—whether they help people quit tobacco for good—is still unknown. The FDA has also approved two medications to help people quit smoking: bupropion (Zyban) and varenicline (Chantix). Both of these medications appear to reduce cravings for tobacco and to block the pleasurable effects nicotine has within the brain. After taking these medications for a few weeks, a person who does smoke a cigarette may feel little or no enjoyment from the experience. Both of these medications are about as effective as NRT in helping people to quit; like NRT, there are still questions as to their long-term efficacy. A small percentage of people who take varenicline may experience disturbing psychological symptoms, ranging from changes in mood, to altered dreams and thoughts of violence or suicide; women who experience any of these symptoms should contact their healthcare providers immediately. allows a person to gradually reduce feelings of withdrawal by providing an alternate source of nicotine. It is available as a patch, gum, lozenge, spray, or inhaler. Although these forms all provide the same drug, they differ in the Speed in which it is delivered. The nicotine patch provides a slow, steady dose of nicotine that lasts all day. Kept in the mouth, nicotine gum and lozenges may take about 30 minutes to take effect. Nicotine sprays (sprayed into the nose like some allergy medicines) and inhalers provide a Strong, short-lasting dose of nicotine within a few minutes. Studies have found that NRT improves a person's chances of quitting by 50% to 70% for the first 3 to 6 months. However, the long—term effectiveness of NRT—whether they help people quit tobacco for good—is still unknown. The FDA has also approved two medications to help people quit smoking: bupropion (Zyban) and varenicline (Chantix). Both of these medications appear to reduce cravings for tobacco and to block the pleasurable effects nicotine has within the brain. After taking these medications for a few weeks, a person who does smoke a cigarette may feel little or no enjoyment from the experience. Both of these medications are about as effective as NRT in helping people to quit; like NRT, there are still questions as to their long-term efficacy. A small percentage of people who take varenicline may experience disturbing psychological symptoms, ranging from changes in mood, to altered dreams and thoughts of violence or suicide; women who experience any of these symptoms should contact their healthcare providers immediately. Electronic cigarettes occupy a gray area between a method of quitting and a new habit. These electronic devices, shaped like cigarettes, deliver a breathable vapor containing nicotine. Some people use electronic cigarettes to taper down their nicotine intake. However, electronic cigarettes do not have FDA approval as quitting devices and are instead sold as "alternatives to cigarettes." In addition, fewer studies have examined electronic cigarettes' effectiveness as a quitting tool. Electronic cigarettes occupy a gray area between a method of quitting and a new habit. These electronic devices, shaped like cigarettes, deliver a breathable vapor containing nicotine. Some people use electronic cigarettes to taper down their nicotine intake. However, electronic cigarettes do not have FDA approval as quitting devices and are instead sold as "alternatives to cigarettes." In addition, fewer studies have examined electronic cigarettes' effectiveness as a quitting tool.

Legal Dimensions of Tobacco Use

Federal and state governments share responsibility for controlling how tobacco products are bought and sold. In 2009, the US Food and Drug Administration (FDA) gained the authority to regulate tobacco products. With this authority, the FDA issued new rules about how tobacco products could be sold, distributed, and marketed, Most of these changes were made to prevent people younger than 18 from purchasing or receiving tobacco products. These FDA requirements included: I Banning the sale of tobacco products to people younger than 18 I Prohibiting the distribution offree cigarettes or the sale of packages containing fewer than 20 cigarettes I Limiting the sale of cigarettes in vending machines to select locations where only adults are present I Prohibiting tobacco company names from appearing as a sponsor of athletic, musical, or cultural events I Requiring that audio advertisements use words alone rather than music or sound effects I Banning the sale or distribution of promotional items with tobacco company brands or logos State governments may tax cigarettes or place additional restrictions on when or where smoking is allowed. All 50 states and the District of Columbia impose a cigarette excise tax; the national average for state cigarette excise taxes is $1.63 per pack. City taxes can occasionally add to these taxes: New York City taxes each package $1.50, for a combined state—local tax rate of $5.85 per package. These taxes have become a valuable revenue source for many state budgets. Many ofthese taxes were enacted to pay for state medical bills associated with smoking. However, as other sources of income have declined, some states are using cigarette tax revenues to pay for their general expenses.

Legal Dimensions

In addition to the legal (or illegal) status of specific drugs, several laws and legal realities affect drugs and women's health. Chief among these is how criminalizing drug use disproportionately affects people of color. While White, Black, and Hispanic Americans use drugs at roughly equal rates, Black and Hispanic Americans are much more likely to be arrested for using or selling drugs. For example, whereas African Americans constitute 14% of marijuana users in general, they account for nearly one-third of all marijuana arrests. Hispanic and African American drug offenders both have a greater chance of being sentenced to prison than White drug offenders (40% and 20% greater, respectively). African Americans also receive longer prison terms for drug offenses than Whites, serving nearly as much time in prison for a drug offense as Whites do for a violent. offense. These disparities may not always be the result of deliberate racism; instead they may be due in large part to a focus on making arrests in urban, low—income areas where Black and Hispanic people live. Harsher sentences for Blacks and Hispanics arrested for drug possession may be due either to unconscious or conscious bias on the part of judges, or due to White arrestees being more likely to live in areas where there are more lenient judges. Whatever their origins, however, racial drug—related disparities have had numerous consequences for the people who are arrested, their families, and their communities. While men are still more likely than women to be sene tenced to prison, the number of women in prison has increased at nearly double the rate for men over the past 35 years. There are now nearly seven times as many women in state and federal prisons as in 1980; in particular, the number of women incarcerated for drug offenses has risen by more than 900% since that year. African American and Hispanic women represent a disproportionate share of this increase. Minority women are also least likely to receive effective drug treatment. Once arrested, many addicts are incarcerated, where their addiction is either left untreated or worsens due to the widespread underground availability of drugs in many prisons. Other legal considerations affecting women are associated with drug use during pregnancy. Several states are now dealing with prenatal substance abuse through their legal systems. This approach shifts the focus to punishment and away from the urgent need to provide appropriate drug treatment programs. These states may require healthcare professionals to report prenatal drug exposure; others have amended their child welfare laws to include prenatal substance abuse, using this as evidence of child abuse to end or diminish parental rights. Only a few states have viewed drug use by pregnant women as a sign of the need for treatment, forcing pregnant users into inpatient treatment programs. Punitive reproductive health policies have an especially negative effect on low—income women and women of color. Most pregnant women charged with crimes for drug abuse are women of color, and drug testing of newborns is implemented almost exclusively by public hospitals that predominantly serve low-income women. Such policies often discourage women from seeking needed prenatal care or drug treatment. The threat of criminal punishment fosters a climate of fear and mistrust between doctors and patients, potentially causing harm to the health of both women and their future children.

Stimulants

Stimulants affect the central nervous system and increase heart rate, blood pressure, strength of heart contractions, blood glucose level, and overall muscle tension. Collectively, these effects place additional stress on the body. Caffeine, one of the most widely used stimulants in the world, is found in many different sources. It has a variety of effects: I Relief of drowsiness I Help in the performance of repetitive tasks I Improved mental capacity for work I Increased basal metabolic rate Caffeine can also cause anxiety, insomnia, irregular heartbeat, faster breathing, upset stomach and bowels, dizziness, and headaches in some women. Women who drink a lot of caffeine and then suddenly stop may experience headaches, irritability, and fatigue. Caneine may temporarily increase the blood pressure, so some women with high blood pressure or heart disease may be advised to limit their consumption. For most women, however, moderate amounts of caffeine are not likely to cause health problems. Cocaine is a popular stimulant made from the leaves of the coca plant (unrelated to the cocoa plant used to make chocolate). About 1.5 million people, or 0.6% of the population, use cocaine on a regular basis. Cocaine can be snorted (inhaled as a powder through the nose), injected or smoked. Cocaine increases levels of dopamine, a Neurotransmitter that creates feelings of pleasure in the body, creating intense feelings of euphoria. With repeated use, the brain becomes tolerant to cocaine, and users need more of it to get high. Crack is a smokable mixture of cocaine and baking soda. Because it causes a person to feel intense highs and lows, this drug produces a powerful chemical and psychological dependence. Crack users often need another "hit" within minutes of the previous one. Smoking cocaine in its "free- base" form also delivers a concentrated high that can disappear within seconds. As a powerful stimulant, cocaine has many negative effects on the body. Cocaine constricts blood vessels and increases the heart rate and blood pressure, increasing the risk for heart attacks or strokes. Cocaine use can cause feelings of paranoia, a loss of judgment, and an intense need to get high again. Cocaine causes additional health problems for pregnant women and their unborn babies; its use can cause miscarriages, premature labor, low birthweight babies, and babies with small head circumferences. Women who use cocaine while pregnant are more likely to miscarry in the first 3 months of pregnancy than women those who do not use drugs as well as those who use heroin or narcotics. Infants born to cocaine and crack users suffer major complications, including drug withdrawal and permanent disabilities. Cocaine can deprive the fetal brain of oxygen or cause brain vessels to burst, so that the fetus experiences the prenatal equivalent of a stroke, resulting in permanent physical and mental damage. In addition, cocaine babies are more likely to have respiratory and kidney problems. Visual problems, low birthweight, seizures, depression, lack of coordination, and developmental retardation are common among cocaine babies as well. Amphetamines are manufactured stimulants sold under a variety of names. Generally found in pill form, they may also be ground and sniffed or made into a solution for injection. Amphetamines were once widely prescribed for weight control because they suppress the appetite and stimulate the central nervous system. These drugs place serious stress on the cardiovascular system, which can lead to severe cardiovascular damage. Methamphetamine, also known as "meth," "crystal meth," "crank," or "ice," is a stimulant with a chemical structure similar to amphetamine. Use of methamphetamine greatly increases dopamine levels in the brain, producing strong feelings of pleasure. Unfortunately, methamphetamine appears to also change the brain in other ways. Prolonged use may reduce a person's motor skills, learning capacity, and ability to feel pleasure from any activities other than using methamphetamine. An estimated 353,000 people (0.1% of the population) regularly use this drug. Anabolic steroids are synthetic derivatives of the male hormone testosterone. These powerful compounds are legitimately prescribed for treatment of burns and injuries, but some athletes and bodybuilders who want to appear muscular and quickly gain muscle mass also use them. Women who take anabolic steroids risk development of a deepened voice, breast reduction, enlargement of the clitoris, changes in or cessation of the menstrual cycle, and growth of facial hair. Other potential effects include an increased risk of heart disease or stroke, liver tumors and jaundice, acne, bad breath, aching joints, and increased aggression. Anabolic steroids can also be addictive, creating some of the same problems with dependence and withdrawal as other drugs.

Treating Alcoholism

The most difficult and significant step for an alcoholic is admitting to an alcohol problem. Often well—intended friends or family members, out of fear, embarrassment, loyalty, or hope, help shield the alcoholic from the truth. Confrontation—either personal or via an accident or drunk—driving conviction—that makes the individual acknowledge the alcohol problem is often a turning point in seeking assistance (Self Assessment 13.2). Recovery from alcoholism is more likely when the person has a strong emotional support system, including concerned family, friends, and employers. Alcoholism is a complex problem. Each case must be treated with sensitivity and recognition of its unique situation and contributing factors. Standard treatment programs focus on the relief of physiological dependence but do not eliminate the underlying disease. Individual personality, psychological factors, and sociocultural factors must be addressed to help the alcoholic regain control of her life. Alcohol treatment programs often follow three steps in the treatment of alcoholism: 1. Managing acute intoxication episodes 2. Correcting chronic health problems associated with alcoholism 3. Changing long—term behavior The most successful treatments combine difierent approaches and provide ongoing support as a person learns to live without alcohol. Many alcohol treatment facilities assist clients in overcoming their physical addiction to alcohol and helping them deal with their withdrawal symptoms (Table 13.6) through detoxification programs. Detoxification programs are generally available in medical or psychiatric hospitals. Psychological addiction is usually addressed shortly after the detoxification process is completed. Programs such as Alcoholics Anonymous (AA), which is entirely run by volunteers who are also recovering alcoholics, provide help and support for people trying to maintain their abstinence from alcohol. Studies conducted by Alcoholics Anonymous show that the average length of sobriety for its members is more than 8 years; 50% of members have been sober for more than 5 years, 24% for between 1 and 5 years, and 26% for less than 1 year. Since the organization began in 1935, AA has supported more than 100,000 groups and had over 2 million members in 150 countries. Alcoholics Anonnnous meetings can now be found in towns and cities across the country almost every day of the week. Women alcoholics who enter treatment programs have special needs. Their treatment programs must be culturally sensitive and incorporate issues such as age, socioeconomic status, drug use, and sexual orientation into their format. Strategies that can help women address their alcohol problems include using culturally appropriate, nonstig- matized language; supportive case management; mentoring or buddy systems; childcare services; and multimedia campaigns that educate and welcome women.

Economic Dimensions

The use and abuse of illicit drugs has a tremendous impact on American society, causing about $200 billion dollars a year in economic damages. Alcohol and tobacco also costs hundreds of billions of dollars every year in medical expenses, accidents, lost productivity at the workplace, and other factors. Drug use has economic consequences at both the individual and the societal level. Individual effects include: ' Physiological changes I Mental dependence ' Conflicts in relationships Societal costs include: ' Burden of drug—related crime I Creation of treatment facilities ' Loss of individual productivity ' Care for children of drug-dependent parents ' The policing of illicit drug availability I Treatment of medical complications resulting from inappropriate drug use The federal government budgeted $25.6 billion for drug control in 2013. The government will use this money to reduce and prevent illicit drug use, and deal with the consequences of illegal drug use. Under President Obama, the Office of National Drug Control Policy shifted its approach to acknowledge drug control as both a public health concern and matter for law enforcement. Under this policy, the nearly $26 billion will focus on six major areas: I Preventing illicit drug use and addiction I Allowing offenders for drug abuse to end their abuse and rebuild their lives while maintaining public safety I Stopping drug trafficking within the United States I Allowing Americans who use drugs to get needed treatment I Securing US. borders against illicit drugs I Working with other countries to improve their drug enforcement laws, reduce corruption, and improve human rights and democratic institutions. Across the board, drug use is more prevalent among people of lower socioeconomic status. Use of certain drugs, such as crack cocaine, is more common among poorer people than among affluent people. These drugs tend to be relatively affordable on a per—dose basis. Most often drugs are exchanged for money, but they may also be exchanged for sex. This practice is most common among poor female drug users, with crack addiction being a prevalent precursor to such behavior. Exchanging drugs for sex puts women at heightened risk for acquiring HIV and other sexually transmitted infections, and for becoming a target for sexual violence. Regular tobacco use also imposes serious economic costs. Today, the price of a pack of cigarettes averages around $5 to $7, with state and city taxes bringing the cost up to more than $10 per pack. State, federal, and local taxes often make up half or more of the price ofciga- rettes sold in stores. State taxes on a package of cigarettes range from $4.35 in New York to $0.17 in Missouri. As a result, a pack-a-day smoker may spend anywhere from $2,000 to $4,000 annually to fund her habit. In response to the price increase, an underground trade of cigarettes is thriving. Some street vendors sell black-market cigarettes for below-market prices, pocketing the money that would otherwise go to taxes. Untaxed cigarettes are available on Indian reservations, in countries outside of the United States, and on the Internet for as little as $2.50 a pack. Organized crime and large—scale smugglers are now participating in the underground cigarette market In addition to the cost of purchasing cigarettes, smokers may have to pay higher premiums for their health insurance coverage. Some companies have even implemented policies against hiring smokers in states where it is legal to do so.

Health Consequences for Women Who Smoke

Tobacco use kills roughly 50% the people who use it. Cigarette smoke causes numerous health problems, primarily for the lungs, but also for almost every system in the body. Health risks to smokers vary depending on the amount smoked, the depth of cigarette inhalation, the tar and nicotine content of cigarettes, and the duration of smoking. Inhalation patterns and puffing behavior affect the degree of exposure to carbon monoxide and other toxic compounds. The health consequences of smoking also depend largely on when a Person starts smoking, and when, if ever, he or she quits. On average, women who smoke will lose 14.5 years of life from smoking. Symptoms of smoking—related illness usually take years to develop, although irritation symptoms such as watery eyes, nasal irritation, squinting, and coughing develop fairly soon after a woman starts (Figure 13.3). In addition, smoking causes premature signs of aging including wrinkles, blotchy skin, and discolored teeth. Cigarette smoking increases the risk of coronary heart disease, the number—one cause of death among both men and women in the United States. Smoking doubles a woman's risk of myocardial infarction (heart attack) and doubles to quadruples her risk of sudden cardiac death. Young and middle—age women who smoke have substantially higher rates of both fatal and nonfatal stroke than nonsmokers. Each year, more than 8,800 deaths from stroke and 40,000 deaths from coronary heart disease are attributed to smoking in women (see Figure 13.4). Smoking is also a major risk factor for arteriosclerosis and peripheral vascular disease. Cigarette smoking is a major risk factor for cancers throughout the body. Cancer accounts for about one-third of all smoking-related deaths (Figure 13.4). Smoking is associated with an increased risk of at least 15 types of cancer, including cancers of the lung, larynx, pharynx, mouth, esophagus, kidney, pancreas, cervix, and bladder in women (see Figure 13.5). Smoking accounts for more than 80% of lung cancer deaths—lung cancer is an especially deadly form of cancer, and it now is the leading cause of cancer-related deaths among women. Both cigar and cigarette smoking are associated with cancers of the lung, oral cavity, and esophagus. In addition to increasing the risk for heart disease and cancer, cigarette smoking severely damages the respiratory system. Chronic obstructive pulmonary disease (COPD) is characterized by permanent airflow obstruction and extended periods of disability and restricted activity. Cigarette smoking is the major risk factor for developing COPD, with 80% to 90% of COPD deaths being attributed to smoking. Over the past few years, more women than men have died from COPD (66,000 females compared to 61,000 males). Females who smoke also are nearly 13 times more likely to die from COPD than are female nonsmokers. COPD encompasses many conditions, including emphysema and Chronic bronchitis, which usually occur together. With emphysema, the limitation of airflow results from gradual, irreversible disease changes in the lung tissue after years of assault. The air sacs in the lungs are destroyed, which compromises the lungs' ability to bring in oxygen and remove carbon dioxide from the body. As a result, breathing becomes labored, and the heart must work harder to transport oxygen. Chronic bronchitis is characterized by constant inflammation of the bronchial tubes. The inflammation thickens the walls of the bronchi, and the production of mucus increases, resulting in a constricting or narrowing of the air passages. Women who smoke face an increased risk of osteoporosis and early menopause, with smokers reaching spontaneous menopause one to two years earlier than nonsmoking women. The age differences in menopause appear to be smoking—dose dependent. Smoking reduces fertility and may increase back pain. In addition, cigarette smoking can worsen the symptoms or complications of allergies, asthma, and existing disorders of the pulmonary and circulatory system.

Effects of Alcohol

Alcohol is a central nervous system depressant that effectively impairs all major body systems. When consumed in small quantities, it has a mild, relaxing effect. Consumption of larger quantities results in compromised sensory motor coordination, judgment, emotional control, and reasoning capabilities. Once ingested, alcohol circulates throughout the body, affecting nearly every bodily function (Figure 13.6). Alcohol usually takes about 15 minutes to reach the bloodstream, and the peak effect occurs in 1 hour. Once in the bloodstream, alcohol quickly reaches the liver, heart, and brain. The liver is the organ that metabolizes alcohol and removes it from the body. This exposure makes the liver the organ most vulnerable to alcohol. Heavy drinking may lead to alcoholic hepatitis, which is characterized by inflammation and destruction of liver cells, and cirrhosis, which produces progressive scarring of liver tissue. More than 90% of heavy drinkers develop fatty liver, a type of liver disease; 20% will develop liver cirrhosis. Compared with men, women develop alcoholimlueed liver disease over a shorter period of time and after consuming less alcohol. Chronic heavy alcohol consumption is also associated with cardiovascular damage. Consuming one or two alcoholic drinks per day may slightly lower the chances of developing coronary heart disease; however, heavier drinking greatly increases the risk. Chronic heavy alcohol use also increases the risk for cancers of the liver, mouth, throat, colon, and breast. To an observer, the most noticeable effects of alcohol are on the brain and behavior. Alcohol alters the activity ofbrain neurons, impairing sensory, motor, and cognitive function. Moderate amounts of alcohol also lower perception, judgment, and psychomotor skills. Alcohol's anesthetic effect may cause diminished perception of pain and temperature, possibly leading to serious injury or exposure to extreme temperatures. Although drinking may decrease judgment, increase interest, and reduce inhibitions in sex, it also impairs a man's ability to achieve or maintain an erection and a woman's ability to achieve orgasm. Additional drinking progressively reduces behavioral activity, which may lead to sleep, general anesthesia, coma, and even death. Alcohol is particularly dangerous when combined with other drugs, such as depressants and antianxiety medications. Of the 100 most frequently prescribed drugs, more than half contain at least one ingredient that interacts adversely with alcohol. Combining alcohol with drugs may heighten the effect of either drug or produce additional harmful effects (Table 13.5). Acetaminophen (brand name Tylenol) can be especially toxic to the liver when taken with many drinks, and in rare cases can lead to acute hepatic failure. Heavy alcohol consumption typically leads to several nutritional problems for the chronic user. Because alcohol dulls the senses of taste and smell, heavy drinkers often skip meals and develop nutritional deficiencies. Alcohol consumption also has been associated with osteoporosis due to alcohol's ability to block the absorption of calcium. Chronic consumption disrupts normal digestive processes, resulting in gastritis (inflammation of the stomach lining), stomach ulcers, and intestinal lesions, which interfere with the metabolism of vitamins and minerals. In addition, alcoholism has been associated with thiamine (vitamin B1) deficiency, which can increase the risk for diseases of the nervous, digestive, muscular, and cardiovascular systems. Physiologically, women appear to have less body water than men of similar body weight and produce less alcohol dehydrogenase, the enzyme responsible for ethanol metabolism. As a result, women absorb about 30% more alcohol than men do into the bloodstream before it can be metabolized in the liver. Alcohol reaches women's brains and other organs more quickly than it does in men, resulting in more rapid intoxication as well as more organ-specific ethanol toxicity. For a woman of average size, one drink has roughly the same effect as two drinks have on the average—sized man. Women alcoholics also are more likely to suffer liver damage than men. Hormone levels affect alcohol metabolism. Studies have found that both the menstrual cycle and the use of oral contraceptives influence blood alcohol levels. The rate of alcohol metabolism and peak BAC attained with a standard dose of alcohol may vary depending on estrogen levels. Moderate alcohol consumption may increase the risk of breast cancer in postmenopausal women taking hormone replacement therapy. These variances may help explain why some women have difficulty predicting their response to alcohol and their feelings of loss of control over their responses. Alcohol can also cross the placental barrier to affect reproductive health and pregnancy. Alcohol's effects on the developing fetus vary depending on the degree and timing of exposure, genetic differences in maternal metabolism of alcohol, maternal nutritional status, and possible interaction with other drug compounds. Women who are alcoholics or who drink heavily during pregnancy are more likely to miscarry. A direct effect of alcohol in pregnant women is fetal alcohol syndrome (FAS). This Syndrome causes physical and mental abnormalities in infants born to mothers who drank alcohol during pregnancy (536 Chapter 6). Fetal alcohol syndrome has the following symptoms: I Small body size and weight I Slower than normal development and failure to catch up I Skeletal deformities I Facial abnormalities I Organ deformities I Central nervous system handicaps Alcohol consumption may inhibit the release of oxytocin and prolactin, two hormones important for initiation and maintenance of lactation. It also may alter the composition of a woman's breast milk and inhibit milk production. Alcohol plays an indirect role in many unwanted pregnancies and sexually transmitted infections (STIs). Because of impaired judgment and reasoning from intoxication, a woman may forget or ignore contraception, make judgments she later regrets, or miss signs of danger. In addition to unwanted pregnancies and STIs, alcohol is often a factor in acquaintance rape cases and incidents of pressured sex.

Cannabis (Marijuana)

Cannabis, known as marijuana, "pot," or "weed," is by far the most used illicit drug. More Americans use marijuana than the number using nonmedical prescription drugs, cocaine, heroin, inhalants, and hallucinogens combined. Marijuana consists of a mixture of crushed leaves and flower buds of the Cannabis saliva plant; this drug is usually smoked, but it is also occasionally cooked and eaten. Hashish is an extract of cannabis that is 2 to 10 times as concentrated as marijuana. Tetrahydrocannabinol (THC) is the primary psychoactive ingredient in both drugs. When taken in low to moderate closes, the effects of marijuana are similar to the eflects of alcohol and some tranquilizers. In contrast to alcohol, however, marijuana at low doses does not dull sensation, but rather may cause slight alterations in perception. Its immediate physical effects include an increased heart rate, bloodshot eyes, and dry mouth and throat. High doses diminish the ability to perceive and react and cause sensory distortion. Hashish users may experience vivid hallucinations and LSD—like psychedelic reactions, and some people experience acute panic attacks. Marijuana use has grown over the past decade, in part because of the belief that it is not a dangerous drug. Marijuana does not tjpically cause the same rapid deterioration of mind and body seen in users of drugs like heroin, methamphetamine, or cocaine. Studies show conflicting results regarding smoking marijuana and its relationship to cancer. However. medical evidence does indicate that marijuana, especially when used chronically, is a harmful drug. In the short term, marijuana impairs problem—solving and lowers coordination; over the long term, marijuana may increase the risk for heart disease and cause respiratory problems. On a personal level, chronic marijuana use is associated with reduced physical and mental health, a lower career status, and absenteeism in school and at work. In women, chronic use of marijuana appears to suppress ovulation and alter hormone levels. Frequent use of this drug during pregnancy may result in lower-birth-weight infants and may be associated with impaired verbal, perceptual, and memory skills, as well as difficulties with decision making and sustained attention in children. Marijuana for medical use has been a subject of controversy for many years. The drug has been studied for its possible analgesic effect; its potential for reducing spasms and spasticity produced by multiple sclerosis and partial spinal cord injury; its use for chemotherapy—related nausea and vomiting; its ability to lower intraocular pressure to treat glaucoma; and its work as an appetite stimulant for wasting syndrome due to HIV infection, anorexia, and cancer. Some believe that evidence for the prescription of marijuana remains inadequate and that other medications produce similar results without the side effects. Others believe that marijuana provides relief for a variety of medical purposes.

Alcohol

Pure alcohol is a colorless liquid obtained by fermentation of a sugar—containing material. Ethyl alcohol (Ethanol) is the type of alcohol found in alcoholic beverages. The amount of alcohol varies from beverage to beverage. Roughly the same amount of alcohol is present in 3 12-ounce bottle or can of beer (4% alcohol), 5-ounces of table wine (10% alcohol), and 1.25 ounces of distilled spirits (40% alcohol). For most people, drinking moderate amounts of alcohol (no more than one drink a day for women or two drinks a day for men) is unlikely to cause any health problems and may even slightly lower the risk of heart disease. However, when a person drinks larger amounts of alcohol on a regular basis, or engages in irresponsible drinking behaviors, numerous health consequences can result.

Prescription Drugs

The three classes of prescription drugs most commonly abused are opioids prescribed for pain, which include morphine, codeine, and oxycodone (e.g., OxyContin, Percodan, Percocet); central nervous system depressants for anxiety and sleep disorders such as barbiturates and benzodiazepines (e.g., Valium, Librium, and Xanax); and stimulants for sleep disorders and attention-deficit hyperactivity disorder (e.g., Dexedrine and Ritalin). Any of these medications, when used improperly, can lead to serious health consequences and even death. Prescription drug use and abuse are on the rise in the United States, especially among older adults, adolescents, and women. In 2010, more than 7 million Americans over the age of 12 (about 3% of the population) reported currently using prescription drugs for nonmedical purposes, more than any illicit drug besides marijuana.

Other Drugs of Informed Decision Making

Understanding the short— and long-term negative effects that drugs can have, while also developing personal strengths and self—confidence, is the foundation that enables a woman to resist drugs effectively. Knowing how to cope with stress in a healthy way can minimize the likelihood that a woman will turn to drugs as a coping mechanism. Early identification and treatment olfer hope to the person who is using drugs. Unfortunately, many people either miss or refuse to see the signs that a person is using drugs. Many treatment and counseling centers ofier free online or telephone services that provide advice on assessing the situation and helpful resources for action. Confronting the substance abuser is sometimes best handled by a group of loved ones and in the presence of a trained counselor. Outlining how the abuse has affected each person in the abuser's life and how much each person cares about the abuser helps to balance the information. It is unrealistic to expect the abuser to quit without assistance. Although offering support is beneficial, the abuser needs to know that treatment and therapy are necessary. Informed decision making is also an essential responsibility with prescribed and OTC medication use. Many women have little or no idea why they take certain prescribed medications, or they have multiple and vague reasons for using complex OTC medications. Drugs, whether prescribed or self—medicated, can have powerful adverse reactions with other drugs, certain foods, alcohol, tobacco, and caflreine. Older women are often subject to dangerous and possibly fatal drug interactions due to the numerous medications and supplements they are taking. Because many of the most serious effects of drugs are often wrongly attributed to "being depressed" or "growing old," women should know about possible adverse drug reactions and side effects so such events can be recognized and reported. They should also know which foods and other drugs interact with the medications being taken and whether specific dietary recommendations have been identified for the medications.

Epidemiological Trends and Issues of Alcohol

results in significant compromise of mental and psychomotor capabilities. In all 50 states, driving with a BAC 0f 0.08 or higher is illegal. The punishment for violating this limit, as well as the number and kinds of other laws related to driving while intoxicated, vary from state to state. Many factors affect BAC and an individual's response to alcohol. For example, BAC increases more quickly when alcohol is consumed at a faster rate and without food. Stronger drinks, smaller body size, older age, or being of Asian or Native American descent can also lead to increased BAC levels when drinking. In addition to higher BACS, some people of Native American or Asian descent experience effects such as nausea, headaches, and flushing of the skin when they drink. With regular alcohol consumption, additional alcohol is required to achieve the same desired psychological effect, although motor coordination and judgment are impaired at the same level. After years of heavy drinking, damage to the liver can sometimes cause "reverse tolerance." Reverse tolerance occurs when a person lacks enough liver enzymes to break down alcohol at normal rate; if this happens a person can quickly become intoxicated after drinking only a small amount of alcohol. Epidemiological Trends and Issues Although alcohol consumption is generally considered a personal and private issue, its effects permeate all sectors and dimensions of society. Alcohol has been a constant component of American life since the colonial period. Attempts to control, restrict, or abolish alcohol in the United States have all met with failure. In 1919, the 18th Amendment to the Constitution was ratified in an attempt to stop the rapid growth of alcohol addiction. This amendment prohibited the manufacture, sale, and transportation of alcohol, ushering in the Prohibition era. During this time, illegal sales of bootlegged beverages and alcoholic prescription "medications" prevailed as people sought ways around the ban. Prohibition was officially repealed in 1933 by the let Amendment. During the 19th and early 20th centuries, most people believed that alcoholics were morally weak. Today, there is a greater awareness of the complex nature of alcoholism. Public admissions of alcoholism by well—known women such as Betty Ford, Drew Barrymore, Lindsay Lohan, and Nicole Richie have reinforced the fact that alcoholism is a personal and pervasive health problem that affects women from all walks of life. Epidemiological Trends and Issues Although alcohol consumption is generally considered a personal and private issue, its effects permeate all sectors and dimensions of society. Alcohol has been a constant component of American life since the colonial period. Attempts to control, restrict, or abolish alcohol in the United States have all met with failure. In 1919, the 18th Amendment to the Constitution was ratified in an attempt to stop the rapid growth of alcohol addiction. This amendment prohibited the manufacture, sale, and transportation of alcohol, ushering in the Prohibition era. During this time, illegal sales of bootlegged beverages and alcoholic prescription "medications" prevailed as people sought ways around the ban. Prohibition was officially repealed in 1933 by the let Amendment. During the 19th and early 20th centuries, most people believed that alcoholics were morally weak. Today, there is a greater awareness of the complex nature of alcoholism. Public admissions of alcoholism by well—known women such as Betty Ford, Drew Barrymore, Lindsay Lohan, and Nicole Richie have reinforced the fact that alcoholism is a personal and pervasive health problem that affects women from all walks of life. According to the National Survey on Drug Use and Health, 47% of females age 12 and older had at least one drink within the past month; this rate increased to 57% among women between the ages of 18 and 25. American Indian/Alaska Native women are most likely to have alcohol dependence or abuse issues (14, compared to White women (6, Black women (4, Latina women (4, or Asian women (2. In general, women are less likely to drink, drink less, and are less likely to become alcohol dependent than men. Although underage drinking is also more common among males than females, it occurs for both genders. In 2010, an estimated one in four (24female teenagers drank within the past month, one in seven (14 had engaged in binge drinking, and one in 25 (4 had drank five or more drinks on at least five separate occasions in the past month. Cultural factors influence the prevalence of alcoholism. In cultures where drinking is a part of family rituals or ceremonies or where there is great disapproval of public drunkenness, there appears to be lower prevalence of heavy drinking. Gender—based social norms often contribute to alcohol consumption patterns. For example, , in some cultures, men are drinkers while women generally abstain. Adult alcohol use is most common in the Northeast (58, followed by the Midwest (55, West (51, and South (48; the rate of alcohol use is also higher in large . metropolitan areas (54 as compared with small metropolitan and nonmetropolitan areas (51% and 46.0%, respectively).

Risk Factors for Alcoholism

A family history of alcohol problems, early initiation of drinking, and Victimization may increase awoman's risk for alcohol abuse or alcoholism. Identical twins, for example, have closer rates of alcohol dependence, abuse, and heavy consumption than fraternal twinS, suggesting a genetic component to alcoholism. There is also a significant association between alcoholism in people who were adopted and their biological parents, further reinforcing this hypothesis. Women who were sexually, verbally, or physically abused also reported more alcohol related problems. Alcoholism is associated with personality disorders, depression, and other mental illnesses. This association appears to be a two-way street: It may result if a person resorts to alcohol abuse to cope with the symptoms of a mental illness or if a person becomes depressed as a result of alcohol abuse. Alcoholism is also associated with antisocial behavior and low self-esteem.

Smoking as an Addiction

Although tobacco smoke contains thousands of compounds, the most significant from a health perspective are nicotine, tar, and carbon monoxide. - Nicotine is the addictive element in cigarettes. It has several effects on the body, including increasing blood pressure, increasing heart rate, and negating hunger. Nicotine stimulates the pleasure centers of the brain, causing physical addiction. While nicotine can harm the body over the long term, it also appears to have short—term benefits: many smokers state that nicotine helps them relax, concentrate, or complete some tasks more easily. These benefits, along with nicotine's addictive potential, help explain why many people continue to smoke despite knowing tobacco's harmful nature. Two studies published in 2007 found that the nicotine available in cigarettes steadily increased from 1997 to 2005, suggesting that cigarette manufacturers have deliberately increased the amount of nicotine available in cigarettes. I Tar is a thick, sticky, dark fluid produced when tobacco is burned. Tar consists of hundreds of compounds, many of which are carcinogenic (capable of promoting growth of cancerous cells) in their own right. Through inhalation, tar settles and accumulates throughout the oral czm'ty and pulmonary system. The combination of tar and smoke further compromises the cardiopulmonary system. I Carbon monoxide is another deadly by-product of cigarettes. This gas interferes with the blood's ability to carry oxygen, impairs normal functioning of the nervous system, and contributes to degradation of the cardiopulmonary system. Smoking is an addictive behavior, with nicotine being the primary addictive pharmacological component. Self- Assessment 13.1 provides an opportunity to assess whether an individual is addicted to cigarette smoking. Smoking cessation results in withdrawal, an adverse reaction characterized by unpleasant symptoms and an intense psychological and physiological demand for nicotine. Symptoms of withdrawal usually include the following: I Cigarette craving I lrritability I Restlessness I Anxiety I Difficulty in concentrating ' Headache ' Drowsiness I Depression (deep, overwhelming feelings of apathy, sadness, or anger) I Varied gastrointestinal disturbances such as diarrhea and constipation The physical and psychological withdrawal symptoms that occur with cigarette smoking cessation vary in their duration and intensity. For heavy smokers, withdrawal symptoms may occur within 2 hours of the last cigarette. The peak period of physiological symptoms from smoking cessation is usually 24 to 48 hours into abstinence, but many smokers report "craving" cigarettes for years.

Alcoholism

An alcoholic is a person who is addicted to alcohol and whose consumption of alcohol interferes with a major aspect of her or his life. Until the early to mid 20th century, dependence on alcohol was largely seen as a sign of weakness or moral failure. Since then, however, alcoholism has been recognized as a chronic disease with genetic, psychological, and environmental components. Alcoholism has a generational cyclic effect. Children of alcoholics are more likely to suffer abuse, to have psychological or emotional problems, to become alcoholics, and to marry alcoholics. Approximately one in five U.S. adults have lived with an alcoholic relative While growing up. Chronic alcohol abuse usually manifests itself as one of the following patterns: I Daily intake of large amounts of alcohol I Regular heavy drinking on weekends ' Periods of sobriety between binges of daily heavy drinking that may last for weeks or months Alcoholism most often appears between ages 20 and 40, but can present in childhood or early adolescence. Alcohol becomes a problem when an individual is no longer able to control when and how much drinking takes place. Clinical diagnosis of alcoholism is based on the presence of at least three of the following symptoms, persisting for a month or more or occurring repeatedly over a longer period of time: I Large amounts of alcohol (5 or more drinks per day) I Persistent desire to quit drinking or one or more unsuccessful attempts to cut down or quit alcohol I Considerable time spent obtaining, using, or recovering from alcohol I Continued drinking despite social, psychological, or physical harm I Withdrawal symptoms, such as physical trembling, sweating, high blood pressure, delusions, and hallucinations, when alcohol intake is curbed I The avoidance or relief of withdrawal symptoms by drinking I Desire or need for a drink to start the day I Denial of an alcohol problem I Sleep problems I Trying, but being unable to stay away from alcohol I Depression and paranoia I Failure to recall what happened during a drinking episode I Dramatic mood swings I Behaviors or activities while drinking that are regretted later I The experience of the following symptoms after drinking: headaches, nausea, stomach pain, heartburn, gas, fatigue, weakness, muscle cramps, irregular or rapid heart rate

Smoking and Women Worldwide

Around the world, an estimated one billion people, or one seventh of the total population, are smokers. The World Health Organization (WHO) estimates that tobacco use kills almost 6 million people each year, with about 5 million dying as a direct result of tobacco use and about 600,000 dying as from exposure to secondhand smoke. Even as smoking rates have fallen in the developed world, smoking has increased in developing countries, where there is typically less government regulation, and people are generally less educated and have fewer medical resources. Four in five of the world's smokers now live in low and middle—income countries. Because tobacco smoking has primarily been a custom and addiction of men, women and children represent the majority of the world's passive or involuntary smokers. Tobacco companies are sawy in the ways they lure new smokers, particularly women. Many tobacco companies have cleverly linked the emancipation of women in the developing world with smoking, similar to methods that were used in Western countries in the early 20th century. According to the Institute for Global Tobacco Control, governments in developing countries may be less aware of the harmful effects of tobacco use on women and children and are often preoccupied with other health issues; they mostly see tobacco as a problem confined to men. If no dramatic changes in prevention and cessation occur, tobacco—related deaths could rise to 8 million a year by 2030. To reduce these deaths, WHO has an initiative to counteract campaigns from tobacco companies, obtain more accurate data through surveillance, encourage governments to implement tighter tobacco—control laws, and help people who want to stop smoking quit successfully.

Blood Alcohol Concentration

Blood alcohol concentration (BAC) is a physiological indicator that clinicians and law enforcement officials use to determine whether a person is legally "drunk." Blood alcohol concentration represents the percentage of alcohol in the blood. A BAC of 0.10 indicates the presence of approximately one part of alcohol per 1,000 parts of other blood components. As Table 13.3 shows, a BAC of 0.10 results in significant compromise of mental and psychomotor capabilities. In all 50 states, driving with a BAC 0f 0.08 or higher is illegal. The punishment for violating this limit, as well as the number and kinds of other laws related to driving while intoxicated, vary from state to state. Many factors affect BAC and an individual's response to alcohol. For example, BAC increases more quickly when alcohol is consumed at a faster rate and without food. Stronger drinks, smaller body size, older age, or being of Asian or Native American descent can also lead to increased BAC levels when drinking. In addition to higher BACS, some people of Native American or Asian descent experience effects such as nausea, headaches, and flushing of the skin when they drink. With regular alcohol consumption, additional alcohol is required to achieve the same desired psychological effect, although motor coordination and judgment are impaired at the same level. After years of heavy drinking, damage to the liver can sometimes cause "reverse tolerance." Reverse tolerance occurs when a person lacks enough liver enzymes to break down alcohol at normal rate; if this happens a person can quickly become intoxicated after drinking only a small amount of alcohol.

Designer Drugs

Designer drugs—sometimes referred to as "club drugs" because they are often sold at nightclubs or raves—are produced in chemical laboratories and then sold illegally. Such synthetic narcotics are particularly dangerous because they are more powerful than those derived from natural substances. The risk of brain damage or fatal overdose from ingestion is correspondingly higher. MDMA (3,4-methylenedioxymethamphetamine), commonly known as "Ecstasy," is the most common designer drug, with about 700,000 users (0.3% of the population). Ecstasy has features of both hallucinogens and stimulants. Other "club drugs" include GHB, Rohypnol, Ketamine, and methamphetamine. In the United States, the drug has been associated with a predominantly White, middle-class population. Immediate effects of the drug include a feeling of warmth and openness. Delayed responses, usually within a day, include insomnia, muscle aches, fatigue, and difficulty concentrating. Chronic use of MDMA can cause brain damage with the extent of damage directly correlated to the extent of MDMA use. Heavy users also have significant impairments in visual and verbal memory.

Drug Dependency

Drug dependency refers to the attachment-physical, psychological or both—that a person may develop to a drug. Physical dependence occurs when physiological changes in the body's cells cause an overpowering, constant need for a drug. lfthe drug is not taken, the user develops withdrawal symptoms, such as intense anxiety, extreme nausea, and deep craving for the drug. Tranquilizers, painkillers, barbiturates, and narcotics may produce physical dependence. Psychological dependence, also referred to as habituation, results in a strong craving for a drug because it produces pleasurable feelings or relieves stress or anxiety. Physical and psychological dependence do not always coexist. For example, marijuana and LSD may not create physical dependence, but their continued use has been demon- strated to cause psychological dependence. Cross—tolerance, or cross-addiction, often presents with drug dependency. In this condition, a state of physical dependence exists in which psychological need for one psychoactive substance leads to dependence on similar substances.

Depressants and Antianxiety Drugs

Drugs that relax the central nervous system are called depressants, sedatives, or hypnotics. The most widely used depressant is alcohol. Depressants have synergistic effects when they are mixed together, causing a combined effect greater on the body than both drugs would have taken individually. As the user builds tolerance, the likelihood of a potentially fatal overdose increases. Barbiturates are depressants used medically for inducing relaxation and sleep, relieving tension, and treating seizures. They may also be administered intravenously as a general anesthetic. Low doses of barbiturates produce mild intoxication and euphoria, and decrease alertness and muscle coordination. With a higher dose, the person may sulfer slurred speech, decreased respiration, cold skin, weak and rapid heartbeat, and unconsciousness. Side effects of these drugs include drowsiness, impaired judgement and performance, and a hangover that may last for hours or days. Regular barbiturate use leads to physical dependence. Barbiturate addicts tend to be sleepy, confused, or irritable. Barbiturates also present problems in pregnancy. These drugs easily Cross the Placenta and Can cause birth defects and behavioral problems. Babies born to mothers who abused sedatives during pregnancy may be Physically dependent on the drugs and are more prone to respiratory problems, feeding difficulties, disturbed sleep, sweating. irritability, and fever. Barbiturate withdrawal is a time-consuming process and medically difficult to manage. Withdrawal symptoms include anxiety, insomnia, delirium, and convulsions. Systemic dependence is so critical that occasionally an abrupt ending of barbiturate use leads to death. Antianxiety drugs, such as benzodiazepines, are primarily prescribed to treat tension and muscular strain. The most commonly used benzodiazepines are alprazolam (Xanax) and diazeparn (Valium). These drugs act quickly, creating effects in less than an hour. Drowsiness and loss of coordination are the most common side effects. When used with other substances, such as alcohol, benzodiazepines can cause serious, possibly life threatening complications. When taken with benzodiazepines, medications such as anesthetics, antihistamines, sedatives, muscle relaxants, and some prescription painkillers may increase central nervous system depression. Similar to the barbiturates, high doses of these drugs result in slurred speech, drowsiness, and stupor. Physiological and physical dependence on antianxiety drugs may occur within 2 to 4 weeks. Withdrawal symptoms from antianxiety drugs may include coma, psychosis, and death.

Psychedelics and Hallucinogens

Hallucinogenic drugs create changes in perceptions and thoughts. Some of their more common effects are changes in mood, sensation, perception, and relations. These drugs produce tolerance to the psychedelic effects, but do not create physical dependence or produce symptoms of withdrawal, even after long—term use. As with most psychoactive drugs, however, there is a danger of psychological dependence. Peyote, lysergic acid diethylamide (LSD), and phencyclidine (PCP) are the three most common hallucinogens in the United States. Mescaline is the active ingredient in peyote, a spineless cactus with a small crown, or button, that is dried and then swallowed. LSD ("acid") also is ingested orally and produces hallucinations, including bright colors and altered perceptions of reality. The hallucinogenic experience, or "trip," increases the body temperature, heart rate, and blood rate; it also causes sweating, chills, and sometimes headaches and nausea. A "bad trip" may result in an acute anxiety reaction that may trigger panic, depression, confusion, fear of insanity, and distorted thoughts and perceptions. The most common delayed reaction of LSD is a "flashback," in which individuals re—experience the perceptual and emotional changes originally produced by the drug. PCP, or "angel dust," is a synthetic drug that can be smoked, snorted, or eaten. PCP not only causes a person to see and hear things that do not exist, but also alters a person's own perception of herself, often producing symptoms similar to those of schizophrenia. About 500,000 Americans over the age of 12 (0.2% of the popu- lation) use hallucinogens.

Drug Use and Abuse

However, drugs can also cause serious harm or death. Drug abuse is the overuse or misuse use of any drug. Any drug has the potential for abuse, including tobacco, alcohol, medications purchased over—the—counter (OTC) or with a prescription, and illegal drugs. Substance abuse, and problems related to substance abuse, are among society's most pervasive health and social concerns. Tobacco use is the greatest preventable cause of death, disability, and disease in the United States; every year, it kills more than 440,000 people through cardiovascular disease, cancer, and other conditions. Chronic alcohol use harms every system in the body. In addition, drunk driving is a factor in one—third of all automobile accidents. Illegal drugs directly cause about 38,000 deaths a year and contribute to deaths from accidents, homicides, and other causes. Other drugs also cause great harm. Every year, millions of people abuse or misuse drugs purchased over the counter or via prescription, sometimes on purpose and sometimes accidentally. Individuals who abuse illegal drugs may experience addiction, cardiac illness and death, neurological damage, numerous mental illnesses, fetal and infant morbidity and mortality, infection with HIV and hepatitis, and other consequences. On a societal level, illegal use contributes to accidents and violent crime, and causes billions of dollars in medical expenses and lost productivity. Although many people consider legal and illegal drugs as separate categories, the line between the two from a health perspective is not always distinct. Many drugs that are illegal today were originally developed for legitimate medical purposes. In addition, the legal status of some drugs has changed with time, and even varies by country or state. In the 1920s and 1930s, for example, alcohol was illegal and marijuana was legal. Today, the reverse is true. In the early 1900s, opium, morphine, and cocaine were openly advertised and sold as "remedies" in the form of tonics, syrups, and elixirs. Coca-Cola contained cocaine until 1906, when the cocaine was replaced by caffeine. Today, marijuana use is tolerated in the Netherlands and in small amounts in most of Europe. In the United States, federal law prohibits the sale or possession of marijuana under any circumstances. However, state laws are more complicated. Eighteen states allow some form of marijuana use with a doctor's approval, and, in 2012 two states, Colorado and Washington legalized the Sale and possession of marijuana. Under federal law, however, marijuana technically remains illegal in all of states: In 2005, the Supreme Court ruled that the federal government can override state laws on patient use. The age at which a person can legally purchase and use alcohol varies throughout Europe and much of the Americas. Many predominately Muslim countries have laws that either outlaw alcohol or severely restrict how it can be bought and sold. Legal drugs in the United States include alcohol, nicotine, caffeine, OTC drugs, and drugs obtained with a medical prescription. Prescribed medications are legal drugs that can be obtained only through the authorization of a licensed physician or dentist. Besides marijuana, drugs that are illegal include cocaine, methamphetamines, and heroin. Despite a declared "war on drugs," drug availability continues to grow. Nearly one-half of Americans over the age of 12 have tried at least one illegal drug. The use of a drug for a purpose for which it was not originally intended is called drug misuse. Drug misuse can be accidental or deliberate, and includes taking more or less of a prescribed or OTC drug or using an outdated or a friend's prescribed medication. Sleep aids, antihistamines, and cough suppressants containing dextromethorphan (DXNI) are frequently misused OTC drugs. Deliberate drug use inconsistent with or in excess of accepted medical practice constitutes drug abuse. The most frequently abused prescribed medications include pain relievers, tranquilizers, stimulants, and sedatives. The dangers of misusing or abusing a particular drug are often associated with the drug's ability to cause addiction. Addiction can cause physical dependence, where the body adjusts to having a drug in its system and goes through observable negative changes when the drug is removed. Many legal drugs—including barbiturates, tranquilizers, analgesics, opiates, alcohol, and tobacco—can cause physical dependence. Besides physical dependence, drugs can create a psychological dependence, called habituation. A combination of physical and psychological dependence can greatly increase a person's risk for addiction. Some people can become so consumed by their addictions that they direct all their energies to compulsive drug—seeking behavior, even as those drugs provide increasingly less pleasure or relief. Drugs typically enter the body through one of three ways: I Oral administration. Swallowing a drug in capsule, tablet, or liquid form is the most common way of consuming a drug. Drugs taken orally do not reach the bloodstream as quickly as those taken by other means. I Through tbe lungs. The user sniffs a powder, such as cocaine; inhales gases, aerosol sprays, or fumes from solvents or other compounds that evaporate quickly; or smokes a substance. - Use of a syringe. Drugs may be injected subcutaneously (under the skin), intramuscularly (into the muscle tissue), or intravenously (directly into a vein). An intravenous injection immediately introduces the drugs into the bloodstream. Intramuscular and subcutaneous injections are slower in action. In addition to the dosage and the route of ingestion, several factors influence the intensity and the duration of drug's effects: I Physical conditions such as a cold, pregnancy, or menstruation may make the body more vulnerable to the effects of a drug. I Genetic differences among individuals may account for varying drug responses. Some people appear to be more sensitive than others to specific classes of drugs, or to drugs in general. I Mindset can also influence a drug's effects. Someone who snorts cocaine to enhance sexual pleasure may feel more stimulated simply because that is what she expects to happen. I Social setting may influence drug effects. Drug effects at a noisy, crowded party are different from the effects produced at an intimate, subdued event. Tolerance is the body's ability to withstand the effects of a drug. Continued use of certain drugs increases tolerance even as they lower the effects of a drug. As a person becomes tolerant, increasingly large doses may become necessary to produce the same effects. Larger doses also increase the risk of toxicity—the level at which a drug becomes poisonous to the body. Toxicity—related damage may be temporary, permanent, or deadly, depending on the drug, dose, and individual. Many people with substance abuse problems may be abusing more than one drug at once; the average user who enters treatment is on five different drugs. The more drugs used, the greater the chance of side effects, complications, and possible life—threatening situations.

Illicit Drugs

Illicit drugs include drugs that are either banned outright, such as heroin, coeaine, and marijuana, as well as legal drugs used for nonlegal means, such as prescription drugs used such as by someone for whom they were not intended or for nonmedical purposes. Every year, about 2 million Americans end up in the emergency room as a result of overdosing, accident, or injury related to drug use (Figure 13.7). In addition to the directly causing physiological harm, drugs may have additional consequences based on how they are taken. For example, sharing needles to inject drugs can transmit hepatitis B and C, and HIV. Table 13.7 summarizes the effects and risks of illicit drugs.

Epidemiological Trends and Issues of Illicit Drugs

In 2010, 22.6 million Americans aged 12 or older, or 8.9% of the population, had used at least one illicit drug within the past month. Women are less likely to use illicit drugs, including marijuana, cocaine, crack, hallucinogens, and inhalants, than men. Users of illicit drugs are more likely to be young, with rates for both 12-to-17 year olds (10.1 and 18-to-25 year olds (21.5 significantly above the national average. With 17.4 million users over the age of 12, marijuana is by far the most commonly used illicit drug, followed by prescription drugs used for nonmedical purposes (7.0 million users), and cocaine (1.5 million users). Among older women, drug overuse and misuse are particular problems. Although they are generally not users of illicit drugs, older women may be likely to be consumers of high levels of medications. Women age 65 or older represent 12% of the general population, but they receive more than 25% of all written prescriptions. Sedatives, hypnotics, antianxiety drugs, antihypertensive drugs, vitamins, analgesics, diuretics, laxatives, and tranquilizers are prescribed for elderly women at a rate that is 2.5 times the prescription rate for elderly men. Women are diagnosed with anxiety and depression disorders more often than men, and so are prescribed drugs more often to treat these disorders. Gender differences in weight, body composition, gastric emptying time, cerebral blood flow, and use of hormones in contraception and hormone therapy can influence the effects of these drugs. Although many use prescribed medication appropriately, some older women develop a dependency on sleeping pills, muscle relaxants such as Valium, or diet pills. In the 1950s and 1960s, many middle-class women were prescribed these medicines, which were widely viewed as acceptable coping tools. Rather than using these drugs therapeutically, many of these women used them to dull emotions, anxiety, or stress caused by the demands of everyday life and became dependent on them.

Inhalants

Inhalants are chemicals that produce vapors with psychoactive effects. Inhalants are most common among young adolescents and teenagers, in part because the chemicals that produce inhalants may be easily obtainable (or already present in the homes) of people in these age groups. Common products used as inhalants include solvents, aerosols, cleaning fluids, and petroleum products. Most inhalants produce the same effects as anesthetics—namely, they slow down bodily functions. Roughly 700,000 Americans over the age of 12, or 0.25% of the population, use inhalants on a regular basis. At low doses, users may feel slightly stimulated; at higher doses, they may feel less inhibited. Inhalants may cause serious medical complications, such as brain damage and memory loss, hepatitis with liver failure, kidney failure, respiratory impairment, destruction of bone marrow and skeletal muscles, blood abnormalities, and irregular heartbeat.

Social Dimensions of Alcohol

Many cultural factors affect women's drinking patterns or behavior. Society's double standard for women often prevails where alcoholism is concerned. Folklore and popular media may portray male drinkers as comical, lovable, or noble but a drunken woman as loose, weak, and immoral. Additionally, greater social sanctions applied to alcoholism make some women less willing to seek help and others less willing to recognize that they need help. Because alcoholic women violate the stereotype of feminine behavior, they often distress their families and friends and even the health professionals who might support them. For both women and men, depression is associated with excess alcohol consumption. In some cases alcohol may be a symptom of depression; in others alcohol use may be a consequence of it. Victimization is also associated with alcohol-related problems. Women who are sexually abused in childhood or physically abused as adults are more likely to experience alcohol—related problems as adults. The relationship between victimization and alcohol may be confounded by the fact that victimization often leads to depression, which in turn is associated with alcohol use. Although the literature includes few studies on alcohol and drug use among lesbians, it has been suggested that lesbians consume more alcohol for longer periods and are more likely than heterosexual women to use alcohol with other drugs. Lesbian women may be at greater risk of alcohol problems because of the social disapproval directed at their sexual orientation.

Informed Decision Making

Many outside and environmental factors affect whether a person eventually uses or becomes addicted to alcohol, tobacco, or other drugs. While these factors cannot always be controlled, all individuals have responsibility for their own decisions. Personal responsibilities regarding drugs include: I Understanding the effects that a particular substance can have on a person's physical and psychological well—being I Being aware of how substance abuse affects personal behaviors and the assessment ofreality I Being able to ascertain and acknowledge that a problem when substance abuse may be present Recognizing the warning signs of addiction and seeking early treatment intervention are important first steps when someone has a problem, Maintaining abstinence after treating the problem is an ongoing process. This process may get easier after the first few weeks or months, but for some people, the desire to use a drug never goes away. If a person does have a relapse, he or she should start on the recovery process from the beginning.

Narcotics

Narcotics include the opiates—opium and its derivatives, morphine, codeine, and heroin—and some other nonopiate synthetic drugs. All narcotics have sleep—inducing and pain-relieving properties. Some opiates may be used medically for pain relief, but they have a high potential for abuse. Narcotics relax the user and, when injected, may produce an immediate rush. They also may result in restlessness, nausea, and vomiting. With large doses, the skin becomes moist, cold, and bluish, and the pupils become smaller. Respiration slows, and the user may become unresponsive. Death is possible. Over time, opiate users may develop heart infections, skin abscesses, and congested lungs. Infections from unsterile equipment increase the risk of hepatitis, tetanus, and HIV infection. Roughly 200,000 Americans, or 0.06% of the population, use heroin. Although narcotics such as heroin affect awornan's ability to conceive, many addicts still can become pregnant. Use of heroin during pregnancy may affect the developing brain of the fetus or cause behavioral abnormalities in childhood. A baby of a heroin addict is born an addict as well and often suffers severe withdrawal symptoms after birth.

Tobacco of Informed Decision Making

Quitting smoking is the single most significant step most women who smoke can to improve their chances of wellbeing. Regardless of the difficulty—and breaking any addictive behavior is undeniably difficult—smoking causes serious damage to the body and shortens the life span. Quitting smoking at any point brings serious health benefits. Many options to help women quit smoking are available, including counseling, enlisting the help of friends and family, nicotine replacement therapy, electronic cigarettes, and bupropion or varenicline. Avoiding secondhand smoke is not always simple. Although legislation now restricts smoking in many areas, smoking still occurs in some restaurants, bars, and smoking lounges; women who work or otherwise spend lots of time in these areas maybe at risk for asthma or other lung conditions. Some children of smoking parents may be exposed to tobacco smoke in their own homes, ears, and even in the womb before birth. Nonsmokers desire for a "smoke—free" environment presents a potential threat to smokers, who feel that their rights to smoke are violated. The challenge for nonsmokers is to assert their right to a smoke-free environment in a nonviolent but assertive manner. Much of the resistance by smokers is defensive, as they are reminded of their own need to quit and their fear of failure and frustration with the process. Women often do not consider tobacco to be a drug. In reality, tobacco can decrease the effects of certain medications such as acetaminophen, antidepressants, and insulin taken for diabetes. Smoking also increases the risk of heart and blood vessel disease when taking oral contraceptives. When relevant, women should mention tobacco when healthcare providers inquire about medications or drug use.

Smoking and Pregnancy

Quitting smoking may be one of the most significant things a pregnant woman can do to optimize the well—being of her baby. It is estimated that smoking during pregnancy is responsible for 11% of stillbirths and a 5% of newborn deaths. Smoking is believed be a factor in 17% to 30% of low-birthweight babies, 14% of preterm deliveries, and 10% of all infant deaths. The prevalence of smoking during pregnancy has declined steadily over the past 20 years, with about one in seven pregnant women smoking during the last 3 months of pregnancy. About 45% of smoking women who become pregnant quit during pregnancy, half the women who quit during this time relapse within 6 months of delivery. Cigarette smoking during pregnancy retards fetal growth and is associated with miscarriage, stillbirth, sudden infant death syndrome (SIDS), and infant mortality. Pregnant women who smoke more are at additional risk. Nicotine and carbon monoxide are considered the two most important components in cigarettes that constitute major hazards to the fetus: I Nicotine reduces fetal breathing movements and uterine blood flow, and increases fetal heart rate. I Carbon monoxide reduces the amount of oxygen available to the fetus by as much as 25%.

Secondhand and Third-Hand Smoking

Smokers are not the only ones affected by cigarette smoke. Secondhand smoke, or environmental tobacco smoke (ETS), is air contaminated with chemicals from cigarette smoke. Nonsmokers who breathe secondhand smoke are at increased risk of developing asthma, lung cancer, heart disease and other conditions; secondhand smoke also increases smokers' exposure to carcinogens and dangerous chemicals. Secondhand smoke nearly 50,000 adults each year in the United States-about 46,000 from heart disease and about 3,000 from lung cancer. Secondhand smoke is also a concern for babies and young children, whose lungs are more sensitive than the lungs of adults. Secondhand smoke increases a child's risk of low birthweight; sudden infant death syndrome (SIDS); acute lower respiratory tract infections, such as bronchitis and pneumonia; induction and exacerbation of asthma; chronic respiratory symptoms; and middle—ear infections. The greatest source of exposure to secondhand smoke for children, infants, and most adults is the home. For adults living in households where no one smokes, the workplace is the greatest source of exposure to ETS. The separation of smokers and nonsmokers within the same airspace reduces, but does not eliminate, exposure to ETS. As of 2012, 27 states and the District of Columbia prohibit smoking in restaurants, bars, and government buildings, and seven states prohibit smoking in restaurants; the remaining states have weaker laws that allow smoking in at least some public locations. Many states have also legally mandated that most workplaces follow a nonsmoking policy. "Third-hand smoke," or the leftover nicotine and other chemicals that accumulate on walls, furniture, clothing, and other surfaces in areas where smoking has occurred, also creates health risks. These chemicals may last on surfaces for weeks or months. While third—hand smoke does not appear to be as dangerous as secondhand smoke, it still may increase the risk for asthma, lung cancer, and other conditions. More research is needed to fully understand the risks of third—hand smoke.

Codependency of Informed Decision Making

The concept ofcodependency is important for many women who become embroiled within the chaos of another person's life. The term "co—dependent" describes a person obsessed, tormented, or dominated by the behavior of others. The term grew out of the older notion of "co—alcoholic," a term once applied to the wives of heavy drinkers. The premise of codependency is that everyone in a user's or abuser's family is diseased. Consciously or unconsciously, and to their lifelong detriment, codependents interact with the user and ; "enable" this person to partake in her addiction. Codependents often feel helpless, miserable, hopeless, and angry as they accept the victim role. A woman may be codependent in a relationship with a lover, spouse, parent, child, or friend. A codependent typically feels responsible for the behavior and mood of the other. The codependent must learn how to separate her own life from that of the addicted person's. The recovery from codependence is similar to recovery from alcohol or drug dependence in that only the codependent can take the necessary steps toward her own recovery. A codependent must learn not to try to control someone else's life and to stop playing the victim role. Many codependents have received useful support and encouragement from programs such as the twelve-step program of Al-Anon, a support group for family and friends of alcoholics.

Tobacco

The health consequences of smoking are devastating to women's health. Tobacco causes 10 times as many deaths as illicit drug use, and more than the total deaths from accidents, illicit drug use, HIV, murders, and suicides combined. Half of all Americans who smoke will die from a smoking-related disease. Lung cancer is the leading cause of cancer death among US. women and men; roughly 90% of all lung cancer deaths and 30% of all cancer deaths are attributable to smoking. Environmental exposure to smoke exhaled from a cigarette (secondhand smoke) as well as leftover chemicals that accumulate in a room where someone has smoked (third—hand smoke) also increase the risk for lung cancer, asthma, and other conditions.

Societal Costs of Smoking

The human costs are the greatest toll associated with smoking. Annual tobacco-related deaths exceed the number of deaths from alcohol, illegal drugs, homicide, suicide, car accidents, fire, and AIDS combined. Each year, approximately 443,000 deaths in the United States are attributed to cigarette smoking. Women make up 174,000 (about 40 of these deaths (Table 13.2). These deaths translate into more than two million years of women's lives lost every year. The economic costs of smoking in the United States are estimated at $167 billion per year, including costs from lost productivity and medical expenditures.

Sociocultural Dimensions

The path toward drug abuse is often complex for women, yet certain patterns emerge. A person may become more likely to abuse drugs when there is a breakdown of protective factors, such as family, friends, or a supportive environment. Harmful events such as trauma, a disrupted financial situation, abrupt changes in living conditions, or failed relationships can also increase the likelihood of drug abuse. Several factors increase the likelihood of drug abuse in women. I Significant life stresses, such as divorce, loneliness, and dissatisfaction with a career I Sexual abuse and physical abuse, beginning before the age of 11 and occurring repeatedly I Mental illnesses such as anxiety, depression, or personality disorder Society's double Standard for women prevails in drug use. Women face greater stigma for drug abuse than men, sometimes because of their potential position as mothers, sometimes because perceived irresponsibility is forgiven more easily in men than in women, and sometimes for other reasons. These social sanctions against addiction can make it harder for women to seek help, or make their friends and families less willing to recognize the addiction and intervene. Females also have a higher rate of substance abuse co—occurring with other psychiatric disorders, such as depression, anxiety, posttraumatic stress disorder, eating disorders, and borderline personality disorder. The connection between mental illness and drug abuse is not always clear. Some women with mental illness may use drugs in an attempt to self—medicate their symptoms, while in other cases, women may develop mental illnesses as a result of the consequences of drug abuse. In some cases, both mental illness and drug abuse may result from the same trauma or event. Pregnant drug users are at increased risk for miscarriage, ectopic pregnancy, stillbirth, low weight gain, anemia, hypertension, low-birthweight babies, and other medical problems. HIV infection, a possible consequence of intravenous drug use, is another risk among pregnant drug users. Approximately 4.4% of pregnant women between the ages of 15 and 44 use illicit drugs, less than half of the rate of women who were not pregnant in the same age group (10.9. However, rates of drug use vary considerably among pregnant women ofdiflrerent age groups: 16.2% of pregnant women between the ages of 15 and 26 reported currently using illegal drugs, nearly 10 times the rate (1.9 of pregnant women between the ages of 26 and 44.

Legal Issues of Alcohol Use and Alcoholism

There are many legal issues related to drinking. During Prohibition (1920—1933), alcohol was illegal in the United States. Although the let amendment made alcohol legal again, both states and the federal government have since enacted laws that limit its use. Nationally, alcohol is legally restricted to people 21 and older; most other countries have legal drinking ages of 18 or 19. In addition to setting age limits on alcohol use, states have enacted laws governing drinking and driving, drunk and disorderly behavior, purchase of alcohol for a minor, and driving with an open container of alcohol. Most of the penalties associated with alcohol abuse or misuse involve misdemeanor charges or fines, but some—for example, drunk driving violations—entail mandatory jail time in many states.

Treatment Dimensions of Drug Dependency

There are three basic approaches to drug-abuse treatment; detoxification, therapeutic communities, and outpatient drug-free programs. The best type of treatment program for any woman may depend on her circumstances, preferences, drug use, and history. - Detoxification is the supervised withdraw from drug dependence, either with or without medication hospital or outpatient setting. I therapeutic communities are highly structured, drug-free environments in which abusers live under strict rules while participating in group and individual therapy. I Outpatient drug—free programs are available through community and treatment facilities. Self—help programs include Narcotics Anonymous and Pills Anonymous, which follow the philosophy of Alcoholics Anonymous. In these programs, users admit to their helplessness and put their faith in a "higher power." Many people do not recognize their own drug problems, and require intervention by friends and family before theywill seek treatment (see Self-Assessment 13.3).

Societal Costs of Alcohol Use and Alcoholism

With more than 126 million Americans reporting current use of alcohol and 17 million calling themselves heavy drinkers, the economic, social, and personal costs of alcohol-related crimes, accidents, illnesses, and deaths are profound. One estimate of cost of alcohol abuse and alcoholism in the United States is $224 billion per year, of Show $750 per person. Most of these costs come from binge or heavy drinking. This estimate includes healthcare costs of people who use or are affected by alcohol, lost productivity, law enforcement and criminal justice expenses, and motor vehicle accidents caused by drunk driving. The costs to society from alcohol cannot be measured just in terms of dollars. More than 75,000 deaths in the United States are attributed to alcohol every year; just under one—third (21,000) of these deaths are women. About half ofalcohol—related deaths are a result of chronic conditions, while the other half are a result of falls, homicides, motor vehicle accidents, suicides, and other acute conditions. Chronic alcohol use contributes to several often—fatal illnesses, most notably liver disease, cancer, and cardiovascular disease, and can damage most organs in the body (Table 13.4). Drunk driving, or driving under the influence of alcohol, affects not only the people who drink, but their passengers and other drivers. Alcohol is a factor in one in three automobile-related fatalities, causing an estimated 11,000 deaths a year. While men make up the majority (80 of drunk drivers, both sexes drink and drive, and both sexes are injured or killed as a result of drunk driving.

Why Women Smoke

Women often initiate cigarette smoking in adolescence in the context of social interactions with peers. Adolescents are more likely to be smokers if their parents, older siblings or Peers smoke. Many smokers report that their primary reason for smoking is to give them something to do in social situations and/or to "fill time." The social situations in which smoking occurs, as well as the physical effects of nicotine, strongly affect smoking dependence in women. (See It's Your Health 13.2.) Many women hesitate to quit smoking over a fear of unwanted weight gain. Even many pregnant women who smoke indicate that their reason for doing so is to avoid weight gain. Smokers do tend to weigh less than nonsmokers There is no scientific consensus yet regarding the physiological or biochemical mechanism that is responsible for this relationship between weight regulation and smoking behavior. Some evidence indicates that nicotine elevates the body's basal metabolic rate (BMR). The average person gains between 4 and 10 pounds upon quitting smoking, but exercise combined with a smoking cessation program can decrease this weight gain and increase rates of abstinence from smoking. Women's concerns about weight gain and the maintenance of their smoking behavior sadly reflect their willingness to risk long—term detrimental—and potentially catastrophic—consequences in exchange for dealing with body image and weight-control issues. Teenage girls, in particular, often believe that smoking helps them control their weight, and this belief dissuades many from quitting this behavior. Health professionals, educators, mothers, and other female role models must Strike a balance between recognizing that girls have concerns about their weight, while trying to refocus them on healthy behaviors, self-esteem, and safer coping strategies.