chp 13

Why People Smoke: Mental Disorders

About half of smokers report a mental illness, including depression, anxiety, and bipolar disorder. People with mental health conditions who smoke are at greater risk of dying prematurely of smoking-related disease and may find quitting more difficult without intensive support.

Asian American Community

Asian Americans tend to drink very little or not at all, in part because of an inborn physiological reaction to alcohol that causes facial flushing, rapid heart rate, lowered blood pressure, nausea, vomiting, and other symptoms. A very high percentage of women of all Asian American nationalities abstain completely. Some sociologists have expressed concern, however, that as Asian Americans become more assimilated into American culture, they'll drink more—and possibly suffer very adverse effects from alcohol.

Predrinking/Pregaming

Drinking before going out has become increasingly common on college campuses, where predrinking (also called pregaming, preloading, or front-loading) is announced and celebrated in text messages, e-mails, blogs, YouTube videos, and Facebook posts. In various studies, a greater proportion of white than Hispanic/Latino, African American, and Pacific Islander American students reported prepartying in the previous month. Within all ethnic groups, prepartyers consumed more drinks per week and experienced a higher number of alcohol-related consequences than non-prepartyers. Predrinkers consistently report much higher alcohol consumption during the evening and more negative consequences, such as getting into fights, being arrested, or being referred to a university's mandatory alcohol intervention program.

Drinking and Driving

Drunk driving, the most frequently committed crime in the United States, claims almost 10,000 lives a year. In the ACHA survey, 19.8 percent of students reported driving after having had any alcohol; 1.4 percent reported driving after five or more drinks. Traditional-age undergraduates typically are more likely to drink and drive as they get older, with the biggest jump between ages 21 and 23. Colleges have reported some success in using text messages and emails to reduce the risk of driving under the influence. Since states began setting the legal drinking age at 21, the NHTSA estimates that more than 26,000 lives have been saved. Safety groups, such as Mothers Against Drunk Driving (MADD) and Students Against Destructive Decisions (SADD), attribute the decline in alcohol-related deaths to enforcement tools such as sobriety checkpoints and to the states' adoption of a uniform drunken driving standard of a BAC of 0.08 percent. Since courts have held establishments that serve alcohol liable for the consequences of allowing drunk customers to drive, many bars and restaurants have joined the campaign against drunk driving.

E-Cigarettes and Vaping

E-cigarettes are battery-powered devices that deliver aerosolized nicotine and additives flavored with chocolate, mint, candy, and other sweetness. Designed to mimic the look and feel of smoking, they are marketed as a relatively benign alternative to cigarettes, without tar, carbon monoxide, and other harmful ingredients. "Vaping," the term for using e-cigarettes, comes from the cloud of vapor released by electronic cigarettes. More than 100 brands are available, and sales have soared into the billions of dollars. Vaping has gained popularity not just among smokers but also among adolescents and young adults, including many who have never smoked cigarettes but are attracted to the sweet-flavored e-cigarettes. About 1 in every 5 high school students and 1 in every 20 middle school students report using e-cigarettes in the previous 30 days. Health officials warn that vaping increases the likelihood of subsequent use of traditional cigarettes, marijuana, opioids, and other illicit drugs, as well as both short- and long-term health risks. Some fear that young nonsmokers who start using e-cigarettes are setting themselves up for a lifetime of nicotine dependence. According to the ACHA, more than 8 in 10 students have never tried electronic cigarettes (see Table 13.3). Nonetheless, vaping on campus has been linked with illicit drug use, mental health problems, and impulsivity in university students. Students who use Juul, a popular e-cigarette brand, are more likely to be male, non-Hispanic white, freshmen or sophomores, and current cigarette smokers. Their reasons for using include curiosity, a friend's recommendation, ease of use, and lack of a bad smell. Cigarette smokers report being attracted to e-cigarettes for several reasons, including lower cost, perceived lesser danger, freedom to use them in some places where cigarettes are banned, and enjoyment of the "smoking experience." However, puffing on e-cigarettes produces airway constriction and inflammation, might lead to serious lung diseases, including emphysema. The smoke in brands such as Juul may expose users to ultrafine particles that can be inhaled deep into the lungs, cancer-causing chemicals, and heavy metals such as nickel, tin, and lead. Other potential risks include headache, cough, dizziness, sore throat, nose bleeds, chest pain or other cardiovascular problems, and allergic reactions such as itchiness and swelling of the lips. Regular use may lead to nicotine addiction (see Consumer Alert). Health experts continue to debate the risks and benefits of e-cigarettes, as well as the need for greater regulation. Because the long-term effects of e-cigarettes on the cardiovascular system are not known, physicians do not consider them safe for use at any age. E-cigarettes pose the greatest risk to teenagers and young adults, whose brains are still developing, and to pregnant women.

Alcohol, Gender, and Race

Experts in alcohol treatment are increasingly recognizing racial and ethnic differences in risk factors for drinking problems, patterns of drinking, and most effective types of treatment.

"Secondhand" Drinking Problems Heavy alcohol use can endanger both drinkers and others. Secondhand problems caused by others' alcohol use include:

Loss of sleep. Interruption of studies. Assaults. Vandalism. Unwanted sexual advances. Students living on campuses with high rates of binge drinking are two or more times as likely to experience these secondhand effects as those living on campuses with low rates. In one study, nearly three-quarters of campus rapes happened when the victims were so intoxicated that they were unable to consent or refuse.

African American Community

Overall, African Americans consume less alcohol per person than whites, yet twice as many blacks die of cirrhosis of the liver each year. In some cities, the rate of cirrhosis is 10 times higher among African American men than among white men. Alcohol also contributes to high rates of hypertension, esophageal cancer, and homicide among African American men.

Understanding Alcohol

Pure alcohol is a colorless liquid obtained through the fermentation of a liquid containing sugar. Ethyl alcohol, or ethanol, is the type of alcohol in alcoholic beverages. Hospitals have reported cases of alcohol poisoning, some fatal, after consumption of hand sanitizers, such as Purell, which contain 60 percent ethyl alcohol. Some people drink it straight as a "Purell shot," and others use salt to separate the ethyl alcohol from the glycerin in the gel. Another type—methyl, or wood, alcohol—is a poison that should never be consumed. Any liquid containing 0.5 to 80 percent ethyl alcohol by volume is an alcoholic beverage; however, different drinks contain different amounts of alcohol. The types of alcohol consumed vary around the world. Beer accounts for most of the alcohol consumed in the United States. People in southern European countries such as France, Spain, Italy, and Portugal prefer wine.

12-Step Self-Help Programs

The best-known and most commonly used self-help program for alcohol problems is AA, which offers support from others struggling with the same illness, from a sponsor available at any time of the day or night, and from fellowship meetings that are held every day of the year. Because anonymity is a key part of AA, it has been difficult for researchers to study its success, but it is generally believed to be a highly effective means of overcoming alcoholism and maintaining abstinence. Its 12 steps, which emphasize honesty, sobriety, and acknowledgment of a "higher power," have become the model for self-help groups for other addictive behaviors, including drug abuse (discussed in Chapter 12) and compulsive eating.

High-Risk Drinking on Campus

The most common types of undergraduate high-risk drinking are binge drinking, bingeing combined with disordered eating, predrinking, underage drinking, and consumption of caffeinated alcoholic beverages. Obviously, many factors influence students' drinking behaviors.

According to the ACHA, 21 percent of students have never used alcohol. African American students are more likely than white undergraduates to abstain and to report never having had an alcoholic drink or not having a drink in the past 30 days. They also drink less frequently and consume fewer drinks per occasion than whites. Students who don't drink give various reasons for their choice, including:

Under age 21. Not having access to alcohol. Parental or peer pressure. Cost. Not liking the taste. Spiritual and religious values. Students who place high importance on religion consume less alcohol, even when in an environment where drinking is the norm.

Various studies have linked AmED use to risky behaviors on campus, including:

Unprotected sex and sex under the influence of drugs or alcohol. More high-risk drinking behaviors, such as consuming large amounts of alcohol. Increased danger of becoming alcohol dependent. Twice the likelihood of being hurt or injured as those who don't consume AmEDs.

The Perils of Predrinking

When students get together to drink before a game or a night out, they usually consume large quantities of alcohol quite rapidly. In part that's because they're drinking in places without restraints on how much they can drink. Various studies have shown that students drink more and have higher blood-alcohol concentrations on days when they predrink. They also are at greater risk of blackouts, passing out, hangovers, and alcohol poisoning. In addition to drinking more alcohol, predrinkers are more likely to use other drugs, such as marijuana and cocaine. The combined effects of these substances further increase the risks of injury, violence, or victimization.

Why People Smoke: Substance Abuse

Young adults who drink alcohol or abuse drugs are more likely to use a range of tobacco products, including cigarettes, cigars, e-cigarettes, and other forms of tobacco.

How Nicotine Works

A colorless, oily compound, nicotine is poisonous in concentrated amounts. If you inhale while smoking, 90 percent of the nicotine in the smoke is absorbed into your body. Even if you draw smoke only into your mouth and not into your lungs, you still absorb 25 to 30 percent of the nicotine. The FDA has concluded that nicotine is a dangerous, addictive drug that should be regulated. Yet in recent years tobacco companies have increased the levels of addictive nicotine by an average of 1.6 percent per year. Faster than an injection, smoking speeds nicotine to the brain in seconds (see Figure 13.5). Nicotine affects the brain in much the same way as cocaine, opiates, and amphetamines, triggering the release of dopamine, a neurotransmitter associated with pleasure and addiction, as well as other messenger chemicals. Because nicotine acts on some of the same brain regions stimulated by interactions with loved ones, smokers subconsciously come to regard cigarettes as a friend that they turn to when they're stressed, sad, or mad. Nicotine may enhance smokers' performance on some tasks but leaves other mental skills unchanged. Nicotine also acts as a sedative. How often you smoke and how you smoke determine nicotine's effect on you. If you're a regular smoker, nicotine will generally stimulate you at first and then tranquilize you. Shallow puffs tend to increase alertness because low doses of nicotine facilitate the release of the neurotransmitter acetylcholine, which makes the smoker feel alert. Deep drags, on the other hand, relax the smoker because high doses of nicotine block the flow of acetylcholine. Nicotine stimulates the adrenal glands to produce adrenaline, a hormone that increases blood pressure, speeds up the heart rate by 15 to 20 beats a minute, and constricts blood vessels (especially in the skin). Nicotine also inhibits the formation of urine, dampens hunger, irritates the membranes in the mouth and throat, and dulls the taste buds so foods don't taste as good as they would otherwise. Nicotine withdrawal usually begins within hours. Symptoms include craving, irritability, anxiety, restlessness, and increased appetite.

Tobacco Use in America Despite widespread awareness of the dangers of tobacco, about 14 percent of Americans smoke cigarettes. The more and the longer that individuals smoke, the greater their risks of heart disease, respiratory problems, several types of cancer, and a shortened lifespan. Consider these facts:

According to the CDC, 8.6 million Americans suffer from serious smoking-related illnesses. Smoking rates are highest among the poor, the mentally ill, drug and alcohol abusers, Native Americans, and lesbian, gay, bisexual, and transgender persons. The groups with the lowest smoking rates include women with undergraduate or graduate degrees, men with graduate degrees, Hispanic and Asian women, people over age 65, and residents of Utah. Individuals with undergraduate and graduate degrees are least likely to smoke. Asians and Hispanics have the lowest smoking rates. Smoking rates vary in different states. Utah has the fewest smokers (about 12 percent); Kentucky has the most (29 percent). In the United States, 57 percent of adults have never been smokers; 22 percent are former smokers. Approximately 20 percent of current smokers do not smoke daily. Among adults over age 18, about 13 percent—14 percent of men and 12 percent of women—smoke to the extent that they are dependent on nicotine. Tobacco dependence is more prevalent among young adults between the ages of 18 and 29 (17 percent) than among those ages 65 and older (4 percent).

Binge Drinking

According to the National Institute of Alcohol Abuse and Alcoholism, a binge is a pattern of drinking alcohol that brings blood-alcohol concentration (BAC) (discussed later in this chapter) to 0.08 gram-percent or above. For a typical adult man, this pattern corresponds to consuming five or more drinks in about 2 hours; for a woman, four or more drinks in the same amount of time. According to the Surgeon General's report on addiction in America, 66.7 million people in the United States engaged in binge drinking in the previous month. On average, binge drinkers consume eight drinks during a drinking episode, with men consuming more drinks than women and those between ages 18 and 34 drinking more than older binge drinkers. According to various reports, binge-drinking rates range from 1 percent to more than 70 percent at different campuses. The average is 40 percent.

Interaction with Other Drugs

Alcohol can interact with other drugs—prescription and nonprescription, legal and illegal. Of the 100 most frequently prescribed drugs, more than half contain at least one ingredient that interacts adversely with alcohol. Because alcohol and other psychoactive drugs may work on the same areas of the brain, their combination can produce an effect much greater than that expected of either drug by itself. For example, the liver combines alcohol and cocaine to produce cocaethylene, which intensifies the drug's effects and may increase the risk of sudden death. Alcohol is particularly dangerous when combined with other depressants and antianxiety medications

Digestive System

Alcohol first reaches the stomach, where it is partially broken down. The remaining alcohol is absorbed easily through the stomach tissue into the bloodstream. In the stomach, alcohol triggers the secretion of acids, which irritate the stomach lining. Excessive drinking at one sitting may result in nausea; chronic drinking may result in peptic ulcers (breaks in the stomach lining) and bleeding from the stomach lining. The alcohol in the bloodstream eventually reaches the liver. The liver, which bears the major responsibility of fat metabolism in the body, converts this excess alcohol to fat. After a few weeks of four or five drinks a day, liver cells start to accumulate fat. Alcohol also stimulates liver cells to attract white blood cells, which normally travel throughout the bloodstream, engulfing harmful substances and wastes. If white blood cells begin to invade body tissue, such as the liver, they can cause irreversible damage. More than 2 million Americans have alcohol-related liver diseases, such as alcoholic hepatitis and cirrhosis of the liver.

Cardiorespiratory System

Alcohol gets mixed reviews regarding its effects on the cardiorespiratory system. Several studies have shown that people who drink moderate amounts of alcohol have lower mortality rates after a heart attack as well as a lower risk of heart attack compared to abstainers and heavy drinkers. However, new research suggests that alcohol may not be as healthy for everyone's heart as previously believed. Light or moderate drinking does not improve cardiovascular health in men and may have only a slight beneficial effect, if any, on women. Heavy drinkers remain at greater risk even after reducing their alcohol intake (see Chapter 10). However, some cardiologists contend that the benefits of moderate drinking may be overstated, especially because of alcohol's contribution to the epidemic of obesity around the world. Heavier drinking triggers the release of harmful oxygen molecules called free radicals, which can increase the risks of heart disease, stroke, and cirrhosis of the liver. Alcohol use can weaken the heart muscle directly, causing a disorder called cardiomyopathy. The combined use of alcohol and other drugs, including tobacco and cocaine, greatly increases the likelihood of damage to the heart.

Heart Disease and Stroke

Although a great deal of publicity has been given to the link between cigarettes and lung cancer, heart attack is actually the leading cause of death for smokers. The federal Office of the Surgeon General blames cigarettes for 1 in every 10 deaths attributable to heart disease. Smoking is more dangerous than the two most notorious risk factors for heart disease: high blood pressure and high cholesterol. If smoking is combined with one of these, the chances of heart attack are four times greater. Women who smoke and use oral contraceptives have a 10 times greater risk of suffering heart attacks than women who do neither. In addition to contributing to heart attacks, cigarette smoking increases the risk of stroke two to three times in men and women, even after other risk factors are taken into account. Even people who have smoked for decades can reduce their risk of heart attack if they quit smoking. However, studies indicate some irreversible damage to blood vessels. Progression of atherosclerosis (hardening of the arteries) among former smokers continues at a faster pace than among those who never smoked.

Other Forms of Tobacco

Although cigarettes remain the most widely used form of tobacco, more college students are trying new or "alternative" tobacco products. Especially popular among young adults ages 18 to 24 are flavored non-cigarette tobacco products, including hookahs, cigars, and smokeless tobacco. Some use multiple products, including cigarettes, bidis, clove cigarettes, smokeless tobacco, and snus. "Polytobacco use" is more likely than any single form of tobacco to lead to nicotine addiction as well as additional health risks. Two percent of Americans smoke cigars; 2 percent use smokeless tobacco. Ingesting tobacco may be less deadly than smoking cigarettes, but it is dangerous. Smoking cigars, clove cigarettes, and pipes, and chewing or sucking on smokeless tobacco, all put the user at risk of cancer of the lip, tongue, mouth, and throat, as well as other diseases and ailments. Despite claims of lower risk, "safer" cigarettes still jeopardize smokers' health.

Health Effects on Students An estimated 6.4 million young people will eventually suffer premature death or diminished quality of life, or both, as a result of smoking-related diseases:

Although little research has focused specifically on college students, young people who smoke are less physically fit and suffer diminished lung function and growth. Young smokers frequently report symptoms such as wheezing, shortness of breath, coughing, and increased phlegm. They also are more susceptible to respiratory diseases. Young adults who smoke are three times more likely to have consulted a doctor or mental health professional because of an emotional or psychological problem and almost twice as likely to develop symptoms of depression. Frequent smoking has been linked to panic attacks and panic disorder in young people. Long-term health consequences of smoking in young adulthood include dental problems, lung disorders (including asthma, chronic bronchitis, and emphysema), heart disease, and cancer. Young women who smoke may develop menstrual problems, including irregular periods and painful cramps. If they use oral contraceptives, they are at increased risk of heart disease or stroke. Male smokers suffer a more rapid decline in brain function as they age so that early dementia-like symptoms may appear as early as age 45.

Many health experts consider the use and abuse of alcohol the primary health concern for college students. Here are some reasons:

Although the percentage of students who drink hasn't changed much over the years, drinking patterns have. At many schools, students' social lives revolve around parties, games, and bar crawls. More students drink simply to get drunk and drink a lot during each drinking episode. About one-third of students increase alcohol use and encounter more related problems throughout the college years, one-third do not change previous patterns, and one-third decrease drinking. More college women drink now than in the past, and they drink more than in the past. In the American College Health Association survey, 30 percent of female students reported drinking more than four drinks the last time they socialized or partied. College women who drink are at greatly increased risk of unwanted sexual activity. Alcohol can affect every aspect of a student's life. Nearly 160,000 freshmen drop out of college after their first year for alcohol- or drug-related reasons, according to the Core Institute, which surveys drinking practices on campuses. College drinking is responsible for an estimated 1,700 annual alcohol-related deaths, 599,000 injuries, more than 696,000 physical attacks, and more than 97,000 sexual assaults. Binge drinking (discussed later in this chapter) has been linked with lower grades, poorer performance on memory tests, and higher levels of both depression and anxiety. College men drink more, and more often, and more intensely than college women. They report consuming an average of almost six drinks the last time they partied or socialized; 29 percent drank six or more. Caucasians drink more than African Americans or Asian Americans. Fraternity and sorority members, athletes, and vigorous exercisers use more alcohol more often than other students. The students who drink the least are those attending two-year institutions, religious schools, commuter schools, and historically black colleges and universities.

Alcohol Mixed with Energy Drinks

AmED (alcohol mixed with energy drinks) refers to any combination of alcohol with caffeine and other stimulants. Energy drinks themselves can increase cardiovascular and metabolic risks for young adults. Alcohol adds to the dangers. Premixed beverages, often malt-based or distilled spirits-based, usually have a higher alcohol content (5 to 12 percent) than beer (4 to 5 percent). Some states classify them as liquor, thereby limiting the locations where they can be sold. Like the energy drinks discussed in Chapter 4, AmEDs have surged in popularity among teens and young adults. The Food and Drug Administration (FDA) has banned some premixed AmEDs, but young people continue to combine energy drinks like Red Bull with vodka or other forms of alcohol. AmED users are most likely to be younger men who score higher on measures of risk-taking propensity. In a recent study of college students, most had neutral or negative views of AmED. The most frequent users had positive expectations, such as being able to party longer. The caffeine in these drinks may mask the depressant effects of alcohol, but it has no effect on the liver's metabolism of alcohol and thus does not reduce blood-alcohol concentrations or reduce alcohol-related risks.

Alcohol Use Disorder

An estimated 8.5 percent of adults in the United States—12.4 percent of men and 4.9 percent of women—have an alcohol use disorder. The prevalence of this problem is greatest among individuals ages 18 to 29 (16.2 percent) but declines over the lifetime to 1.5 percent of those age 65 or older.

Certain people should not drink at all. These include:

Anyone younger than age 21. Underage drinking (discussed later in this chapter) poses many medical, behavioral, and legal dangers. Anyone who plans to drive, operate motorized equipment, or engage in other activities that require alertness and skill (including sports and recreational activities). Women who are pregnant or trying to become pregnant. Individuals taking certain over-the-counter (OTC) or prescription medications. People with medical conditions that can be made worse by drinking. Recovering alcoholics.

Tar and Carbon Monoxide

As it burns, tobacco produces tar, a thick, sticky dark fluid made up of several hundred different chemicals—many of them poisonous, some of them carcinogenic (enhancing the growth of cancerous cells). As you inhale tobacco smoke, tar and other particles settle in the forks of the branchlike bronchial tubes in your lungs, where precancerous changes are apt to occur. In addition, tar and smoke damage the mucus and the cilia in the bronchial tubes, which normally remove irritating foreign materials from the lungs. Smoke from cigarettes, cigars, and pipes also contains carbon monoxide, the deadly gas that comes out of the exhaust pipes of cars, in levels 400 times those considered safe in industry. Carbon monoxide interferes with the ability of the hemoglobin in the blood to carry oxygen, impairs normal functioning of the nervous system, and is at least partly responsible for the increased risk of heart attacks and strokes in smokers.

Consequences of Drinking Among the other problems linked to drinking are:

Atypical behavior. Under the influence of alcohol, students behave in ways they normally wouldn't. Some sext or post comments and photos they later regret on social media. Male heavy drinkers are more prone to behave in ways that are considered "antisocial," or contrary to the standards of our society, such as forcing or trying to force unwanted sexual contact, driving drunk, exposing themselves, or having sex with a stranger. Although some college students "mature out" of heavy drinking once they leave college, others do not and are at risk for poor adaptation to adulthood, including continued problem drinking and associated health outcomes. Academic problems. The more that students drink, the more likely they are to fall behind in schoolwork, miss classes, have lower GPAs, and face suspensions. In general, students with an A average have three to four drinks per week, whereas students with D or F averages drink almost ten drinks a week (see Figure 13.1). Risky sexual behavior. About one in five college students reports engaging in unplanned sexual activity, including having sex with someone he or she just met and having unprotected sex. Drinking, including social drinking, increases the likelihood of risky sex and unwanted sexual experiences. Sexual assault. In a recent survey, almost 20 percent of undergraduate women reported some type of completed sexual assault since entering college. Most occurred after women voluntarily consumed alcohol; a few occurred after they were unknowingly given a drug in their drinks. Intimate partner violence. Each year an estimated 80 percent of college men perpetrate psychological aggression; 20 to 30 percent, physical aggression; and 15 to 20 percent, sexual aggression against a dating partner. Heavy drinking increases the likelihood of all three forms, especially physical violence. Alcohol increases the likelihood that women will be either perpetrators or victims of partner aggression. Unintentional injury. More than 30 percent of college drinkers have been injured as a result of drinking. Increased alcohol use increases their likelihood of causing injury to others, having a car accident, and suffering burns or a fall serious enough to require medical attention. The costs of emergency treatment for alcohol-related injuries can be more than half a million dollars a year at schools with 40,000 or more students. Consequences beyond college. Alcohol-related convictions, including carrying a false I.D. or driving under the influence of alcohol, remain on an individual's criminal record and could affect a student's graduate school and professional opportunities. In a recent study, students who had planned to attend graduate school were less likely to enroll if they abused or became dependent on alcohol. Illness and death. Many students suffer short-term health consequences of drinking, such as headaches and hangovers. Heavy alcohol use in college students is associated with immunological problems and digestive and upper respiratory disorders. Even moderate drinking can contribute to infertility in women. Longer-term consequences of heavy drinking include liver disease, stroke, heart disease, and certain types of cancer. About 300,000 of today's college students will eventually die from alcohol-related causes, including drunk-driving accidents, cirrhosis of the liver, various cancers, and heart disease.

Who Binge-Drinks in College? An estimated four in ten college students drink at binge levels or greater. They consume 91 percent of all alcohol that undergraduates report drinking. Hundreds of studies have created a portrait of who binge drinkers are and how they differ from others: An estimated four in ten college students drink at binge levels or greater. They consume 91 percent of all alcohol that undergraduates report drinking. Hundreds of studies have created a portrait of who binge drinkers are and how they differ from others:

Binge drinkers are more likely to be male than female, although one in three women—up from one in four—reports binge drinking. Binge drinkers are more likely to be white than any other ethnic or racial group. (African American women are least likely to binge.) Most are under age 24. More binge drinkers are enrolled in four-year colleges than in two-year ones. Binge drinkers tend to be residents of states with fewer alcohol control policies. Binge drinkers tend to be involved in athletics and socialize frequently. They often belong to a fraternity or sorority. They are more likely to be dissatisfied with their bodies, not prone to exercise, eat poorly, and go on unhealthy diets. Binge drinkers tend to be behind in schoolwork or miss class. They are often users of other substances, including nicotine, marijuana, cocaine, and LSD. Binge drinkers are likely to black out, be injured or hurt, to engage in unplanned or unprotected sexual activity, or to get in trouble with campus police.

Recovery

Recovery from alcoholism is a lifelong process of personal growth and healing. The first two years are the most difficult, and relapses are extremely common. By some estimates, more than 90 percent of those recovering from substance use will use alcohol or drugs in any one 12-month period after treatment. However, approximately 70 percent of those who get formal treatment stop drinking for prolonged periods. Even without treatment, 30 percent of alcoholics are able to stop drinking for long periods. Those most likely to remain sober after treatment have the most to lose by continuing to drink: They tend to be employed, married, and upper-middle class. Recovering alcoholics who help other alcoholics stay sober are better able to maintain their own sobriety. Increasingly, treatment programs focus on relapse prevention, which includes the development of coping strategies and learning techniques that make it easier to live with alcohol cravings and rehearsal of various ways of saying "no" to offers of a drink. According to outcomes research, social skills training—a combination of stress management therapy, assertiveness and communication skills training, behavioral self-control training, and behavioral marital therapy—has proved effective in decreasing the duration and severity of relapses after one year in a group of alcoholics. A new approach to relapse behavior, Mindfulness-Based Relapse Prevention, teaches clients meditation techniques as a way of coping with cravings and high-risk relapse situations.

The words bottle and glass also can be deceiving:

Drinking a 16-ounce bottle of malt liquor, which is 6.4 percent alcohol, is not the same as drinking a 12-ounce glass of light beer (3.2 percent alcohol): The malt liquor contains 1 ounce of alcohol and is the equivalent of two drinks. Two bottles of high-alcohol wines (such as Cisco), packaged to resemble much less powerful wine coolers, can lead to alcohol poisoning, especially in those who weigh less than 150 pounds. With distilled spirits (such as bourbon, scotch, vodka, gin, and rum), alcohol content is expressed in terms of proof, a number that is twice the percentage of alcohol—for example, 100-proof bourbon is 50 percent alcohol, and 80-proof gin is 40 percent alcohol. Many mixed drinks are equivalent to one and a half or two standard drinks; for instance, see the margarita in Figure 13.2. Palcohol, the first powdered alcohol product to be marketed and sold in the United States, is sold in individual-serving size packets that, when added to 6 ounces of liquid, are equivalent to a standard drink. This study assessed awareness of powdered alcohol and likelihood to use and/or misuse powdered alcohol among college students. In a recent study of college students, 16.4 percent had heard of powdered alcohol, but after reading a brief description, 23 percent indicated that they would use the product if available. Of these, 62 percent also indicated likelihood of misusing the product—for example, by snorting it or mixing it with alcohol. Hazardous drinkers were six times more likely to say they might misuse the product.

Why People Smoke: Genetics

Researchers speculate that genes may account for about 50 percent of smoking behavior, with environment playing an equally important role. Studies have shown that identical twins, who have the same genes, are more likely than fraternal twins to have matching smoking profiles. If one identical twin is a heavy smoker, the other is also likely to be; if one smokes only occasionally, so does the other. According to NIDA research, genetic factors play a more significant role for initiation of smoking in women than in men, but they play a less significant role in smoking persistence for women.

Cancer Smoking is linked to at least 10 different cancers and accounts for 30 percent of all deaths from cancer:

Smoking is the cause of more than 80 percent of all cases of lung cancer. The more people smoke, the longer they smoke, and the earlier they start smoking, the more likely they are to develop lung cancer. At highest risk are those who have accumulated 30 "pack-years" of smoking—for example, by smoking 20 cigarettes a day for 30 years. Smoking causes about 130,000 lung cancer deaths each year. Smokers of two or more packs a day have lung cancer mortality rates 15 to 25 times greater than nonsmokers. If smokers stop smoking before cancer has started, their lung tissue tends to repair itself, even if there were already precancerous changes. However, their risk is never as low as that of individuals who never smoked. Cigarette smoking is associated with stomach and duodenal ulcers and with mouth, throat, and other types of cancer, including deadly bladder cancers. The risk of breast cancer increases among women who smoke, especially among those who start smoking early. In a recent study, the risks were highest among women who started smoking before their first menstrual cycle and those who started smoking after their first periods but before having their first child.

Social Smoking Some college students who smoke say they are "social smokers" who average less than one cigarette a day and smoke mainly in the company of others. On the positive side, social smokers smoke less often and less intensely than other smokers and are less dependent on tobacco. However, they are still jeopardizing their health. The more they smoke, the greater the health risks they face. Even smokers who don't inhale or nonsmokers who breathe in secondhand smoke are at increased risk for negative health effects. Here are some examples:

Smoking less than a pack of cigarettes a week has been shown to damage the lining of blood vessels and to increase the risk of heart disease as well as of cancer. In women taking birth control pills, even a few cigarettes a week can increase the likelihood of heart disease, blood clots, stroke, liver cancer, and gallbladder disease. Pregnant women who smoke only occasionally still run an increased risk of giving birth to unhealthy babies. Social smokers are less motivated than smokers with tobacco use disorder to quit and make fewer attempts to do so. Many end up smoking more cigarettes for many more years than they intended.

In its most recent Diagnostic and Statistical Manual (DSM-5), the American Psychiatric Association defines an alcohol use disorder as a problematic pattern of alcohol use leading to significant impairment or distress and characterized by at least two of the following:

Drinking larger amounts of alcohol or drinking for a longer time than intended. A strong urge or craving to use alcohol. Persistent desire or unsuccessful efforts to cut down or control alcohol use. Spending a great deal of time obtaining or using alcohol or recovering from its effects. Use of alcohol in physically hazardous situations. Continued alcohol use despite social, interpersonal, or occupational problems caused by drinking. Tolerance, as defined by a need for markedly increased amounts of alcohol to achieve the desired effect or a markedly diminished effect with continued use of the same amount of alcohol. Withdrawal, including symptoms such as sweating, rapid pulse, increased hand tremors, insomnia, nausea or vomiting, temporary hallucinations or illusions, physical agitation or restlessness, anxiety, or seizures. Alcoholism, as defined by the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine, is a primary, chronic disease whose development and manifestations are influenced by genetic, psychosocial, and environmental factors. The disease is often progressive and fatal. Its characteristics include an inability to control drinking; a preoccupation with alcohol; continued use of alcohol despite adverse consequences; and distorted thinking, most notably denial. Like other diseases, alcoholism is not a matter of insufficient willpower but a complex problem that can have serious consequences yet can improve with treatment.

Compared with men who smoke the same amount, women are at greater risk for developing smoking-related illnesses. Here are some examples:

Lung cancer now claims more women's lives than breast cancer. As discussed later in this chapter, both active and passive smoking increase a woman's risk of breast cancer. Teenage girls who smoke may be at increased risk of osteoporosis because girls who smoke build up less bone during this critical growth period in their lives. Women who smoke are less fertile and experience menopause 1 or 2 years earlier than women who don't smoke. Smoking also greatly increases the possible risks associated with taking oral contraceptives. Women who smoke during pregnancy increase their risk of miscarriage and pregnancy complications, including bleeding, premature delivery, and birth defects such as cleft lip or palate. Smoking narrows the blood vessels and reduces blood flow to the fetus, resulting in lower birth weight, shorter length, smaller head circumference, and possibly lower IQ. Smoking may double or even triple the risk of stillbirth. Youngsters whose mothers smoked during pregnancy tend to have problems with hyperactivity, inattention, and impulsivity. Some of these behavior problems persist through the teenage years and even into adulthood. At ages 16 to 18, children exposed to prenatal smoking have higher rates of conduct disorder, substance use, and depression than others. According to the U.S. Surgeon General, women account for 39 percent of smoking-related deaths each year, a proportion that has doubled since 1965. Each year, American women lose an estimated 2.1 million years of life due to premature deaths attributable to smoking. If she smokes, a woman's annual risk of dying more than doubles after age 45 compared with a woman who has never smoked. Compared with men, women seem to have a higher behavioral dependence on cigarettes. For them, wearing a nicotine patch or chewing nicotine gum does not substitute for the "hand-to-mouth" behaviors associated with smoking, such as lighting a cigarette, inhaling, and handling the cigarette. Women are more likely to quit successfully when they use a combination of nicotine replacement and a device like a nicotine inhaler to substitute for smoking behaviors. LGBTQIA young adults have higher smoking rates, with the heaviest smoking among transgender individuals.

Underage Drinking on Campus

Each year, approximately 5,000 young people under age 21 die as a result of underage drinking. This figure includes about 1,900 deaths from motor vehicle crashes, 1,600 homicides, and 300 suicides, as well as hundreds due to other injuries, such as falls, burns, and drownings. Students under age 21 drink less often than older students but tend to drink more heavily and to experience more negative alcohol-related consequences. More underage students report drinking "to get drunk" and drinking at binge levels when they consumed alcohol. Underage college students are most likely to drink if they can easily obtain cheap alcohol, especially beer. They tend to drink in private settings, such as dorms and fraternity parties, and to experience negative drinking-related consequences, such as doing something they regretted, forgetting where they were or what they did, causing property damage, getting into trouble with police, and being hurt or injured. The drinking behavior of underage students also depends on their living arrangements. Those in controlled settings, such as their parents' home or a substance-free dorm, are less likely to binge-drink. Students living in fraternities or sororities are most likely to binge-drink, regardless of age. A number of university chancellors and presidents have signed a public statement calling for informed, dispassionate discussion of the Amethyst Initiative, a proposal that supports a series of educational and policy-level efforts to enable 18- to 20-year-old adults to purchase, possess, and consume alcoholic beverages at their own discretion. Opponents note that the minimum legal drinking age of 21 has reduced alcohol-related deaths, injuries, and traffic crashes. Various factors may inhibit the ability of underage students to drink responsibly, including less self-efficacy.

Why Is Predrinking Popular? College students predrink for a variety of reasons, including:

Economy. Many say they want to avoid paying for expensive drinks at a bar, although most end up drinking at least as much when they're out as they do when they don't predrink. Intoxication. A growing number of students seem to want to get drunk as quickly as possible. Socializing. Predrinking gives students a chance to chat with their friends, which often isn't possible in noisy, crowded clubs or bars. Anxiety reduction. By drinking alone before meeting strangers, students say they feel less shy or self-conscious—but their risk of alcohol-related problems increases. Group bonding. For some young men, drinking together may serve as a way of bonding and building confidence prior to interacting with the opposite sex.

Tobacco Use on Campus About one in every four to five students currently smokes, but a majority—77 percent—have never smoked (see Snapshot on Campus Now: Student Smoking). Here is what we know about student smokers:

Eight in 10 college smokers started smoking before age 18. They report smoking on twice as many days and smoke nearly four times as many cigarettes as those who began smoking at an older age. White students have the highest smoking rates, followed by Hispanic, Asian, and African American students. Although black students are least likely to smoke, more are doing so than in the past. Smoking rates remain consistently lower at predominantly black colleges and universities, however. About equal percentages of college men and women smoke, although women are somewhat more likely than men to report smoking daily. Many college students say they smoke as a way of managing depression or stress. Studies consistently link depression with the use of tobacco products, including electronic cigarettes. Smokers are significantly more likely to have higher levels of perceived stress than nonsmokers. The more depressed students are (particularly women), the more likely they are to use nicotine as a form of self-medication. Male students who smoke are more likely to say that smoking makes them feel more masculine and less anxious. More than half of female smokers feel that smoking helps them control their weight, although only 3 percent say it is their primary reason for smoking. Overweight female students are more likely to smoke to lose weight and to see weight gain as a barrier to quitting. Students can and do change their smoking behavior. As psychologists have noted, often those who quit smoking between ages 18 and 26 become less impulsive and negative over time, so they may "mature out" of this unhealthy behavior.

Native American Community

European settlers introduced alcohol to Native Americans. Because of the societal and physical problems resulting from excessive drinking, at the request of tribal leaders, the U.S. Congress in 1832 prohibited the use of alcohol by Native Americans. Many reservations still ban alcohol use, so Native Americans who want to drink may have to travel long distances to obtain alcohol, which may contribute to the high death rates from hypothermia and pedestrian and motor vehicle accidents among Native Americans. (Injuries are the leading cause of death among this group.) Certainly, not all Native Americans drink, and not all who drink do so to excess. However, they have three times the general population's rate of alcohol-related injury and illness. Cirrhosis of the liver is the fourth leading cause of death among this cultural group. While many Native American women don't drink, those who do have high rates of alcohol-related problems, which affect both them and their children. Their rate of cirrhosis of the liver is 36 times that of white women. In some tribes, 10.5 of every 1,000 new borns have fetal alcohol syndrome, compared with an average 2 of 1,000 in the general population.

Causes Although the exact cause of alcohol use disorders is not known, certain factors—including biochemical imbalances in the brain, heredity, cultural acceptability, and stress—all seem to play a role. They include the following:

Genetics. Scientists have not yet identified conclusively a specific gene that puts people at risk for alcoholism. However, epidemiological studies have shown evidence of heredity's role. Studies of twins suggest that heredity accounts for two-thirds of the risk of becoming alcoholic in both men and women. Parental alcoholism. According to researchers, alcoholism is four to five times more common among the children of alcoholics, who may be influenced by the behavior they see in their parents. Drug abuse. Alcoholism is associated with the abuse of other psychoactive drugs, including marijuana, cocaine, heroin, amphetamines, and various antianxiety medications. Stress and traumatic experiences. Many people start drinking heavily as a way of coping with psychological problems.

Gender

Historically, men have been far more likely to drink alcohol and to drink in ways that affect their health, but this gender gap is closing. Women across the globe are now nearly as likely to drink and to engage in excessive, harmful drinking. Researchers have not identified any single reason why more women are drinking although they speculate that drinking has become more socially acceptable as women have gained more education, greater job opportunities, and financial independence

Alcohol Intoxication

If you drink too much, the immediate consequence is that you get drunk—or, more precisely, intoxicated. Alcohol intoxication, which can range from mild inebriation to loss of consciousness, is characterized by at least one of the following signs: slurred speech, poor coordination, unsteady gait, abnormal eye movements, impaired attention or memory, stupor, or coma. Medical risks of intoxication include falls, hypothermia in cold climates, and increased risk of infections because of suppressed immune function. Time and a protective environment are the recommended treatments for alcohol intoxication.

Moderate amounts of alcohol can have disturbing effects on perception and judgment, including the following:

Impaired perceptions. You're less able to adjust your eyes to bright lights or to distinguish between sounds or judge their direction well. Dulled smell and taste. Alcohol may cause some vitamin deficiencies, and the poor eating habits of heavy drinkers result in further nutrition problems. Diminished sensation. On a freezing winter night, you may walk outside without a coat and not feel the cold. Altered sense of space. You may not realize, for instance, that you have been in one place for several hours. Impaired motor skills. Writing, typing, driving, and other abilities involving your muscles are impaired. This is why law enforcement officers sometimes ask suspected drunk drivers to touch their nose with a finger or to walk a straight line. Sleep problems. Even a single drink can increase snoring in normal sleepers and worsen sleep apnea in those with this disorder. Among young adults, binge drinking increases the frequency and severity of sleep problems. Impaired sexual performance. While drinking may increase your interest in sex, it may also impair sexual response, especially a man's ability to achieve or maintain an erection. As Shakespeare wrote, "It provokes the desire, but it takes away the performance."

Alcohol-Related Problems on Campus

In a recent study, about 9 in 10 undergraduates reported "secondhand exposure" to alcohol abuse in the previous month, including interpersonal harm as well as greater anxiety, stress, and depression. Women were at greater risk of mental health consequences. Men were more likely than women to injure themselves, have unprotected sex, get involved in a fight, or physically injure another person. Women were more likely to have someone use force or threat of force to have sex with them (see Table 13.1). Students who drink heavily also are much more likely to abuse prescription drugs

Alcohol Poisoning

In large enough doses, alcohol can and does kill. Alcohol depresses nerves that control involuntary actions, such as breathing and the gag reflex (which prevents choking). A fatal dose of alcohol will eventually suppress these functions. Because alcohol irritates the stomach, people who drink an excessive amount often vomit. If intoxication has led to a loss of consciousness, a drinker is in danger of choking on vomit, which can cause death by asphyxiation. Blood-alcohol concentration can rise even after a drinker has passed out because alcohol in the stomach and intestine continues to enter the bloodstream and circulate throughout the body.

Why People Smoke: Stress

In studies that have analyzed the impact of life stressors, depression, emotional support, marital status, and income, researchers have concluded that an individual with a high stress level is approximately 15 times more likely than a person with low stress to be a smoker.

Tobacco

In the past, teenagers were most likely to take their first puff of tobacco from a cigarette. Now electronic cigarettes, or e-cigarettes, have become a common entry into tobacco use. Among college students, 9 percent smoked cigarettes within the last 30 days, while about 4 percent used e-cigarettes. About 3 percent of U.S. adults are current e-cigarette users. There is no risk-free method of using tobacco. Any exposure to tobacco smoke can cause both immediate and long-term damage to the body. Tobacco continues to kill more people than AIDS, alcohol, drug abuse, car crashes, murders, suicides, and fires combined. According to the Centers for Disease Control (CDC), more than 480,000 Americans die each year from smoking or exposure to secondhand smoke, while 16 million suffer from smoking-related illnesses. if you smoke and are under age 35, you can add 10 years to your lifespan by quitting

Smoking, Sex, and Race Almost 1 billion men in the world smoke—about 35 percent of men in developed countries and 50 percent of men in developing countries. Male smoking rates are slowly declining, but tobacco still kills about 5 million men every year. Men also face specific risks because smoking:

Increases the risk of aggressive prostate cancer. May affect male hormones, including testosterone. Can reduce blood flow to the penis, impairing a man's sexual performance and increasing the likelihood of erectile dysfunction. Is a risk factor for developing rheumatoid arthritis for men, but not for women. About 250 million women in the world are daily smokers. Cigarette smoking among women is declining in the United States, but in several southern, central, and eastern European countries, cigarette smoking rates among women are either stable or increasing. On average, girls who begin smoking during adolescence continue smoking for 20 years, which is 4 years longer than boys. Cigarette smoking is a major cause of disease and death in racial and ethnic minority groups. Among adults, Native Americans and Alaska Natives have the highest rates of tobacco use. African American and Southeast Asian men also have a high smoking rate. Asian American and Hispanic women have the lowest rates of smoking. Tobacco use is significantly higher among white college students than among Hispanic, African American, and Asian American students. Tobacco is the substance most abused by Hispanic youth, whose smoking rates have soared in the past 10 years. In general, smoking rates among Hispanic adults increase as they adopt the values, beliefs, and norms of American culture. Recent declines in the prevalence of smoking have been greater among Hispanic men with at least a high school education than among those with less education.

Alcoholism Treatments

Individuals whose drinking could be hazardous to their health may choose from a variety of approaches, including medication, behavioral therapy, or both. There is no one path to sobriety. A wide variety of treatments may offer help and hope to those with alcohol-related problems. Men and women who have remained sober for more than a decade credit a variety of approaches, including Alcoholics Anonymous (AA), individual psychotherapy, and other groups, such as Women for Sobriety.

Medical Complications As previously discussed, excessive alcohol use adversely affects virtually every organ system in the body, including the brain, the digestive tract, the heart, muscles, blood, and hormones (see Figure 13.4). In addition, because alcohol interacts with many drugs, it can increase the risk of potentially lethal overdoses and harmful interactions. A summary of the major risks and complications follows:

Liver disease. Chronic heavy drinking can lead to alcoholic hepatitis (inflammation and destruction of liver cells) and, in the 15 percent of people who continue drinking beyond this stage, cirrhosis (irreversible scarring and destruction of liver cells). The liver eventually may fail completely, resulting in coma and death. Cardiorespiratory disease. Heavy drinking can weaken the heart muscle (causing cardiac myopathy), elevate blood pressure, and increase the risk of stroke. Cancer. Heavy alcohol use may contribute to cancer of the liver, stomach, and colon, as well as malignant melanoma, a deadly form of skin cancer. Brain damage. Long-term heavy drinkers may suffer memory loss and be unable to think abstractly, recall names of common objects, and follow simple instructions. Chronic brain damage resulting from alcohol consumption is second only to Alzheimer's disease as a cause of cognitive deterioration in adults. Vitamin deficiencies. Alcoholism is associated with vitamin deficiencies, especially of thiamin . Lack of thiamin may result in Wernicke-Korsakoff syndrome, which is characterized by disorientation, memory failure, hallucinations, and jerky eye movements, and it can be disabling enough to require lifelong custodial care. Digestive problems. Alcohol triggers the secretion of acids in the stomach that irritate the mucous lining and cause gastritis. Chronic drinking may result in peptic ulcers (breaks in the stomach lining), bleeding from the stomach lining, and chronic pancreatitis.

The factors that most influence students to binge-drink are:

Low price for alcohol. Beer, which is cheap and easy to obtain, is the beverage of choice among binge drinkers. Easy access to alcohol. In one study, the density of alcohol outlets (such as bars) near campus affected the drinking of students. Proximity to other binge drinkers. Students who attend a school or live in a residence with many binge drinkers tend to become binge drinkers themselves. Peer pressure. Those who believe that close friends are likely to binge end up bingeing themselves. Family attitudes. Students whose parents drank or did not disapprove of their children drinking are more likely to binge. Early access to alcohol. Places with lower drinking ages are associated with more frequent binge episodes. Campus environment. Students tend to binge-drink at the beginning of the school year and then cut back as the semester progresses and academic demands increase. Binge drinking also peaks following exam times, during home football weekends, and during spring break. Drinking games. Two-thirds of college students engage in drinking games—such as beer pong or "Beirut"—that involve binge drinking. Although these games vary in many ways, all share a common theme: becoming intoxicated in a short period of time. Men are more likely to participate than women and to consume larger amounts of alcohol, often six drinks or more. Drinking game players who don't monitor or regulate how much they're drinking are at risk of extreme intoxication. Drinking games have been implicated in alcohol-related injuries and deaths from alcohol poisoning.

Moderate Alcohol Use

Many people describe themselves as "light" or "moderate" drinkers. However, these are not scientific terms. It is more precise to think in terms of the amount of alcohol that seems safe for most people. The federal government's Dietary Guidelines for Americans recommend no more than one drink a day for women and no more than two drinks a day for men. The American Heart Association (AHA) advises that alcohol account for no more than 15 percent of the total calories consumed by an individual every day, up to an absolute maximum of 1.75 ounces of alcohol a day—the equivalent of three beers, two mixed drinks, or three and a half glasses of wine. Moderate alcohol use has been linked with some positive health benefits, including lower risks of heart disease. In addition, middle-aged women who report light to moderate drinking are less likely to put on excessive weight over time. However, even occasional binges of four to five drinks a day can undo alcohol's positive effects. The benefits of alcohol also are related to age. Below age 40 drinking at all levels is associated with an increased risk of death. Among people older than 50 or 60, moderate drinkers have the lowest risk of death. Using a mathematical model, researchers have determined that alcohol-related problems occur at every drinking level, including just two drinks, but increase fivefold at three drinks and more gradually thereafter. Individuals who drink heavily have a higher mortality rate than those who have two or fewer drinks a day. However, the boundary between moderate and heavy drinking isn't the same for everyone. For some people, the upper limit of safety is zero: Once they start, they can't stop.

The signs of alcohol poisoning include:

Mental confusion, stupor, coma, or the inability to be roused. Vomiting. Seizures. Slow breathing (fewer than eight breaths per minute). Irregular breathing (10 seconds or more between breaths). Hypothermia (low body temperature), bluish skin color, paleness. Alcohol poisoning is a medical emergency requiring immediate treatment. Black coffee, a cold shower, and letting a person "sleep it off" do not help. Without medical treatment, breathing slows, becomes irregular, or stops. The heart beats irregularly. Body temperature falls, which can cause cardiac arrest. Blood sugar plummets, which can lead to seizures. Vomiting creates severe dehydration, which can cause seizures, permanent brain damage, or death. Even if the victim lives, an alcohol overdose can result in irreversible brain damage.

Why People Smoke

Most people are aware that an enormous health risk is associated with smoking, but many don't know exactly what that risk is or how it might affect them. One of the key factors linked with the onset of a smoking habit is being young. Children who start smoking early in life are at greater risk of both nicotine and alcohol dependence later in life, as well as school failure, crime, injury, and premature death. According to a recent poll, nearly 90 percent of adults who smoke report that, if they could do it over again, they would not have started. In order to help adolescents avoid that regret as well as smoking's many dangers, some legislators have proposed raising the minimum legal age for purchasing tobacco products to 21.

Why People Smoke: Addiction

Nicotine addiction is as strong as or stronger than addiction to drugs such as cocaine and heroin. The first symptoms of nicotine addiction can begin within a few days of starting to smoke and after just a few cigarettes, particularly in teenagers.

Do you know what a "drink" is? Most students—particularly freshmen, sophomores, and women—don't. In one experiment undergraduates defined a "drink" as one serving, regardless of how big it was or how much alcohol it contained. In fact, one standard drink can be any of the following:

One bottle or can (12 ounces) of beer, which is 5 percent alcohol. One glass (4 or 5 ounces) of table wine, such as burgundy, which is 12 percent alcohol. One small glass (2.5 ounces) of fortified wine, which is 20 percent alcohol. One shot (1 ounce) of distilled spirits (such as whiskey, vodka, or rum), which is 50 percent alcohol. All of these drinks contain close to the same amount of alcohol—that is, if the number of ounces in each drink is multiplied by the percentage of alcohol, each drink contains the equivalent of approximately 0.5 ounce of 100 percent ethyl alcohol. Drinks at college parties vary greatly in their alcoholic content. It may be impossible for students to monitor their alcohol intake simply by counting the number of drinks they consume. In one study, when asked to pour a liquid into cups of various sizes to reflect what they perceived to be one beer, one shot, or the amount of liquor in one mixed drink, undergraduates overpoured beer by 25 percent, shots by 26 percent, and mixed drinks by 80 percent.

Why Students Stop Drinking

Only 1 percent of students ages 18 to 24 receive treatment for alcohol or drug abuse. Nonetheless, as many as 22 percent of alcohol-abusing college students "spontaneously" reduce their drinking as they progress through college. Unlike older adults, who often hit bottom before they change their drinking behaviors, many college students go through a gradual process of reduced drinking. Researchers refer to this behavioral change as early cessation, natural reduction, natural recovery, or spontaneous recovery. As with other behavioral changes, individuals must be ready to change their drinking patterns. In one study, students who binged frequently, who experienced more alcohol-related interpersonal and academic problems, who did not also use marijuana, and who lived in a residence hall where binge drinking was the norm showed a greater readiness to change. Psychologists have found that students "mature out" of heavy drinking as they become less impulsive and develop healthier coping behaviors. Several interventions have proven effective in reducing alcohol consumption and alcohol-related problems on college campuses. They include getting personalized feedback about drinking habits, learning moderation strategies, challenging expectations, identifying risky situations, and setting goals for responsible drinking.

Cancer

Overall past and current drinking may contribute to about 10 percent of all cancer cases in men and 3 percent in women. Alcohol consumption has been specifically implicated as a cause of cancers of the oral cavity, pharynx, larynx, esophagus, liver, colon-rectum, pancreas, and female breast. According to a recent analysis, alcohol use accounts for approximately 3.5 percent of cancer deaths, or about 1 in 30, each year in the United States. Each alcohol-attributable cancer death results in about 18 years of potential life lost. Although cancer deaths are more common among persons who consume an average of three drinks or more per day, approximately 30 percent of deaths occur among people who drink less than three drinks per day. About 15 percent of breast cancer deaths among women in the United States may be attributable to alcohol consumption. Alcohol may make women more vulnerable to cancer by increasing estrogen levels. Health officials recommend that women should not exceed one drink a day, and those at an elevated risk for breast cancer, perhaps because of family history, should avoid alcohol or consume alcohol only occasionally.

Why People Smoke: Limited Education

People who have graduated from college are much less likely than high school graduates who have not also graduated from college to smoke; those with fewer than 12 years of education are more likely to smoke. An individual with 8 years or less of education is 11 times more likely to smoke than someone with postgraduate training.

The most common reason people drink alcohol is to relax and relieve stress. Because it depresses the central nervous system, alcohol can make people feel less tense. Here are some other reasons men and women drink:

Social ease. When people use alcohol, they may seem bolder, wittier, or sexier. At the same time, they become more relaxed and seem to enjoy each other's company more. Because alcohol lowers inhibitions, some people see it as a prelude to seduction. Happiness. In a study that used smartphones to check on drinkers' moods, individuals reported feeling happier at the moment of drinking, but this sense of euphoria didn't persist for long. Role models. Athletes, musicians, and other famous people who write, sing, or talk about drinking can make alcohol abuse seem normal or acceptable. Advertising. Brewers and beer distributors spend millions of dollars every year promoting the message: If you want to have fun, have a drink. Young people may be especially responsive to such sales pitches. Relationship issues. Single, separated, or divorced men and women drink more and more often than married ones. Early exposure to alcohol. A first drink—even a first sip—of alcohol in the middle-school years has been linked to later alcohol misuse. Childhood traumas. Female alcoholics often report that they were physically or sexually abused as children or suffered great distress because of poverty or a parent's death. Individuals being treated for alcoholism are likely to have experienced sexual, physical, or emotional abuse as well as physical or emotional neglect. Unemployment. Individuals who lose their jobs are at increased risk of alcohol use and misuse, including more daily consumption and more binge drinking.

College Tobacco-Control Policies

The American College Health Association (ACHA) has recommended that all forms of tobacco be banned on college campuses, both indoors and outdoors. Many schools have 100 percent smoke- or tobacco-free policies; others prohibit smoking everywhere but in designated areas. Universities that have banned smoking from designated residence halls report decreased damage to the buildings, increased retention of students, and improved enforcement of marijuana policies. Although a majority of students and faculty support restrictions on tobacco use, current and former smokers as well as users of non-cigarette combustible products, such as e-cigarettes, are most likely to oppose such bans. Enforcement of campus tobacco bans varies, and student smokers often ignore or disregard their schools' policies. Schools are experimenting with various ways to increase compliance, including passing out informational cards and training undergraduates as "ambassadors" to be advocates for no-tobacco policies.

Blood-Alcohol Concentration

The amount of alcohol in your blood at any given time is your blood-alcohol concentration (BAC). It is expressed in terms of the percentage of alcohol in the blood and is often measured from breath or urine samples. Law enforcement officers use BAC to determine whether a driver is legally drunk. All the states have followed the recommendation of the federal Department of Transportation to set 0.08 percent—the BAC that a 150-pound man would have after consuming about three mixed drinks within an hour—as the threshold at which a person can be cited for drunk driving (see Figure 13.3). Using a formula for blood-alcohol concentration developed by highway transportation officials, researchers calculate that when college students drink, their typical BAC is 0.079, dangerously close to the legal limit. A BAC of 0.05 percent indicates approximately 5 parts alcohol to 10,000 parts other blood components. Most people reach this level after consuming one or two drinks and experience all the positive sensations of drinking—relaxation, euphoria, and well-being—without feeling intoxicated. If they continue to drink past the 0.05 percent BAC level, they start feeling worse rather than better, gradually losing control of speech, balance, and emotions. At a BAC of 0.2 percent, they may pass out. At a BAC of 0.3 percent, they could lapse into a coma; at 0.4 percent, they could die.

Binge Drinking and Disordered Eating

The combination of two risky behaviors—disordered eating and heavy drinking—poses special dangers to students. As discussed in Chapter 5, disordered eating can range from excessive concern about weight to binge eating to extreme weight-control methods, such as purging. In some studies, as many as 60 percent of college women reported binge eating and purging, while 9 percent of college men reported some form of disordered eating. In women, the combination of these behaviors increases the risk of many negative consequences, including blackouts, unintended sexual activity, and forced sexual intercourse. Some students restrict calories from food prior to planned drinking—some to avoid weight gain and others to enhance the effects of alcohol. The popular media have created the term "drunkorexia" to describe this risky behavior, but it is not an official psychiatric term.

Increased Risk of Dying Alcohol kills. Drinking, which claims 100,000 lives each year, is the third leading cause of death after tobacco and improper diet and lack of exercise, and involves the following:

The leading alcohol-related cause of death is injury. Alcohol plays a role in almost half of all traffic fatalities, half of all homicides, and a quarter of all suicides. The second leading cause of alcohol-related deaths is cirrhosis of the liver, a chronic disease that causes extensive scarring and irreversible damage. As many as half of patients admitted to hospitals and 15 percent of those making office visits seek or need medical care because of direct or indirect effects of alcohol. Young drinkers—teens and those in their early 20s—are at highest risk of dying from injuries, mostly car accidents. Drinkers over age 50 face the greatest danger of premature death from cirrhosis of the liver, hepatitis, and other alcohol-linked illnesses. Most studies of the relationship between alcohol consumption and death from all causes show that moderate drinkers—those who consume approximately seven drinks per week—have a lower risk of death than abstainers, while heavy drinkers have a higher risk than either group. In one 10-year study, never-drinkers showed no elevated risk of dying, while consistent heavier drinkers were at higher risk than other men of dying of any cause.

Alcohol impairs driving-related skills regardless of the age of the driver or the time of day it is consumed. However, younger students who drink and drive are at greatest risk:

Underage drinkers are more likely to drive after drinking, to ride with intoxicated drivers, and to be injured after drinking—at least in part because they believe that people can drive safely and legally after drinking. More young women than ever before are driving drunk and getting into fatal car accidents. More young women than men involved in deadly crashes had high blood-alcohol levels, according to a recent analysis of data from the National Highway Traffic Safety Administration (NHTSA). According to national surveys, men have higher rates of alcohol-impaired driving than women. The highest rates are among those ages 18 to 29 and 35 to 44 and those with higher education and income. Of the 5,000 alcohol-related deaths among 18- to 24-year-olds, 80 percent were caused by alcohol-related traffic accidents. A young person dies in an alcohol-related traffic crash an average of once every 3 hours.

The Impact of Alcohol on the Body

Unlike food or drugs in tablet form, alcohol is directly and quickly absorbed into the bloodstream through the stomach walls and upper intestine. The alcohol in a typical drink reaches the bloodstream in 15 minutes and rises to its peak concentration in about an hour. The bloodstream carries the alcohol to the liver, heart, and brain Alcohol has a major effect on the brain, damaging brain cells, impairing judgment and perceptions, and often leading to accidents and altercations. Alcohol also damages the digestive system, especially the liver. Most of the alcohol you drink can leave your body only after metabolism by the liver, which converts about 95 percent of the alcohol to carbon dioxide and water. The other 5 percent is excreted unchanged, mainly through urination, respiration, and perspiration. Alcohol is a diuretic, a drug that speeds up the elimination of fluid from the body, so it's a good idea to drink water when you drink alcohol to maintain your fluid balance. Also, alcohol lowers body temperature, so you should never drink in an attempt to get or stay warm.

Tobacco Use Disorder In its DSM-5, the American Psychiatric Association defines a tobacco use disorder as "a problematic pattern of tobacco use leading to clinically significant impairment or distress," characterized by at least two of the following signs and symptoms within a 12-month period:

Use of tobacco in larger amounts or over a longer period than was intended. Persistent desire or unsuccessful efforts to cut down or control tobacco use. A great deal of time spent in activities necessary to obtain or use tobacco. Craving, or a strong desire or urge to use tobacco. Interference with obligations at work, school, or home because of continued tobacco use. Persistent or recurrent social or interpersonal problems, such as arguments about smoking, caused or exacerbated by tobacco. Giving up or cutting back on important social, occupational, or recreational activities. Recurrent tobacco use in physically hazardous situations, such as smoking in bed. Continued tobacco use despite a persistent or recurrent physical or psychological problem caused or exacerbated by tobacco. Tolerance, as indicated by a need for markedly increased amounts of tobacco to achieve the desired effect or a markedly diminished effect with continued use of the same amount of tobacco. Withdrawal, as indicated by symptoms such as irritability, frustration, anger, anxiety, difficulty concentrating, increased appetite, restlessness, depressed mood, and insomnia, or use of tobacco or closely related substances to avoid such symptoms.

Why Students Binge-Drink

Young people who came from, socialized within, or were exposed to "wet" environments—settings in which alcohol is cheap and accessible and drinking is prevalent—are most likely to engage in binge drinking. Students who report drinking at least once a month during their final year of high school are more likely to binge-drink in college than those who drank less frequently in high school.

Why People Smoke: Underestimation of Risks

Young people who think the health risks of smoking are fairly low are more likely than their peers to start smoking. In a 2-year study, teenagers who thought they had little chance of developing either short-term problems—such as a higher risk of colds or a chronic cough—or long-term problems—such as heart disease, cancer, and respiratory diseases—were three to four times more likely to start smoking.

Why do students stop heavy drinking? Here are some common responses:

"It was just getting old." Vomiting. Urinating in hallways. Being physically fondled. Sexual assault. Violence. Accidents. Injuries. Unprotected intercourse. Emergency room visits. Vicarious experiences, such as a roommate's arrest for driving under the influence or a sorority sister's date rape.

Why Students Drink

Alcohol has been part of campus life for a very long time. Away from home, often for the first time, many students are excited by and apprehensive about their newfound independence. Social motives are the most common reason for drinking—and for problem drinking—on campus. When students feel overwhelmed, awkward, or insecure or when they just want to let loose and have a good time, they reach for a drink. Being less engaged in their studies and more willing to risk negative academic consequences for the sake of partying increase the likelihood of excessive drinking.

Health Effects of Cigarette Smoking

As many as 98 percent of tobacco-related deaths, including many due to secondhand smoke, are attributable to "combustible," or smokable, products. Figure 13.6 shows a summary of the physiological effects of tobacco and the other chemicals in tobacco smoke. If you're a smoker who inhales deeply and started smoking before age 15, you're trading a minute of future life for every minute you now spend smoking.

Respiratory Diseases

Smoking quickly impairs the respiratory system, including the cough reflex, a vital protective response. Cigarette smokers are up to 18 times more likely than nonsmokers to die of noncancerous diseases of the lungs. Even some teenage smokers show signs of respiratory difficulty—breathlessness, chronic cough, excess phlegm production—compared with nonsmokers of the same age.

Snus

Snus (rhymes with "loose") is a smokeless tobacco product similar to snuff and chewing tobacco. It was originally developed in Sweden and banned elsewhere in Europe, but tobacco companies have introduced snus in the United States in recent years. Users, generally white males between the ages of 18 and 24, pack snus under their upper lip and then swallow the byproduct rather than spit it out. Snus may pose less of a cancer risk than other forms of tobacco, but it can lead to or exacerbate other conditions, such as gastroesophageal reflux.

Water Pipes (Hookahs)

A water pipe (known by different terms, such as hookah, narghile, arghile, and hubble-bubble, in different parts of the world) allows smoke to pass through water prior to inhalation. Although also used to smoke other substances, including marijuana and hashish, water pipes are most often used with flavored tobacco, made by mixing shredded tobacco with honey or molasses and dried fruit. This mix is most commonly called shisha in the United States. According to the ACHA, 23.2 percent of college students have smoked tobacco from a water pipe (see Table 13.4). Individuals with Middle Eastern backgrounds and their friends are most likely to use hookahs. As with conventional cigarettes, students overestimate their peers' use of hookahs.

Cigars and Pipes Cigar use has declined in the past few years; however, after cigarettes, cigars are the tobacco product most widely used by college students:

About 2.3 percent of adults age 18 or older in the United States smoke cigars. White and African American students are more likely to smoke cigars than Hispanic or Asian American students. About 4 in 10 cigar smokers—particularly those who are female, younger, and less wealthy—report using flavored cigars. Many cigarette smokers switch to pipes to reduce their risk of health problems. But former cigarette smokers may continue to inhale, even though pipe smoke is more irritating to the respiratory system than cigarette smoke. People who have smoked only pipes and who do not inhale are less likely to develop lung and heart disease than cigarette smokers. However, they are likely to suffer respiratory problems and to develop—and die of—cancer of the mouth, larynx, throat, and esophagus.

Medications The most widely prescribed medications for alcoholism recovery include the following:

Disulfiram (Antabuse), in use for more than 50 years, causes unpleasant effects when even small amounts of alcohol are consumed. These include flushing of the face, headache, nausea, vomiting, chest pain, weakness, blurred vision, mental confusion, sweating, choking, breathing difficulty, and anxiety. These effects begin about 10 minutes after alcohol enters the body and last for an hour or more. Acamprosate (Campra), combined with counseling and social support, helps the brains of people who have consumed large amounts of alcohol to work normally again. Acamprosate does not prevent withdrawal symptoms and has not been shown to work in people who have not stopped drinking alcohol or who also abuse substances such as street drugs or prescription medications. Naltrexone (Revia, Decade, Vivitrol) reduces cravings, perhaps by blocking the normal pleasurable reaction of the part of the brain that reacts to alcohol or opioids.

Many factors affect your BAC and response to alcohol, including the following:

How much and how quickly you drink. The more alcohol you put into your body, the higher your BAC. If you chug drink after drink, your liver, which metabolizes about 0.5 ounce of alcohol an hour, won't be able to keep up—and your BAC will soar. What you're drinking. The stronger the drink, the faster and harder the alcohol hits. Straight shots of liquor and cocktails such as martinis get alcohol into your bloodstream faster than beer or table wine. Beer and wine not only contain lower concentrations of alcohol but also contain nonalcoholic substances that slow the rate of absorption (passage of the alcohol into body tissues). Mixers. Carbon dioxide—whether in champagne, ginger ale, or a cola—whisks alcohol into your bloodstream. Also, the alcohol in warm drinks—such as a hot rum toddy or warmed sake—moves into your bloodstream more quickly than the alcohol in chilled wine or scotch on the rocks. Mixing alcohol with a diet soft drink causes higher alcohol concentrations, as measured by breath analysis, in both women and men, compared to mixing alcohol with a nondiet beverage. Your size. If you're a large person (whether due to fat or to muscle), you'll get drunk more slowly than someone smaller who's drinking the same amount of alcohol at the same rate. Heavier individuals have a larger water volume, which dilutes the alcohol they drink. Your sex. Women have lower quantities of a stomach enzyme that neutralizes alcohol, so one drink for a woman has the impact that two drinks have for a man. Hormone levels also affect the impact of alcohol. Women are more sensitive to alcohol just before menstruation, and birth control pills and other forms of estrogen can intensify alcohol's impact (see Figure 13.3). Your age. The same amount of alcohol produces higher BACs in older drinkers, who have lower volumes of body water to dilute the alcohol than younger drinkers do. People over 50 may become impaired after only one or two drinks. Your race. Many members of certain ethnic groups, including Asians and Native Americans, are unable to break down alcohol as quickly as Caucasians. This can result in higher BACs, as well as uncomfortable reactions, such as flushing and nausea, when they drink. Other drugs. Some common medications—including aspirin, acetaminophen (Tylenol), and ulcer medications—can cause blood-alcohol levels to increase more rapidly. Individuals taking these drugs can be over the legal limit for blood-alcohol concentration after as little as a single drink. Family history of alcoholism. Some children of alcoholics don't develop any of the usual behavioral symptoms that indicate someone is drinking too much. It's not known whether this behavior is genetically caused or is a result of growing up with an alcoholic. Eating. Food slows the absorption of alcohol by diluting it, by covering some of the membranes through which alcohol would be absorbed, and by prolonging the time the stomach takes to empty. Eating while consuming alcohol can significantly reduce alcohol concentrations. Expectations. In various experiments, volunteers who believed they were given alcoholic beverages but were actually given nonalcoholic drinks acted as if they were guzzling the real thing and became more talkative, relaxed, and sexually stimulated. Physical tolerance. If you drink regularly, your brain becomes accustomed to a certain level of alcohol. You may be able to look and behave in a seemingly normal fashion, even though you drink as much as would normally intoxicate someone your size. However, your driving ability and judgment will still be impaired. Your drinking companions. According to new research, the people around you can influence your sense of inebriation. If surrounded by others who are also drunk, you are more likely to underestimate how drunk you are. If your companions are sober, you are more aware of alcohol's impact on you. Tolerance. Once you develop tolerance, you may drink more to get the desired effects from alcohol. In some people, this can lead to abuse and alcoholism. On the other hand, after years of drinking, some people become exquisitely sensitive to alcohol. Such reverse tolerance means that they can become intoxicated after drinking only a small amount of alcohol.

Psychological Benefits of Quitting

Quitting may be as good for your mental health as it is for your physical health, according to analysis of 3 years of data on 4,800 daily smokers in the United States. Significantly fewer of those who quit were less likely to report alcohol or drug problems or anxiety or depression than those who continued to smoke.

Latino Community

The various Hispanic cultures tend to discourage any drinking by women but encourage heavy drinking by men as part of machismo, or feelings of manhood. Hispanic men have higher rates of alcohol use and abuse than the general population and suffer a high rate of cirrhosis. Moreover, American-born Hispanic men drink more than those born in other countries. Few Hispanics with severe alcohol problems enter treatment, partly because of a lack of information, language barriers, and poor community-based services. Hispanic families generally try to resolve problems themselves, and their cultural values discourage the sharing of intimate personal stories, which characterizes Alcoholics Anonymous and other support groups. Churches often provide the most effective forms of help.

Thirdhand Smoke

Thirdhand smoke is the nicotine residue that is left behind on furniture, walls, and carpet after a cigarette has been smoked in a room. According to scientists, particulates made up of ozone and nicotine can become airborne a second time and, because they are so small, easily penetrate into the deepest parts of the lung. Over time, they could contribute to breathing problems such as asthma or possibly even cancer. Hookah or water-pipe smoking raises levels of secondhand and thirdhand smoke even higher than cigarette smoke in the room where smoking occurs as well as adjacent rooms. Recent research has documented that thirdhand smoke causes DNA damage in human cells. Because ozone can continue to pull nicotine off surfaces and back into the air for months, exposure to thirdhand smoke may continue long after smoking in the area has ceased. The danger may be greatest to infants, children, pregnant women, and the elderly. Secondhand smoke is the most common and hazardous form of indoor air pollution. Thirdhand smoke remains in houses, apartments, and hotel rooms even after smokers move out. The toxins it contains can enter the body by breathing, ingestion, or skin absorption. Among the effects on nonsmokers is an increased risk of breathing problems and cancer. The danger may be greatest to infants, children, pregnant women, and the elderly.

Tobacco's Immediate Effects

Tobacco, an herb that can be smoked or chewed, directly affects the brain. While its primary active ingredient is nicotine, tobacco smoke contains almost 400 other compounds and chemicals, including gases, liquids, particles, tar, carbon monoxide, cadmium, pyridine, nitrogen dioxide, ammonia, benzene, phenol, acrolein, hydrogen cyanide, formaldehyde, and hydrogen sulfide.

Quitting Tobacco Use Numbers show the difficulty of quitting, but there are effective treatments:

Two-thirds of smokers want to quit, but many make as many as 30 attempts before finally breaking their nicotine habit. About half of whites who have smoked were able to kick the habit, compared with 45 percent of Asian Americans, 43 percent of Hispanics, and 37 percent of African Americans. About 8 in 10 African Americans choose menthol cigarettes, compared with just one-quarter of adults of other races, which may make quitting harder. Smokers who work with a counselor specially trained to help them quit and who also use medications or nicotine patches or gum are three times more likely to kick the habit than smokers who try to quit without any help, according to large recent study.

More than 170 million Americans—about two-thirds of the population—report drinking alcohol in the previous year. Most do not misuse alcohol. According to the National Institute on Alcohol Abuse and Alcoholism.

56 percent of adults over age 18 are current regular drinkers. 13 percent are in frequent drinkers. 6 percent are former regular drinkers. 9 percent are former infrequent drinkers. About 14 percent have never drunk alcohol. White men and women are more likely to drink than other adults: 70 percent of white men say they drink, compared to 57 percent of black men, 55 percent of Asian men, and 58 percent of American Indian or Alaska Native men. Among women, 59 percent of white women drink, compared with 40 percent of blacks, 32 percent of Asians, and 45 percent of American Indian or Alaska Natives. The median age of first alcohol use is 15. Drinking typically increases in the late teens, peaks in the early 20s, and decreases as people age. The median age of onset for alcohol use disorders is 19 to 20.

Alcohol-Related Disorders

As many as one in six adults in the United States may have a problem with drinking, which means, by the simplest definition, that they use alcohol in any way that creates difficulties, potential difficulties, or health risks. Like alcoholics, problem drinkers are individuals whose lives are in some way impaired by their drinking. The only difference is degree. Alcohol becomes a problem, and a person becomes an alcoholic, when the drinker can't "take it or leave it." He or she spends more and more time anticipating the next drink, planning when and where to get it, buying and hiding alcohol, and covering up secret drinking. Daytime drinking and drinking alone can be signs of a serious problem, even though the drinker may otherwise appear to be in control.

Why People Smoke: Weight Control

Concern about weight is a significant risk factor for smoking among young women. Daily smokers are two to four times more likely to fast, use diet pills, and purge to control their weight than nonsmokers. Although black women smoke at substantially lower rates than white women, the common factor in predicting daily smoking among all women, regardless of race, is concern with weight.

To help an intoxicated person, follow these guidelines:

Continually monitor the individual. If the person is "out," check breathing and wake the person often to be sure he or she is not unconscious. Do not force the person to walk or move around. Do not allow the person to drive a car or ride a bicycle. Do not give the person food, liquid (including coffee), medicines, or drugs to "sober up." Do not give the person a cold shower; the shock of the cold could cause unconsciousness.

Why People Smoke: Parent Role Models

Children who start smoking are 50 percent more likely than youngsters who don't smoke to have at least one smoker in their family. A mother who smokes seems to be a particularly strong influence in making smoking seem acceptable. The majority of youngsters who smoke say that their parents also smoke and are aware of their own tobacco use.

Immune System

Chronic alcohol use can inhibit the production of both white blood cells, which fight off infections, and red blood cells, which carry oxygen to all the organs and tissues of the body. Alcohol may increase the risk of infection with human immunodeficiency virus (HIV) by altering the judgment of users so that they more readily engage in activities such as unsafe sex that put them in danger. If you drink when you have a cold or the flu, alcohol interferes with the body's ability to recover. It also increases the chance of bacterial pneumonia in flu sufferers.

Other Smoking-Related Problems Smoking, which affects almost every organ system in the body:

Contributes to gum disease and the loss of teeth and teeth-supporting bone, even in individuals with good oral hygiene. Worsens the symptoms or complications of allergies, diabetes, hypertension, cirrhosis of the liver, peptic ulcers, and disorders of the lungs or blood vessels. Is an independent risk factor for high-frequency hearing loss and adds to the danger of hearing loss for those exposed to noise. May increase the likelihood of anxiety, panic attacks, and social phobias. May cause fires that claim thousands of lives.

Why People Smoke: Adolescent Experimentation and Rebellion

For teenagers, smoking may be a coping mechanism for dealing with boredom and frustration; a marker of the transition into high school or college; a bid for adult status; a way of gaining admission to a peer group; or a way to have fun, reduce stress, or boost energy. The teenagers most likely to begin smoking are those least likely to seek help when their emotional needs are not met. They might smoke as a means of gaining social acceptance or to self-medicate when they feel helpless, lonely, or depressed.

Water Pipes (Hookahs) Characteristics of users include the following:

Male. 18 to 24 years old. White and, in some studies, Hispanic/Latino. Some college education. Belonging to a sexual minority. Also using cigarettes, cigars, and other tobacco products.

Bidis

Skinny, sweet-flavored cigarettes called bidis (pronounced "beedees") have become a smoking fad among teens and young adults. For centuries, bidis were popular in India, where they are known as the poor man's cigarette and sell for less than five cents a pack. They look strikingly like clove cigarettes or marijuana joints and are available in flavors like grape, strawberry, and mandarin orange. Bidis are legal for adults and even minors in some states and are sold on the Internet as well as in stores. Although bidis contain less tobacco than regular cigarettes, their unprocessed tobacco is more potent. Smoke from bidis has about three times as much nicotine and carbon monoxide and five times as much tar as smoke from regular filtered cigarettes. Because bidis are wrapped in nonporous brownish leaves, they don't burn as easily as cigarettes, and smokers have to inhale harder and more often to keep them lit. In one study, smoking a single bidi required 28 puffs, compared to 9 puffs for a cigarette.

Premature Death

Smoking kills, robbing smokers of a decade of life. Smokers are half as likely to live to age 80 as nonsmokers. But smoking doesn't kill only the elderly. According to a CDC study, individuals who smoked between ages 12 and 39 have an 86 percent greater risk of dying before age 55 as compared with nonsmokers.

The following list summarizes key influences on student drinking:

Social norms. Compared with other factors, such as race, sex, year in school, and fraternity/sorority membership, social norms (discussed in Chapter 1) have the strongest association with how much college students drink. In a recent study, more than eight in ten students overestimated how many and how much their peers drink. Overestimation of heavy drinking by peers is associated with more frequent heavy drinking. Coping. Students turn to alcohol to cope with everyday problems and personal issues. Those with symptoms of depression who lack skills to cope with daily problems, particularly males, are more likely to drink than others, as are those who feel anxious, angry, hostile, nervous, guilty, or ashamed. Social anxiety. Both traditional-age and older undergraduates who report social anxiety are more likely to drink, including heavy episodic drinking, as a way of coping. Party schools. Colleges and universities in the Northeast, those with a strong Greek system, and those where athletics predominate have higher drinking rates than others. Students who never join or who drop out of a fraternity or sorority report less risky drinking behavior than those who go Greek. Living arrangements. Drinking rates are highest among students living in fraternity and sorority houses, followed by those in on-campus housing (dormitories, residence halls) and off-campus apartments or houses. Study-abroad students are at risk for increased and problematic drinking behavior. Undergraduates living at home with their families drink the least. Weekends and special occasions. Students drink more heavily on weekends and holidays than on typical weekdays. The highest drinking days include Halloween, New Year's Eve, and St. Patrick's Day. Alcohol consumption typically soars on big-game days for various sports, when a significant number of students engage in "extreme ritualistic alcohol consumption," defined as consuming 10 or more drinks on the same day for a male and 8 or more for a female. Many students celebrate their 21st birthday by drinking—and those who party with fraternity or sorority members drink more than those who toast the big day with romantic partners. Spring break. Annual excursions devoted to nonstop partying with thousands of other young people have become notorious for extreme drinking. Frequent consequences include intoxication, alcohol poisoning, accidents, and risky sexual behavior. Students who overestimate their peers' alcohol consumption during spring break drink more than those who don't assume that everyone else is drinking heavily. Participation in sports. Students who place a higher moral priority on loyalty to a group, such as a team, fraternity, or sorority, tend to have more favorable attitudes toward drinking. College athletes, who generally drink more alcohol more often than nonathletes, may be at greater risk because many are younger than 21, belong to Greek organizations, have lower GPAs, or spend more time socializing than other students. Those who play team sports tend to drink heavily. Male hockey and female soccer players drink the most; male basketball players and cross-country or track athletes of both sexes, the least. Parental attitudes. Students who believe that their parents approve of drinking are more likely to drink and to report having a drinking-related problem. Those whose parents communicate clear zero-tolerance messages about alcohol are least likely to drink. Parents also influence stopping or limiting drinking. First-year transition. Some students who drank less in high school than classmates who weren't headed for college start drinking, and drinking heavily, in college—often during their first 6 weeks on campus and during school breaks. But heavy drinkers often continue to maintain or increase their risky drinking behaviors, and some nondrinkers or light drinkers also increase their alcohol consumption throughout college. Sexual victimization. Women who've experienced sexual assault are at greater risk of binge drinking. Risky drinking, including bingeing, in itself increases the risk of sexual victimization.

Quitting Tobacco Use

The U.S. Public Health Service's most recent guidelines for treating tobacco use and dependence recognize tobacco dependence as "a chronic disease that often requires repeated intervention and multiple attempts to quit." Once a former smoker takes a single puff, the odds of a relapse are 80 to 85 percent. Smokers are most likely to quit on the third, fourth, or fifth attempt. Some interventions aim at reducing exposure to tobacco, for example, by using less toxic products such as pharmaceutical nicotine and potentially reduced-exposure tobacco products as an alternative to cigarettes. Smoking cessation, however, remains the only guaranteed way to reduce the harm caused by tobacco smoking.

More Americans are choosing not to drink, and alcohol consumption is at its lowest level in decades. About a quarter of adults—31 percent of women and 18 percent of men—report drinking no alcohol in the past year.

With fewer people drinking alcohol, nonalcoholic beverages have grown in popularity. They appeal to drivers, boaters, individuals with health problems that could worsen with alcohol, older individuals who can't tolerate alcohol, anyone taking medicines that interact with alcohol (including antibiotics, antidepressants, and muscle relaxers), and everyone interested in limiting alcohol intake. Under federal law, these drinks can contain some alcohol but a much smaller amount than regular beer or wine. Nonalcoholic beers and wines on the market also are lower in calories than alcoholic varieties.

Health Problems Later in Life

Young adults who drink heavily put themselves at risk of health problems later in life. On average, men with alcohol dependence in young adulthood have an average of three medical conditions in their 60s, compared with two for nondrinkers. Men who experienced alcoholism for at least 5 years in early adulthood scored lower on standard measures of both physical and mental health once they reached their 60s. This increased risk persisted whether or not the person quit drinking by age 30 or continued to drink.

According to the Centers for Disease Control and Prevention (CDC), more than 480,000 Americans die each year from smoking or exposure to secondhand smoke, while 16 million suffer from smoking-related illnesses.

t

Young adults are the most frequent users of alcohol in the United States. The highest proportion of heavy drinkers and individuals with diagnosable alcohol use disorders are 18 to 25 years old. According to the 2017 National Survey on Drug Use and Health, 53.6 percent of college students between the ages of 18 and 22 drank alcohol during the past month, compared with 48.2 percent of their non-college-attending peers. About 35 percent of students reported binge drinking, defined as consuming five or more drinks on the same occasion

t

About one in five college students tends to overestimate how much alcohol he or she has consumed; about one in ten underestimates his or her alcohol consumption.

t

Hookah Use on Campus Many students assume that water-pipe smoking is safer than cigarette smoking. but the existing research indicates that the risks are similar, if not greater:

A typical 1-hour hookah smoking session involves inhaling 100 to 200 times the volume of smoke inhaled from a single cigarette. Waterpipe smoking can lead to nicotine dependence. In a recent meta-analysis, water-pipe smoking was significantly associated with lung cancer, respiratory illnesses, low birth weight, and periodontal disease. Smoke from a water pipe contains the same harmful or potentially harmful substances as cigarette smoke, often at higher levels. Water-pipe smoking usually occurs in a group setting. Commercial water-pipe venues, offering ready-to-smoke water pipes, have proliferated in many college towns. Students who use water pipes tend to be younger, male, and white. They also are more likely than other undergraduates to perceive water-pipe tobacco smoking as less harmful and less addictive than cigarette smoking.

Smokeless Tobacco

An estimated 3 percent of adults in the United States use smokeless tobacco products (sometimes called "spit"). Use of chewing tobacco by teenage boys, particularly in rural areas, has surged 30 percent in the past decade. About 9 percent of college men (and 0.4 percent of women) use smokeless tobacco. These substances include snuff, finely ground tobacco that can be sniffed or placed inside the cheek and sucked; and chewing tobacco, tobacco leaves mixed with flavoring agents such as molasses. With both, nicotine is absorbed through the mucous membranes of the nose or mouth. Smokeless tobacco causes a user's heart rate, blood pressure, and epinephrine (adrenaline) levels to jump. In addition, it can cause cancer and noncancerous oral conditions and lead to nicotine addiction and dependence. People who use smokeless tobacco, or "snuff," become just as hooked on nicotine as cigarette smokers—if not more. Those who both smoke and use snuff may be especially nicotine dependent. Powerful carcinogens in smokeless tobacco include nitrosamines, polycyclic aromatic hydrocarbons, and radiation-emitting polonium. Its use can lead to the development of white patches on the mucous membranes of the mouth, particularly on the site where the tobacco is placed. Most lesions of the mouth lining that result from the use of smokeless tobacco dissipate 6 weeks after the use of the tobacco product is stopped. However, when first found, about 5 percent of these lesions are cancerous or exhibit changes that progress to cancer within 10 years if not properly treated. Cancers of the lips, pharynx, larynx, and esophagus have all been linked to smokeless tobacco. Nicotine replacement with gum or patches decreases cravings for smokeless tobacco and helps with short-term abstinence; however, it does not improve long-term abstinence. Behavioral approaches are more effective for long-term quitting. Tobacco control programs, such as higher taxes on smokeless tobacco products, media campaigns, health warnings, and cessation programs, affect smokeless tobacco use but some individuals continue to use other forms of tobacco.

Electronic Cigarettes

As described earlier in the chapter, e-cigarettes are compact, battery-powered devices that allow users to inhale a vaporized liquid nicotine solution instead of tobacco. They simulate the act of smoking and provide smokers with a nicotine "fix" without exposing themselves and others to the toxins in tobacco smoke. Most electronic cigarettes resemble traditional cigarettes and are reusable, with replaceable and refillable components. Although research on their long-term efficacy is limited, e-cigarettes seem as effective as nicotine patches in helping smokers quit. Some people continue to smoke both traditional and e-cigarettes. As e-cigarettes have gained popularity, they have triggered considerable debate about their potential harms and the distinction between "bad" nicotine in cigarettes and "good" nicotine in devices used to stop smoking. Researchers have found that puffing on e-cigarettes produces airway constriction and inflammation, which might lead to respiratory symptoms and serious lung diseases such as emphysema. Other potential risks include headache, cough, dizziness, sore throat, nose bleeds, chest pain or other cardiovascular problems, and allergic reactions such as itchiness and swelling of the lips. There have been reports of e-cigarettes overheating, igniting, or exploding. Some argue that using e-cigarettes, referred to as "vaping," may promote continued smoking by allowing smokers of conventional cigarettes to use these alternatives in no-smoking environments or by encouraging people to take up this "safe" form of smoking. On the other hand, their use appears to enhance quitting motivation and significantly reduce cravings in smokers and exposure to toxins for nonsmokers. However, transitioning from cigarettes to the electronic versions may increase the risk for higher and more hazardous patterns of alcohol use.

Weight and Waists

At 7 calories per gram, alcohol has nearly as many calories as fat (9 calories per gram) and significantly more than carbohydrates or protein (which have 4 calories per gram). Since a standard drink contains 12 to 15 grams of alcohol, the alcohol in a single drink adds about 100 calories to your daily intake. A glass of wine contains as many calories as some candy bars; you would have to walk a mile to burn them off. In addition to being a calorie-dense food, alcohol stimulates the appetite, so you're likely to eat more. Obesity plus daily drinking boosts the risks of liver disease in men and women.

Brain and Behavior

At first when you drink, you feel up. In low dosages, alcohol affects the regions of the brain that inhibit or control behavior, so you feel looser and act in ways you might not otherwise act. However, you also experience losses of concentration, memory, judgment, and fine motor control, and you have mood swings and emotional outbursts. Moderate and heavy drinkers show signs of impaired intelligence, slowed reflexes, and difficulty remembering. Because alcohol is a central nervous system depressant, it slows down the activity of the neurons in the brain, gradually dulling the responses of the brain and nervous system. One or two drinks act as a tranquilizer or relaxant. Additional drinks result in a progressive reduction in central nervous system activity, leading to sleep, general anesthesia, coma, and even death. Heavy alcohol use may pose special dangers to the brains of drinkers at both ends of the age spectrum. Adolescents who drink regularly show impairments in their neurological and cognitive functioning. Elderly people who drink heavily appear to have more brain shrinkage, or atrophy, than those who drink lightly or not at all. In general, moderate drinkers have healthier brains and a lower risk of dementia than those who don't drink and those who drink to excess.

Nicotine Inhaler

Available only by prescription, a nicotine inhaler consists of a mouthpiece and a cartridge containing a nicotine-impregnated plug. The smoker inhales through the mouthpiece, using either shallow or deep puffs. The inhaled air becomes saturated with nicotine, which is absorbed mainly through the tissues of the mouth. The inhaler releases less nicotine per puff than a cigarette and does not contain a cigarette's harmful tars, carbon monoxide, and smoke. Treatment is recommended for 3 months, with a gradual reduction over the next 6 to 12 weeks. Total treatment should not exceed 6 months.

The bodies of men and women respond to alcohol in different ways:

Because they have a far smaller quantity of a protective enzyme in the stomach to break down alcohol before it's absorbed into the bloodstream, women absorb about 30 percent more alcohol into their bloodstream than men (see Table 13.2). The alcohol travels through the blood to the brain, so women become intoxicated much more quickly. Blood-alcohol concentration rises faster and stays elevated longer in women than in men. This increases negative health consequences, including increased risk of alcohol-related heart disease, immune disorders (which include autoimmune diseases) and infectious diseases, breast cancer, and liver damage. Nearly 14 million American women—one in eight—binge drink about three times a month, averaging about six drinks per binge. The risks to girls and women include injuries, sexual assault, chronic diseases, unintended pregnancy, learning and memory problems, and alcohol dependence. A poor body image and expectations that alcohol will enhance social confidence are risk factors for women's excessive drinking. An estimated 15 percent of women drink alcohol while pregnant, most having one drink or less per day. Even light consumption of alcohol can lead to fetal alcohol effects (FAE): low birth weight, irritability as newborns, and permanent mental impairment. Drinking in the latter part of the first trimester may be most likely to cause the physical characteristics typical of FAE. A few drinking binges of four or more drinks a day during pregnancy may significantly increase the risk of childhood mental health and learning problems. One of every 750 newborns has a cluster of physical and mental defects called fetal alcohol syndrome disorders (FASD): small head, abnormal facial features, jitters, poor muscle tone, sleep disorders, sluggish motor development, failure to thrive, short stature, delayed speech, mental retardation, and hyperactivity. Alcohol interferes with male sexual function and fertility through direct effects on testosterone and the testicles. Damage to the nerves in the penis by heavy drinking can lead to impotence. In women who drink heavily, a drop in female hormone production may cause menstrual irregularity and infertility.

Virtual Support

Electronic communications via cell phones, emails, text messages, blogs, and social networking sites may be particularly effective in helping young smokers quit. In the few research studies that have been done, these approaches generally resulted in higher quitting rates—but only if continued over time. Short text messages can help individuals track their smoking urges and provide encouragement in resisting them. Other options include apps for smartphones and online support groups. In one study, smokers who strictly adhered to a stop-smoking phone app were over four times more likely to quit successfully.

Stop-Smoking Groups

Joining a support group doubles your chances of quitting for good. Options include the American Cancer Society's Freshstart program, the American Lung Association's Freedom from Smoking program, stop-smoking classes (available through student health services on many college campuses as well as through community public health departments), and commercial smoking-cessation programs. Some smoking-cessation programs rely primarily on aversion therapy, which provides a negative experience every time a smoker has a cigarette. This may involve taking drugs that make tobacco smoke taste unpleasant, undergoing electric shocks, having smoke blown at you, or rapid smoking (inhaling smoke every 6 seconds until you're dizzy or nauseated). Nicotine Anonymous, a nonprofit organization based on the 12-Step programs to recovery developed by Alcoholics Anonymous, acknowledges the power of nicotine and provides support to help smokers, chewers, and dippers live free of nicotine.

Health Effects of Secondhand Smoke Environmental tobacco smoke is both dangerous and deadly. A proven culprit in the development of lung cancer, secondhand smoke leads to an estimated 3,000 deaths among adult nonsmokers every year (see Figure 13.7). Here are some of its dangers:

Living with a smoker increases a nonsmoker's chances of developing lung cancer by 20 to 30 percent. Both smoking and secondhand smoke increase a postmenopausal woman's risk of breast cancer. Secondhand smoke may increase the risks of cancer of the nasal sinus cavity and of the pharynx in adults, and it may increase the risks of leukemia, lymphoma, and brain tumors in children. Exposure to tobacco smoke irritates the airways and contributes to respiratory diseases such as asthma. Because of its toxic effects on the heart and blood vessels, it may increase the risk of heart disease by an estimated 25 to 30 percent. In the United States, secondhand smoke is thought to cause about 46,000 heart disease deaths a year. Secondhand smoke may increase the risk of developing Alzheimer's disease or other dementias. Children are particularly vulnerable to secondhand smoke, beginning before birth. Prenatal exposure to tobacco can affect a child's growth, cognitive development, and behavior both before and after birth. Birth weight decreases in direct proportion to the number of cigarettes a mother smoked. As they grow, children of smokers tend to be shorter and weigh less than those of nonsmokers. They also may be at higher risk of atherosclerosis

Environmental Tobacco Smoke

Maybe you don't smoke—never have, never will. That doesn't mean you don't have to worry about the dangers of smoking, especially if you live or work with people who smoke. Environmental tobacco smoke, or secondhand cigarette smoke, the most hazardous form of indoor air pollution, ranks behind cigarette smoking and alcohol as the third-leading preventable cause of death. On average, a smoker inhales what is known as mainstream smoke eight or nine times with each cigarette, for a total of about 24 seconds. However, the cigarette burns for about 12 minutes, and everyone in the room (including the smoker) breathes in what is known as sidestream smoke. According to the American Lung Association, incomplete combustion from the lower temperatures of a smoldering cigarette makes sidestream smoke dirtier and chemically different from mainstream smoke. It has twice as much tar and nicotine, five times as much carbon monoxide, and 50 times as much ammonia. And because the particles in sidestream smoke are small, this mixture of irritating gases and carcinogenic tar reaches deeper into the lungs and poses a greater threat, especially to infants and children. If you're a nonsmoker sitting next to someone smoking seven cigarettes an hour, even in a ventilated room, you'll take in almost twice the maximum amount of carbon monoxide set for air pollution in industry—and it will take hours for the carbon monoxide to leave your body. Even a little secondhand smoke is dangerous. As a cancer-causing agent, secondhand smoke may be twice as dangerous as radon gas and more than 100 times more hazardous than outdoor pollutants regulated by federal law. Secondhand smoke also increases the sick leave rates among employees.

Medications and Other Treatments

Medications also can help smokers quit. In a study that followed smokers for six weeks, varenicline (brand name Chantix) helped the highest percentage of smokers to quit, followed by bupropion (Zyban), originally developed to treat depression. The most common side effects of Chantix include nausea, insomnia, and abnormal dreams. Combining nicotine replacement products (such as a patch and lozenges) can be as effective as Chantix alone, but requires adherence to two treatments rather than just one. Hypnosis may help some people quit smoking. Hypnotherapists use their techniques to create an atmosphere of strict attention and give smokers in a mild trance positive suggestions for breaking their cigarette habit. A form of acupuncture, in which a circular needle or staple is inserted in the flap in front of the opening to the ear, has also had some success. When smokers feel withdrawal symptoms, they gently move the needle or staple, which may increase the production of calming chemicals in the brain.

Quitting on Your Own

More than 90 percent of former smokers quit on their own—by throwing away all their cigarettes, by gradually cutting down, or by first switching to a less potent brand. One characteristic of successful quitters is that they see themselves as active participants in health maintenance and take personal responsibility for their own health. Physically active smokers have greater success quitting, possibly because participating in one healthy behavior, such as exercise, leads to adoption of other positive behaviors. Often they experiment with a variety of strategies, such as learning relaxation techniques. In women, exercise has proved especially effective for quitting and avoiding weight gain. Making a home a smoke-free zone also increases a smoker's likelihood of successfully quitting.

Nicotine Replacement Therapy (NRT)

NRT uses a variety of products that supply low doses of nicotine in a way that allows smokers to taper off gradually over a period of months. Nicotine replacement therapies include nonprescription products (nicotine gum, lozenges, nicotine-free cigarettes, and nicotine patches) and prescription products (nicotine nasal spray, nicotine inhalers, and e-cigarettes). The nasal spray, dispensed from a pump bottle, delivers nicotine to the nasal membranes and reaches the bloodstream faster than any other nicotine replacement therapy product. The inhaler delivers nicotine into the mouth and enters the bloodstream much more slowly than the nicotine in cigarettes. Electronic cigarettes, or e-cigarettes, mimic the experience of smoking, right down to the glowing tip and smokelike vapor. The FDA has approved the use of nicotine replacement gums, lozenges, and skin patches for a longer period of time. None of these smoking cessation therapies appear to raise the risk of serious cardiovascular disease events. Although not without some risks, these products are substantially less dangerous than cigarettes and other combustible forms of tobacco. Although NRT is touted as an aid to permanent cessation of smoking, recent studies have found equivalent rates of relapse among smokers, regardless of whether they used nicotine replacement therapy, with or without professional counseling. Pregnant women and individuals with heart disease shouldn't use nicotine replacements. The most effective approaches combine medication—nicotine patches or Chantix, for instance—with psychological intervention. Each doubles a person's chance of quitting successfully. Nicotine replacement therapy has proved more beneficial for men than for women—particularly with higher doses of nicotine.

Nicotine Gum

Nicotine gum (available in less expensive generic forms as well) contains a nicotine resin that's gradually released as the gum is chewed. Absorbed through the mucous membrane of the mouth, the nicotine doesn't produce the same rush as a deeply inhaled drag on a cigarette. However, the gum maintains enough nicotine in the blood to diminish withdrawal symptoms. Although this gum is lightly spiced to mask nicotine's bitterness, many users say that it takes several days to become accustomed to its unusual taste. Its side effects include mild indigestion, sore jaws, nausea, heartburn, and stomachache. Also, because nicotine gum is heavier than regular chewing gum, it may loosen fillings or cause problems with dentures. Drinking coffee or other beverages may block absorption of the nicotine in the gum; individuals trying to quit smoking shouldn't ingest any substance immediately before or while chewing nicotine gum. Most people use nicotine gum as a temporary crutch and gradually taper off (rather painlessly) until they can stop chewing it; however, 5 to 10 percent of users transfer their dependence from cigarettes to the gum. When they stop using nicotine gum, they experience withdrawal symptoms, although the symptoms tend to be milder than those prompted by quitting cigarettes. Intensive counseling to teach smokers coping methods can greatly increase success rates.

Nicotine Patches

Nicotine transdermal delivery system products, or patches, provide nicotine, their only active ingredient, via a patch attached to the skin by an adhesive. Like nicotine gum, the nicotine patch minimizes withdrawal symptoms, such as the intense craving for cigarettes. Nicotine patches help nearly 20 percent of smokers quit entirely after 6 weeks, compared with 7 percent on a placebo patch. Some insurance programs pay for patch therapy. Nicotine patches, which cost between $3.25 and $4 each, are replaced daily during therapy programs that run between 6 and 16 weeks. Extended use for 24 weeks provides added benefit. Some patches deliver nicotine around the clock and others for just 16 hours (during waking hours). Those most likely to benefit from nicotine patch therapy are people who smoke more than a pack a day, are highly motivated to quit, and participate in counseling programs. While using the patch, 37 to 77 percent of people are able to abstain from smoking. When combined with counseling, the patch can be about twice as effective as a placebo, enabling 26 percent of smokers to abstain for 6 months. Occasional side effects include redness, itching, or swelling at the site of the patch application; insomnia; dry mouth; and nervousness.

Quitting and the Risks Associated with Smoking

Not smoking another cigarette is a gift to your body and your life; however, it is not a guarantee that there will be no consequences of the cigarettes you've already smoked Within a year of quitting, an ex-smoker's risk of heart disease drops to half that of active smokers. After 15 years, it approaches that of people who've never smoked. This is great news because the risk of dying prematurely from heart disease is far greater than that of dying from cancer (see Table 13.5). The risk of lung cancer from smoking fades more slowly, perhaps because of permanent DNA damage to lung cells. Even 10 to 15 years after quitting, an ex-smoker is several times more likely to die of lung cancer than someone who has never smoked. Former smokers are also more vulnerable to the effects of secondhand smoke in the workplace, even if they haven't lit up for the last 10 years. Does the lung cancer risk ever go away? That may depend partly on how old you are when you quit. Women who quit before age 30 are no more likely to die from lung cancer than those who never smoked. However, a study of American veterans started in the 1950s showed that, even 40 years later, former smokers had a 50 percent greater chance of dying from lung cancer than lifetime nonsmokers. While quitting sooner is better than later, later is better than never. Even smokers who quit in their 60s significantly reduce their lung cancer risk— and add several years to their life expectancy.

Combined Treatments

While counseling and medication are each beneficial, the combination is more effective than either alone. In a study of community college students, a computer-assisted interactive smoking cessation program helped almost one in five students stop. One campus-based program that employed peer facilitators to help smokers quit and avoid relapse reported a success rate of 88 percent. Being in the group was the single most powerful contributor to quitting, and participants said their sense of connectedness helped them quit and stay smoke-free. Community-based programs, such as initiatives for a smoke-free environment, also have proven effective, particularly for low-income urban populations.

The health effects of hookah use include the following:

Short term Increased heart rate. Increased blood pressure. Impaired lung function. Carbon monoxide intoxication. Long term Chronic bronchitis. Emphysema. Coronary artery disease. Periodontal (gum) disease. Osteoporosis. Increased risk of lung, stomach, and esophageal cancer.

Clove Cigarettes (Kreteks)

Sweeteners have long been mixed with tobacco, and clove, a spice, is an ingredient commonly added to the recipe for cigarettes. Clove cigarettes typically contain two-thirds tobacco and one-third clove. Consumers of these cigarettes are primarily teenagers and young adults. Many users believe that clove cigarettes are safer because they contain less tobacco, but this isn't necessarily the case. The CDC reports that people who smoke clove cigarettes may be at risk of serious lung injury. Regular kretek smokers have 13 to 20 times the risk for abnormal lung function as nonsmokers. Clove cigarettes deliver twice as much nicotine, tar, and carbon monoxide as moderate-tar American brands. Eugenol, the active ingredient in cloves (which dentists have used as an anesthetic for years), deadens sensation in the throat, allowing smokers to inhale more deeply and hold smoke in their lungs for a longer time. Chemical relatives of eugenol can produce the kind of damage to cells that may lead to cancer.

Here are some of the facts you need to know about hookah use:

The charcoal used to heat tobacco in the hookah produces smoke that contains high levels of carbon monoxide, metals, and cancer-causing chemicals. A hookah smoking session may expose the smoker to more smoke over a longer period of time than occurs when smoking a cigarette. The volume of smoke inhaled during a typical hookah session is about 90,000 milliliters, compared with 500 to 600 milliliters inhaled when smoking a cigarette. In a recent meta-analysis, water-pipe smoking was significantly associated with lung cancer, respiratory illnesses, low birth weight, and periodontal disease. Hookah smokers may absorb higher concentrations of the same toxins found in cigarettes. In a 6-month follow-up among college students, hookah users reported smoking more cigarettes more often over time. When those who smoke both hookah and cigarettes try to quit, they have lower success rates than cigarette smokers. The interventions that have proven most effective include providing information on the consequences of hookah smoking, assessing readiness to quit, and making individuals aware of withdrawal symptoms. Hookah use increases secondhand and thirdhand smoke (discussed later in this chapter) in the room where smoking occurs as well as in adjacent rooms to levels higher than those associated with cigarette smoking.

Physical Benefits of Quitting

Young adults who quit smoking see improvements in coughing and other respiratory symptoms within a few weeks, according to a recent study of college students ages 18 to 24. Quitting eliminates the excess risk of dying from heart disease fairly quickly. After 15 smoke-free years, the risk of smoking-related cancers drops to that of someone who never smoked. Table 13.5 provides a more complete list of reasons to quit smoking.