© 2002 Society for the Study of Addiction to Alcohol and Other Drugs Addiction, 97, 918–921

LEAD REVIEW

Regulating TobaccoROBERTA L. RABIN & STEPHEN SUGARMAN

with contributions from FRANK J. CHALOUPKA,

CHRISTINA CZART, ROBERT KAGAN, WILLIAM P.

NELSON, NANCY RIGOTTI, JOHN SLADE,

MELANIE WAKEFIELD & KENNETH WARNER, eds

New York, Oxford University Press, 2001, 281 pp,$19.95 (paperback), $49.95 (cloth), ISBN 0 19 513907 0 / 0 19 514756 1 (paperback)

Reading Regulating Tobacco is like touring a well-tendedbotanical garden, knowing it could soon be bulldozed flat.

There is much to admire in this compact volume ofreview articles. In it, the authors contribute to the development of healthy public policy by offering theirperspectives on contemporary facets of tobacco control.They do so with admirable efficiency and readability, eachof the nine chapters providing a self-contained contribu-tion to our understanding of the complex social, political,legal and cultural landscape surrounding the sale anduse of tobacco. Some of the chapters—such as the lateJohn Slade’s masterful articulation of the importance ofbanning tobacco advertising and Robert Rabin’s synthe-sis of recent tobacco litigation—are themselves reasonenough to buy and circulate this collection. Other chapters, such as Kenneth Warner’s controversial per-spectives on harm reduction and Stephen Sugarman’sattempts to give context to a proposed global tobaccotreaty, are good fodder for thought. The lives of US citizens would probably be improved if their policymakers were to read this book carefully.

Policy leaders in other parts of the world may want toread these contributions with more cautious enthusiasm.By framing their analysis within the ambit of what theyconsider achievable within the United States, the authorshave set themselves a myopic and narrow focus. Viewedfrom across the border, their lens provides a distortedpicture of policies available to communities that wish tomake progress against the leading cause of preventabledeath. Policy options such as high taxes and advertising,which seem ambitious to these US authors, are wellaccepted in many other parts of the globe. Recom-mendations for health-care systems to address support

for citizens who are stopping smoking are confined to US-style managed care organizations, even though much ofthe world operates under different structures. Holdingtobacco companies accountable through a flurry ofprivate civil suits may be the best legal strategy in theUnited States, but may not work well in jurisdictionswhere class-action and contingency payments are notallowed, and looking to municipalities and subnationalgovernments to take up the regulatory challenge that theUS national legislature avoids may not be useful to policymakers in unitary states. Audiences outside the UnitedStates may thus wish for more than the authors’ made-for-the-US approach.

A more substantial limitation, however, is the book’sfailure to call attention to the regulatory bulldozerswarming up outside the garden gates.

The global trading regime has undergone profoundchanges in the last decade, unleashing powerful newthreats to health-based tobacco policies. Unlike previousgenerations of trade agreements, the North AmericanFree Trade Agreement (NAFTA) and the World TradeOrganization (WTO) contain rules that extend beyondborder issues, cutting to the heart of governments’ abilityto regulate—including their ability to regulate tobacco.

NAFTA contains powerful investment provisions themere threat of which tobacco companies have alreadywielded against Canadian parliamentarians to thwartplans to reduce the attractiveness of cigarettes by requir-ing them to be sold in plain packages. Phillip Morrisrecently assailed the Canadian proposal to remove the‘light’ and ‘mild’ descriptors from cigarette packages asviolating NAFTA and the WTO treaties on technical barriers to trade (TBT) and intellectual property (TRIPS).Negotiations are now under way in Geneva on the WTO’sservices treaty—the little-known General Agreement on Trade in Services (GATS). This treaty, designed for continuous, ratchet-like expansion, applies already totobacco advertising, sales and distribution and its pro-posed constraints on domestic regulation, which wouldinclude tobacco regulations, are among the most exces-sive restrictions ever contemplated in a binding inter-national commercial treaty. The new round of WTOnegotiations agreed to last November in Doha incorpo-rates GATS and also include other matters such as invest-ment that are likely to affect the ability of member

Book ReviewsCompiled by Susan Savva & Griffith Edwards

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countries—including, critically, developing countries—to regulate tobacco. These negotiations could effectivelyneuter the World Health Organization’s proposed globaltobacco treaty, the Framework Convention on TobaccoControl (FCTC).

As pleasant and rewarding as such an exercise is,further learned examination of the regulatory specimensin our garden is no longer sufficient. The eminent authorsof this important book, other tobacco researchers, publichealth advocates and readers must urgently turn theirattention to, and begin to grapple with, the new interna-tional ‘trade’ treaties that now threaten the regulation oftobacco in the public interest. There is no time to lose; thebulldozers are clanking into position and they are notabout to wait.

CYNTHIA CALLARD

Executive Director of Physicians for a Smoke-Free CanadaOttawaCanada

J IM GRIESHABER-OTTO

Independent ‘Trade’ Policy ConsultantCedar Isle ResearchVancouverCanada

References

Bloom, J. (2001) Public Health, International Trade and theFramework Convention on Tobacco Control. Washington, DC: Campaign for Tobacco-Free Kids (available at http://www.tobaccofreekids.org/campaign/global/reports.shtml#report1).

Callard, C., Collishaw, N. & Swenarchuk, M. (2001) AnIntroduction to International Trade Agreements and Their Impact on Public Measures to Reduce Tobacco Use. Ottawa: World Health Organization Western Pacific Regional Office,Commonwealth. Medical Association Trust, Physicians for aSmoke-Free Canada (information available at http://www.smoke-free.ca/eng_home/news_press.htm ).

Sinclair, S. (2000) GATS: How the World Trade Organization’s New‘Services’ Negotiations Threaten Democracy. Ottawa: CanadianCentre for Policy Alternatives (information available athttp://www.policyalternatives.ca).

FURTHER REVIEWS

Beating the Dragon: The Recovery from DependentDrug UseJAMES MCINTOSH & NEIL MCKEGANEY

Harlow, England, Prentice Hall, 2002, 176 pp, £17.99,ISBN 0 13 087171 0

Beating the Dragon is a highly readable study that adds to the growing genre of international literature on thestages and processes of addiction recovery. McIntosh &

McKeganey depict the natural or treatment-assistedrecovery processes of 70 individuals from Scotland whohad been dependent upon opiates and/or other drugs.

Following a brief review of previous research onrecovery, Beating the Dragon takes the reader through achronology of the lives of its subjects, with chapters on becoming and being addicted, deciding to quit andremaining abstinent. The authors’ goals in this text areto document successful recovery from addiction, illus-trate the ‘strength, fortitude, openness, commitment andresilience’ exhibited by people in recovery and convey thehigh degree of individuality represented in the processesof addiction recovery. These goals are ably met, primarilyby allowing the voices of the recovering addicts to expresstheir evolving identities and the details of their evolvinglife-styles. The most common stages of recovery includeda progressive depreciation of pharmacological rewards;the sudden or gradual recognition of a spoiled life;enhanced attachment with parents, partners and chil-dren; hope for the future; and reconstruction of personalidentity, social relationships and daily life-style.

While much of the findings of McIntosh & McKeganeyecho earlier work, particularly that of Biernacki (1986)and Waldorf (1983), there are some fresh contributionsin Beating the Dragon. This book is one of the few worksin which addicts describe in their own words the value ofmethadone in their recovery processes. Given the con-tinued stigma and controversy attached to methadone at both public and professional levels, this contributionalone is noteworthy. The chapter on children alsoexpands the scope of earlier studies by portraying theimpact of addiction and recovery on the ongoing develop-ment of children and the family as a whole.

McIntosh & McKeganey’s vivid portrayal of recoveryas a complex and time-enduring process for the individ-ual and family challenges the serial episodes of discon-nected, acute interventions that often typify professionalinterventions into the lives of addicts and their families.If one were to construct a model of professional intervention for McIntosh & McKeganey’s addicts (highproblem severity, co-occurring problems, deep enmesh-ment in drug and criminal subcultures and low socialsupports), that model might be labeled more aptly ‘recovery management’ than ‘treatment’. Such a recov-ery management model would emphasize early engage-ment and stabilization; sustained monitoring, feedbackand support; construction of a recovery-based identityand social network; the provision of recovery support ser-vices (sober housing, employment); and, whenever nec-essary, early re-intervention. That refined vision alonemakes Beating the Dragon a worthy read.

For those who have spent their careers studying andtreating addiction, Beating the Dragon is a welcome invi-tation into the world of recovery. Its methodology is an

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affirmation that addiction and recovery can be studiedfrom the inside, through the voices of those who haveexperienced both. The growing legitimization of the first-person voices of addiction and recovery is in itselfnoteworthy, as is the promising shift in focus from theethnography of problems (addiction) to the ethnographyof solutions (recovery).

WILLIAM WHITE

Chestnut Health SystemsBloomington, ILUSA

References

Biernacki, P. (1986) Pathways from Heroin Addiction: RecoveryWithout Treatment. Philadelphia: Temple University Press.

Waldorf, D. (1983) Natural recovery from opiate addiction: somesocial-psychological processes of untreated recovery. Journal ofDrug Issues, 13, 237–280.

Innovations in Adolescent Substance AbuseInterventionsERIC WAGNER & HOLLY WALDRON, eds

London, Pergamon Press, 2001, xii + 394 pp, NLG165/US$ 81.50, ISBN 0 08 043577 7

Consumption of substances having addictive potential isa ubiquitous feature of adolescents in western society.Indeed, during the adolescent stage of development theprevalence of consumption is so high that this behavioris tacitly accepted as normative. Despite media cam-paigns and education programs directed at informingyouth about the array of dangers associated with druguse, the prevalence rate has not declined substantially.For example, the 30-day prevalence of illicit substanceuse in the United States has dropped by only about 5% during the past 25 years. The ineffectiveness oflarge-scale and arguably superficial programs is, uponreflection, not unexpected considering that adolescentsubstance users are a heterogeneous population withrespect to motivation, consumption pattern, drug preferences and psychiatric morbidity. Accordingly, theoverarching question in intervention research and practice remains: ‘What works for whom?’

This edited volume contains 16 chapters devoted toin-depth discussions of empirically based prevention andtreatment programs. Following an introductory chapterthat succinctly describes a broad range of assessmentmeasures, and evaluates the appropriateness of the DSMtaxonomic system for adolescents, the chapters consist offive reviews on a wide range of topics pertaining to pre-vention and treatment. Most of the chapters describe specific multi-modal programs that, for the most part,have been developed by the authors. Several chapters are

devoted to topics pertaining to a particular method, population or setting. The editors are to be commendedfor encompassing the most important themes and issuescurrently engaging researchers involved in devisingeffective interventions, although an integrative over-arching theoretical framework is not provided. Thisshortcoming aside, the roster of contributions is impres-sive and each chapter, considered as an independentunit,is comprehensive and up to date. Efficacy data areprovided in most of the chapters, albeit in a rather basic form. Unfortunately, the characteristics of non-responders is not thoroughly addressed, thereby mitigat-ing determination of the usefulness of the variousinterventions. Thus, while each chapter is informative, itis not possible for the practitioner to determine readily themost appropriate intervention for a particular populationand type of setting.

From an environmentalist perspective, this bookcovers the empirical literature. Chapters focus on family,school, peers and community. Less emphasis is placed onthe psychological, psychiatric or biological attributes ofthe indvidual. Inasmuch as prognosis is the product ofthe interaction or ‘fit’ between the characteristics of theperson and the characteristics of the intervention, the need for a more focused emphasis on this issue isunderscored.

This is a fine book. The chapters are thorough, clearlywritten and grounded in empirical research. As adver-tised, the book is a valuable resource for counselors, psychologists, educators, social workers, as well as otherprofessionals involved in the design and delivery of pre-vention and treatment services.

RALPH E. TARTER

University of PittsburghPittsburgh, PAUSA

Ecstasy: The Complete Guide. A Comprehensive Look atthe Risks and Benefits of MDMAJ. HOLLAND, ed.

Rochester, Vermont, Park Street Press, 2001, 454 pp,£17.99, ISBN 089281857 3

In the early 1970s and 1980s, MDMA (ecstasy) waswidely used in America as an adjunct to psychotherapy.However, in 1985 the Drug Enforcement Agency (DEA)put MDMA under stringent control as a Schedule 1 drug.The implication was that the substance had no routinemedical utility, and it became difficult to conduct humanresearch on its alleged therapeutic deployment.

Julie Holland’s edited volume is intended as a fight-back against that DEA ruling. ‘This book is about theimportance of bringing MDMA back into the field of

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medicine’. Dr Holland is a psychiatrist and researcher ofsome experience, and her views deserve attention.

Among the chapters put on offer are several com-prehensive and critical scientific reviews of outstandingquality which tackle difficult questions in a fair-mindedway. Statements by John Henry and Joseph Rella on‘Medical risks associated with MDMA use’, and byMatthew Baggot and John Mendelson on ‘Does MDMAcause brain damage?’ are of Pulitzer quality. With all theprovisos duly entered, and no hint of the partisan, one isled to conclude that each year MDMA kills a smallnumber of users somewhat randomly. It probably also, inthe long term, compromises cognitive functioning andaffective control in many more people.

Superb and balanced scientific review, and then silli-ness as Julie Holland goes about her fight-back campaignall too stridently and ignores what her own authors aretelling her. I had a sense of fairness surrendered for partisan purposes when on page 19 I came upon the following unpleasant innuendo:

Supporting the claims that Ecstasy is a dangerousdrug is the NIDA-funded research of the JohnsHopkins neurologist George Ricaurte, who has madea career out of giving large doses of MDMA to

laboratory animals and publicizing the axonalchanges he has documented.

From then on one sees an attempt at fight-backtainted by the editor’s habit of entering her own square-bracketed comments to snipe at authors with whom she disagrees, her recruitment of some authors whowould make Timothy Leary look like a dispassionate commentator and her habit of substituting anecdote forevidence. The nadir comes in the editor’s personallyscripted chapter 17, ‘Using MDMA in the treatment ofschizophrenia’. The end-piece to this chapter comprisesthree case pastiches headed ‘Testimonials’ in which sadly troubled schizophrenics say variously ‘I strongly believe MDMA has huge potential for the treatment ofschizophrenia’, ‘With the very first use, MDMA com-pletely changed my life’ and ‘I felt as if my mentalproblem had been washed away’. How’s that for a snakeoil advertisement?

This is a book of astonishing ambiguity in which bril-liant authors keep strange company. With a few veryhonourable exceptions, it more deserves a wooden spoonthan a Pulitzer award.

GRIFFITH EDWARDS

Editor-in-Chief, Addiction