Uso de Sustancia y Adicción Substance Use and ADICCTION

8/14/2019 Uso de Sustancia y Adiccin Substance Use and ADICCTION

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Addiction and related diseases are tak-

ing an ever greater toll on the health

and well-being of people everywhere.Worldwide trends reflect an overall

increase in the use of illicit, addictivedrugs and alcohol. Even more disturb-

ing is the increase in drug use amongthe youngest sectors of the population.

According to the United States Sub-stance Abuse and Mental Health Ser-vice Administration (SAMHSA, 1999),

drug use has gradually but steadilyincreased, mainly due to increased use

among 1213-year-olds. The WorldHealth Organization (WHO) reports a

similar trend among youth throughoutthe globe, noting lower ages of initia-

tion of drug use and a greater availabil-ity of illegal drugs (WHO,1996).

In both industrialized and develop-

ing countries, the use of inhalants andhallucinogens has increased signifi-

cantly among 1217-year-olds, partic-ularly among street children, indige-

nous youth, and other marginalizedadolescents. Other substances on therise include heroin, opioids, cocaine,

and alcohol (WHO, 1996).

Nicotine, a powerfully addictivesubstance, has long been known toserve as a gateway drug, leading to

the use and abuse of other addictivesubstances such as alcohol and nar-cotics. In the United States, for

instance, household survey data from1997 reveal that the rates of illegal

drug use by youth who smoked and

used alcohol increased from 32.5% in

1996 to 42.8% in 1997 (SAMHSA,

1999). In fact, further analysis showsthat the only increase in drug use dur-ing this period occurred among adoles-cent smokers and users of alcohol. See

Figure 1.Tobacco is dangerous to health not

only because its use frequently leads tothe initiation of other heavier drugs;

more importantly, tobacco in and ofitself endangers human health, and itsuse leads to nicotine addiction, tobac-

co related illnesses, andamong halfof all adult smokerspremature death.

As noted by WHO in The World

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Heavy

alcoh

olus

e

Marijua

na/

hashish

use

Othe

rillic

it

drugu

se

Current smokersCurrent nonsmokers

20

15

10

5

0

Percent

Figure 1. Comparison ofsubstance use by smoking

status, age-adjusted,United States, 1997.

Substance Useand Addict ion

Source: SAMHSA.


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TOBACCO-FREE YOUTH

Health Report, 1999 Making a Differ-

ence (WHO, 1999), The joint proba-bility of trying smoking, becomingaddicted and dying prematurely ishigher than for any other addiction(such as alcohol, for which the likeli-

hood of addiction is much lower).Furthermore, experts characterize thedependency caused by nicotine-deliv-ery products (e.g., cigarettes, cigars,pipes, smokeless tobacco) as greater

than the dependency caused by eitherheroin or cocaine (WHO, 1999).Studies carried out by the UnitedStates Centers for Disease Control andPrevention (CDC) reveal that around70% of smokers want to quit, but lessthan 3% are able to do so and remainsmoke-free over the long-term (CDC,1999 August).

THE DEPENDENCYTHAT KILLS

Nearly thirty-five years have passedsince the United States Surgeon Gener-al published the first report identifyingthe harmful effects of cigarettes onhuman health. In this groundbreakingreport, the Surgeon General docu-mented that smoking cigarettes led tochronic bronchitis, lung cancer, andcancer of the larynx in men (U.S.

Department of Health, Education, andWelfare, 1964).

Subsequent studies have document-ed the relationship between tobaccouse and more than thirty additionaldiseases, such as cardiovascular disease;cerebrovascular disease; chronicobstructive pulmonary disease; cancersof the mouth, esophagus, throat, blad-

der, cervix and pancreas; and, amonginfants exposed to maternal smoking,low birthweight and sudden infantdeath syndrome.

Exposure to environmental tobaccosmoke also has been linked to death

and disease. A recent WHO report(WHO, 1999) on environmentaltobacco smoke and childrens healthreveals an association between thisexposure and pneumonia, bronchitis,coughing, wheezing, worsening ofasthma, and middle-ear infections inchildren. In addition, environmentaltobacco smoke is associated with ahigher risk of lung cancer causing anestimated 3,000 deaths each year in theUnited States aloneand it also

increases the risk of heart disease(CDC, 1999).Every year, tobacco is responsible

for 3.5 million deaths: it is the leadingcause of foreseeable deaths around theworld. Despite the dangers of tobaccouse, people continue to smoke, and theannual death toll continues to rise. Infact, WHO estimates that there are 1.1billion smokers in the world, and 88million of them live in developingcountries (WHO,1999) (see Figure 2).If this trend is not reversed, tobacco

use will be responsible for 10 milliondeaths annually by the year 2030, ofwhich 70% will occur in developingcountries (WHO, 1998 April).

Preventing these deaths is of para-mount importance and a priorityof public health professionals aroundthe world.

The longer a person continues touse tobacco, the greater the health risks.The mortality rate of smokers is threetimes greater than that of non-smokersin all age groups, starting in early adult-

hood. Individuals who become addict-ed to nicotine in adolescencenearly60% of all youth who experiment withsmokinghave a 50% chance of dyingfrom tobacco as they become adultsmokers, with a loss of around 22 yearsof normal life expectancy (U.S. Depart-ment of Health and Human Services,1994) (WHO, 1999 May).

In 1997, adolescents between 12 and 17 years old

who smoked cigarettes were nearly 12 times as like-

ly as nonsmoking youth to use illegal, addictive

drugs and 23 times as likely to drink heavily.

(United States Substance Abuse and M ental Health Services Adm inistration)


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In the United States, more than 20% ofdeaths today are related to tobacco useinitiated decades ago, when prevalenceof consumption in adults was morethan 45%. Since then, adult tobaccouse has decreased to around 25%, andhas remained somewhat stable for the

last decade. However, the prevalence oftobacco use among adolescents,although declining in the 1980s,increased in the 1990s. In 1997, smok-ing rates among young adults ages 18to 25 stood at 40.6%, up from 34.6%

just three years earlier (SAMHSA1999).

Since 1990, the CDC has surveyedadolescent smoking at schools acrossthe United States using the Youth RiskBehavior Surveillance System. Datafrom 1997 show that 70% of the stu-

dents surveyed had experimented withsmoking at least once, 36% of studentshad smoked a cigarette in the previousthirty days, and 44.5% reported havingused some form of tobacco (cigarettes,smokeless tobacco, or cigars) in the pre-vious month (CDC, 1999 August).

The costs of tobacco usein bothhuman and economic termswill

wreak havoc on nations around theworld at increasing rates as the num-bers of new smokers continue to climb.In terms of economic costs, U.S. med-ical expenses to treat diseases related totobacco use have been estimated at $50to $73 billion annually (CDC, 1999

August). WHO has described thetobacco epidemic as both a majordrain on the worlds financialresources, and a major threat to sus-tainable and equitable development(WHO, 1998 June).

TOBACCO USE INLATIN AMERICA

Historically, indigenous populations in

the Americas have used tobacco in heal-ing practices, ceremonies, and rituals.In the first part of the 20th century,tobacco began to be increasingly usedas the popularity of the cigarette inten-sified after World War I (DHHS andPAHO, 1992). In the past couple ofdecades, several factors have begun toinfluence an increase in the use of

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SUBSTANCE USE AND ADDICTION

Of the 1.1 billion smokers in theworld, 88 million live in the devel-oping world. If smoking ratescontinue to rise, 7 million people indeveloping countries will die oftobacco-related causes in the

year 2030.

Men Women

50

45

40

35

30

25

20

15

10

5

0

Developing countries Developed countries

Figure 2. WHO estim ates of smokingprevalence in developing and developed

countr ies, by gender, May 1999.

Source: WHO, 1999.


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tobacco in Latin America. Demograph-ic changes have expanded tobaccosmarket potential, including a reduction

in birth rates and mortality with subse-quent population growth; greaterurbanization; greater access to educa-tion, followed by higher employmentand increased purchasing power; and alarger proportion of women in the

workforce.The fact that tobacco is cultivated inthe Region also may have acceleratedthe smoking trend. In many tobacco-producing countries (e.g., Argentina,

Brazil, Cuba, Honduras, and Mexico)and cigarette-manufacturing countries(e.g., Brazil, Colombia, and Venezuela),tobacco and its products translate intomajor export earnings (WHO, 1997).Population groups that are vulnerable

to tobaccos appealsuch as adoles-centsare likely to be exposed totobacco if they participate in the tobac-co production and manufacturingworkforce. Such everyday exposure mayreinforce a perception that tobacco useis widespread and socially acceptable.

In developing countries in theRegion of the Americas tobacco isresponsible for some 135,000 preventa-ble deaths each year (WHO, 1997). InMexico alone, an estimated one in four

deaths is related to tobacco-use (Insti-tuto Nacional de Enfermedades Respi-ratorias, 1997) (see Tables 1 and 2).

Unlike the United States and Cana-da, most Latin American and Caribbean

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TOBACCO-FREE YOUTH

Table 1. Tobacco-related deaths inthe Region of the Americas, 1996.

United States 500,000

Latin America 100,000

English-speaking Caribbean 35,000

Canada 35,000Total 670,000

Source: WHO, 1997.

Table 2. Percentage of population (> 12 years old)using tobacco, by country.

At least In the In the

once previous year previous month

Bolivia (1992) 46.8 34.1 24.9

Canada (1994) 54.5 27.0

Chile (1996) 70.2 47.5 40.4

Colombia (1996) 38.8 25.9 22.2

Costa Rica (1995) 35.2 18.3 17.5

Paraguay (1991) 24.3

United States (1994) 73.3 31.7 28.6

Mexico (1993) 45.4 25.1

Peru (1997) 62.1 42.0 31.7

Venezuela (1996) 31.8 25.7 24.4

Source: PAHO, 1998.

In Latin America and the Caribbean, tobacco isresponsible for 135,000 preventable deaths each

yeara human cost too great to compensate for

any financial gain from tobacco production.


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countries do not have country-specific,standardized surveillance systems inplace to systematically monitor eitherthe prevalence of smoking or the toll ittakes on human health and well-being.The most recent prevalence data avail-

able for the Americas was renderedthrough the WHO Tobacco orHealth initiative in the mid-1990s(WHO, 1997).

Analysis of this important, althoughlimited, data reveals that in the early1990s per capita consumption of ciga-rettes in persons over 15 years of ageaveraged 1,300 cigarettes per year.Low-consumption countries, such asPeru and Guatemala, reported only350 cigarettes consumed per capita per

year, and high consumption countries,such as Venezuela and Cuba, reportedper capita consumption at around2,000 cigarettes per year.

According to WHO estimates, 40%of men and 21% of women smoke indeveloping countries in the Region ofthe Americas (WHO, 1998), but thisfigure masks the considerable variationbetween countries and among popula-tion groups. For instance, data revealthat two out of three men smoke in the

Dominican Republic, and as many asone-quarter of all women are smokersin Brazil, Chile, Cuba, and Uruguay(WHO, 1997) (See Figure 3).

A PAHO/WHO survey conductedin 1992 showed that in urban areas of

the most developed Latin Americancountries, young peopleespeciallyyoung womenwere beginning tosmoke at a higher speed than that oftheir predecessors. Smoking amonggirls has been reported to almost equalsmoking among boys in Argentina,Chile, and Cuba, for instance (seeFigure 4).

However, the difference in smokingprevalence between genders is moreaccentuated in other countries. For

instance, in Honduras in 1995, lessthan 10% of school age girls werereported to smoke, compared to morethan 35% of boys the same age (Insti-tuto Hondureo para la Prevencindel Alcoholismo, Drogadiccin yFarmacodependencia, 1996) (see Fig-ure 5). And in Bolivia, the differencein smoking between genders was justas great in urban areas (43% malesmokers v. 18% female smokers) asin rural areas (44% v. 17%) (Centro

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Current smokers Lifetime prevalence

80

64

48

32

16

0

11th grade females

11th grade males

8th grade females

8th grade males

Figure 3. Percentage of current smokers and lifetim eprevalence of smoking among 3,635 students,by school grade and gender, Argentina, 1997.

Source: Morello, 1997.

Tobacco cultivation in the Americ-as may also have helped to fuelthe increase in tobacco use inLatin America and the Caribbean.Adolescents working in tobaccoproduction are exposed to tobac-

co on a daily basis, which mayreinforce their view that tobaccouse is widespread and sociallyacceptable.


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TOBACCO-FREE YOUTH

Percent

Male Female

25

20

15

10

5

0

1516-year-olds 1719-year-olds

Figure 6. Smoking prevalenceamong youth 15-to-16 and

17-to-19 years old, by gender,Cuba, 1995.

Source: M INSAP, 1995.

Percent

Males Females

40

30

20

10

0

Latinoamericano de InvestigacionCientifica, 1998).

Although the reported age of smok-ing initiation varies across the Region,it does appear to be dropping. Asmeasured by a nationwide survey in

Cuba, for example, more than 35%of adult smokers surveyed in 1995started smoking before the age of 14(Ministerio de Salud Pblica, 1995). Asurvey of students conducted in

Uruguay in the 1980s revealed theaverage age of smoking initiation to bebetween 15 and 16 years old (Ruocco,et al., 1989).

Partly as a result of earlier smokingonset, the number of young smokers

addicted to nicotine continues toclimb through adolescence into adult-hood (see Figure 6). In Cuba, almosthalf of adolescent smokers between theages of 17 and 19 years old described

Source: IHADFA, 1996.

Figure 5. Percentage ofschool-age children

reported to have ever smoked,by gender, Honduras, 1995.

1994 1996

35

30

25

20

15

10

5

0

Male Female

Figure 4. Percentage of 1218-year-oldswho smoked in the previous month, by

gender, Chile, 19941996.

Source: CONACE, 1996.


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that they had tried to quit at least once(Ministerio de Salud Pblica, 1995).

TOBACCO CONTROLEFFORTSTobacco control achievements varybetween countries in the Region of theAmericas: the United States and Cana-da have made great progress regulatingtobacco, but other countries have madeless progress in reducing tobacco use.This was reflected in the late 1980s,when tobacco use in Latin Americadeclined only modestly (11%) whilethe United States and Canada experi-enced a reduction of 28% and 35%,respectively (PAHO, 1989).

Economic and political factors seemto be responsible for the disparitybetween tobacco control efforts inindustrialized countries in NorthAmerica and developing nations in theRegion. The latter countries may behindered in their ability to achieve bet-ter tobacco control due to the factthat many of these countries dependheavily on income generated from theproduction or manufacturing of tobac-co products.

The relative lack of national regula-

tory action in some countries in theRegion is likely associated with thedubious power of the tobacco industryto stimulate the economy and generate

jobs and taxes. Both tobacco and alco-hol are legalized drugs that con-tribute much needed income forresource-poor countries through taxa-tion policies. In an effort to preservethis income, policy makers frequentlyfail to implement restrictions on thepromotion and consumption of ciga-rettes. Anti-tobacco legislation is often

minimal at best and is rarely enforced.Economic losses resulting from

tobacco, although staggering, have notbeen clearly communicated. WHOreports that most analyses of the eco-nomic effects of tobacco reveal that adecline in production would not resultin overall lower employment or eco-

nomic output (WHO, 1999 April).They further state that the alleged eco-nomic benefits of tobacco are illusoryand misleading when all the costsassociated with the product are notconsidered. Unfortunately, the eco-

nomic losses associated with thesedrugs are rarely measured or factoredinto the equation.

The perceived economic benefits oftobacco also may be part of the reasonwhy so few developing country govern-ments in the Americas have initiatedcomprehensive tobacco control or pre-vention campaigns. Nongovernmentalorganizations have taken on much ofthe responsibility for leading suchtobacco control activities as World NoTobacco Day or smoking cessation andsubstance abuse prevention programs.

Despite the lack of progress intobacco control relative to their indus-trialized neighbors, several developingcountries in the Region have madeimpressive strides. For instance, someadvertising restrictions are now in placein Chile, Colombia, Costa Rica, Mexi-co and Panama, and smoking has beenbanned on most commercial flights inthe Region (WHO, 1999).

The Coordinating Committee of

Tobacco Control in Latin America(CLACCTA), founded in 1985, hasbeen actively involved in motivatingcountries in the Region to adopt tobac-co control policies. In addition, theInteragency Committee for the Con-trol of Smoking in Latin America wascreated in 1995. It includes representa-tion from the Centers for Disease Con-trol and Prevention, the Society AgainstCancer and the National Cancer Insti-tute, both from the United States,CLACCTA, the International Union of

Struggle Against Cancer, Health Cana-da, and the Pan American HealthOrganization. The Interagency Com-mittees main function is to providefinancial and technical support for par-ticipating national programs thatreduce the supply of and the demandfor tobacco.

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Tobacco-control efforts vary fromcountry to country, and can rangefrom prevention campaigns, toadvertising restrictions, to legisla-tion. This sign on a building inCosta Rica attempts to enforce asmoking ban legislation.


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TOBACCO-FREE YOUTH

In 1995, the Interagency Commit-tee established the following five goalsfor participating countries:

to increase by 10% the number of

former smokers within five years,

to reduce by 10% the incidence of

tobacco use among young people

between 12 and 16 years old with-

in five years,

to raise by 2 years the age at which

tobacco consumption is permitted

within five years, and

to reduce by 5% mortality ratesfrom noncommunicable, tobacco-

related diseases within ten years.

In order to meet these targets,despite the tobacco industrys organizedopposition, committed policy supportand the assistance of private and gov-ernmental organizations is critical.

TOBACCO INDUSTRYPRACTICES IN THEAMERICAS

As tobacco control tightens in industri-alized countries, multinational tobaccocompanies are strategically increasingtheir penetration into resource-poorcountries in the Region, where they candirect their efforts at potentially lucra-tive markets vulnerable to the tobaccoappeal, such as adolescents and women.

By and large, these groups are notsufficiently protected by regulationslimiting tobacco promotion or access totobacco. Industry marketing and adver-tising that target these groups remainslargely unchallenged. The tobaccoindustry in developing countrieswhose financial resources often outstripthose of national governmentshaveorganized powerful tobacco lobbyists

SMOKING PREVENTION AND CONTROLPROGRAMS IN THE REGION

According to the report on the Regional Encounter on Smoking,which took place in Rio de Janeiro in August 1998, the status of

smoking prevention and control programs in the Am ericas can bedescribed as foll ows:

Almost all the countries in the Region have a basic govern-mental or non-governmental infrastructure for the preventionand the control of smoking.

Smoking cessation services are frequently led by ecclesiasticand community organizations. Financing by governments israre.

These systems use a multidisciplinary approach to monitorsmoking.

Educational programs in schools have not been used much inthese control activities, although evaluation studies indicate

that these programs can be effective.

In almost all the countries, public inform ation activities are car-ried out, but their effectiveness and impact on tobacco usebehavior are unknown.

Research for International Tobacco Contr ol, 1998.


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who have managed to thwart tobaccocontrol legislation in countries such asArgentina and Uruguay as part of anaggressive tobacco promotion strategyaimed at increasing consumption in theRegion (Weissman, 1998 [as cited in

Hammond, 1998]).Promoting tobacco products not

only involves lobbying against tobaccocontrol, but it also entails a hugeinvestment in publicity and marketingcampaignswhich, in effect, dimin-ishes the impact of any existing nation-al policies that attempt to regulatetobacco. Publicity is a very importantcomponent of the tobacco industrysstrategy, and it is used worldwide tomaintain tobacco demand. In 1996 theU.S. Federal Trade Commission esti-mated annual tobacco industry pro-motional expenses at $5 billion in theU.S. alone.

The industry has traditionallyargued that their tremendous invest-ment in publicity and marketing cam-paigns is not intended to increase con-sumption but to merely preserve marketshare, maintain the loyalty of smokersto a given brand, and promote cigaretteswith low tar and nicotine content. Sincevery few smokers change brands of

products, however, this enormous effortand expense hardly seem warranted.

The use of publicity as a strategictool to increase tobacco use is ubiqui-tous in the Regions developing coun-tries, where extensive publicity and

promotion of tobacco have becomecommonplace. Promotional productssuch as clocks, lights, displays, andattractive posters have made their wayto the most isolated towns and kiosks.In addition, most televised sports (e.g.,auto racing and soccer matches) andcultural events have been sponsored bythe tobacco industry for decades, mak-ing sports leagues now heavily depend-ent on tobacco money.

In addition to promoting theirpotentially lethal products, tobaccocompanies also use publicity campaignsto try to shape their public image as anindustry concerned about the health ofadolescents. These campaigns frequent-ly involve the creation of alliancesbetween tobacco manufacturers orretailers and Ministries of Health andof Education, tobacco control organi-zations, or Offices of the First Lady. Asa result of such alliances, government,university, or nonprofit organizationsthat have joined forces with the tobac-

THE CASE OF MEXICO

In the recently published Addicted to Profit: Big Tobaccos Expand-ing Global Reach (1998), Ross Hammond describes the rise of bigtobacco (a.k.a. Phil ip M orri s and Brit ish Am erican Tobacco) in Mex-ico upon the opening of its markets to foreign investment. In July1997, the two i ndustry giants paid a total of US$ 2.1 bill ion fo r tw oMexican cigarette companies.

The report explains that M exico is especially attractive to m ulti-national cigarette producers because of its cheap labor, qualitytobacco leaf, young population, and few restrictions on tobacco.

Industry critics believe that one of the prim ary goals of the buyoutsis to establish the country as a platform from wh ich to cheaply pro -duce cigarettes for export to other developing countries.

However, the potential to develop Mexican markets (includingthe worlds fifteenth largest cigarette market) has apparently notgone unnoticed. The foreign subsidiaries have boosted marketingexpenditures and honed their advertising strategy to portray theirproduct as meeting Mexican consumers desires for internationalstatus, romance, and rebellion.


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TOBACCO-FREE YOUTH

co industry are subsequently limited intheir power to reduce tobacco con-sumption through anti-industry strate-gies. Unfortunately, such alliances areall too common in the Regions devel-oping countries.

Industrialized countries have recent-ly begun to acknowledge the conse-quences of the tobacco industrys target-ing of developing countries on theglobal burden of disease, and they are

beginning to help these countries pro-mote national and local tobacco controlmeasures. In addition, some developingcountriesGuatemala, Nicaragua, andVenezuela, for examplehave followedthe example of the United States andhave begun to hold multinationaltobacco companies accountable bydemanding compensation for healthcare costs stemming from tobacco-related death and disease.

TOBACCO INDUSTRY PRACTICES

MarketingCigarettes can be heavily prom oted wi th very positive im agery thatprom otes a notion that smoking is acceptable, even healthy, or that

risk-taking is glamorous. Tobacco companies have also beenallowed to engage in o ften quite deceptive behavior that reassuressmokers and keeps them in the tobacco market. Tobacco compa-nies, often un fettered by governments, manipulate the dependenceof smokers by offering justification for continued smoking andmarketing alternatives to cessation.

Public RelationsEither directly, or through funded front groups, tobacco compa-nies often attack the scientific evidence on the effects of smoking.The industry also adopts the stance that smoking is not as harmfulas other activities, or that everything is harmful. These publicrelations strategies are often so far removed from scientific realitythat they would not work for most consumer products. But tobac-

co, because of the dependency i t creates, is not li ke other products.Smokers are often strongly motivated to find ways to justify con-tinued smoking, and wh ile others might recognize these strategiesas attempts to deceive consumers, smokers may view them as abeacon of hope in their efforts to justify continued smoking there-by avoiding the hardship o f a cessation attempt.

Packaging and LabelingCigarettes are sold in attractive packaging and offered in smallquantitiessuch as a single day s supply). If health messages arerequired on packaging and advertising, tobacco companies oftensuccessfully ensure that messages are as small and inconspicuousas possible, and are rarely updated, essentially undermining the

effect of t he warnings.

ProductsA lack of health-based product standards means that cigarettes canbe manufactured in order to be very effective nicotine delivery sys-tems. Nicotine delivery can easily be manipulated and cigarettescan be m ade more palatable by leaf blending and using additives.

PAHO, 1999.

Although required by law, healthmessages on cigarette packagesoften are inconspicuous or diffi-cult to read. Note the contrast

between the crisp and clear brandname on the front of the pack andthe almost illegible health mes-sage on the side.

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Uso de Sustancia y Adicción Substance Use and ADICCTION