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Foreword
One way and another modern society has become highly medicated. On the one hand thereis the daily round of prescription medicines issued by National Health Service doctors and otherprescribing clinicians and an unknown level of prescribing from the private sector. On the otherhand there is the huge use of lay medication through over-the-counter purchases at pharmaciesand the informal use of substances, both legal and illegal to ameliorate the human condition.
This report concentrates on the particular use of alcohol, tobacco and other mind-altering drugsfrom a public health perspective in the North West Region of England. The terms of referencefor the report were to try and produce a joined-up view of these three types of substance use.
This contrasts with the customary compartmentalisation of our understanding of them and theirsocial impacts and attempts to tackle the adverse consequences of substance misuse. In the mindof the general public and of the media a distinction is implicity drawn between the legal use ofalcohol and tobacco and the illegal use of other substances. Yet as this report makes clear wecannot properly understand substance use from a public health point of view, and search forpolicy options and service solutions, unless we have a clear overview of the way in which societyas a whole and sub-groups within it, use a range of chemicals to mediate their experience ofeveryday life. Nor is the use of substances of whatever kind neatly compartmentalised.
The annual toll in terms of premature death and disability from alcohol and tobacco use withinthe North West region is immense. The toll from illegal drug use is less but no less distressing.
If we are to get upstream of substance use of all kinds we need a better understanding of theways in which we all handle stress so that we may find health promoting and protectingalternatives. This report is a beginning for our region.
JOHN R ASHTON C.B.E.
Regional Director of Public Health
North West

Acknowledgements
We would like to thank Professor John Ashton, NHS Executive North West, who commissionedthis report, and Dr. Iqbal Sram, Professor Qutub Syed and Rod Thomson on the project steeringgroup for their support during the production of the report. We thank Andrew Williamson forhis assistance in developing this work; all the busy staff at substance use agencies whocompleted a questionnaire; and Shirley Ashton, Caryl Beynon, Jeff Lake, Diana Leighton, JimMcVeigh, Chris Owen, Lyn Owens, Lorna Porcellato and Jane Roberts for their comments on themanuscript. We would also like to thank all the administrative staff at the Public Health Sector,Liverpool John Moores University, for their invaluable support.
Introduction
I) Introduction
Regardless of the variety of labels that different cultures attach to substances such as heroin,
alcohol, ecstasy, cigarettes (nicotine) or prescribed compounds like tranquillisers and painkillers,
they are all drugs. Each alters the body’s physiology in a different way providing desired effects
such as euphoria1 or pain relief2. However, such responses are always accompanied by side
effects that may include: acute and chronic term mental damage2, increased risk of diseases
such as cancer3, accidents through disorientation4 and long-term dependence5. Both in the short
and long term drugs can alter behaviour and personalities. Alcohol and amphetamine use may
increase violent tendencies6. Equally, the withdrawal from substances by those dependent on, for
instance, cigarettes or heroin may lead to irritability and aggression7.
Clearly, some substances have far stronger relationships with different types of disease. Tobaccoconsumption is strongly related to increased risks of cancer and coronary heart disease7 (SeeChapters 2 and 6). The relationship between chronic alcohol consumption and liver disease iswell documented8 (see Chapters 1 and 5) as is the relationship between injecting drug use andinfection with blood borne viruses such HIV, Hepatitis B and Hepatitis C4 (see Chapters 3 and7). However, while the effects of using different substances may vary, the reasons for use,populations most effected by use and wider repercussions for Public Health have similaritiesacross a range of substances. Despite such shared causes (see below), historical and politicalfactors have often led to segregated and disproportionate responses dependent on thesubstance used (cf. alcohol, ecstasy, cannabis, tobacco or cocaine). The following report aims to provide a broad overview of substance use and its health costs(Chapters 1, 2, 3, 4), and the prevalence of substance use and its burden on health (Chapters5, 6, 7, 8), in general across the UK and more specifically in the North West Health Region. Theinformation within this report is intended to help support a broader understanding of substanceuse issues, more strategic responses to the health risks posed by each substance and anintegrated approach, where appropriate, to prevention, cessation and treatment and care. II) Substance Use - Shared Risk Factors
Strong relationships exist between the use of alcohol, tobacco and other substances such as
cannabis and ecstasy. These begin from the earliest stages when patterns of use are developing
and are still factors later in life when established users try to reduce consumption or abstain.
Table I summarises some international research on factors predicting use of different substances
in adolescents. Levels of deprivation, family problems, poor school performance, criminal
activity and self-reported factors such as a history of depression all predict the use of alcohol,
tobacco and drugs at early ages.
A relationship between consumption of one substance within a particular social group (orsetting) and an increased risk of consuming other substances is not surprising. Even in the youngest age groups, social conditions result in a range of substances being consumed together.
The young boy or girl using cigarettes in even pre-teen years may be at greater risk of illegalalcohol consumption or sniffing glue or fuel as part of a covenant of secrecy with like-mindedfriends. Furthermore, while the long-term risks from cigarettes or alcohol are significant(Chapters 1, 2), the immediate health risks posed by solvent and fuel abuse account for one inforty of all deaths among young people aged 15 to 19 in the UK9. Differentials in tax on alcohol and tobacco across Europe have resulted in even more similaritiesbetween legal and illegal drug consumption by young people in the UK. Illegal importers ofcigarettes and alcohol now target underage people for their subsequent sale as young peopledrinking underage are looking to maximise limited funds and are unlikely to reveal theirsources10. With 9% of 11-15year olds smoking11 (see Chapter 6), significant illegal andunderage trading in cigarettes must also occur. In fact, smuggling cigarettes is now so profitablethat criminals (in some cases) have turned from illegal drug importation to cigarettes in order toimprove profits12. For the young person this means their pusher of illegally imported tobaccomay also be the pusher of other substances (cannabis, ecstasy or harder drugs); a market suchcriminals will be anxious to exploit. Table I: Summary of studies assessing risk factors for the use of different
substances in adolescents

Risk Factor Alcohol Tobacco Drugs
Note: Blanks (-) do not necessarily indicate that no studies exist for risk factors and substance types. Numerous other studies not identified in this report exist for all substance types.
Thus, for young people, a wide range of legal and illegal substances share similar socio-economic risk factors. Higher levels of use are found amongst those with educational, familyand other social problems as well as those identified as indulging in other risk behaviours at anearly age (e.g. sexual activity). Links between the use of different substances means that thoseusing one substance will often be exposed to others and the illegality of underage tobacco andalcohol purchase means the judicial differences between legal and illegal substances may beless relevant to those under 18. Furthermore, a closer relationship between all substances maynow be developing through shared routes of supply (i.e. illegal importation). III) Substance Use: Social Patterns of Use
Cultural patterns of substance use dictate that close links between the use of different substances
continue across all age groups. For instance, when people consume ecstasy it is rarely in
isolation from other substances. Many start their night with alcohol and tobacco before
consuming ecstasy (and sometimes amphetamine and cocaine) either in or before visiting a
nightclub or late night bar. Later individuals may ‘come down’ using a combination of tobacco
and cannabis51. In other groups, a pint and a cigarette may be a less complex pattern of use
(applicable to a different, often older, population) but the linkage between substances remains52.
The repercussions of those socially using one substance being routinely exposed to supply of
others are at least two fold:
• First, it increases the opportunity for users of one substance (e.g. alcohol) to be recruited to use of another (e.g. tobacco, ecstasy, cocaine). This is mediated through a combination of availability, peer pressure and an uninhibited attitude induced, for instance, through alcohol or cannabis consumption. • Secondly, those attempting to quit, for instance smoking, are re-exposed when out consuming alcohol. In fact, potential quitters often find themselves most tempted when socially drinking alcohol53. Cigarette companies are all too aware of how vulnerable individuals consuming alcohol in pubs and clubs are to smoking and often choose these settings to promote and distribute free products.
More directly, use of one substance may require using another. For cannabis users, thoseattempting to quit tobacco use can relapse through the continued exposure to nicotine from joints(cannabis and tobacco cigarettes). Some argue smoking joints is a significant gateway intohabitual cigarette use. A realisation of this factor by some cannabis users (combined with aknowledge of the relationship between tobacco and lung cancer) may have resulted in areduction in the tobacco content of joints. The strong link between cannabis smoking and lungcancer54,55 has gone relatively unnoticed as prevention messages addressing lung cancer havenot considered both substances (despite 42% of young people having consumed cannabis, 14%of whom are regular users56; see Chapter 7). Equally, a series of studies have now identified cigarette smoking as a gateway drug into theuse of other substances such as cannabis57,58. In particular when considering social drug use the relationship between cigarette use and other drugs can be stronger than the relationshipbetween drugs and alcohol. In a recent study (1999-2000) of associations between drug useand both alcohol and tobacco (n=1315 16-35 years old UK residents travelling abroad forholidays59), smokers were significantly more likely than non-smokers to have recently usedamphetamine, ketamine, cannabis, ecstasy, LSD (Lysergic Acid Diethylamide), cocaine and GHB(Gamma Hydroxybutyrate; see Appendix 1 for drug definitions). In contrast, consumption ofalcohol was only predictive of cannabis and ecstasy consumption. IV) Media, Product Promotion and Confidence
Relatively strict rules govern the content of any material used in the media that may directly
promote legal or illegal drug use60,61,62. However, product placement still allows cigarettes
promotion through media icons consuming tobacco on screen while programmes and adverts
promoting alcohol are ubiquitous. Age certification for films and television watersheds reduce
the exposure of young people. Currently however one of the most popular sets of toys is
Thunderbirds and almost the entire puppet cast can be seen smoking and drinking in videos of
the original series. Some films have been accused of presenting glamorous images of even hard
drug use (e.g. Pulp Fiction). Most often however, the strong relationships between alcohol,
tobacco and illegal drugs are used more subtly by the media and promotional organisations.
The clubbing phenomenon which developed in the late 1980s, and was closely associated withthe consumption of ecstasy, also produced it’s own imagery63. Shortly afterwards designer drinksbegan to emerge using similar images attempting to attract custom from clubbers and evenyounger “would be clubbers”. Despite the existence of a voluntary code of practice on themarketing of alcohol, advertising, promotions and sponsorship deals within the alcohol industrycontinually appear to be aimed towards young age groups64. Although cigarettes have not yetadopted the same marketing strategies, to the same effect they have developed strategicsponsorship deals. Brands such as Benson and Hedges and Silk Cut have sponsored populardance club listings magazines (Club On and UK Club Guide). Cream, one of the biggest andbest-known nightclubs in the UK and possibly in the world, is sponsored by Smirnoff65.
In addition to direct and indirect promotion of substance use, unattainable ideals of body imagepromoted through the media have been associated with the use of a range of legal and illegalsubstances. Across all age groups, but in particular in young girls, smoking has been seen asone method for controlling weight to obtain an ‘ideal’ figure66. More recently however, bodyimage has also become a major concern for young boys. Performance Enhancing Drugs (PEDs;especially steroids) are no longer solely used by professional athletes but now used by youngmen in order to enhance their physique67. A recent study in Liverpool found that 1 in 50 menbetween the ages of 25 and 29 were using (usually injecting) steroids68 (see Chapter 8). In otherparts of the world the figure is already much higher69. With issues of body image unaddressedwe may expect increasing levels of both PED consumption and smoking especially in youngerpeople. Substance use is by no means limited to physical enhancement. Cigarettes are used to improve alertness often by those working, driving or partying late at night. Equally however,amphetamines are consumed either to extend the length of a night out or in some cases by thoseworking through the night for instance in preparation for a school exam13. Legal highs2 (seeChapter 4) and even caffeine could be considered to fulfil the same functions. Substances, legaland illegal, are consumed to enhance body and mind but equally when individuals questiontheir physical, mental and social ability, substances are used to elevate confidence13. Smokingor Dutch courage (alcohol) in preparation for a stressful event are common reasons forsubstance consumption but prescribed medication or illegal consumption of cannabis or cocainecan be taken for the same confidence enhancing reason. Even those using methadone and inemployment often save their dose until they come home after work when they use it to relax andsocialise70. Again, although legal status varies and physiological effects may be different thereasons for consumption are similar, if not the same.
V) Substance Use - A Medicated Society
Although the media may be a regularly used vehicle for promoting substance use, an engrained
medical attitude (throughout society) that:
‘a pill is the answer to most problems’ may also be at the root of increasing substance use. At one end of the scale this may be typifiedby an individual seeing a doctor with a cold and insisting on antibiotics even though they areunlikely to have any beneficial effect. At the other end of the spectrum researchers havesuggested that children whose parents regularly provide them with medicines for simple ailmentsare more likely to turn to illegal drugs to address their own problems71. The blurred boundariesbetween attitudes towards consumption of prescribed and illegal pills is further exemplified byteenage consumption in Spain. Teenagers no longer even enquire specifically what the drugs(usually tablets) are that they are purchasing. They indiscriminately buy a handful of “pastillas”(pills) which is now their slang for drugs96. Further work is clearly needed on the relationship between general medicinal consumptionincluding prescribed medicines (see Chapters 4, 8) and the effects this has on the attitudes ofyoung people towards consumption of other substances. However, we should not rule out thepossibility that a relaxed familial attitude to drug taking in general may in fact be related toillegal drug consumption. Perhaps all pharmaceuticals (prescribed or not) like tobacco, cannabisand cocaine should be examined as potential gateway drugs.
VI) Substance Use - Interactions Between Effects
Consumption of multiple substances at the same time is now commonplace. However, the almost
infinite number of combinations of prescribed medicines, legal substances and illegal drugs
make pathological and even fatal combinations an increasing concern. Alcohol especially is
regularly consumed with other drugs with potentially life threatening effects. Drugs such as GHB
(also known as liquid Ecstasy) and ketamine can suppress respiratory activity. Such effects are
enhanced by the presence of alcohol3. Accident and Emergency Unit presentations indicate that
the increasing popularity of such drugs in nightclubs has not displaced the use of alcohol, but
rather that alcohol is being consumed together with dangerous drug cocktails72.
As well as damage to oneself the potential for accidents involving others is also increased throughcombined use. For established illegal drugs we now have reasonable information about how longthey are retained in the body73. However, in particular for newer drugs, understanding of howlong effects persist is very limited. Individuals using moderate amounts of alcohol (e.g. less thanthe driving limit) may be further disorientated when driving from the combination of alcohol anddrugs either recently consumed or at residual amounts from an earlier dose. Recent figuressuggest that as many as 1 in 5 drivers killed on the roads have blood/alcohol levels above thelegal limit74 whilst 18% are thought to be under the influence of drugs75 (see Chapters 1, 3). Combined (as well as individual) use of substances can also promote other risk behaviours. Theeuphoria and disorientation associated with alcohol and drugs may increase libido, reducesexual inhibitions and distance thoughts of safe sexual practices76,5. The result, though lessimmediate than traffic accidents, can be equally damaging to health with increased risks ofsexually transmitted infections, unwanted pregnancies and ultimately ruined lives76. Reports ofrecreational use of Viagra in nightclubs77 raise fears of the spread of HIV and AIDS, through thereduction of self-induced and pathological impotence78. Equally however, recreational use ofViagra in conjunction with “poppers” (inhalant nitrates) can be particularly dangerous due topossible hypotension caused through the interaction of these drugs79. Prescribed medicines also interact with legal and illegal substances. For instance GHB is now apopular cruising drug (i.e. used when looking for sex) amongst the gay community80. However,it can interact dangerously with prescribed medicines for conditions such as HIV. Finally, nophysiological interaction between drugs may be necessary but the effect of consuming one drugmay make using another more hazardous. Individuals injecting heroin or other substances maybe more likely to share needles or other injecting equipment (accidentally or intentionally) if theyuse other substances in advance. Equally, someone smoking a cigarette or joint late at night afterconsuming alcohol may fall asleep causing a fire. VII) Treatment
Considering the significant health and other costs of substance use, the range of treatments
available for those seeking help is severely limited. Despite similar causes underlying the reasons
for substance use (see above) services are usually quite specific. Most drug services deal
primarily (and sometimes exclusively) with heroin addiction. There are few that provide services
primarily for amphetamine users or cocaine and crack addicts. Consequently, before individuals
engage with drug services they have usually progressed to severe problematic and often
injecting drug use. Importantly, however, alcohol addiction often accompanies such problematic
use81 and some services and the structures that direct them (Drug Action Teams; DATs) have
begun to adapt to address both issues. Thus, some DATs have now become Drug and Alcohol
Action Teams (DAATs). Few services however are poised to deal with the environment in which
users live, the problems that led to their addiction and the underlying causes that made
individuals susceptible to problematic drug use in the first instance.
For heroin, limited resources dictate that following a period of maintenance therapy individuals are often returned to an environment populated by individuals still using the same drug (e.g.
heroin using friends) and containing the same stresses from which drugs initially provided therelief. Not surprisingly even those who manage to become drug free usually relapse within twoyears82. This scenario is not limited to heroin. A similar pathway of maintenance therapycombined with a slow withdrawal has also been adopted for cigarettes (e.g. nicotine patchesand zyban). Without a concerted attempt to tackle the routes of such substance use (from herointo tobacco) long term success may be difficult. Most worryingly while the causes of substanceuse are still poorly understood and services addressing them scarce, pharmaceuticalcompanies invest in new products to maintain a broader range of drug users (e.g. cocaineusers). Development of a combined service response to substance use can also be hampered by aclinical focus. National Strategic Frameworks on, for instance coronary heart disease83, focus onparticular pathologies associated especially with smoking. This tends to segregate efforts toaddress substance use according to the illnesses they produce and not the underlying factors thatlead to the addiction. Equally separate alcohol, drugs and tobacco strategies can only bejustified if they focus on factors specific to each set of substances. As a result, once again, littleis developed to understand or address common factors underpinning consumption.
We require more information on the use and patterns of use of different substances throughoutthe population. However, clinicians in generic services (e.g. primary care) often feeluncomfortable exploring such matters partly out of ignorance but also because they may beconsumers (or ex-consumers) themselves. VIII) Judicial
The judicial status of different drugs in the UK owes more to history and subsequent politics than
to any impartial assessment of the effects on Public Health of their consumption. Cigarette
smoking is one of the largest ever killers on a global scale. The cost of alcohol consumption in
morbidity, violence and lives (see Chapters 1, 4) is immense. In contrast, between 1989 and
1996 only 60 individuals died as a result of consuming ecstasy4, yet ecstasy is a class A drug,
whilst both cigarettes and alcohol are legal.
It is estimated that a third of all acquisitive crimes are drug-related84. In 1995, 656 opiate drugusers committed 31,575 crimes in a period of three months before they entered treatment81.
However, the majority of drug arrests are not for heroin, cocaine or crack but still for cannabispossession85. Perhaps cannabis is a gateway into other drug use and arguably then suchmeasures could be justified. Equally however the stress and life changes associated with an arrestfor cannabis86 may be the very factors that push individuals into the use of harder substances. At least in the short term it is unlikely that the law on substances will change to one that isevidence based and consistent. However, a focus on neglected aspects of enforcement mightrepresent an intermediate step. In the UK 9% of children aged 11 to 15 smoked cigarettes during199987 and yet prosecutions for selling cigarettes to those under age are rare88. These individuals are not only illegal dealers but specifically exploit younger individuals. Equally, agreater understanding of the close links between all substance use and young delinquentbehaviour should mean that police or others contacting truants or those breaking curfews mightimmediately consider if referral to substance services is necessary. Some such measures arealready being developed89. IX) Substance Use - Positive Aspects?
Few drugs have only negative influences on health. Much has been made scientifically and in the
media, of the positive effects of alcohol consumption. The evidence has been gratefully received
by predominantly alcohol-using scientific, medical and general populations alike. Evidence
suggests that moderate alcohol consumption (in particular red wine) may have health-protecting
effects including reduced risk of coronary heart disease90,91,92. Furthermore, consumers of a range
of substances (including alcohol, cannabis, ecstasy and even tobacco) claim that their use
improves socialising93, helps them relax5 and consequently they would argue adds to their quality
of life. However, we rarely assess positive aspects of different drug use on a level playing field.
Alcohol has positive effects but these accompany violence, pathology, vandalism, crime, car
crashes and other unnecessary deaths. Methadone is advocated for the treatment of heroin and
arguably can claim some positive benefits81. However, methadone alone now accounts for more
drug related deaths per year than heroin and 18% of all problematic drug users reported to the
national drug misuse database now report misusing methadone94. Even more tenuously, some
argue the positive case for cigarettes based on revenue raised through taxes. However, they
exclude the millions of young people they annually condemn to tobacco addiction by advocating
overt and covert tobacco promotion and sales. Equally, at the other end of the scale we
acknowledge the damage caused by ecstasy, cannabis or a whole range of other substances but
rarely admit that they may sometimes relieve stress and anxiety and promote social wellbeing.
X) Summary
Understanding the links between deprivation, social conditions and substance use, as well as
how use of one substance may encourage or discourage use of another, all urgently require
more research. At present even fundamental issues including correlates of different substance
use with socio-economic conditions are poorly understood. Furthermore, assessing the
effectiveness of new initiatives to tackle substance use is hampered by a dearth of good
behavioural data on smoking, alcohol and other drug use.
A medical focus within the NHS along with legal segregation of substances means that differentdrugs are all too frequently addressed in relative isolation. In reality the use and causes of useof many drugs are intimately linked and should be addressed together. For some substances(e.g. cocaine and amphetamine) a segregated approach means that there are often no servicesavailable to meet users’ needs (see Chapter 11). Problematic drug treatment services arepredominantly for heroin users while someone with a small amphetamine or even cocaine habitmay arguably be more akin to a tobacco addict. More generally, the use of more drugs to treat those already prone to addiction needs serious consideration; especially while the causes of the habit remain unaddressed. Without a holisticapproach, many prone to drug use will simply use any new drug (prescribed or otherwise)along with their existing substances. To a large extent the clear links between alcohol, smoking and illegal drugs have been hiddenas drug treatment has been broadly equated to heroin services and drug use to problematicconsumption of opiates (mainly heroin). In general however, the consumption of substancesshares environmental causes, social patterns of consumption and similar problems withcessation. Furthermore, it is from within this population of substance users that the chaotic heroinconsumers are usually drawn95. Consequently, to deal with substance use at all levels and stemthe ever-increasing epidemic of drug problems requires a coordinated response to preventionand cessation based on the shared causes of use and not diverging patterns of pathology.
The following chapters are a first attempt at compiling a broad overview of substance use. Theyare not comprehensive as many specific texts already provide such detailed information specificto a particular drug or groups of drugs. However, we hope they help provide some of theepidemiological information necessary for those with interests in one field of substance use toidentify and explore shared approaches with colleagues in others.
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Call for papers_global environmental justice_bremen revised

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