Healthy People 2010Conference Edition

# 26 {#section .Chapter-#}

# Substance Abuse

Co-Lead Agencies: National Institutes of Health; Substance Abuse and
Mental Health Services Administration

### Contents {#contents .Heading-Special}

[Goal 3](#goal)

[Overview 3](#overview)

[Issues and Trends 3](#issues-and-trends)

[Disparities 6](#disparities)

[Opportunities 7](#opportunities)

[Interim Progress Toward Year 2000 Objectives
9](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives
11](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives 13](#healthy-people-2010-objectives)

[Adverse Consequences of Substance Use and Abuse
13](#adverse-consequences-of-substance-use-and-abuse)

[Substance Use and Abuse 22](#substance-use-and-abuse)

[Risk of Substance Use and Abuse 38](#risk-of-substance-use-and-abuse)

[Treatment for Substance Abuse 43](#treatment-for-substance-abuse)

[State and Local Efforts 45](#state-and-local-efforts)

[Related Objectives From Other Focus Areas
47](#related-objectives-from-other-focus-areas)

[Terminology 49](#terminology)

[References 51](#references)

##  {#section-1 .unnumbered}

## Goal

Reduce substance abuse to protect the health, safety, and quality of
life for all, especially children.

## Overview

Substance abuse and its related problems are among society's most
pervasive health and social concerns. Each year, about 100,000 deaths in
the United States are related to alcohol consumption.^1^ Illicit drug
abuse and related acquired immunodeficiency syndrome (AIDS) deaths
account for at least another 12,000 deaths. In 1995, the economic cost
of alcohol and drug abuse was \$276 billion.^2^ This represents more
than \$1,000 for every man, woman, and child in the United States to
cover the costs of health care, motor vehicle crashes, crime, lost
productivity, and other adverse outcomes of alcohol and drug abuse.

### Issues and Trends

A substantial proportion of the population drinks alcohol. Forty-four
percent of adults aged 18 years and older (more than 82 million persons)
report having consumed 12 or more alcoholic drinks in the past year.^3^
Among these current drinkers, 46 percent report having been intoxicated
at least once in the past year---nearly 4 percent report having been
intoxicated weekly. More than 55 percent of current drinkers report
having consumed five or more drinks on a single day at least once in the
past year---more than 12 percent did so at least once a week. Nearly 20
percent of current drinkers report having consumed an average of more
than two drinks per day. Nearly 10 percent of current drinkers (about 8
million persons) meet diagnostic criteria for alcohol dependence. An
additional 7 percent (more than 5.6 million persons) meet diagnostic
criteria for alcohol abuse.^4^

Alcohol use and alcohol-related problems also are common among
adolescents.^5^ Age at onset of drinking strongly predicts development
of alcohol dependence over the course of the lifespan. About 40 percent
of those who start drinking at age 14 years or under develop alcohol
dependence at some point in their lives; for those who start drinking at
age 21 years or older, about 10 percent develop alcohol dependence at
some point in their lives.^6^ Persons with a family history of
alcoholism have a higher prevalence of lifetime dependence than those
without such a history.^7^

Excessive drinking has consequences for virtually every part of the
body. The wide range of alcohol-induced disorders is due (among other
factors) to differences in the amount, duration, and patterns of alcohol
consumption, as well as differences in genetic vulnerability to
particular alcohol-related consequences.^8^

Light-to-moderate drinking can have beneficial effects on the heart,
particularly among those at greatest risk for heart attacks, such as men
over age 45 years and women after menopause.^9^ Moderate drinking
generally refers to consuming one or two drinks per day. Moderate
drinking, however, cannot be achieved by simply averaging the number of
drinks. For example, consuming seven drinks on a single occasion will
not have the same effects as consuming one drink each day of the
week.![](media/image1.wmf){width="4.501388888888889in"
height="4.911111111111111in"}

Long-term heavy drinking increases risk for high blood pressure, heart
rhythm irregularities (arrhythmias), heart muscle disorders
(cardiomyopathy), and stroke. Long-term heavy drinking also increases
the risk of developing certain forms of cancer, especially of the
esophagus, mouth, throat, and larynx.^10^ Heavy alcohol use also
increases risk for cirrhosis and other liver disorders^11^ and worsens
the outcome for patients with hepatitis C.^12^ Drinking also may
increase the risk for developing cancer of the colon and rectum.^10^
Women's risk of developing breast cancer increases slightly if they
drink two or more drinks per day.^13^

Alcohol use has been linked with a substantial proportion of injuries
and deaths from traffic crashes, falls, fires, and drownings.^11^ It
also is a factor in homicide, suicide, marital violence, and child
abuse^14^ and has been associated with high-risk sexual
behavior.^11,\ 15,\ 16^ Persons who drink even relatively small amounts
of alcoholic beverages may contribute to alcohol‑related death and
injury in occupational incidents or if they drink before operating a
vehicle.^11^ In 1996, alcohol use was associated with 41 percent of all
motor vehicle crash fatalities, a significantly lower percentage than in
the 1980s.^17^

Although there has been a long-term drop in overall use, many Americans
still use illicit drugs. In 1997, there were 13.9 million current users
of any illicit drug in the total household population aged 12 years and
older, representing 6.4 percent of the total population.^18^ Marijuana
is the most commonly used illicit drug, and 60 percent of users abuse
marijuana only.^18^ Thirty-six percent of persons aged 12 years and
older have used an illegal drug in their lifetime. Of these, more than
90 percent used marijuana or hashish, and approximately 30 percent tried
cocaine.^18^ Relatively rare in 1996, methamphetamine use began
spreading in 1997.^18,\ 19^

Estimated rates of chronic drug use also are significant. Of the
estimated 4.4 million chronic drug users in the United States in 1995,
3.6 million were chronic cocaine users (primarily crack cocaine), and
810,000 were chronic heroin users.^20^

Drug dependence is a chronic, relapsing disorder. Addicted persons
frequently engage in self-destructive and criminal behavior. Research
has confirmed that treatment can help end dependence on addictive drugs
and reduce the consequences of addictive drug use on society. While no
single approach for substance abuse and addiction treatment exists,
comprehensive and carefully tailored treatment works.^21^

Drug use among adolescents aged 12 to 17 years doubled between 1992 and
1997, from 5.3 percent to 11.4 percent.^18^ Youth marijuana use has been
associated with a number of dangerous behaviors. Nearly 1 million youth
aged 16 to 18 years (11 percent of the total) have reported driving in
the past year at least once within 2 hours of using an illegal drug
(most often marijuana).^22^ Adolescents aged 12 to 17 years who smoke
marijuana were more than twice as likely to cut class, steal, attack
persons, and destroy property than those who did not smoke
marijuana.^23^ Drug and alcohol use by youth also is associated with
other forms of unhealthy and unproductive behavior, including
delinquency and high-risk sexual activity.

Illegal use of drugs, such as heroin, marijuana, cocaine, and
methamphetamine is associated with other serious consequences, including
injury, illness, disability, and death as well as crime, domestic
violence, and lost workplace productivity. Drug users and persons with
whom they have sexual contact run high risks of contracting gonorrhea,
syphilis, hepatitis, tuberculosis, and human immunodeficiency virus
(HIV). The relationship between injection drug use and HIV/AIDS
transmission is well-known. Injection drug use also is associated with
hepatitis B and C infections.^24^ The use of cocaine, nitrates, and
other substances can produce cardiac irregularities and heart failure,
convulsions, and seizures. Cocaine use temporarily narrows blood vessels
in the brain, contributing to the risk of strokes (bleeding within the
brain) and cognitive and memory deficits.^25^ Long‑term consequences,
such as chronic depression, sexual dysfunction, and psychosis, may
result from drug use.

Substance abuse, including tobacco use and nicotine dependence, is
associated with a variety of other serious health and social problems.
An analysis of the epidemiological evidence reveals that 72 conditions
requiring hospitalization are wholly or partially attributable to
substance abuse.^26^

Substance abuse contributes to cancers that, until recently, were
thought to be unrelated. Advances in research techniques since the
1980s, including advanced brain imaging and the study of the effects of
alcohol and drug abuse on individual cells, have helped to document the
alteration of healthy systems by all forms of substance abuse, including
marijuana use. Researchers have identified lasting brain and nervous
system damage from drugs, including changes in nerve cell structure
associated with alcohol and drug dependence. Other research has focused
on the long‑term effects of alcohol and drug abuse on the immune system
as well as the effects of prenatal alcohol and drug exposure on the
behavior and development of children.

Research confirms that a substantial number of frequent users of
cocaine, heroin, and illicit drugs other than marijuana have
co-occurring chronic mental health disorders. Some of these persons can
be identified by their behavior problems at the time of their entry into
elementary school.^27^ Such youth tend to use substances at a young age
and exhibit sensation‑seeking (or "novelty‑seeking") behaviors. These
youth benefit from more intensive preventive interventions, including
family therapy and parent training programs.^28,\ 29^

The stigma attached to substance abuse increases the severity of the
problem. The hiding of substance abuse, for example, can prevent persons
from seeking and continuing treatment and from having a productive
attitude toward treatment. Compounding the problem is the gap between
the number of available treatment slots and the number of persons
seeking treatment for illicit drug use or problem alcohol use.

### Disparities

Substance abuse affects all racial, cultural, and economic groups.
Alcohol is the most commonly used substance, regardless of race or
ethnicity, and there are far more persons who smoke cigarettes than
persons who use illicit drugs. Usage rates for an array of substances
reveal that, for adolescents aged 12 to 17 years:

-   Whites and Hispanics are more likely than African Americans to use
    alcohol.

-   Whites are more likely than African Americans and Hispanics to use
    tobacco.

-   Whites are more likely than African Americans and Hispanics to use
    illicit drugs.

Additional findings include the following:

  --------------- ----------- ---------- -------------- -------- --------- ------------ ------ -----------
  **Substance Use                                                                              
  in the Past                                                                                  
  Year, 1997**                                                                                 

                  **White**              **Hispanic**                      **African           
                                                                           American**          

  **Substance**   **All\      **Aged 12  **All\                  **Aged 12 **All\              **Aged 12
                  Ages**      to 17      Ages**                  to 17     Ages**              to
                              Years**                            Years**                       17Years**

                  Percent                                                                      

  Alcohol         67.8        36.0                      55.6     32.5      52.7         27.3   

  Cigarette       33.7        29.1                      30.4     20.8      32.5         18.2   

  Any illicit     11.3        19.6                      9.9      16.5      12.1         15.7   
  drug                                                                                         

  Marijuana       9.1         16.3                      7.5      13.8      9.9          13.4   

  Cocaine         1.9         2.5                       2.0      2.3       2.4          0.2    

  Inhalants       1.2         5.2                       1.1      3.7       0.4          1.0    

  Heroin          0.2         \*                        0.6      \*        0.5          \*     
  --------------- ----------- ---------- -------------- -------- --------- ------------ ------ -----------

\*Not available

Source: National Household Survey on Drug Abuse: Population Estimates
1997, SAMHSA

Older adolescents and adults with co-occurring substance abuse and
mental health disorders need explicit and appropriate treatment for
their disorders. Those who suffer from co-occurring disorders, however,
are frequently turned away from treatment designed for one or the other
problem but not for both. (See Focus Area 18. Mental Health and Mental
Disorders).

The population aged 65 years and older faces risks for alcohol-related
problems, although this group consumes comparatively low amounts of
alcoholic beverages.^30^ Adverse alcohol-drug interaction can put older
people in the hospital, since many take multiple medications. In
addition, many cases of memory deficits and dementia now are understood
to result from alcoholism.^31^

### Opportunities

The direct application of prevention and treatment research knowledge is
particularly important in solving substance abuse problems. Developing
adaptations of research-proven programs for diverse racial and ethnic
populations, field testing them with high-quality process and outcome
evaluations, and providing them where they are most needed are critical.
Interventions appropriate to the population to be served, including
interventions to address gaps in substance abuse treatment capacity,
must be identified and implemented by Federal, Tribal, regional, State,
and community-based providers in a variety of settings.

Scientific research has identified many opportunities to prevent
alcohol-related problems. For example, studies indicate that
school-based programs focused on altering perceived peer-group norms
about alcohol use^32,\ 33^ and developing skills in resisting peer
pressures to drink^34,\ 35,\ 36^ reduce alcohol use among participating
students. Communitywide programs involving school curricula, peer
leadership, parental involvement and education, and community task
forces also have reduced alcohol use among adolescents.^37^

Raising the minimum legal drinking age to 21 years was accompanied by
reduced alcohol consumption, traffic crashes, and related fatalities
among young persons under age 21 years.^38^ Reductions in
alcohol-related traffic crashes are associated with many policy and
program measures^39^---among them, administrative revocation of licenses
for drinking and driving^40^ and lower legal blood alcohol limits for
youth^41^ and adults.^42^ Community programs involving multiple city
departments and private citizens have reduced driving after drinking and
traffic deaths and injuries.^43^ In addition, a combination of community
mobilization, media advocacy, and enhanced law enforcement has been
shown to reduce alcohol-related traffic crashes and sales of alcohol to
minors.^44^

Higher prices or taxes for alcoholic beverages are associated with lower
alcohol consumption and lower levels of a wide variety of adverse
outcomes---including the probability of frequent beer consumption by
young persons,^45^ the probability of adults drinking five or more
drinks on a single occasion,^46^ death rates from cirrhosis^47^ and
motor vehicle crashes,^48,\ 49^ frequency of drinking and driving,^50^
and some categories of violent crime.^51^ One study suggests that, among
adults, the effect of alcoholic beverage prices on frequency of heavy
drinking varies with knowledge of the health consequences of heavy
drinking: better informed heavy drinkers are more responsive to price
changes.^52^

In college settings, brief one-on-one motivational counseling has proved
effective in reducing alcohol-related problems among high-risk
drinkers.^53^ Research on the effect of the density of alcohol outlets
on violence is inconclusive.^54,\ 55^

Many opportunities to prevent drug-related problems have been
identified. Core strategies for preventing drug abuse among youth
include raising awareness, educating and training parents and others,
strengthening families, providing alternative activities, building
skills and confidence, mobilizing and empowering communities, and
environmental approaches. Studies indicate that making youth and others
aware of the health, social, and legal consequences associated with drug
abuse has an impact on use. Parents also play a primary role in helping
their children understand the dangers of substance abuse and in
communicating their expectation that drug and alcohol use will not be
tolerated. Research suggests that improving parent/child attachment and
supervision and monitoring also protects youth from substance abuse.
Alternative activities for youth teach social skills and provide an
alternative to substance abuse. According to one study, programs that
help young persons develop psycho social and peer resistance skills are
more successful than other programs in preventing drug abuse.^21^
Findings suggest that having community partnerships in place for
sustained periods of time produces significant results in decreasing
alcohol and drug use in males. Literature shows that having "buy-in"
from local participants greatly enhances the success of any endeavor.
Studies also show that changing norms is extremely effective in reducing
substance abuse and related problems.^21^

For substance abuse prevention to be effective, people need access to
culturally, linguistically, and age-appropriate services; job training
and employment; parenting training; general education; more behavioral
research; and programs for women, dually diagnosed patients, and persons
with learning disabilities. Particular attention must be given to young
persons under age 18 years who have an addicted parent, since these
youth are at increased risk for substance abuse. Because alcoholism and
drug abuse continue to affect lesbians, gay men, and transgendered
persons at two to three times the rate of the general population,^56^
programs that address the special risks and needs of these population
groups also are needed. Government, employers, the faith community, and
other organizations in the private and nonprofit sectors must increase
their level of cooperation and coordination to ensure that multiple
service needs are met.

The prevention and treatment of substance abuse require that all abused
substances be addressed---from tobacco and alcohol to marijuana and
other illicit drugs. Tobacco prevention and treatment are equally
important parts of a comprehensive substance abuse prevention program.
(See Focus Area 27. Tobacco Use.)

## Interim Progress Toward Year 2000 Objectives

Of the 20 substance abuse objectives in Healthy People 2000, 2 have met
or surpassed their targets. More than 90 percent of worksites with 50 or
more employees have adopted policies on alcohol and drugs (1995),
exceeding the Healthy People 2000 target of 60 percent. One additional
target has been met---monitoring access to treatment programs by the
under served (1996).

Progress has been made toward other objectives. Alcohol-related motor
vehicle crash deaths declined to 6.5 per 100,000 population (1996),
attributed in part to passage of State laws mandating administrative
license revocation, setting maximum blood alcohol concentration levels
of 0.08 percent for drivers aged 21 years and older, and establishing
zero tolerance for alcohol in the blood of drivers under age 21 years.
The cirrhosis death rate declined to 7.4 per 100,000 population,
although the rate for American Indians or Alaska Natives remains
significantly higher than that of other groups. Average age of first use
of harmful substances by adolescents aged 12 to 17 years has increased.
In addition, past-month use of alcohol by adolescents aged 12 to 17
years has declined, as has steroid use by high school seniors.

Less progress has been made toward other targets. Past-month use of
marijuana and cigarettes among adolescents aged 12 to 17 years has
increased since 1994. Among high school seniors, both perception of harm
and perception of social disapproval of substance abuse have declined.
For the total population, rates of drug-related deaths and
drug-abuse-related emergency department visits have increased.

Note: Unless otherwise noted, data are from Centers for Disease Control
and Prevention, National Center for Health Statistics, *Healthy People
2000 Review, 1998-99.*

## Healthy People 2010---Summary of Objectives

### **Substance Abuse** {#substance-abuse-1 .Heading-Special-Sub}

**Goal:** Reduce substance abuse to protect the health, safety, and
quality of life for all, especially children.

+--------+-------------------------------------------------------------+
| #      | **Objective**                                               |
| #####  |                                                             |
| Number |                                                             |
+--------+-------------------------------------------------------------+
| **A    |                                                             |
| dverse |                                                             |
| Conseq |                                                             |
| uences |                                                             |
| of     |                                                             |
| Sub    |                                                             |
| stance |                                                             |
| Use    |                                                             |
| and    |                                                             |
| A      |                                                             |
| buse** |                                                             |
+--------+-------------------------------------------------------------+
| 26-1   | Motor vehicle crash deaths and injuries                     |
+--------+-------------------------------------------------------------+
| 26-2   | Cirrhosis deaths                                            |
+--------+-------------------------------------------------------------+
| 26-3   | Drug-induced deaths                                         |
+--------+-------------------------------------------------------------+
| 26-4   | Drug-related hospital emergency department visits           |
+--------+-------------------------------------------------------------+
| 26-5   | Alcohol-related hospital emergency department visits        |
+--------+-------------------------------------------------------------+
| 26-6   | Adolescents riding with a driver who has been drinking      |
+--------+-------------------------------------------------------------+
| 26-7   | Alcohol- and drug-related violence                          |
+--------+-------------------------------------------------------------+
| 26-8   | Lost productivity                                           |
+--------+-------------------------------------------------------------+
| **Sub  |                                                             |
| stance |                                                             |
| Use    |                                                             |
| and    |                                                             |
| A      |                                                             |
| buse** |                                                             |
+--------+-------------------------------------------------------------+
| 26-9   | Substance-free youth                                        |
+--------+-------------------------------------------------------------+
| 26-10  | Adolescent and adult use of illicit substances              |
+--------+-------------------------------------------------------------+
| 26-11  | Binge drinking                                              |
+--------+-------------------------------------------------------------+
| 26-12  | Average annual alcohol consumption                          |
+--------+-------------------------------------------------------------+
| 26-13  | Low-risk drinking among adults                              |
+--------+-------------------------------------------------------------+
| 26-14  | Steroid use among adolescents                               |
+--------+-------------------------------------------------------------+
| 26-15  | Inhalant use among adolescents                              |
+--------+-------------------------------------------------------------+
| **Risk |                                                             |
| of     |                                                             |
| Sub    |                                                             |
| stance |                                                             |
| Use    |                                                             |
| and    |                                                             |
| A      |                                                             |
| buse** |                                                             |
+--------+-------------------------------------------------------------+
| 26-16  | Peer disapproval of substance abuse                         |
+--------+-------------------------------------------------------------+
| 26-17  | Perception of risk associated with substance abuse          |
+--------+-------------------------------------------------------------+
| **Tre  |                                                             |
| atment |                                                             |
| for    |                                                             |
| Sub    |                                                             |
| stance |                                                             |
| A      |                                                             |
| buse** |                                                             |
+--------+-------------------------------------------------------------+
| 26-18  | Treatment gap for illicit drugs                             |
+--------+-------------------------------------------------------------+
| 26-19  | Treatment in correctional institutions                      |
+--------+-------------------------------------------------------------+
| 26-20  | Treatment for injection drug use                            |
+--------+-------------------------------------------------------------+
| 26-21  | Treatment gap for problem alcohol use                       |
+--------+-------------------------------------------------------------+
| *      |                                                             |
| *State |                                                             |
| and    |                                                             |
| Local  |                                                             |
| Eff    |                                                             |
| orts** |                                                             |
+--------+-------------------------------------------------------------+
| 26-22  | Hospital emergency department referrals                     |
+--------+-------------------------------------------------------------+
| 26-23  | Community partnerships and coalitions                       |
+--------+-------------------------------------------------------------+
| 26-24  | Administrative license revocation laws                      |
+--------+-------------------------------------------------------------+
| 26-25  | Blood alcohol concentration (BAC) levels for motor vehicle  |
|        | drivers                                                     |
+--------+-------------------------------------------------------------+

## Healthy People 2010 Objectives

### Adverse Consequences of Substance Use and Abuse

26-1. Reduce deaths and injuries caused by alcohol- and drug-related
motor vehicle crashes.

Target and baseline:

  --------------- ------------------------------- ------------------- -------------
  **Objective**   **Reduction in Consequences\    **1997\             **2010\
                  of Motor Vehicle Crashes**      Baseline**          Target**

                                                  Per 100,000         
                                                  Population          

  **26-1a.**      Alcohol-related deaths          6.1                 4

  **26-1b.**      Alcohol-related injuries        122                 65

  **26-1c.**      Drug-related deaths             **Developmental**   

  **26-1d.**      Drug-related injuries           **Developmental**   
  --------------- ------------------------------- ------------------- -------------

**Target setting method:** Consistent with the U.S. Department of
Transportation for 26-1a; 47 percent improvement for 26-1b.

**Data source:** Fatality Analysis Reporting System (FARS), DOT,
National Highway Traffic Safety Administration (NHTSA); General
Estimates System (GES), DOT.

+------------------------------------------+--------------+------------+
| **Total Population, 1997 (unless         | **Alc        |            |
| noted)**                                 | ohol-Related |            |
|                                          | Motor\       |            |
|                                          | Vehicle      |            |
|                                          | Crashes**    |            |
+==========================================+==============+============+
|                                          | **26-1a.\    | **26-1b.\  |
|                                          | Deaths**     | Injuries** |
+------------------------------------------+--------------+------------+
|                                          | Rate per     |            |
|                                          | 100,000      |            |
+------------------------------------------+--------------+------------+
| > **TOTAL**                              | 6.1          | 122        |
+------------------------------------------+--------------+------------+
| **Race and ethnicity**                   |              |            |
+------------------------------------------+--------------+------------+
| > American Indian or Alaska Native       | 19.2 (1995)  | DNC        |
+------------------------------------------+--------------+------------+
| > Asian or Pacific Islander              | 2.4 (1995)   | DNC        |
+------------------------------------------+--------------+------------+
| > Asian                                  | DNC          | DNC        |
+------------------------------------------+--------------+------------+
| > Native Hawaiian and other Pacific      | DNC          | DNC        |
| > Islander                               |              |            |
+------------------------------------------+--------------+------------+
| > Black or African American              | 6.4 (1995)   | DNC        |
+------------------------------------------+--------------+------------+
| > White                                  | 6.0 (1995)   | DNC        |
+------------------------------------------+--------------+------------+
|                                          |              |            |
+------------------------------------------+--------------+------------+
| > Hispanic or Latino                     | DNA          | DNC        |
+------------------------------------------+--------------+------------+
| > Not Hispanic or Latino                 | DNA          | DNC        |
+------------------------------------------+--------------+------------+
| > Black or African American              | DNA          | DNC        |
+------------------------------------------+--------------+------------+
| > White                                  | DNA          | DNC        |
+------------------------------------------+--------------+------------+
| **Gender**                               |              |            |
+------------------------------------------+--------------+------------+
| > Female                                 | 2.9          | DNA        |
+------------------------------------------+--------------+------------+
| > Male                                   | 9.4          | DNA        |
+------------------------------------------+--------------+------------+
| **Age**                                  |              |            |
+------------------------------------------+--------------+------------+
| > All persons aged 15 to 24 years        | 11.7         | DNA        |
+------------------------------------------+--------------+------------+
| **Education level**                      |              |            |
+------------------------------------------+--------------+------------+
| > Less than high school                  | DNC          | DNC        |
+------------------------------------------+--------------+------------+
| > High school graduate                   | DNC          | DNC        |
+------------------------------------------+--------------+------------+
| > At least some college                  | DNC          | DNC        |
+------------------------------------------+--------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Progress has been achieved in reducing the rate of alcohol-related
driving fatalities, which declined from 9.8 deaths per 100,000
population in 1987 to 6.1 deaths per 100,000 in 1997. However, fatal
injuries caused by motor vehicle crashes in which either a driver or
nonoccupant (that is, pedestrian or bicyclist) was under the influence
of alcohol or drugs remain a serious problem in the United States.

Of particular concern is the fatality rate among Native Americans and
persons aged 15 to 24 years. In 1994, the alcohol involvement rate in
fatal traffic crashes for American Indian or Alaska Native men was four
times higher (28 per 100,000 population) than for the general
population. For persons aged 15 to 24 years, the rate was 11.7 per
100,000 population in 1997. Based on these rates, about 3 in every 10
persons in the United States will be involved in an alcohol-related
crash sometime in their lives. The alcohol‑related traffic fatality rate
for youth, however, has decreased by more than 50 percent since 1982,
from 22 deaths per 100,000 population to 10 deaths per 100,000
population in 1996.^57^ The National Highway Traffic Safety
Administration estimates that since 1975, over 17,300 lives have been
saved by enforcement of minimum drinking age laws.^57^

The number of children who are victims of alcohol- and drug-related
traffic crashes also is significant. In 1997, of traffic crashes in
which 3,157 children under age 16 years were killed, nearly 21 percent
were alcohol related.

Crash-related injuries also are a serious problem. In 1997,
crash-related injuries totaled 3,399,000, compared to 41,967
crash-related deaths.^58^ A reduction in all injuries resulting from
alcohol- and drug‑related driving is needed. Such injuries significantly
contribute to emergency department use and overall health care costs and
cause personal tragedies for families.

Although alcohol and its relationship to motor vehicle crashes has been
studied more extensively than other substances, tracking drug‑related
fatalities and injuries is needed. This extension will promote the
understanding that driving while under the influence of drugs is a
serious problem and will help reduce drug-related fatalities.

Reductions in traffic crashes are the result, in part, of many policy
and program measures---among them, raising the minimum legal drinking
age to 21 years,^59^ administrative revocation of licenses for drinking
and driving,^60^ lower legal blood alcohol limits for youth^41^ and
adults,^42^ and higher prices through increased taxation of alcoholic
beverages.^48,\ 49^ Higher prices for alcoholic beverages also are
associated with reduced frequency of drinking and driving.^50^ In
addition, community programs involving multiple city departments and
private citizens have reduced both driving after drinking and traffic
deaths and injuries.^43^

26-2. Reduce cirrhosis deaths.

**Target:** 3 deaths per 100,000 population.

**Baseline:** 9.4 cirrhosis deaths per 100,000 population in 1998
(preliminary data; age adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

+----------------------------------------------+-----------------------+
| **Total Population, 1997\***                 | **Cirrhosis Deaths**  |
+==============================================+=======================+
|                                              | Rate per 100,000      |
+----------------------------------------------+-----------------------+
| > **TOTAL**                                  | 9.6                   |
+----------------------------------------------+-----------------------+
| **Race and ethnicity**                       |                       |
+----------------------------------------------+-----------------------+
| > American Indian or Alaska Native           | 24.2                  |
+----------------------------------------------+-----------------------+
| > Asian or Pacific Islander                  | 3.4                   |
+----------------------------------------------+-----------------------+
| > Asian                                      | DNC                   |
+----------------------------------------------+-----------------------+
| > Native Hawaiian and other Pacific Islander | DNC                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | 10.7                  |
+----------------------------------------------+-----------------------+
| > White                                      | 9.6                   |
+----------------------------------------------+-----------------------+
|                                              |                       |
+----------------------------------------------+-----------------------+
| > Hispanic or Latino                         | 15.9                  |
+----------------------------------------------+-----------------------+
| > Not Hispanic or Latino                     | 9.6                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | 10.9                  |
+----------------------------------------------+-----------------------+
| > White                                      | 8.9                   |
+----------------------------------------------+-----------------------+
| **Gender**                                   |                       |
+----------------------------------------------+-----------------------+
| > Female                                     | 6.2                   |
+----------------------------------------------+-----------------------+
| > Male                                       | 13.6                  |
+----------------------------------------------+-----------------------+
| **Education level** (aged 25 to 64 years)    |                       |
+----------------------------------------------+-----------------------+
| > Less than high school                      | 20.1                  |
+----------------------------------------------+-----------------------+
| > High school graduate                       | 14.0                  |
+----------------------------------------------+-----------------------+
| > At least some college                      | 5.8                   |
+----------------------------------------------+-----------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*New data for population groups will be added when available.

Sustained heavy alcohol consumption is the leading cause of cirrhosis, 1
of the 10 leading causes of death in the United
States.^61,\ 62,\ 63,\ 64,\ 65^ Cirrhosis occurs when healthy liver
tissue is replaced with scarred tissue until the liver is unable to
function effectively. Changes in alcohol consumption patterns over time
are associated with changes in the death rate from cirrhosis.
Improvements in disease management and in the availability of treatment
for alcoholism, however, also may have contributed to a decline in
cirrhosis deaths since 1973. In addition, higher State excise tax rates
on distilled spirits are associated with lower death rates from
cirrhosis.^47^

26-3. Reduce drug-induced deaths.

**Target:** 1 per 100,000 population.

**Baseline:** 5.1 drug-induced deaths per 100,000 population in 1998
(preliminary data; age adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

+----------------------------------------------+-----------------------+
| **Total Population, 1997\***                 | **Drug-Induced        |
|                                              | Deaths**              |
+==============================================+=======================+
|                                              | Rate per 100,000      |
+----------------------------------------------+-----------------------+
| > **TOTAL**                                  | 6.0                   |
+----------------------------------------------+-----------------------+
| **Race and ethnicity**                       |                       |
+----------------------------------------------+-----------------------+
| > American Indian or Alaska Native           | 6.6                   |
+----------------------------------------------+-----------------------+
| > Asian or Pacific Islander                  | 1.6                   |
+----------------------------------------------+-----------------------+
| > Asian                                      | DNC                   |
+----------------------------------------------+-----------------------+
| > Native Hawaiian and other Pacific Islander | DNC                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | 9.0                   |
+----------------------------------------------+-----------------------+
| > White                                      | 5.7                   |
+----------------------------------------------+-----------------------+
|                                              |                       |
+----------------------------------------------+-----------------------+
| > Hispanic or Latino                         | 6.0                   |
+----------------------------------------------+-----------------------+
| > Not Hispanic or Latino                     | 6.0                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | 9.2                   |
+----------------------------------------------+-----------------------+
| > White                                      | 5.6                   |
+----------------------------------------------+-----------------------+
| **Gender**                                   |                       |
+----------------------------------------------+-----------------------+
| > Female                                     | 3.6                   |
+----------------------------------------------+-----------------------+
| > Male                                       | 8.3                   |
+----------------------------------------------+-----------------------+
| **Education level** (aged 25 to 64 years)    |                       |
+----------------------------------------------+-----------------------+
| > Less than high school                      | 18.4                  |
+----------------------------------------------+-----------------------+
| > High school graduate                       | 13.9                  |
+----------------------------------------------+-----------------------+
| > At least some college                      | 5.8                   |
+----------------------------------------------+-----------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*New data for population groups will be added when available.

Causes of drug‑induced deaths include drug psychosis, drug dependence,
suicide, and intentional and accidental poisoning that result from
illicit drug use. Declining initiation, number of cases, and intensity
of drug abuse should be reflected in fewer drug‑induced deaths. However,
the prevention of suicide, accidental poisoning, and fatal interaction
among medications contributes to changes in the statistics measured in
this objective.

26-4. Reduce drug-related hospital emergency department\
visits.

**Target:** 350,000 visits per year.

**Baseline:** 542,544 drug-related hospital emergency department visits
in 1998.

**Target setting method:** 35 percent improvement.

**Data source:** Drug Abuse Warning Network (DAWN), SAMHSA.

Drug-related hospital emergency department (ED) visits are another major
indicator of the harmful effects of drugs. In hospital EDs, a
"drug‑related episode" is defined as one resulting from the nonmedical
use of a drug. This includes the unprescribed use of prescription drugs,
use of drugs contrary to approved labeling, and use of illicit drugs.
Episodes are abstracted from medical records by hospital staff or hired
clerks. To be counted as having a drug-related episode, the ED patient
must be aged 6 years or older and meet four criteria: the patient was
treated in the hospital's ED; the presenting problem was induced by or
related to drug use; the case involved the nonmedical use of a legal
drug or any use of an illegal drug; and the patient's reason for taking
the substance(s) included dependence, suicide attempt or gesture, or
psychic effects.

"Suicide attempt or gesture" and dependence were the most frequently
cited motives for taking a substance that resulted in an ED episode,
with each accounting for 35 percent of all episodes in 1998. In 1998, 55
percent of the drug-related ED episodes occurred among adolescents and
adults aged 16 to 34 years and 44 percent among persons aged 35 years
and older. Whites accounted for 54 percent of drug-related ED episodes.
African Americans and Hispanics accounted for 25 percent and 11 percent,
respecitively.^66^

26-5. (Developmental) Reduce alcohol-related hospital\
emergency department visits.

**Potential data source:** National Hospital Ambulatory Medical Care
Survey (NHAMCS), CDC, NCHS.

Alcohol consumption is associated with a wide range of events that can
result in ED visits---among them, traffic crashes, violence, and alcohol
poisoning. In 1996, alcohol-related hospital ED visits (2.2 million)
accounted for 2.4 percent of all ED visits.^67^ Visits related to both
alcohol and drugs accounted for an additional 0.4 percent. However,
these figures, based on a national probability survey of hospital EDs,
are probably underestimates since information on alcohol involvement
often is missing from ED medical records.^67^

An analysis of 1995 data from the same survey found that alcohol-related
visits are 1.6 times as likely as other ED visits to be injury related;
in 20 percent of alcohol-related visits, the principal diagnosis is
alcohol abuse or alcohol dependence.^68^ Other studies, based on smaller
samples and different measures of alcohol involvement, suggest a large
proportion of young persons and trauma victims are intoxicated when they
visit the ED.^69,\ 70,\ 71^

Screening for alcohol problems in the ED offers an opportunity for early
intervention and appropriate referral of patients and may reduce
subsequent illness, injury, and death.^72^ Policy measures that reduce
specific alcohol-related problems^11^---for example, traffic crashes or
violence---also may help reduce alcohol-related ED visits.

26-6. Reduce the proportion of adolescents who report that they rode,
during the previous 30 days, with a driver who had been drinking
alcohol.

**Target:** 30 percent.

**Baseline:** 37 percent of students in grades 9 through 12 reported
riding with a driver who had been drinking alcohol in 1997.

**Target setting method:** Better than the best.

**Data source:** Youth Risk Behavior Survey (YRBS), CDC, NCCDPHP.

+----------------------------------------------+-----------------------+
| **Students in Grades 9 Through 12, 1997**    | **Rode With Drinking  |
|                                              | Driver During\        |
|                                              | Previous 30 Days**    |
+==============================================+=======================+
|                                              | Percent               |
+----------------------------------------------+-----------------------+
| > **TOTAL**                                  | 37                    |
+----------------------------------------------+-----------------------+
| **Race and ethnicity**                       |                       |
+----------------------------------------------+-----------------------+
| > American Indian or Alaska Native           | DSU                   |
+----------------------------------------------+-----------------------+
| > Asian or Pacific Islander                  | DSU                   |
+----------------------------------------------+-----------------------+
| > Asian                                      | DNC                   |
+----------------------------------------------+-----------------------+
| > Native Hawaiian and other Pacific Islander | DNC                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | DNC                   |
+----------------------------------------------+-----------------------+
| > White                                      | DNC                   |
+----------------------------------------------+-----------------------+
|                                              |                       |
+----------------------------------------------+-----------------------+
| > Hispanic or Latino                         | 43                    |
+----------------------------------------------+-----------------------+
| > Not Hispanic or Latino                     | DNC                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | 34                    |
+----------------------------------------------+-----------------------+
| > White                                      | 37                    |
+----------------------------------------------+-----------------------+
| **Gender**                                   |                       |
+----------------------------------------------+-----------------------+
| > Female                                     | 35                    |
+----------------------------------------------+-----------------------+
| > Male                                       | 38                    |
+----------------------------------------------+-----------------------+
| **Family income level**                      |                       |
+----------------------------------------------+-----------------------+
| > Poor                                       | DNC                   |
+----------------------------------------------+-----------------------+
| > Near poor                                  | DNC                   |
+----------------------------------------------+-----------------------+
| > Middle/high income                         | DNC                   |
+----------------------------------------------+-----------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Health risk behaviors that contribute to the leading causes of illness,
death, and social problems among youth and adults often are established
during youth, extend into adulthood, and are interrelated. In the United
States, 72 percent of all deaths among school-aged youth and young
adults result from four causes: motor vehicle crashes, other
unintentional injuries, homicide, and suicide. Many high school students
practice behaviors that may increase their likelihood of death from
these four causes. Hispanic students are more likely than African
American or white students to ride with a driver who has been drinking.

Rates of drinking across State surveys ranged from 19.4 percent to 52.5
percent (median: 36.0 percent). Across the local surveys, the rates
ranged from 20.7 percent to 43.1 percent (median: 32.1 percent).^73^
Reducing the number of adolescents who ride in a motor vehicle with
another adolescent driver who has been drinking is an important step to
lower motor-vehicle related deaths and injuries.

26-7. (Developmental) Reduce intentional injuries resulting from
alcohol- and illicit drug-related violence.

**Potential data source:** National Crime Victimization Survey (NCVS),
U.S. Department of Justice, Bureau of Justice Statistics.

A review of the literature found that the percentage of homicide
offenders who were drinking when they committed the offense ranged from
7 to 85 percent, with most studies finding the figure greater than 60
percent.^74^ Drugs, and most commonly alcohol, also are a factor in a
significant number of firearm-related deaths.^75^ In 1996, juvenile and
adult arrestees testing positive for drugs had been frequently arrested
for violent offenses, such as robbery, assault, and weapons offenses.
Two-thirds of victims who experienced violence by an intimate (a current
or former spouse, boyfriend, or girlfriend) reported that alcohol had
been involved. Among spousal victims, three out of four incidents
involved an offender who was drinking. Thirty-one percent of strangers
who were victimized believed that the offender was using alcohol.^76^
Efforts are underway to establish targeted prevention and treatment
programs aimed at reducing violence related to or caused by alcohol and
drug use.^77,\ 78^ Efforts are underway to develop surveillance systems
aimed at reinforcing local community activities.^79^

26-8. (Developmental) Reduce the cost of lost productivity in the
workplace due to alcohol and drug use.

**Potential data source:** Periodic estimates of economic costs of
alcohol and drug use, NIH, NIAAA and NIDA.

The economic cost of alcohol and drug abuse in the United States was
estimated at \$276 billion for 1995,^2^ with \$167 billion attributed to
alcohol abuse and \$110 billion to drug abuse. Productivity losses
accounted for \$119 billion of the costs of alcohol abuse and \$77
billion of the costs of drug abuse.

The majority of alcohol-related productivity losses (62 percent) were
attributed to alcohol-related illness. These costs, measured as impaired
earnings among those with a history of alcohol dependence, may result
from increased unemployment, poor job performance, and limited career
advancement. The adverse effects of early alcohol use on educational
attainment may underlie these effects. Productivity losses were greatest
for males who started drinking before age 15 years.

For drug abuse, most (56 percent) of the estimated productivity losses
were associated with crime, including lost earnings of victims (3
percent) and incarcerated perpetrators (26 percent) of drug-related
crime and foregone legitimate earnings because of participation in the
drug trade (28 percent). Studies from offender populations have found
early onset of drinking and drug use and high dropout rates; these may
reflect causal linkages.^2^

As indicators of the adverse consequences of alcohol and drug misuse,
estimates of lost productivity have important limitations, including
concerns about statistical and methodological issues and data quality
and completeness. For example, productivity losses cannot be observed
directly, implying some inherent imprecision in these estimates, so that
changes in productivity losses may not be detected. Also, there is
persistent uncertainty in quantifying the causal roles of alcohol and
drugs in generating productivity losses. Finally, some likely effects on
productivity are omitted from current estimates, mainly because suitable
data are lacking. These measurement concerns notwithstanding, efforts to
reduce or delay alcohol and drug use may lead to significant reductions
in productivity losses over the long run.

### Substance Use and Abuse

26-9. Increase the age and proportion of adolescents who\
remain alcohol and drug free.

Target and baseline:

+------------+-------------------------------+------------+------------+
| **O        | **Increase Average Age of     | **1997\    | **2010**   |
| bjective** | First Use in Adolescents Aged | Baseline** |            |
|            | 12 to 17 Years**              |            | **Target** |
+------------+-------------------------------+------------+------------+
|            |                               | Average    |            |
|            |                               | Age in     |            |
|            |                               | Years      |            |
+------------+-------------------------------+------------+------------+
| **26-9a.** | Alcohol                       | 13.1       | 16.1       |
+------------+-------------------------------+------------+------------+
| **26-9b.** | Marijuana                     | 13.7       | 17.4       |
+------------+-------------------------------+------------+------------+

**Target setting method:** Better than the best for alcohol use;
consistent with Office of National Drug Control Policy for marijuana
use.

**Data source:** National Household Survey on Drug Abuse (NHSDA),
SAMHSA.

+----------------------------------------+--------------+--------------+
| **Adolescents Aged 12 to 17 Years,     | **26-9a.\    | **26-9b.\    |
| 1997**                                 | First        | First        |
|                                        | Alcohol      | Marijuana    |
|                                        | Use**        | Use**        |
+========================================+==============+==============+
|                                        | Average Age  |              |
|                                        | in Years     |              |
+----------------------------------------+--------------+--------------+
| > **TOTAL**                            | 13.1         | 13.7         |
+----------------------------------------+--------------+--------------+
| **Race and ethnicity**                 |              |              |
+----------------------------------------+--------------+--------------+
| > American Indian or Alaska Native     | 13.3         | 14.1         |
+----------------------------------------+--------------+--------------+
| > Asian or Pacific Islander            | 12.7         | 13.8         |
+----------------------------------------+--------------+--------------+
| > Asian                                | DNC          | DNC          |
+----------------------------------------+--------------+--------------+
| > Native Hawaiian and other Pacific    | DNC          | DNC          |
| > Islander                             |              |              |
+----------------------------------------+--------------+--------------+
| > Black or African American            | 12.9         | 13.6         |
+----------------------------------------+--------------+--------------+
| > White                                | 13.1         | 13.7         |
+----------------------------------------+--------------+--------------+
|                                        |              |              |
+----------------------------------------+--------------+--------------+
| > Hispanic or Latino                   | 13.0         | 13.5         |
+----------------------------------------+--------------+--------------+
| > Not Hispanic or Latino               | DNA          | DNA          |
+----------------------------------------+--------------+--------------+
| > Black or African American            | DNA          | DNA          |
+----------------------------------------+--------------+--------------+
| > White                                | DNA          | DNA          |
+----------------------------------------+--------------+--------------+
| **Gender**                             |              |              |
+----------------------------------------+--------------+--------------+
| > Female                               | 13.4         | 14.0         |
+----------------------------------------+--------------+--------------+
| > Male                                 | 12.7         | 13.5         |
+----------------------------------------+--------------+--------------+
| **Family income level**                |              |              |
+----------------------------------------+--------------+--------------+
| > Poor                                 | 12.9         | 13.2         |
+----------------------------------------+--------------+--------------+
| > Near poor                            | 13.0         | 13.8         |
+----------------------------------------+--------------+--------------+
| > Middle/high income                   | 13.1         | 13.8         |
+----------------------------------------+--------------+--------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Target and baseline:

  --------------- ----------- ------------------------------ --------- ---- ------------- ---- ------------- --
  **Objective**               **Increase in High School                     **1998\            **2010\       
                              Seniors Never Using                           Baseline**         Target**      
                              Substances**                                                                   

                                                             Percent                                         

  **26-9c.**      Alcoholic                                            19                 29                 
                  beverages                                                                                  

  **26-9d.**      Illicit                                              46                 56                 
                  drugs                                                                                      
  --------------- ----------- ------------------------------ --------- ---- ------------- ---- ------------- --

**Target setting method:** Better than the best.

**Data source:** Monitoring the Future Study, NIH, NIDA.

+------------------------------------+----------------+----------------+
| **High School Seniors, 1998**      | **26-9c.\      | **29-9d.\      |
|                                    | Never Used\    | Never Used Any |
|                                    | Alcoholic\     | Illicit Drug** |
|                                    | Beverages**    |                |
+====================================+================+================+
|                                    | Percent        |                |
+------------------------------------+----------------+----------------+
| > **TOTAL**                        | 19             | 46             |
+------------------------------------+----------------+----------------+
| **Race and ethnicity**             |                |                |
+------------------------------------+----------------+----------------+
| > American Indian or Alaska Native | DSU            | DSU            |
+------------------------------------+----------------+----------------+
| > Asian or Pacific Islander        | DNC            | DNC            |
+------------------------------------+----------------+----------------+
| > Asian                            | DSU            | DSU            |
+------------------------------------+----------------+----------------+
| > Native Hawaiian and other        | DNC            | DNC            |
| > Pacific Islander                 |                |                |
+------------------------------------+----------------+----------------+
| > Black or African American        | 28             | 55             |
+------------------------------------+----------------+----------------+
| > White                            | 16             | 44             |
+------------------------------------+----------------+----------------+
|                                    |                |                |
+------------------------------------+----------------+----------------+
| > Hispanic or Latino               | 18             | 43             |
+------------------------------------+----------------+----------------+
| > Not Hispanic or Latino           | DNC            | DNC            |
+------------------------------------+----------------+----------------+
| > Black or African American        | DNC            | DNC            |
+------------------------------------+----------------+----------------+
| > White                            | DNC            | DNC            |
+------------------------------------+----------------+----------------+
| **Gender**                         |                |                |
+------------------------------------+----------------+----------------+
| > Female                           | 19             | 50             |
+------------------------------------+----------------+----------------+
| > Male                             | 18             | 43             |
+------------------------------------+----------------+----------------+
| **Family income level**            |                |                |
+------------------------------------+----------------+----------------+
| > Poor                             | DNC            | DNC            |
+------------------------------------+----------------+----------------+
| > Near poor                        | DNC            | DNC            |
+------------------------------------+----------------+----------------+
| > Middle/high income               | DNC            | DNC            |
+------------------------------------+----------------+----------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

An important goal of U.S. policy for the prevention of substance abuse
among youth is to increase the percentage of young persons who reach
adulthood without using tobacco, illicit drugs, or alcohol. (See Focus
Area 27. Tobacco Use.) Strengthening the ability of children and
teenagers to reject all such substances is an important and critical
element in prevention activities because the required skills and
attitudes can carry over into adulthood, long after family constraints
and other influences have lost their effectiveness.^80^

From 1985 until 1995, the percentage of high school seniors who reported
they had never used tobacco, drugs, or alcohol increased
dramatically.^81^ This increase clearly demonstrated the value of the
national investment in prevention because it followed many years of
virtually no change in the percentage of high school seniors who
reported they had never used any substance.

To achieve overall prevention goals, local activities are important.
Some of the best prevention approaches involve comprehensive,
multistrategy prevention interventions. Comprehensive community‑based
programs include interventions that influence individual behavior and
attitudes through education, for example, and interventions that change
environments through controls on the availability of substances.
Comprehensive programs must be applied universally to the general
population and in a more intensive fashion to selected and indicated
groups and persons known to be at high risk for serious drug problems or
to targeted groups of persons already exhibiting early signs of drug
use. The need to sustain universal preventive interventions, selective
preventive interventions, and indicated preventive interventions
requires coordination among schools, State and local governments,
businesses, the faith community, civic groups, and other elements of the
community.

26-10. Reduce past-month use of illicit substances.

**26-10a.** Increase the proportion of adolescents not using alcohol or
any illicit drugs during the past 30 days.

**Target:** 89 percent.

**Baseline:** 77 percent of adolescents aged 12 to 17 years reported no
alcohol or illicit drug use in past 30 days in 1997.

**Target setting method:** Better than the best.

**Data source:** National Household Survey on Drug Abuse (NHSDA),
SAMHSA.

+----------------------------------+---+-----------+----------+-----------+
| **Adolescents Aged 12 to 17      | * |           | **No\    | **No      |
| Years, 1997**                    | * |           | Alcohol  | Illicit   |
|                                  | 2 |           | Use in   | Drug Use  |
|                                  | 6 |           | Past 30  | in Past   |
|                                  | - |           | Days\*** | 30        |
|                                  | 1 |           |          | Days\***  |
|                                  | 0 |           |          |           |
|                                  | a |           |          |           |
|                                  | . |           |          |           |
|                                  | \ |           |          |           |
|                                  | N |           |          |           |
|                                  | o |           |          |           |
|                                  | A |           |          |           |
|                                  | l |           |          |           |
|                                  | c |           |          |           |
|                                  | o |           |          |           |
|                                  | h |           |          |           |
|                                  | o |           |          |           |
|                                  | l |           |          |           |
|                                  | o |           |          |           |
|                                  | r |           |          |           |
|                                  | I |           |          |           |
|                                  | l |           |          |           |
|                                  | l |           |          |           |
|                                  | i |           |          |           |
|                                  | c |           |          |           |
|                                  | i |           |          |           |
|                                  | t |           |          |           |
|                                  | D |           |          |           |
|                                  | r |           |          |           |
|                                  | u |           |          |           |
|                                  | g |           |          |           |
|                                  | U |           |          |           |
|                                  | s |           |          |           |
|                                  | e |           |          |           |
|                                  | \ |           |          |           |
|                                  | i |           |          |           |
|                                  | n |           |          |           |
|                                  | P |           |          |           |
|                                  | a |           |          |           |
|                                  | s |           |          |           |
|                                  | t |           |          |           |
|                                  | 3 |           |          |           |
|                                  | 0 |           |          |           |
|                                  | D |           |          |           |
|                                  | a |           |          |           |
|                                  | y |           |          |           |
|                                  | s |           |          |           |
|                                  | * |           |          |           |
|                                  | * |           |          |           |
+==================================+===+===========+==========+===========+
|                                  |   | Percent   |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > **TOTAL**                      | 7 |           | 80       | 89        |
|                                  | 7 |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| **Race and ethnicity**           |   |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > American Indian or Alaska      | 5 |           | DSU      | DSU       |
| > Native                         | 5 |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Asian or Pacific Islander      | 8 |           | DSU      | DSU       |
|                                  | 6 |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Asian                          | D |           | DNC      | DNC       |
|                                  | N |           |          |           |
|                                  | C |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Native Hawaiian and other      | D |           | DNC      | DNC       |
| > Pacific Islander               | N |           |          |           |
|                                  | C |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Black or African American      | 8 |           | DNA      | DNA       |
|                                  | 0 |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > White                          | 7 |           | DNA      | DNA       |
|                                  | 6 |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
|                                  |   |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Hispanic or Latino             | 7 |           | 81       | 90        |
|                                  | 8 |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Not Hispanic or Latino         | D |           | DNA      | DNA       |
|                                  | N |           |          |           |
|                                  | A |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Black or African American      | D |           | 84       | 89        |
|                                  | N |           |          |           |
|                                  | A |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > White                          | D |           | 78       | 88        |
|                                  | N |           |          |           |
|                                  | A |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| **Gender**                       |   |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Female                         | 7 |           | 80       | 89        |
|                                  | 8 |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Male                           | 7 |           | 79       | 88        |
|                                  | 6 |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| **Family income level**          |   |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Poor                           | 7 |           | DNA      | DNA       |
|                                  | 8 |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Near poor                      | 7 |           | DNA      | DNA       |
|                                  | 8 |           |          |           |
+----------------------------------+---+-----------+----------+-----------+
| > Middle/high income             | 7 |           | DNA      | DNA       |
|                                  | 7 |           |          |           |
+----------------------------------+---+-----------+----------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for no alcohol use and no illicit drug use are displayed to
further characterize the issue.

**26-10b.** Reduce the proportion of adolescents reporting use of
marijuana during the past 30 days.

**Target:** 0.7 percent.

**Baseline:** 9.4 percent of adolescents aged 12 to 17 years reported
marijuana use in past 30 days in 1997.

**Target setting method:** Better than the best (consistent with the
Office of National Drug Control Policy).

**Data source:** National Household Survey on Drug Abuse (NHSDA),
SAMHSA.

+---------------------------------------------------+------------------+
| **Adolescents Aged 12 to 17 Years, 1997**         | **Use of         |
|                                                   | Marijuana in     |
|                                                   | Past 30 Days**   |
+===================================================+==================+
|                                                   | Percent          |
+---------------------------------------------------+------------------+
| > **TOTAL**                                       | 9.4              |
+---------------------------------------------------+------------------+
| **Race and ethnicity**                            |                  |
+---------------------------------------------------+------------------+
| > American Indian or Alaska Native                | 3.8              |
+---------------------------------------------------+------------------+
| > Asian or Pacific Islander                       | 0.8              |
+---------------------------------------------------+------------------+
| > Asian                                           | DNC              |
+---------------------------------------------------+------------------+
| > Native Hawaiian and other Pacific Islander      | DNC              |
+---------------------------------------------------+------------------+
| > Black or African American                       | 9.2              |
+---------------------------------------------------+------------------+
| > White                                           | 9.5              |
+---------------------------------------------------+------------------+
|                                                   |                  |
+---------------------------------------------------+------------------+
| > Hispanic or Latino                              | 8.4              |
+---------------------------------------------------+------------------+
| > Not Hispanic or Latino                          | 9.5              |
+---------------------------------------------------+------------------+
| > Black or African American                       | 9.1              |
+---------------------------------------------------+------------------+
| > White                                           | 9.8              |
+---------------------------------------------------+------------------+
| **Gender**                                        |                  |
+---------------------------------------------------+------------------+
| > Female                                          | 8.4              |
+---------------------------------------------------+------------------+
| > Male                                            | 10.3             |
+---------------------------------------------------+------------------+
| **Family income level**                           |                  |
+---------------------------------------------------+------------------+
| > Poor                                            | DNA              |
+---------------------------------------------------+------------------+
| > Near poor                                       | DNA              |
+---------------------------------------------------+------------------+
| > Middle/high income                              | DNA              |
+---------------------------------------------------+------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

**26-10c**. Reduce the proportion of adults using any illicit drug
during the past 30 days.

**Target:** 3.0 percent.

**Baseline:** 5.8 percent of adults aged 18 years and older used any
illicit drug during the past 30 days in 1997.

**Target setting method:** Better than the best (consistent with Office
of National Drug Control Policy).

**Data source:** National Household Survey on Drug Abuse (NHSDA),
SAMHSA.

+-----------------------------------------------+----------------------+
| **Adults Aged 18 Years and Older, 1997**      | **Illicit Drug Use   |
|                                               | in Past 30 Days**    |
+===============================================+======================+
|                                               | Percent              |
+-----------------------------------------------+----------------------+
| **TOTAL**                                     | 5.8                  |
+-----------------------------------------------+----------------------+
| **Race and ethnicity**                        |                      |
+-----------------------------------------------+----------------------+
| > American Indian or Alaska Native            | 11.3                 |
+-----------------------------------------------+----------------------+
| > Asian or Pacific Islander                   | 3.4                  |
+-----------------------------------------------+----------------------+
| > Asian                                       | DNC                  |
+-----------------------------------------------+----------------------+
| > Native Hawaiian and other Pacific Islander  | DNC                  |
+-----------------------------------------------+----------------------+
| > Black or African American                   | 7.1                  |
+-----------------------------------------------+----------------------+
| > White                                       | 5.7                  |
+-----------------------------------------------+----------------------+
|                                               |                      |
+-----------------------------------------------+----------------------+
| Hispanic or Latino                            | 5.1                  |
+-----------------------------------------------+----------------------+
| Not Hispanic or Latino                        | DNA                  |
+-----------------------------------------------+----------------------+
| > Black or African American                   | DNA                  |
+-----------------------------------------------+----------------------+
| > White                                       | DNA                  |
+-----------------------------------------------+----------------------+
| **Gender**                                    |                      |
+-----------------------------------------------+----------------------+
| > Female                                      | 3.8                  |
+-----------------------------------------------+----------------------+
| > Male                                        | 8.1                  |
+-----------------------------------------------+----------------------+
| **Education level**                           |                      |
+-----------------------------------------------+----------------------+
| > Less than high school                       | 6.9                  |
+-----------------------------------------------+----------------------+
| > High school graduate                        | 6.0                  |
+-----------------------------------------------+----------------------+
| > At least some college                       | 5.4                  |
+-----------------------------------------------+----------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Past-month use of any illicit drug and marijuana was about the same in
1997 as in 1996 and most of the 1990s for adults aged 18 years and
older.^82^ But young adults aged 18 to 25 years continued to be the age
group with the highest rates of use. Past-month use of drugs increased
among adolescents aged 12 to 17 years, and the 1997 rates of past month
use of any illicit drug (11 percent) and marijuana (9 percent) were
significantly higher than the 1996 rates of use by this age group (9
percent and 7 percent, respectively). Furthermore, past-month use of
illicit drugs by youths was significantly higher in 1997 than at any
time during the 4 years between 1991 and 1994. Past-month use of alcohol
was about the same in 1997 as in 1996.^82^

The first goal of the 1998 National Drug Control Strategy is to "educate
and enable America's youth to reject illegal drugs as well as the
underage use of alcohol and tobacco."^83^ In response to this goal,
specific targets for the reduction of drug use among adolescents aged 12
to 17 years have been established under the Youth Substance Abuse
Prevention Initiative (YSAPI). These targets, which have a baseline of
1996 and goals for the year 2002 (7 years), are as follows:

-   Reverse the upward trend and reduce past-month use of marijuana
    among adolescents aged 12 to 17 years by 20 percent (1996 baseline:
    7.1 percent; target: 5.7 percent in 2002).

-   Reduce past-month use of any illicit drugs among adolescents aged 12
    to 17 years by 20 percent (1996 baseline: 9.0 percent; target: 7.2
    percent in 2002).

-   Reduce past-month use of alcohol among adolescents aged 12 to 17
    years by 10 percent (1996 baseline: 18.8 percent; target: 16.9
    percent in 2002).

These targets were used as the basis for identifying Healthy People
2010\
objectives.

Adopting a multicomponent approach to youth substance abuse prevention
may increase the long-term effectiveness of prevention efforts. This
approach includes focusing on mobilizing and leveraging resources,
raising public awareness, and countering pro-use messages. Several
strategies may be effective, such as increasing the involvement of
parents and parent groups at the local level, increasing the number of
adult volunteers involved in drug prevention at the local level,
changing normative attitudes among youth from "everyone's using drugs"
to "everyone has better things to do than drugs," and increasing the
proportion of youth participating in positive skill-building activities.

26-11. Reduce the proportion of persons engaging in binge\
drinking of alcoholic beverages.

Target and baseline:

  --------------- ---------------------------------- ------------- ------------
  **Objective**   **Reduction in Students Engaging   **1998\       **2010\
                  in Binge Drinking During Past 2    Baseline**    Target**
                  Weeks**                                          

                                                     Percent       

  **26-11a.**     High school seniors                32            11

  **26-11b.**     College students                   39            20
  --------------- ---------------------------------- ------------- ------------

**Target setting method:** Better than the best.

**Data source:** Monitoring the Future Study, NIH, NIDA.

+---------------------------------------+--------------+--------------+
| **High School Seniors and College\    | **Binge      |              |
| Students, 1998**                      | Drinking     |              |
|                                       | Past 2       |              |
|                                       | Weeks**      |              |
+=======================================+==============+==============+
|                                       | **26-11a.\   | **26-11b.\   |
|                                       | High School  | College\     |
|                                       | Seniors**    | Students**   |
+---------------------------------------+--------------+--------------+
|                                       | Percent      |              |
+---------------------------------------+--------------+--------------+
| > **TOTAL**                           | 32           | 39           |
+---------------------------------------+--------------+--------------+
| **Race and ethnicity**                |              |              |
+---------------------------------------+--------------+--------------+
| > American Indian or Alaska Native    | DSU          | DSU          |
+---------------------------------------+--------------+--------------+
| > Asian or Pacific Islander           | DNC          | DNC          |
+---------------------------------------+--------------+--------------+
| > Asian                               | DSU          | DSU          |
+---------------------------------------+--------------+--------------+
| > Native Hawaiian and other Pacific   | DNC          | DNC          |
| > Islander                            |              |              |
+---------------------------------------+--------------+--------------+
| > Black or African American           | 12           | DNA          |
+---------------------------------------+--------------+--------------+
| > White                               | 36           | DNA          |
+---------------------------------------+--------------+--------------+
|                                       |              |              |
+---------------------------------------+--------------+--------------+
| > Hispanic or Latino                  | 28           | DSU          |
+---------------------------------------+--------------+--------------+
| > Not Hispanic or Latino              | DNC          | DNC          |
+---------------------------------------+--------------+--------------+
| > Black or African American           | DNC          | DNC          |
+---------------------------------------+--------------+--------------+
| > White                               | DNC          | DNC          |
+---------------------------------------+--------------+--------------+
| **Gender**                            |              |              |
+---------------------------------------+--------------+--------------+
| > Female                              | 24           | 31           |
+---------------------------------------+--------------+--------------+
| > Male                                | 39           | 52           |
+---------------------------------------+--------------+--------------+
| **Family income level**               |              |              |
+---------------------------------------+--------------+--------------+
| > Poor                                | DNC          | DNC          |
+---------------------------------------+--------------+--------------+
| > Near poor                           | DNC          | DNC          |
+---------------------------------------+--------------+--------------+
| > Middle/high income                  | DNC          | DNC          |
+---------------------------------------+--------------+--------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Target and baseline:

  --------------- ---------------------------------- ------------ ------------
  **Objective**   **Reduction in Adults and          **1997\      **2010\
                  Adolescents Engaging in Binge      Baseline**   Target**
                  Drinking During Past Month**                    

                                                     Percent      

  **26-11c.**     Adults aged 18 years and older     16           6

  **26-11d.**     Adolescents aged 12 to 17 years    8.3          3.0
  --------------- ---------------------------------- ------------ ------------

**Target setting method:** Better than the best.

**Data source:** National Household Survey on Drug Abuse (NHSDA),
SAMHSA.

+-------------------------------------------+------------+------------+
| **Select Age Groups Engaging in Binge\    | **26-11c.\ | **26-11d.\ |
| Drinking During Past Month, 1997**        | Adults     | A          |
|                                           | Aged 18    | dolescents |
|                                           | Years and  | Aged 12 to |
|                                           | Older**    | 17 Years** |
+===========================================+============+============+
|                                           | Percent    |            |
+-------------------------------------------+------------+------------+
| > **TOTAL**                               | 16         | 8.3        |
+-------------------------------------------+------------+------------+
| **Race and ethnicity**                    |            |            |
+-------------------------------------------+------------+------------+
| > American Indian or Alaska Native        | 22         | DSU        |
+-------------------------------------------+------------+------------+
| > Asian or Pacific Islander               | 7          | DSU        |
+-------------------------------------------+------------+------------+
| > Asian                                   | DNC        | DNC        |
+-------------------------------------------+------------+------------+
| > Native Hawaiian and other Pacific       | DNC        | DNC        |
| > Islander                                |            |            |
+-------------------------------------------+------------+------------+
| > Black or African American               | DNA        | DNA        |
+-------------------------------------------+------------+------------+
| > White                                   | DNA        | DNA        |
+-------------------------------------------+------------+------------+
|                                           |            |            |
+-------------------------------------------+------------+------------+
| > Hispanic or Latino                      | 18         | 7.4        |
+-------------------------------------------+------------+------------+
| > Not Hispanic or Latino                  | DNA        | DNA        |
+-------------------------------------------+------------+------------+
| > Black or African American               | 12         | 3.9        |
+-------------------------------------------+------------+------------+
| > White                                   | 17         | 9.3        |
+-------------------------------------------+------------+------------+
| **Gender**                                |            |            |
+-------------------------------------------+------------+------------+
| > Female                                  | 8          | 6.8        |
+-------------------------------------------+------------+------------+
| > Male                                    | 25         | 9.3        |
+-------------------------------------------+------------+------------+
| **Family income level**                   |            |            |
+-------------------------------------------+------------+------------+
| > Poor                                    | 15         | DNA        |
+-------------------------------------------+------------+------------+
| > Near poor                               | 15         | DNA        |
+-------------------------------------------+------------+------------+
| > Middle/high income                      | 17         | DNA        |
+-------------------------------------------+------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Binge drinking is a national problem, especially among males and young
adults. Nearly 15 percent of persons 12 or older reported binge drinking
in the past 30 days, with young adults aged 18 to 25 years more likely
(27 percent) than all other age groups to have engaged in binge
drinking. In all age groups, more males than females engaged in binge
drinking: among adults, the ratio was two or three to one. Rates of
binge drinking varied little by educational attainment. People with some
college, however, were more likely than those with less than a high
school education to binge drink.

The perceived acceptance of problematic drug-using behavior among
family, peers, and society influences an adolescent's decision to use or
avoid alcohol, tobacco, and drugs.^12^ The perception that alcohol use
is socially acceptable correlates with the fact that more than 80
percent of American youth consume alcohol before their 21st birthday,
whereas the lack of social acceptance of other drugs correlates with
comparatively lower rates of use. Similarly, widespread societal
expectations that young persons will engage in binge drinking may
encourage this highly dangerous form of alcohol consumption.^5^

Passage of higher minimum purchase ages for alcoholic beverages during
the mid-1980s reduced but did not eliminate under aged drinking.^59^
Many States are examining the use of additional restrictions and
penalties for alcoholic beverage retailers to ensure compliance with the
minimum purchase age.

To address the problem of binge drinking and reduce access to alcohol by
underaged persons, several additional policies and strategies may be
effective, including:

-   Tougher State restrictions and penalties for alcoholic beverage
    retailers to ensure compliance with the minimum purchase age.

-   Restrictions on the sale of alcoholic beverages at recreational
    facilities and entertainment events where minors are present.

-   Improved enforcement of State laws prohibiting distribution of
    alcoholic beverages to anyone under age 21 years and more severe
    penalties to discourage distribution to underaged persons.

-   Implementation of server training and standards for responsible
    hospitality.^84,\ 85^ (Management and server training educates
    waitresses, waiters, bartenders, and supervisory staff on ways to
    avoid serving alcohol to minors and intoxicated persons). States
    could require periodic server training or use the regulatory
    authority of alcohol distribution licensing to mandate a minimal
    level of training for individual servers.

-   Institution of a requirement that college students reporting to
    student health services following a binge drinking incident receive
    an alcohol screening that would identify the likelihood of a health
    risk. An alcohol screening would provide student health services
    with the information needed to assess the student's drinking and
    refer the student to an appropriate intervention.

-   Restrictions on marketing to underaged populations, including
    limiting advertisements and promotions. Although alcohol advertising
    has been found to have little or no effect on overall
    consumption,^86,\ 87^ this strategy may reduce the demand that
    results in illicit purchase or binge consumption.

-   Higher prices for alcoholic beverages. Higher prices are associated
    with reductions in the probability of frequent beer consumption by
    young persons^45^ and in the probability of adults drinking five or
    more drinks on a single occasion.^46^

Binge drinking among women of childbearing age (defined as 18 to 44
years) also is a problem because of the risk for prenatal alcohol
exposures. Approximately half of the pregnancies in the United States
are unintended,^88^ and most women do not know they are pregnant until
after the sixth week of gestation.^89^ Such prenatal alcohol exposures
can result in fetal alcohol syndrome and other alcohol-related
neurodevelopmental disorders.^90^

26-12. Reduce average annual alcohol consumption.

**Target:** 2 gallons.

**Baseline:** 2.19 gallons of ethanol per person aged 14 years and older
were consumed in 1996.

**Target setting method:** 9 percent improvement.

**Data source:** Alcohol Epidemiologic Data System (AEDS), NIH, NIAAA.

Annual estimates of per capita consumption for persons aged 14 years and
over provide a valuable means for monitoring trends in U.S. alcohol
consumption. These estimates are based on population figures as they
relate to information on beverage sales, tax receipt data, or both. The
data come primarily from States, with some data provided by beverage
industry sources.

An overall downward trend in per-person ethanol consumption, after a
peak in 1981 of 2.76 gallons, masks substantial differences in
consumption trends for different types of alcoholic beverages.
Per-person consumption of beer, wine, and distilled spirits declined
during the 1990s. The sharpest decline occurred for distilled spirits,
down by more than 40 percent since its peak in the 1970s. The downward
trend in alcohol consumption can be attributed to a variety of factors,
including changing lifestyles and heightened awareness of the health and
safety risks of excessive alcohol consumption.

Consumption of alcohol can be influenced by laws and regulations,
particularly minimum drinking age laws^91^ and those that affect the
prices of alcoholic beverages. A substantial and growing body of
economic research has established that consumption of beer, wine, and
distilled spirits declines in response to increases in the prices or
taxes associated with these beverages.^11^ Most studies have found that
demand for beer is less responsive to price changes than are demands for
wine or distilled spirits. In addition, evidence suggests important
differences in the price responsiveness of light, moderate, and heavy
drinkers. The heaviest-drinking 5 percent of drinkers (who report about
four or more standard drinks per day and consume 36 percent of all
alcohol)^46^ and heavy drinkers who are ill-informed about health
problems associated with heavy drinking^52^ may not respond
significantly to price changes. These findings suggest the importance of
using a range of effective prevention and treatment interventions.

26-13. Reduce the proportion of adults who exceed guidelines for
low-risk drinking.

Target and baseline:

  --------------- ------------------------------ --------------- --------------
  **Objective**   **Reduction in Adults          **1992\         **2010\
                  Exceeding Guidelines for       Baseline**      Target**
                  Low-Risk Drinking**                            

                                                 Percent         

  **26-13a.**     Females                        72              50

  **26-13b.**     Males                          74              50
  --------------- ------------------------------ --------------- --------------

**Target setting method:** Better than the best.

**Data source:** National Longitudinal Alcohol Epidemiologic Survey,
NIH, NIAAA.

+------------------------------------------+-------------+-------------+
| **Current Drinkers Aged 21 Years and     | **26-13a.\  | **26-13b.\  |
| Older, 1992**                            | Females\    | Males\      |
|                                          | Exceeding   | Exceeding   |
|                                          | Guideline** | Guideline** |
+==========================================+=============+=============+
|                                          | Percent     |             |
+------------------------------------------+-------------+-------------+
| > **TOTAL**                              | 72          | 74          |
+------------------------------------------+-------------+-------------+
| **Race and ethnicity**                   |             |             |
+------------------------------------------+-------------+-------------+
| > American Indian or Alaska Native       | 85          | 97          |
+------------------------------------------+-------------+-------------+
| > Asian or Pacific Islander              | 64          | 53          |
+------------------------------------------+-------------+-------------+
| > Asian                                  | DNC         | DNC         |
+------------------------------------------+-------------+-------------+
| > Native Hawaiian and other Pacific      | DNC         | DNC         |
| > Islander                               |             |             |
+------------------------------------------+-------------+-------------+
| > Black or African American              | 65          | 75          |
+------------------------------------------+-------------+-------------+
| > White                                  | 72          | 74          |
+------------------------------------------+-------------+-------------+
|                                          |             |             |
+------------------------------------------+-------------+-------------+
| > Hispanic or Latino                     | 72          | 80          |
+------------------------------------------+-------------+-------------+
| > Not Hispanic or Latino                 | 72          | 74          |
+------------------------------------------+-------------+-------------+
| > Black or African American              | 65          | 74          |
+------------------------------------------+-------------+-------------+
| > White                                  | 72          | 74          |
+------------------------------------------+-------------+-------------+
| **Education level**                      |             |             |
+------------------------------------------+-------------+-------------+
| > Less than high school                  | 72          | 75          |
+------------------------------------------+-------------+-------------+
| > High school graduate                   | 73          | 78          |
+------------------------------------------+-------------+-------------+
| > At least some college                  | 71          | 72          |
+------------------------------------------+-------------+-------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Males may be at risk for alcohol-related problems if they drink more
than 14 drinks per week or more than 4 drinks per occasion.^92^ Females
may be at risk if they drink more than seven drinks per week or more
than three drinks per occasion.^92^ (A drink is defined as 0.54 ounces
of ethanol---about the amount of alcohol in 12 ounces of regular beer, 5
ounces of wine, or 1.5 ounces of 80-proof distilled spirits.) Most
persons who exceed these guidelines do so by drinking more than the
specified maximum number of drinks per occasion at least once a year.
Drinking more than the per-occasion maximum impairs mental performance
and physical coordination, increasing the risk of injury.

Guidelines for males and females differ in part because females
metabolize alcohol less efficiently than males (so they are at greater
risk for some health problems than males who drink the same amount).
Females also have less body water than males, so they become more
intoxicated than males after drinking the same amount of alcohol.^93^
Both males and females have less body water as they age. Older persons
can lower their risk of alcohol problems by drinking no more than one
drink a day.^94^

Some persons should not drink any alcohol.^92,\ 95^ They include:

-   Children and adolescents.

-   Females who are pregnant or considering pregnancy.

-   Persons who are alcohol dependent.

-   Persons with health problems (for example, ulcers) that may be made
    worse by drinking alcohol.

-   Persons who are taking prescription or over-the-counter drugs that
    interact with alcohol.

-   Persons who plan to drive or engage in other activities requiring
    attention or skill.

26-14. Reduce steroid use among adolescents.

Target and baseline:

  --------------- ------------------------------ -------------- ------------
  **Objective**   **Reduction in Steroid Use     **1998\        **2010\
                  Among Adolescents in Past      Baseline**     Target**
                  Year**                                        

                                                 Percent        

  **26-14a.**     8th graders                    1.2            0.4

  **26-14b.**     10th graders                   1.2            0.4

  **26-14c.**     12th graders                   1.7            0.4
  --------------- ------------------------------ -------------- ------------

**Target setting method:** Better than the best.

**Data source:** Monitoring the Future Study, NIH, NIDA.

+------------------------------+-----------+------------+------------+
| **Adolescents, 1998**        | **Steroid |            |            |
|                              | Use in    |            |            |
|                              | Past      |            |            |
|                              | Year**    |            |            |
+==============================+===========+============+============+
|                              | *         | **26-14b.\ | **26-14c.\ |
|                              | *26-14a.\ | 10th       | 12th       |
|                              | 8th       | Graders**  | Graders**  |
|                              | Graders** |            |            |
+------------------------------+-----------+------------+------------+
|                              | Percent   |            |            |
+------------------------------+-----------+------------+------------+
| > **TOTAL**                  | 1.2       | 1.2        | 1.7        |
+------------------------------+-----------+------------+------------+
| **Race and ethnicity**       |           |            |            |
+------------------------------+-----------+------------+------------+
| > American Indian or Alaska  | DSU       | DSU        | DSU        |
| > Native                     |           |            |            |
+------------------------------+-----------+------------+------------+
| > Asian or Pacific Islander  | DNC       | DNC        | DNC        |
+------------------------------+-----------+------------+------------+
| > Asian                      | DSU       | DSU        | DSU        |
+------------------------------+-----------+------------+------------+
| > Native Hawaiian and other  | DNC       | DNC        | DNC        |
| > Pacific Islander           |           |            |            |
+------------------------------+-----------+------------+------------+
| > Black or African American  | 0.7       | 0.5        | 0.9        |
+------------------------------+-----------+------------+------------+
| > White                      | 1.1       | 1.3        | 1.5        |
+------------------------------+-----------+------------+------------+
|                              |           |            |            |
+------------------------------+-----------+------------+------------+
| > Hispanic or Latino         | 1.4       | 1.2        | 2.4        |
+------------------------------+-----------+------------+------------+
| > Not Hispanic or Latino     | DNC       | DNC        | DNC        |
+------------------------------+-----------+------------+------------+
| > Black or African American  | DNC       | DNC        | DNC        |
+------------------------------+-----------+------------+------------+
| > White                      | DNC       | DNC        | DNC        |
+------------------------------+-----------+------------+------------+
| **Gender**                   |           |            |            |
+------------------------------+-----------+------------+------------+
| > Female                     | 0.7       | 0.6        | 0.3        |
+------------------------------+-----------+------------+------------+
| > Male                       | 1.6       | 1.9        | 2.8        |
+------------------------------+-----------+------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

The self‑administration by athletes of so‑called performance‑enhancing
substances has led to risky injection practices. These substances
include steroids and over‑the‑counter stimulant drugs and herbs, with
steroids the most common. Nonmedical use of steroids poses serious
problems since such use is illegal and dangerous. Behavioral and health
problems associated with steroid use include suicides, homicides, liver
damage, and heart attacks.^96^

Many substance abuse researchers believe that attempts to enhance
athletic performance with steroids and other substances reduce the
perceived negative consequences of substance abuse and increase the
likelihood of using illicit drugs for other purposes. In addition,
limited access to needles and other equipment results in a high rate of
needle-sharing among adolescent teammates who inject
performance-enhancing substances. While steroid use by male athletes has
attracted the most attention, information suggests that adolescent
females are increasing their use of steroids.^96^

26-15. Reduce the proportion of adolescents who use inhalants.

**Target:** 0.7 percent.

**Baseline:** 4.4 percent of adolescents aged 12 to 17 years used
inhalants in the past year in 1997.

**Target setting method:** Better than the best.

**Data source:** National Household Survey on Drug Abuse (NHSDA),
SAMHSA.

+-------------------------------------------------+--------------------+
| **Adolescents Aged 12 to 17 Years, 1997**       | **Inhalant Use in  |
|                                                 | Past Year**        |
+=================================================+====================+
|                                                 | Percent            |
+-------------------------------------------------+--------------------+
| > **TOTAL**                                     | 4.4                |
+-------------------------------------------------+--------------------+
| **Race**                                        |                    |
+-------------------------------------------------+--------------------+
| > American Indian or Alaska Native              | DSU                |
+-------------------------------------------------+--------------------+
| > Asian or Pacific Islander                     | DSU                |
+-------------------------------------------------+--------------------+
| > Asian                                         | DNC                |
+-------------------------------------------------+--------------------+
| > Native Hawaiian and other Pacific Islander    | DNC                |
+-------------------------------------------------+--------------------+
| > Black or African American                     | DNA                |
+-------------------------------------------------+--------------------+
| > White                                         | DNA                |
+-------------------------------------------------+--------------------+
|                                                 |                    |
+-------------------------------------------------+--------------------+
| > Hispanic or Latino                            | 3.7                |
+-------------------------------------------------+--------------------+
| > Not Hispanic or Latino                        | DNA                |
+-------------------------------------------------+--------------------+
| > Black or African American                     | 1.0                |
+-------------------------------------------------+--------------------+
| > White                                         | 5.2                |
+-------------------------------------------------+--------------------+
| **Gender**                                      |                    |
+-------------------------------------------------+--------------------+
| > Female                                        | 4.5                |
+-------------------------------------------------+--------------------+
| > Male                                          | 4.4                |
+-------------------------------------------------+--------------------+
| **Family income level**                         |                    |
+-------------------------------------------------+--------------------+
| > Poor                                          | DNA                |
+-------------------------------------------------+--------------------+
| > Near poor                                     | DNA                |
+-------------------------------------------------+--------------------+
| > Middle/high income                            | DNA                |
+-------------------------------------------------+--------------------+
| **Regions**                                     |                    |
+-------------------------------------------------+--------------------+
| > Northeast                                     | 2.9                |
+-------------------------------------------------+--------------------+
| > North central                                 | 3.4                |
+-------------------------------------------------+--------------------+
| > South                                         | 4.2                |
+-------------------------------------------------+--------------------+
| > West                                          | 7.1                |
+-------------------------------------------------+--------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Approximately 12.3 million, or 6.0 percent, of the 216 million persons
surveyed in 1997 reported lifetime inhalant use.^97^ About 2.3 million
persons (1 percent) used inhalants in the past year, and 883,000 persons
(0.4 percent) used them in the past month. Among adolescents aged 12 to
17 years between 1996 and 1997, there was a significant increase in the
lifetime rate of inhaling gasoline or lighter fluid fumes (from 1.9
percent in 1996 to 2.7 percent in 1997), spray paint (from 1.4 percent
in 1996 to 2.2 percent in 1997), and anesthetics, such as ether (0.2
percent in 1996 to 0.4 percent in 1997). Among adolescents, there were
no significant differences between males and females in the use of
inhalants.

Overall, important age, racial and ethnic, and regional differences were
found in the number of cases of inhalant use in 1997. Current use was
highest among adolescents aged 12 to 17 years, whereas lifetime use was
highest among the 18- to 25-year age group. For both lifetime and
past-year use, whites were more likely to report lifetime inhalant use
than either African Americans or Hispanics. Hispanics reported higher
rates than African Americans. Respondents living in metropolitan areas
were significantly more likely to have used inhalants in the past year
than those living in nonmetropolitan areas. Respondents in the West
reported significantly higher levels of past-year inhalant use than did
those in all other regions.^18^

### Risk of Substance Use and Abuse

26-16. Increase the proportion of adolescents who disapprove of
substance abuse.

Target and baseline:

  --------------- --------------------------------- ------------- ------------
  **Objective**   **Increase in Adolescents Who\    **1998\       **2010\
                  Disapprove of Having One or Two   Baseline**    Target**
                  Alcoholic Drinks Nearly Every                   
                  Day**                                           

                                                    Percent       

  **26-16a.**     8th graders                       77            83

  **26-16b.**     10th graders                      75            83

  **26-16c.**     12th graders                      69            83
  --------------- --------------------------------- ------------- ------------

**Target setting method:** Better than the best.

**Data source:** Monitoring the Future Study, NIH, NIDA.

+----------------------------------+----------+------------+-----------+
| **Adolescents, 1998**            | **Dis    |            |           |
|                                  | approval |            |           |
|                                  | of       |            |           |
|                                  | Daily\   |            |           |
|                                  | Alcohol  |            |           |
|                                  | Dr       |            |           |
|                                  | inking** |            |           |
+==================================+==========+============+===========+
|                                  | **       | **26-16b.\ | *         |
|                                  | 26-16a.\ | 10th\      | *26-16c.\ |
|                                  | 8th      | Graders**  | 12th      |
|                                  | G        |            | Graders** |
|                                  | raders** |            |           |
+----------------------------------+----------+------------+-----------+
|                                  | Percent  |            |           |
+----------------------------------+----------+------------+-----------+
| > **TOTAL**                      | 77       | 75         | 69        |
+----------------------------------+----------+------------+-----------+
| **Race and ethnicity**           |          |            |           |
+----------------------------------+----------+------------+-----------+
| > American Indian or Alaska      | DSU      | DSU        | DSU       |
| > Native                         |          |            |           |
+----------------------------------+----------+------------+-----------+
| > Asian or Pacific Islander      | DNC      | DNC        | DNC       |
+----------------------------------+----------+------------+-----------+
| > Asian                          | DSU      | DSU        | DSU       |
+----------------------------------+----------+------------+-----------+
| > Native Hawaiian and other\     | DNC      | DNC        | DNC       |
| > Pacific Islander               |          |            |           |
+----------------------------------+----------+------------+-----------+
| > Black or African American      | 80       | 80         | 82        |
+----------------------------------+----------+------------+-----------+
| > White                          | 77       | 74         | 66        |
+----------------------------------+----------+------------+-----------+
|                                  |          |            |           |
+----------------------------------+----------+------------+-----------+
| > Hispanic or Latino             | 72       | 75         | 77        |
+----------------------------------+----------+------------+-----------+
| > Not Hispanic or Latino         | DNC      | DNC        | DNC       |
+----------------------------------+----------+------------+-----------+
| > Black or African American      | DNC      | DNC        | DNC       |
+----------------------------------+----------+------------+-----------+
| > White                          | DNC      | DNC        | DNC       |
+----------------------------------+----------+------------+-----------+
| **Gender**                       |          |            |           |
+----------------------------------+----------+------------+-----------+
| > Female                         | 73       | 68         | 58        |
+----------------------------------+----------+------------+-----------+
| > Male                           | 82       | 81         | 80        |
+----------------------------------+----------+------------+-----------+
| **Family income level**          |          |            |           |
+----------------------------------+----------+------------+-----------+
| > Poor                           | DNC      | DNC        | DNC       |
+----------------------------------+----------+------------+-----------+
| > Near poor                      | DNC      | DNC        | DNC       |
+----------------------------------+----------+------------+-----------+
| > Middle/high income             | DNC      | DNC        | DNC       |
+----------------------------------+----------+------------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Target and baseline:

  --------------- ------------------------------ --------------- -------------
  **Objective**   **Increase in Adolescents Who\ **1998\         **2010\
                  Disapprove of Trying Marijuana Baseline**      Target**
                  or Hashish Once or Twice**                     

                                                 Percent         

  **26-16d.**     8th graders                    69              72

  **26-16e.**     10th graders                   56              72

  **26-16f.**     12th graders                   52              72
  --------------- ------------------------------ --------------- -------------

**Target setting method:** Better than the best.

**Data source:** Monitoring the Future Study, NIH, NIDA.

+----------------------------------+-----------+-----------+-----------+
| **Adolescents, 1998**            | **D       |           |           |
|                                  | isapprove |           |           |
|                                  | of Trying |           |           |
|                                  | M         |           |           |
|                                  | arijuana\ |           |           |
|                                  | or        |           |           |
|                                  | Hashish** |           |           |
+==================================+===========+===========+===========+
|                                  | *         | *         | *         |
|                                  | *26-16d.\ | *26-16e.\ | *26-16f.\ |
|                                  | 8th\      | 10th      | 12th      |
|                                  | Graders** | Graders** | Graders** |
+----------------------------------+-----------+-----------+-----------+
|                                  | Percent   |           |           |
+----------------------------------+-----------+-----------+-----------+
| > **TOTAL**                      | 69        | 56        | 52        |
+----------------------------------+-----------+-----------+-----------+
| **Race and ethnicity**           |           |           |           |
+----------------------------------+-----------+-----------+-----------+
| > American Indian or Alaska\     | DSU       | DSU       | DSU       |
| > Native                         |           |           |           |
+----------------------------------+-----------+-----------+-----------+
| > Asian or Pacific Islander      | DNC       | DNC       | DNC       |
+----------------------------------+-----------+-----------+-----------+
| > Asian                          | DSU       | DSU       | DSU       |
+----------------------------------+-----------+-----------+-----------+
| > Native Hawaiian and other      | DNC       | DNC       | DNC       |
| > Pacific Islander               |           |           |           |
+----------------------------------+-----------+-----------+-----------+
| > Black or African American      | 71        | 61        | 59        |
+----------------------------------+-----------+-----------+-----------+
| > White                          | 69        | 53        | 48        |
+----------------------------------+-----------+-----------+-----------+
|                                  |           |           |           |
+----------------------------------+-----------+-----------+-----------+
| > Hispanic or Latino             | 64        | 59        | 61        |
+----------------------------------+-----------+-----------+-----------+
| > Not Hispanic or Latino         | DNC       | DNC       | DNC       |
+----------------------------------+-----------+-----------+-----------+
| > Black or African American      | DNC       | DNC       | DNC       |
+----------------------------------+-----------+-----------+-----------+
| > White                          | DNC       | DNC       | DNC       |
+----------------------------------+-----------+-----------+-----------+
| **Gender**                       |           |           |           |
+----------------------------------+-----------+-----------+-----------+
| > Female                         | 71        | 57        | 55        |
+----------------------------------+-----------+-----------+-----------+
| > Male                           | 68        | 55        | 47        |
+----------------------------------+-----------+-----------+-----------+
| **Family income level**          |           |           |           |
+----------------------------------+-----------+-----------+-----------+
| > Poor                           | DNC       | DNC       | DNC       |
+----------------------------------+-----------+-----------+-----------+
| > Near poor                      | DNC       | DNC       | DNC       |
+----------------------------------+-----------+-----------+-----------+
| > Middle/high income             | DNC       | DNC       | DNC       |
+----------------------------------+-----------+-----------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Disapproval of substance abuse is inversely related to adolescents'
reports of use. For example, multi-year tracking of the results of the
Monitoring the Future Study indicates that marijuana use among youth
declines as the percentage of youth expressing disapproval of the drug
increases. Similarly, an increase in marijuana use among youth during
the early 1990s coincided with an apparent decline in the percentage of
parents and peers expressing strong disapproval.^97^

26-17. Increase the proportion of adolescents who perceive great risk
associated with substance abuse.

Target and baseline:

  --------------- ---------------------------------- ------------- ------------
  **Objective**   **Increase in Adolescents Aged 12  **1997\       **2010\
                  to 17 Years Perceiving Great Risk\ Baseline**    Target**
                  Associated With Substance Abuse**                

                                                     Percent       

  **26-17a.**     Consuming five or more alcoholic   47            80
                  drinks at a single occasion once                 
                  or twice a week                                  

  **26-17b.**     Smoking marijuana once per month   31            80

  **26-17c.**     Using cocaine once per month       54            80
  --------------- ---------------------------------- ------------- ------------

**Target setting method:** Better than the best (consistent with Office
of National Drug Control Policy).

**Data source:** National Household Survey on Drug Abuse (NHSDA),
SAMHSA.

+-------------------------------------+-----------+---------+---------+
| **Adolescents Aged 12 to 17 Years,  | **        |         |         |
| 1997**                              | Perceived |         |         |
|                                     | Risk      |         |         |
|                                     | From**    |         |         |
+=====================================+===========+=========+=========+
|                                     | *         | **2     | **2     |
|                                     | *26-17a.\ | 6-17b.\ | 6-17c.\ |
|                                     | Alcohol** | Mari    | Co      |
|                                     |           | juana** | caine** |
+-------------------------------------+-----------+---------+---------+
|                                     | Percent   |         |         |
+-------------------------------------+-----------+---------+---------+
| ######## TOTAL                      | 47        | 31      | 54      |
+-------------------------------------+-----------+---------+---------+
| ####### Race and ethnicity          |           |         |         |
+-------------------------------------+-----------+---------+---------+
| > American Indian or Alaska Native  | DSU       | DSU     | DSU     |
+-------------------------------------+-----------+---------+---------+
| > Asian or Pacific Islander         | DSU       | DSU     | DSU     |
+-------------------------------------+-----------+---------+---------+
| > Asian                             | DNC       | DNC     | DNC     |
+-------------------------------------+-----------+---------+---------+
| > Native Hawaiian and other         | DNC       | DNC     | DNC     |
| > Pacific\                          |           |         |         |
| > Islander                          |           |         |         |
+-------------------------------------+-----------+---------+---------+
| > Black or African American         | DNA       | DNA     | DNA     |
+-------------------------------------+-----------+---------+---------+
| > White                             | DNA       | DNA     | DNA     |
+-------------------------------------+-----------+---------+---------+
|                                     |           |         |         |
+-------------------------------------+-----------+---------+---------+
| > Hispanic or Latino                | 49        | 35      | 53      |
+-------------------------------------+-----------+---------+---------+
| > Not Hispanic or Latino            | DNA       | DNA     | DNA     |
+-------------------------------------+-----------+---------+---------+
| > Black or African American         | 54        | 35      | 65      |
+-------------------------------------+-----------+---------+---------+
| > White                             | 44        | 29      | 53      |
+-------------------------------------+-----------+---------+---------+
| ####### Gender                      |           |         |         |
+-------------------------------------+-----------+---------+---------+
| > Female                            | 51        | 32      | 54      |
+-------------------------------------+-----------+---------+---------+
| > Male                              | 43        | 30      | 55      |
+-------------------------------------+-----------+---------+---------+
| ####### Family income level         |           |         |         |
+-------------------------------------+-----------+---------+---------+
| > Poor                              | DNA       | DNA     | DNA     |
+-------------------------------------+-----------+---------+---------+
| > Near poor                         | DNA       | DNA     | DNA     |
+-------------------------------------+-----------+---------+---------+
| > Middle/high income                | DNA       | DNA     | DNA     |
+-------------------------------------+-----------+---------+---------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

The perception of risk in using illegal drugs is an important factor in
decreasing drug use. As perception of harmfulness decreases, use tends
to increase.^18^ Therefore, youth need to be informed of the many risks,
such as HIV infection, associated with use of alcohol, tobacco, and
illegal drugs. (See Focus Area 27. Tobacco Use.) People who use or abuse
drugs or alcohol sometimes reported being so high or intoxicated that
they forgot to use a condom.^18^ Therefore, informing youth about the
connection between substance use and abuse and other problem behaviors,
such as nonsafe sex, dating violence, and suicide, is important.

The percentage of adolescents aged 12 to 17 years who perceive great
risk associated with substance abuse is on the decline.^18^ The
percentage perceiving great risk in using marijuana once a month
decreased from 40 percent (1990) to 33 percent (1994‑96). The percentage
of youth perceiving great risk in using cocaine once a month decreased
from 63 percent in 1994 to 54 percent in 1996. Perception of risk in
having five or more drinks once or twice a week decreased from 58
percent in 1992 to 45 percent in 1996.^18^

The attitude of influential adults about alcohol and drugs is another
critical predictor of attitudes in youth. Many adults who have regular
contact with youth communicate ambivalent messages about alcohol and
drug use.^98^ In addition, more than 11 million children and adolescents
under age 18 years have at least one parent who is addicted to alcohol
or drugs.^99^ As a result, the messages about harm and risk that they
receive are sometimes impacted by family dynamics and denial. Risk and
harm messages targeted to youth must therefore take this into account.

### Treatment for Substance Abuse

26-18. (Developmental) Reduce the treatment gap for illicit drugs in the
general population.

**Potential data source:** National Household Survey on Drug Abuse
(NHSDA), SAMHSA.

The treatment gap is the difference between the number of persons who
need treatment for the use of illicit drugs and the number of persons
who are receiving treatment in a given year. Despite the widely
acknowledged problem of drug abuse in the United States, accepted
estimates of the number of persons who need treatment and the number who
receive treatment are not available.^100,\ 101^ It is estimated that 5.3
million persons are most in need of treatment.^77^ National efforts are
underway to estimate better the size of the gap, to develop strategies
to expand capacity, and to eliminate barriers to access for those in
need. These strategies involve seeking changes in financial barriers
created by funding constraints and inadequate health and disability
insurance coverage^102^ and improvements in gender-specific and
culturally appropriate treatment methods.^103^

Strategies address the specific and unique needs of select populations,
including adolescents,^104^ females, and elderly persons.^105^

26-19. (Developmental) Increase the proportion of inmates\
receiving substance abuse treatment in correctional\
institutions.

**Potential data source:** Uniform Facilities Data Set Survey of
Correctional\
Facilities, OAS, SAMHSA.

Much attention has been focused on the link between substance abuse and
criminality, in part because of the large increase in the number of
individuals incarcerated for drug-related offenses, such as possession,
trafficking, and crimes of violence. In general, criminal offenders
frequently have high occurrences\
of a substance abuse history, may or may not have previously received
treatment, and without treatment have a greater likelihood of committing
a criminal offense.^106,\ 107,\ 108^

26-20. Increase the number of admissions to substance abuse treatment
for injection drug use.

**Target:** 200,000 admissions.

**Baseline:** 167,960 admissions for injection drug use in 1997.

**Target setting method:** 19 percent improvement.

**Data source:** Treatment Episodes Data System, OAS, SAMHSA.

The 167,960 admissions to treatment for injection drug use indicates a
large unmet need for treatment in this group, because estimates of
injection drug users in the Nation are as high as 810,000.^83^ Better
data are needed on this group's need for treatment. Because of the
consequences associated with HIV/AIDS, injection drug users are a high
priority population group needing substance abuse treatment. HIV
infection among females and infants in the United States can be traced
primarily to contaminated drug "works" and to sexual relations with
infected drug users. Pediatric AIDS is a particularly virulent problem
among the children of persons involved in drug-related lifestyles. To
address these problems, substance abuse treatment must be provided for
injection drug users. Such treatment will be most effective against HIV
if it includes information, counseling, and other assistance on how to
prevent HIV and unintended pregnancy.

26-21. (Developmental) Reduce the treatment gap for alcohol problems.

**Potential data source:** Office of Applied Studies, SAMHSA.

Although alcohol problems are diverse and vary along many dimensions,
they can be described in part by their duration (acute, intermittent,
chronic) and severity (mild, moderate, substantial, severe).^110^ As
with illicit drugs, availability of resources and access to clinically
appropriate and effective treatment for alcohol problems are
limited.^11,\ 110^ The size of the gap is not well defined. Wide
variability exists among jurisdictions in total treatment capacity and
in how that capacity is distributed among settings and
modalities.^11,\ 110^

Increasing the availability of treatment for alcohol problems is
critical because of the pervasive impact these problems have on all
aspects of society.^111,\ 112^ Alcohol problems have an effect on such
important components of human capital as level of school attainment,
work experience, health status, and family structure. Strategies to be
employed here are similar to those needed to improve access to
appropriate primary, rehabilitative, and long-term care through
addressing the many barriers that exist at multiple levels.^113^ Key
patient-level barriers include lack of knowledge or skepticism about the
effectiveness of treatment and lack of money or insurance coverage to
pay for treatment. System-level barriers include lack of trained
personnel, stigma, lack of health and disability insurance coverage, and
inadequate reimbursement for clinically necessary services through
public funding mechanisms such as the Substance Abuse Prevention and
Treatment Services Block Grant and Medicaid.^114,\ 115^

### State and Local Efforts

26-22. (Developmental) Increase the proportion of persons who are
referred for followup care for alcohol problems, drug problems, or
suicide attempts after diagnosis or treatment for one of these
conditions in a hospital emergency\
department.

**Potential data source:** National Hospital Ambulatory Medical Care
Survey (NHAMCS), CDC, NCHS.

Alcohol problems, drug problems, and suicide attempts frequently cause
ED visits, but these conditions may be overlooked during the visit or
inadequately addressed when plans for followup are made. Some ED
patients are treated for physical manifestations of alcohol problems,
drug problems, or suicide attempts and released without appropriate
evaluation, treatment, or referral for underlying behavioral risk
factors that may cause a repeat ED visit.^116^ These risk factors
include hazardous patterns of alcohol consumption, use of illicit drugs,
and predisposition to suicidal thoughts or actions. The effectiveness of
ED interventions for these risk factors is determined by how well the
affected patients are evaluated and treated in the ED and by the extent
of communication and coordination with other settings and organizations
in the community.^117^ EDs are strategically well-positioned to ensure
appropriate referrals for followup care, but underlying behavioral risk
factors must be identified and appropriate followup services must be
available.

26-23. (Developmental) Increase the number of communities\
using partnerships or coalition models to conduct\
comprehensive substance abuse prevention efforts.

**Potential data source:** Community Partnerships Data, SAMHSA.

A comprehensive program of interventions at the community level is
crucial to effective substance abuse prevention.^118,\ 119^ Such
programs enable communities to address issues related to their
environments, not just their at-risk populations. Improving the
environment means changing local ordinances and policies, coordinating
local prevention services, increasing resident participation,
communicating with the local media on how they portray local
communities, and addressing numerous other conditions. Because of the
diversity of communities, no single partnership model is expected to be
the sole model used. However, desirable procedures and practices, such
as how a community should get mobilized, are now being promoted.^119^

A recent 48-community study shows that community partnerships that
showed statistically significant reductions in substance abuse shared a
number of common characteristics. These include: a communitywide vision
that reflects the consensus of diverse groups and citizens throughout
the community; a strong core of community partners; an inclusive, broad
membership of organizations from all parts of the community; an ability
to avoid or resolve conflict; decentralized groups that implement a
large number of locally tailored prevention programs that effectively
target local causes of drug use and empower residents to take action and
make decisions; low staff turnover; and extensive prevention activities
and support for improvements in local prevention policies.^120^

26-24. Extend administrative license revocation laws, or\
programs of equal effectiveness, for persons who drive under the
influence of intoxicants.

**Target:** All States and the District of Columbia.

**Baseline:** 41 States and the District of Columbia had administrative
license revocation laws for persons who drive under the influence of
intoxicants in 1998.

**Target setting method:** Total coverage.

**Data source:** DOT, NHTSA.

Administrative license revocation (ALR) has proven to be a successful
deterrent to driving while under the influence of intoxicants. ALR laws
provide for administrative action separate from the judicial process
that follows when a person is arrested for driving under the influence
of alcohol or drugs. Colorado, Illinois, Maine, New Mexico, North
Carolina, and Utah observed significant reductions in alcohol‑related
fatal crashes following the implementation of ALR laws. A 1991 study
examined the costs and benefits of the procedure and found that
reinstatement fees assessed to offenders more than covered the expenses
of the program and that States also benefitted from the cost savings of
fewer nighttime crashes. Another study found that ALR reduced fatal
crashes an average of 9 percent during late-night hours when drivers are
most likely to have been drinking alcohol. As a result of an ALR
publicity campaign, the rate of fatal crashes during late-night hours
was further reduced.^121^

26-25. Extend legal requirements for maximum blood alcohol concentration
levels of 0.08 percent for motor vehicle\
drivers aged 21 years and older.

**Target:** All States and the District of Columbia.

**Baseline:** 16 States had legal requirements for maximum blood alcohol
concentration levels of .08 percent for motor vehicle drivers aged 21
years and older in 1998.

**Target setting method:** Total coverage.

**Data source:** DOT, NHTSA.

More than 80 percent of the drivers involved in fatal crashes had blood
alcohol concentration (BAC) levels exceeding 0.08 percent. An average
man weighing 170 pounds must consume in 1 hour more than four drinks on
an empty stomach to reach a 0.08 BAC level.^122^ Most States that have
enacted 0.08 BAC legislation experienced significant decreases in
alcohol-related fatal crashes. For example, a 12 percent reduction in
alcohol-related fatalities occurred in California in 1990, the year 0.08
legislation and an ALR law went into effect.^122^

As of August 1998, 50 States and the District of Columbia had
established BAC cutoff levels of 0.00, 0.01, or 0.02 to define driving
under the influence for individuals under age 21 years. A zero tolerance
law makes driving with any measurable amount of alcohol in the blood
illegal for persons under age 21 years. Because young drivers place such
a high value on their driver's licenses, the threat of license
revocation has proved to be an effective sanction for this age
group.^122^

## Related Objectives From Other Focus Areas

  ------------------ ----------------------------------------------------------------
  **1. Access to     
  Quality Health     
  Services**         

  1-1.               Persons with health insurance

  1-2.               Health insurance coverage for clinical preventive services

  1-3.               Counseling about health behaviors

  1-4.               Source of ongoing care

  1-5.               Usual primary care provider

  1-6.               Difficulties or delays in obtaining needed health care

  1-7.               Core competencies in health provider training

  1-8.               Racial and ethnic representation in the health professions

  1-10.              Delay or difficulty in getting emergency care

  1-11.              Rapid prehospital emergency care

  1-12.              Single toll-free number for poison control centers

  1-13.              Trauma care systems

  1-14.              Special needs of children

  **3. Cancer**      

  3-10.              Provider counseling about preventive measures

  **6. Disability    
  and Secondary      
  Conditions**       

  6-2.               Feelings and depression among children with disabilities

  **7. Educational   
  and                
  Community-Based    
  Programs**         

  7-1.               High school completion

  7-2.               School health education

  7-3.               Health-risk behavior information for college and university
                     students

  7-4.               School nurse-to-student ratio

  7-5.               Worksite health promotion programs

  7-6.               Participation in employer-sponsored health promotion activities

  7-7.               Patient and family education

  7-8.               Satisfaction with patient education

  7-9.               Health care organization sponsorship of community health
                     promotion activities

  7-10.              Community health promotion programs

  7-11.              Culturally appropriate community health promotion programs

  7-12.              Older adult participation in community health promotion
                     activities

  **9. Family        
  Planning**         

  9-8.               Abstinence before age 15 years

  9-9.               Abstinence among adolescents aged 15 to 17 years

  9-10.              Pregnancy prevention and sexually transmitted disease protection

  9-11.              Pregnancy prevention education

  9-12.              Problems in becoming pregnant and maintaining a pregnancy

  **13. HIV**        

  13-3.              AIDS among persons who inject drugs

  13-4.              AIDS among men who have sex with men and who inject drugs

  13-8.              HIV counseling and education for persons in substance abuse
                     treatment

  13-12.             Screening for STDs and immunization for hepatitis B

  13-13.             Treatment according to guidelines

  **14. Immunization 
  and Infectious     
  Diseases**         

  14-28.             Hepatitis B vaccination among high-risk groups

  **15. Injury and   
  Violence           
  Prevention**       

  15-10.             Emergency department visits

  15-13.             Deaths from unintentional injuries

  15-14.             Nonfatal unintentional injuries

  15-15.             Deaths from motor vehicle crashes

  15-16.             Pedestrian deaths

  15-17.             Nonfatal motor vehicle injuries

  15-18.             Nonfatal pedestrian injuries

  15-29.             Drownings

  15-32.             Homicides

  15-37.             Physical assaults

  **16. Maternal,    
  Infant, and Child  
  Health**           

  16-17.             Prenatal substance exposure

  16-18.             Fetal alcohol syndrome

  **17. Medical      
  Product Safety**   

  17-3.              Provider review of medications taken by patients

  **18. Mental       
  Health and Mental  
  Disorders**        

  18-6.              Primary care screening and assessment

  18-10.             Treatment for both co-occurring disorders

  18-13.             State plans addressing cultural competence

  **23. Public       
  Health             
  Infrastructure**   

  23-2.              Public access to information and surveillance data

  23-3.              Use of geocoding in health data systems

  23-4.              Data for all population groups

  23-5.              Data for Leading Health Indicators, Health Status Indicators,
                     and Priority Data Needs at Tribal, State, and local levels

  23-6.              National tracking of Healthy People 2010 objectives

  23-7.              Timely release of data on objectives

  23-8.              Competencies for public health workers

  23-9.              Training in essential public health services

  23-10.             Continuing education and training by public health agencies

  23-11.             Performance standards for essential public health services

  23-12.             Health improvement plans

  23-14.             Access to epidemiology services

  23-15.             Model statutes related to essential public health services

  23-16.             Data on public health expenditures

  23-17.             Prevention research

  **25. Sexually     
  Transmitted        
  Diseases**         

  25-11.             Responsible adolescent sexual behavior

  25-12.             Responsible sexual behavior messages on television

  25-13.             Hepatitis B vaccine services in STD clinics

  25-14.             Screening in youth detention facilities and jails

  **27. Tobacco      
  Use**              

  27-1.              Adult tobacco use

  27-2.              Adolescent tobacco use

  27-3.              Initiation of tobacco use

  27-4.              Age at first use of tobacco

  27-5.              Smoking cessation by adults

  27-6.              Smoking cessation during pregnancy

  27-7.              Smoking cessation by adolescents

  27-8.              Insurance coverage of cessation treatment

  27-9.              Exposure to tobacco smoke at home among children

  27-10.             Exposure to environmental tobacco smoke

  27-11.             Smoke-free and tobacco-free schools

  27-12.             Worksite smoking policies

  27-13.             Smoke-free indoor air laws

  27-14.             Enforcement of illegal tobacco sales to minors laws

  27-15              Retail license suspension for sales to minors

  27-16.             Tobacco advertising and promotion targeting adolescents and
                     young adults

  27-17.             Adolescent disapproval of smoking

  27-18.             Tobacco control programs

  27-19.             Preemptive tobacco control laws

  27-20.             Tobacco product regulation

  27-21.             Tobacco tax
  ------------------ ----------------------------------------------------------------

## Terminology

(A listing of all abbreviations and acronyms used in this publication
appears in Appendix K.)

**Administrative license revocation (ALR):** Legal procedure that allows
an arresting officer to confiscate immediately the driver's license of a
driver who is found with a blood alcohol concentration (BAC) at or above
the legally set limit or who refuses to take a BAC test. The officer
usually issues a temporary driving permit valid for a short time, often
15 to 20 days, then notifies the offender of his or her right to an
administrative hearing to appeal the revocation. If there is no appeal
or if revocation is upheld, the offender loses his or her driver's
license for a set period (90 days in most States for a first offense and
longer for subsequent offenses).

**Alcohol abuse:** A maladaptive pattern of alcohol use that leads to
clinically significant impairment or distress, as manifested by one or
more of the following occurring within a 12-month period: recurrent
alcohol use resulting in a failure to fulfill major role obligations at
work, school, or home; recurrent alcohol use in physically hazardous
situations; recurrent alcohol-related legal problems; continued alcohol
use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of alcohol. In the
literature on economic costs, alcohol abuse means any cost-generating
aspect of alcohol consumption. This definition differs from the clinical
use of the term, which involves specific diagnostic outcomes.

**Alcohol dependence:** A maladaptive pattern of alcohol use that leads
to clinically significant impairment or distress, as manifested by three
or more of the following occurring at any time in the same 12-month
period: tolerance; withdrawal; often taking alcohol in larger amounts or
over a longer period than was intended; persistent desire or
unsuccessful efforts to cut down or control alcohol use; spending a
great deal of time in activities necessary to obtain alcohol or recover
from its effects; giving up or reducing important social, occupational,
or recreational activities because of alcohol use; continued alcohol use
despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated
by alcohol.

**Alcohol-related crash:** A motor vehicle crash in which either a
driver or a nonmotorist (usually a pedestrian) had a measurable or
estimated BAC of 0.01 grams per deciliter (g/dL) or above.

**Binge drinking:** The National Household Survey on Drug Abuse defines
binge drinking as drinking five or more drinks on the same occasion on
at least 1 day in the past 30 days. The Monitoring the Future Study
defines binge drinking as drinking five or more drinks on the same
occasion during the past 2 weeks.

**Blood alcohol concentration (BAC):** The amount of alcohol in the
bloodstream measured as a percentage, by weight, of alcohol in the blood
in grams per deciliter (g/dL). Legal intoxication has been defined by
States to occur at ranges from as low as 0.05 g/dL to as high as 0.10
g/dL.

**Chronic drug use:** Use of any heroin or cocaine more than 10 days in
the past month.

**Co-occurring disorders:** The simultaneous presence of two or more
disorders, such as the coexistence of a mental health disorder and
substance abuse problems.

**Current drinkers:** Persons who have consumed at least 12 drinks of
any kind of alcohol in the past year.

**Drug dependence:** A pattern of drug use leading to clinically
significant impairment or distress, as manifested by three or more of
the following occurring at any time in the same 12-month period:
tolerance; withdrawal; use in larger amounts or over a longer period of
time than intended; persistent desire or unsuccessful efforts to cut
down; spending a great deal of time in activities necessary to obtain
drug(s); giving up or reducing important social, occupational, or
recreational activities; continued use despite knowledge of having a
persistent or recurrent physical or psychological problem.

**Fatal crash:** A police-reported crash involving a motor vehicle in
transport on a traffic way in which at least one person dies within 30
days of the crash.

**Hepatitis B and C:** Viral infections of the liver spread through
contact with infected blood products, injection use of drugs, and
needle-sharing.

**Indicated preventive interventions:** Interventions targeted to reach
high-risk individuals who are identified as having minimal but
detectable signs or symptoms foreshadowing substance abuse or biological
or familial markers indicating predisposition for substance abuse, even
though they do not meet DSM-III-R diagnostic levels at the current time.

**Inhalants:** Fumes or gases from common household substances, such as
glues, aerosols, butane, and solvents, that are inhaled to produce a
high.

**Injection drug use:** The use of a needle and syringe to inject
illicit drugs (for example, heroin, cocaine, steroids) into the vein,
muscle, skin, or below the skin. Injection drug use places the user at
great risk for transmitting or contracting a number of blood-borne
infectious diseases, including HIV, hepatitis B, and hepatitis C.

**Selective preventive interventions:** Interventions targeted to
individuals or a subgroup of the population whose risk of developing
substance abuse is significantly higher than average. The risk may be
imminent or it may be a lifetime risk. The basis may be biological,
psychological, or environmental.

**Substance abuse:** The problematic consumption or illicit use of
alcoholic beverages, tobacco products, and drugs, including misuse of
prescription drugs.

**Universal preventive interventions:** Interventions targeted to the
public or a whole population group that has not been identified on the
basis of individual risk. The intervention is desirable for everyone in
that group. Universal interventions have advantages in terms of cost and
overall effectiveness for large populations.

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