Public Health & Substance Use Prevention

Traditional definition of public health

The science and art of promoting health, preventing disease, and prolonging life through the organized efforts of society.

Expanded conceptualization of public health

Understanding how lifestyles and living conditions determine health and using policies, programs, services, and supportive environments to protect and promote health.

Main difference between public health and medicine

Public health focuses on promoting, protecting, and preventing at the population level, while medicine focuses on treating and caring for individual people.

Primary focus of public health

Populations.

Primary focus of medicine

Individual people.

Historical approach to public health (1700s-1880s)

Reactively rather than preventively.

Miasma theory

The belief that disease outbreaks resulted from unseen rotting or decay in the environment.

Environmental condition contributing to early city disease spread

Overcrowding.

Sanitary Movement

An 1800s public health reform movement emphasizing improved sanitation and living conditions.

Sanitary Movement infrastructure improvements

Clean drinking water and sewer systems.

Environmental factor associated with infectious disease during reform

Poverty.

John Snow's action in the 1854 London cholera outbreak

He mapped cholera cases and traced the outbreak to contaminated water from a specific pump.

Significance of John Snow's cholera investigation

It helped discredit miasma theory by demonstrating a specific environmental source of disease.

Replacement for miasma theory in the 1900s

Germ theory.

Public health strategies following germ theory

Vaccines, quarantines, and better integration of science, public health, and medicine.

Three major developments in public health from 1900s to present

Institutionalization, professionalization, and a broadened scope.

Institutionalization of public health

Formal organizations and agencies, such as SAMHSA, fund and organize public health efforts.

Professionalization of public health

Specialized professional training became available, such as Master of Public Health (MPH) programs.

Broadening of public health scope

Expanded beyond infectious disease to issues such as substance use and violent crime.

Individualist approach to health

A traditional approach emphasizing medical science and viewing health as determined mainly by physiology and individual lifestyle choices.

Individualist definition of health

Primarily as the absence of disease.

Activities aligning with the individualist approach

Medical care, disease screening/prevention, and treatment.

Collectivist approach to health

A holistic/ecological approach recognizing physiology and lifestyle choices PLUS social and environmental factors as determinants of health.

Modern/alternative public health view

The collectivist approach.

Activities aligning with the collectivist approach

Policy change, healthcare access, community/population intervention, and health promotion.

Individualist vs. collectivist approach

Individualist = physiology and personal lifestyle choices; collectivist = physiology and lifestyle PLUS social and environmental factors.

Triad Model of Causation

A model explaining health outcomes through interactions among the agent, host, and environment.

Three components of the Triad Model

Agent, host, and environment.

Agent in the Triad Model for alcohol dependence

Alcohol.

Host factors in alcohol dependence

Genetics, age, attitudes, expectations, and habits.

Environmental factors in alcohol dependence

Alcohol availability, family influences, and norms.

Major takeaway from the Triad Model

Health problems are not caused by only one factor; they emerge through interactions among the agent, person, and environment.

Health disparities

Differences in health outcomes associated with social, economic, environmental, and demographic inequalities.

Relation between income and health disparities

Income inequalities are associated with inequalities in education, family stability, healthy food access, exposure to dangerous environments, and healthcare access.

Do racial health disparities disappear when income is controlled?

No. BIPOC groups experience increased health risks independent of income.

Food desert

An area where access to healthy food or grocery stores is limited, illustrating how environmental conditions contribute to health disparities.

Healthy People 2020

A large public health initiative involving 26 health indicators, including five related to substances.

Major goals of Healthy People 2020

Longer lives free of preventable disease/injury; health equity and elimination of disparities; environments that promote health; and improved quality of life and development across ages.

Public health surveillance

Ongoing assessment of the health of a community or population through collection, analysis, interpretation, and use of health data.

Basic purpose of public health surveillance

To determine what is happening so priorities, policies, programs, interventions, and advocacy can be based on empirical evidence.

Surveillance data simple meaning

Surveillance tells us "what we know."

What follows from "what we know" in public health?

"What we do" — priorities, policies, programs, interventions, and advocacy based on evidence.

Importance of surveillance systems and intervention studies

They show how public health investigations are conducted and provide evidence about substance-specific interventions.

West Virginia one-community investigation

Examined a cluster of 20 overdoses occurring on one day.

Discoveries from the West Virginia overdose cluster

Potent opioids were being used, and none of the patients received treatment referrals after the emergency department visit.

Purpose of investigating an overdose cluster

It can identify patterns and gaps in care that can guide interventions, policies, and prevention efforts.

YRBSS meaning

Youth Risk Behavior Surveillance Survey.

Who conducts the YRBSS?

CDC.

YRBSS data collection method

Self-report survey.

YRBSS frequency

Biennially.

YRBSS sample population

U.S. high school students in grades 9-12.

What YRBSS examines

High-risk health behaviors including tobacco, alcohol, other drugs, violence, exercise, eating, sexual behaviors, and educational outcomes.

Major goals of YRBSS

Track prevalence over time, examine co-occurring behaviors, and compare behaviors across locations and subpopulations.

Drug use prevalence trend across grade levels in YRBSS

Generally increases with grade level, except inhalant use.

Most commonly used substances in YRBSS

Alcohol, e-cigarettes, marijuana, and prescription drugs used nonmedically.

Inhalant use trend as grade level increases

It decreases.

NSDUH meaning

National Survey on Drug Use and Health.

Who conducts NSDUH?

SAMHSA.

NSDUH frequency

Annually.

NSDUH sample population

U.S. individuals ages 12 and older.

NSDUH data collection method

Approximately 67,000 face-to-face, computer-assisted personal interviews in households.

Focus of NSDUH

Prevalence of tobacco, alcohol, and drug use.

What NSDUH can tell researchers

Prevalence of substance use, number of people with SUD, and number receiving treatment.

Number of people needing SUD treatment (2024 NSDUH)

48.4 million.

Number of people meeting SUD criteria who received treatment (2024 NSDUH)

9.4 million.

Percentage of people needing SUD treatment who received it

Only 19%.

NVSS meaning

National Vital Statistics System.

Who conducts NVSS?

CDC.

NVSS data source

Records of vital events such as births, deaths, marriages, divorces, and fetal deaths.

Focus of NVSS

Broad health-related issues and trends.

Opioid trend identified using vital statistics

Deaths involving heroin, opioids, and synthetic opioids excluding methadone rose from 1999-2021 before beginning to decline.

Peak ED treatment rate for prescription opioid misuse

More than 1,000 people per day.

How public health surveillance informs policy decisions

Researchers examine changes in population behavior following policy changes.

Effect of Quebec increasing cannabis minimum age from 18 to 21

Cannabis use continued increasing overall but increased at a slower pace in Quebec.

Age group significantly affected by Quebec's cannabis minimum-age policy

18-20-year-olds.

What the Quebec cannabis study demonstrates

Policy changes can meaningfully affect behavior but may not produce the broad effects policymakers hope for.

General effect of sales taxes on nicotine product use

They can reduce use or slow increases in use.

Problem with independent taxation of cigarettes and e-cigarettes

People may shift from the taxed product to the other nicotine product rather than reducing overall nicotine use.

Friedman & Pesko finding on nicotine taxes

Taxing one type reduced its use but increased use of the other type.

Broader lesson from the nicotine tax study

Policies can change behavior but can also produce substitution effects and may not have the broad impact intended.

Importance of age of onset in substance-use prevention

Delaying the onset of substance use is one of the most effective ways to reduce later problems and costs.

Association with early onset of substance use

Increased risk of later problems with that same substance.

Association with becoming drunk at or before age 15

Elevated mortality rates.

Risky behaviors associated with adolescent smoking

Violence, unprotected sex, and other substance use.

Predictors of cigarette smoking onset

School conduct problems and academic concerns.

Gateway Hypothesis

The controversial hypothesis that substance use tends to progress through a particular sequence.

Sequence proposed by the Gateway Hypothesis

Beer/wine → hard liquor/cigarettes → cannabis → other "hard" drugs.

Does a sequence prove causation in the Gateway Hypothesis?

No.

Why the Gateway Hypothesis is controversial

The sequence may be too simplistic and could reflect other social, environmental, or individual factors.

Alternative factors explaining the Gateway Hypothesis

Poverty, weak family bonds, inadequate supervision, impulsivity, or general proneness to deviance.

Third variable problem in the Gateway Hypothesis

Another characteristic, such as impulsivity, could cause both earlier and later substance use.

Correlated liabilities model

An alternative explanation proposing common underlying risk factors contribute to multiple substance use rather than one drug causing another.

Evidence for a modified Gateway Hypothesis

Cannabis may act as a gateway only after a high threshold of cannabis-use risk is reached.

Take-home message about the Gateway Hypothesis

More research is needed before concluding that a causal gateway process is occurring.

Three types of prevention programs

Universal/primary, selective/secondary, and indicated/tertiary.

Universal or primary prevention

Prevention directed toward everyone or the general population.

Example of universal prevention in a school

A prevention program provided to all students in the school.

Selective or secondary prevention

Prevention directed toward groups at elevated risk.

Example of selective prevention in a school

A program for students at high risk for alcohol use.

Indicated or tertiary prevention

Prevention directed toward people already engaging in risky behavior or needing treatment.