Introduction

According to a Brandeis University study, "substance abuse and substance abuse-related problems are among society's most pervasive health and social concerns. Some 100,000 people die each year in the United States as a result of alcohol alone. In addition, illicit drug abuse and related AIDS deaths account for at least 12,000 deaths. It costs every man, woman, and child in America nearly $1,000 annually to cover the costs of health care, law enforcement, motor vehicle crashes, crime and lost productivity due to substance abuse." It is for these reasons that efforts to reduce addictions are a priority for public health in New Jersey.

New Jersey has made considerable gains in meeting year 2000 objectives for decreasing death rates due to alcohol-related motor vehicle accidents and deaths due to cirrhosis. However, it is unlikely that other year 2000 targets will be met.

Outlook for Reaching Specific Objectives:
	Achieve target:		Likely	Unlikely	Uncertain
11A.	Reduction in cigarette smoking among:
		age 20 and over
		high school students
11B.	Increase in pregnant women abstaining from:
		alcohol
		tobacco
11C.	Reduction in students using:
		alcohol
		marijuana
		cocaine
11D.	Reduction in adult binge drinking
11E.	Reduction in alcohol-related motor vehicle death rates for:
		total population
		age 15-24
11F.	Reduction in cirrhosis death rates for:
		total population
		minority males
11G.	Reduction in drug-related death rate
11H.	Reduction in time between first use and treatment for:
		alcohol
		other drugs
11I.	Increase in addicted persons treated annually for:
		alcohol
		other drugs

Data Update

11A. Reduce the prevalence of cigarette smoking to:

15.0 percent of the population aged 20 and over
20.0 percent of high school students

Achieve target:	Likely	Unlikely	Uncertain
age 20 and over
high school students

The percentage of persons aged 20 and over who report that they currently smoke can be estimated, based on survey data, from the Behavioral Risk Factor Surveillance System. According to this survey, the trend since 1991 has been stable, and it is not likely that the year 2000 objective for adults will be met.

The estimates of smoking prevalence among high school students are obtained from surveys conducted every three years by the New Jersey Department of Law and Public Safety. The percentages include students who report smoking "on occasion" as well as those who say they smoke from "less than" to "more than" half a pack of cigarettes per day. Results from these surveys have fluctuated over the recent past, but have shown no indication of a decline in the percentage of students who currently smoke. Moreover, the prevalence of smoking among students is almost twice as high as that among adults (taking into account that the data came from two different sources). The data on student smoking do not reflect the potential impact of more recent interventions to reduce youth smoking. However, since the 1995 prevalence of student smoking was about twice the year 2000 target level, it is unlikely the objective will be met.

11B. Increase the percentage of women who abstain from alcohol and tobacco during pregnancy to:

90.0 percent abstinence from tobacco
95.0 percent abstinence from alcohol

Achieve target:	Likely	Unlikely	Uncertain
alcohol
tobacco

The percentages of women who abstained from tobacco and alcohol, respectively, during pregnancy appears to have increased since 1989, when this information was first required to be reported on the birth certificate. At least part of the improvement may have been a result of increased familiarity with the reporting format on the part of those preparing birth certificates. However, the continued improvement may well reflect actual trends. Although the improvement in these measures is encouraging, in the case of tobacco it is unlikely the year 2000 target will be achieved. Reaching the target for alcohol abstinence in uncertain.

11C. Decrease the percentage of high school sophomores, juniors, and seniors who have used the following substances in the past 30 days to:

37.0 percent for alcohol
9.0 percent for marijuana
1.6 percent for cocaine

Achieve target:	Likely	Unlikely	Uncertain
alcohol
marijuana
cocaine

The percentage of high school students who reported having used alcohol in the thirty days prior to interview in the Department of Law and Public Safety's surveys declined steadily from 1980 through 1992. It appeared likely that the year 2000 objective would be met until the 1995 results indicated a reversal in the downward trend. Due to the increase in reported use of alcohol in the last survey, achievement of the objective is now uncertain.

A similar trend occurred in the reported use of marijuana by high school students. The percentage of students who said they had used marijuana in the past 30 days dropped dramatically, from 36 percent in 1980 to 13 percent in 1992, then increased in 1995 to 22 percent. It does not now seem likely that the year 2000 target will be met.

The percentage of students who report using cocaine is small relative to the reported use of alcohol and marijuana, and this percentage also declined during the 1980s. It appears from the past two surveys, however, that the percentage of students using cocaine is increasing, and this objective will not be met.

11D. Decrease the percentage of persons aged 18 years and older who consumed five or more alcoholic drinks per occasion, one or more times during the past month to:

8.7 percent

Achieve target:	Likely	Unlikely	Uncertain

Almost one in seven New Jerseyans consumes five or more drinks on one occasion at least once per month. This is an increase over the percent reported at the beginning of this decade for such "binge drinking." Present patterns are not conducive to reaching the year 2000 objective.

11E. Decrease the death rate due to alcohol-related motor vehicle fatalities per 100,000 population to:

2.0 for the total population
5.0 for youth aged 15-24

Achieve target:	Likely	Unlikely	Uncertain
total population
age 15-24

Among the population as a whole, the death rate from alcohol-related motor vehicle fatalities has been on a fairly steady decline. If the current trend continues, it is likely that the objective of two deaths per 100,000 population will be met by the year 2000.

For youth aged 15 through 24, however, the death rates have fluctuated over the same time period. In general, the rate has declined and it appears possible that the year 2000 target of five deaths per 100,000 persons in this age group will be met.

11F. Decrease the age-adjusted cirrhosis death rate per 100,000 population to:

6.8 for the total population
12.3 for minority males

Achieve target:	Likely	Unlikely	Uncertain
total population
minority males

Epidemiologists have long used chronic liver disease and cirrhosis deaths as an indicator of alcohol abuse prevalence in the population. As overall consumption of alcohol has decreased since 1966, cirrhosis death rates have also steadily declined. In 1992, 1994, 1995, and 1996 chronic liver disease and cirrhosis was displaced as one of the ten leading causes of death in New Jersey.

Since 1985, the age-adjusted death rate from chronic liver disease and cirrhosis has been declining for both the total and the minority male populations. During the late 1980s, the age-adjusted death rate for minority males was slightly more than double that of the total population. In the early 1990s, the minority male rate decreased at a faster rate than that of the entire population. If current trends continue, both populations will meet their targets by the year 2000 and the gap between the minority population and the total population will continue to narrow.

11G. Decrease the age-adjusted drug-related death rate per 100,000 population to:

6.0 for the total population

Achieve target:	Likely	Unlikely	Uncertain

Drug-related deaths are defined as accidental poisonings by drugs, medicinal substances, and biologicals; accidental drug overdoses are included in this category. After a brief period of decline from 1988 to 1990, the age-adjusted drug-related death rate increased steadily until 1995, when it was almost double the 1990 rate. In that year, drug-related causes were the leading cause of unintentional injury deaths among persons aged 25 through 44. In 1996 the rate declined; it is not certain whether this trend will continue, allowing the year 2000 objective to be reached.

11H. For clients in treatment, decrease the average time between first use and treatment to:

13.8 years for alcohol
6.2 years for drugs other than alcohol

Achieve target:	Likely	Unlikely	Uncertain
alcohol
other drugs

The elapsed time between first use of a drug and treatment is a measure of early care, which generally leads to less disability and less severe tissue and organ damage. The current trend in seeking treatment for addictions is that addicted persons are waiting an increasingly longer time from their first use until they seek help. If this trend continues, the year 2000 objectives for both alcohol and other drugs will not be met.

11I. Increase the number of persons addicted to alcohol and/or other drugs who are treated in residential or outpatient programs annually to:

41,449 for alcohol treatment
41,911 for other drug treatment

Achieve target:	Likely	Unlikely	Uncertain
alcohol
other drugs

To decrease morbidity and mortality caused by addiction, the Department seeks to increase the number of persons receiving care and treatment by twenty percent over the 1992 baseline. With an average of 2.8 treatment episodes, many persons recover from their addiction and, for about 30 percent of patients, a single treatment episode is sufficient.

From 1992 through 1996, admissions to treatment for drugs other than alcohol rose to levels near the year 2000 target. It is not certain, however, whether growth will continue, allowing achievement of the objective.

For alcohol treatment, the trend has been one of declining admissions, and achieving the year 2000 objective is not likely.

Discussion

Addiction illnesses continue to be persistent and widespread, both in the United States and in New Jersey. The use of alcohol and tobacco, drugs which are not illegal, but which are addictive and subject to abuse, also continues to be widespread. It is unlikely that most of the year 2000 objectives for reducing the use and deleterious effects of these substances will be met. It takes many years to change the attitudes and behaviors associated with substance abuse, but prevention is the most effective way to reduce the resulting morbidity and mortality. For those who have developed addictions, the Department will continue its efforts to support effective and accessible treatment programs.

In the area of tobacco use and smoking, the primary emphasis is on prevention, both by changing the societal acceptance of tobacco use and smoking, and making tobacco less readily available to youth. Because 60 percent of current smokers started smoking before age 14 and 90 percent of all new smokers are under age 18, it is important that strategies be directed toward youth and preventing the first use. Programmatic initiatives include the following:

• New Jersey approved an increase from $0.40 to $0.80 per pack in the cigarette excise tax, effective in 1998. Research shows that increased price reduces tobacco consumption by teens, who generally have less to spend than their adult counterparts.

• The Tobacco Age of Sale Enforcement (TASE) Program further reduces the availability of cigarettes and other tobacco products to underage youth by providing grants to local health departments to conduct random, unannounced compliance inspections of licensed tobacco vendors. Non-compliant merchants risk fines and license suspension/revocation.

• In 1997 a comprehensive youth anti-tobacco media campaign, which includes radio ads, TV, print ads, billboards, and a website was launched. It encourages kids to not smoke through messages that have credibility with teens.

• The ASSIST Project works with local coalitions to promote effective anti-tobacco policies at the community level, and, with physicians to help them, help their patients stop smoking.

• The Peer Leadership Program trains youth peer leaders and mentors, who then teach other kids to not smoke.

The most recent data reflected in this update show an increase in tobacco use among high school students, but these data predate the initiation of most of these programmatic initiatives. It is expected that outcomes will improve in future surveys as a result of these interventions.

With the recent settlement of lawsuits by states against the tobacco industry, the Department anticipates having resources to greatly expand its tobacco control program, beginning in the year 2000. During the next decade, the prevalence of smoking in New Jersey should decline significantly.

The age-adjusted drug-related death rate, which encompasses accidental drug overdoses as a component of accidental poisonings, has risen steadily since 1990. In part this may be attributable to the easy availability of highly concentrated illegal heroin, and the change in route of heroin administration from injection to inhalation.

The outlook for objectives related to alcohol is mixed. Use of alcohol while operating a motor vehicle has proven more amenable to prevention than other types of alcohol-related behavior. The decline in New Jersey's death rate due to alcohol-related motor vehicle fatalities, both for older youth and adults is largely attributable to the state's aggressive policy against drunk driving. This policy includes community education, strict enforcement, stiff penalties, and mandatory post-conviction education and treatment, if appropriate, for all Driving Under the Influence (DUI) offenders prior to relicensing them to drive.

In addition, the age-adjusted death rate from chronic liver disease and cirrhosis continues its two decade decline. Improvement in this area has been particularly promising among minority males, although their death rate is still higher than that of the total population.

On the other hand, the trend for binge drinking is not encouraging. Binge drinking is defined as consumption by a person of five or more drinks on one occasion, and is a high risk behavior with multiple health and behavioral consequences. It is dangerous whether or not it is addictive, because it increases the risk of injury. Unfortunately, an increasing percentage of adults have reported "binge drinking" behavior.

In general, efforts to affect adult alcohol consumption patterns focus on treatment and education. The time lag between first use (of alcohol or other drugs) and first entry into treatment has continued to increase. Concomitantly, the number of alcohol-dependent persons admitted into treatment has declined. The Department is working with the Department of Human Services' Division of Medical Assistance and Health Services to ensure that behavioral managed care programs include treatment for addictions.

Although the data reflects improvement in recent years, there are still too many pregnant women who use tobacco, alcohol and other dangerous drugs during pregnancy, despite the potential negative impact on the fetus posed by use of these substances. Provision of treatment services to pregnant women and women with dependent children continues to be a major federal and state priority. The Department funds specialized treatment for women, with priority for admission given to pregnant women. Treatment services provided by these programs represent a continuum of care which includes short and long term residential, halfway house, outpatient, intensive outpatient and methadone maintenance.

The Department, in cooperation with the Department of Human Services, has developed a cutting edge approach to removing substance abuse as a barrier to gaining and maintaining employment for welfare recipients in the Work First NJ Program. Using managed care principles, New Jersey has developed a system to identify welfare recipients with potential abuse problems, have them assessed by trained clinicians at their county welfare agencies, and then placed into and moved through treatment according to their individual clinical needs.