Substance Abuse Prevention and Control

1. Substance Abuse –
Prevention & Control
Dr. Saira Mansoor
Department of Community Medicine
Liaquat National Medical College & Hospital

2. Learning Objectives
At the end of this session, the learners shall be able to:
• Explain substance abuse and give its criteria with examples
• Describe the epidemiology of tobacco and smoking in detail
• Relate the health risks of using tobacco, tobacco products and nicotine
• Describe the prevention and control of tobacco in global and local context
• Explain the alcohol consumption in global and local context
• Describe the epidemiology of alcohol misuse
• Describe the prevention and control of alcohol misuse in global and local context

3. Addiction
• Addiction (termed substance dependence by the American Psychiatric Association) is defined as:
“a maladaptive pattern of substance use leading to clinically significant impairment or
distress.” (DSM-IV)
• The definition published in 1969 by the WHO Expert Committee on Drug Dependence was
'persistent or sporadic excessive drug use inconsistent with or unrelated to acceptable
medical practice’
• Psychoactive substance misuse
• “Use of a substance for a purpose not consistent with legal or medical guidelines, as in the non-
medical use of prescription medications. The term is preferred by some to abuse in the belief that
it is less judgmental”

4. Habituation
(noun)
• The action or process of becoming habituated
PSYCHOLOGY
• The diminishing of an innate response to a frequently repeated stimulus.
(Merriam-Webster Dictionary)

5. Substance Use Disorders – Definition
• Substance use disorder, also known as substance dependence, is defined by the IHME based on the
definition within the WHO’s International Classification of Diseases (ICD-10)
• Substance use disorders include alcohol and all illicit drugs (whether prescribed or otherwise)
including opioids, cocaine, amphetamine and cannabis
• The IHME classification does not include tobacco

6. Substance Use Disorders
• The DSM 5 recognizes substance-related disorders resulting from the use of 10 separate
classes of drugs:
• Alcohol
• Caffeine
• Cannabis
• Hallucinogens (phencyclidine or similarly acting arylcyclohexylamines, and other
hallucinogens, such as LSD)
• Inhalants
• Opioids
• Sedatives, hypnotics, or anxiolytics
• Stimulants (including amphetamine-type substances, cocaine, and other stimulants)
• Tobacco
• Other or unknown substances

7. Pathway to Substance Abuse
• The activation of the brain’s reward system is central to problems arising from drug use
• The rewarding feeling that people experience as a result of taking drugs may be so
profound that they neglect other normal activities in favor of taking the drug
• The pharmacological mechanisms for each class of drug are different
• The activation of the reward system is similar across substances in producing feelings of
pleasure or euphoria, which is often referred to as a “high”

8. Criteria for Substance Use Disorders
1. Taking the substance in larger amounts or for longer than you're meant to
2. Wanting to cut down or stop using the substance but not managing to
3. Spending a lot of time getting, using, or recovering from use of the substance
4. Cravings and urges to use the substance
5. Not managing to do what you should at work, home, or school because of substance use
6. Continuing to use, even when it causes problems in relationships
7. Giving up important social, occupational, or recreational activities because of substance use
8. Using substances again and again, even when it puts you in danger
9. Continuing to use, even when you know you have a physical or psychological problem that could have
been caused or made worse by the substance
10. Needing more of the substance to get the effect you want (tolerance)
11. Development of withdrawal symptoms, which can be relieved by taking more of the substance

9. Substance Use Key Facts
• Drug use is directly and indirectly responsible for 11.8 million deaths each year
• Smoking, alcohol and drug use is an important risk factor for early death: 11.4 million die
prematurely as a result each year
• Over 350,000 die from overdoses (alcohol and illicit drug use disorders) each year
• Substance use disorders are much more common in men
• More than half of those who die from alcohol or drug overdoses are younger than 50
• 1.5% of global disease burden results from alcohol and illicit drug addiction; in some
countries it’s over 5%

15. Tobacco
Goal 3. Ensure healthy lives and promote wellbeing for all at all ages
3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil
pollution and contamination
3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all
countries, as appropriate

16. Definition of Tobacco
Products
“Products entirely or partly made of the leaf tobacco as
raw material which are manufactured to be used for
smoking, sucking, chewing or snuffing”
WHO’s Framework
Convention on Tobacco
Control

17. History of Tobacco Timeline
• 6,000 BC – Native Americans first start cultivating the tobacco plant.
• Circa 1 BC – Indigenous American tribes start smoking tobacco in religious ceremonies and
for medicinal purposes.
• 1492 – Christopher Columbus first encounters dried tobacco leaves. They were given to him
as a gift by the American Indians.
• 1492 – Tobacco plant and smoking introduced to Europeans.
• 1571 – European doctors start publishing works on healthy properties of the tobacco plant,
claiming it can cure a myriad of diseases, from toothache to lockjaw and cancer.
• 1600 – Tobacco used as cash-crop – a monetary standard that lasts twice as long as the gold
standard.
• 1602 – King James I condemns tobacco in his treatise A Counterblast to Tobacco.
• 1614 – Tobacco shops open across Britain, selling the Virginia blend tobacco.
• 1633 – Turkey introduces a death penalty for smoking but it doesn’t stay in effect for long
and is lifted in 1647.
• 1650 – Tobacco arrives in Africa – European settlers grow it and use it as a currency.
• 1700 – African slaves are first forced to work on tobacco plantations, years before they
become a workforce in the cotton fields.
• 1730 – First American tobacco companies open their doors in Virginia.
• 1753 – Tobacco genus named by a Swedish botanist Carolus Linnaeus – nicotiana rustica
and nicotiana tabacum named for the first time.
• 1791 – British doctors find that snuff leads to increased risk of nose cancer.
• 1794 – First American tobacco tax.
• 1826 – Nicotine isolated for the first time.
• 1861 – First American cigarette factory produces 20 million cigarettes.
• 1990 – 4 billion cigarettes are sold this year and manufacture is on the rise.
• 1902 – Philip Morris starts selling cigarettes in the US – one of the brands offered is Marlboro.
• 1912 – First reported connection between smoking and lung cancer.
• 1925 – Philip Morris starts marketing to women, tripling the number of female smokers in just
10 years.
• 1947 – Lorillard chemist admits that there is enough evidence that smoking can cause cancer.
• 1950 – 50% of a cigarette now consists of the cigarette filter tip.
• 1967 – Surgeon General definitively links smoking to lung cancer and presents evidence that it
is causing heart problems.
• 1970 – Tobacco manufacturers legally obliged to print a warning on the labels that smoking is a
health hazard.
• 1970 – 1990 – Tobacco companies faced with a series of lawsuits. Courts limit their advertising
and marketing.
• 1992 – Nicotine patch is introduced – in the following years more cessation products will start
being developed.
• 1996 – Researchers find conclusive evidence that tobacco damages a cancer-suppressor gene.
• 1997 – Liggett Tobacco Company issues a statement acknowledging that tobacco causes
cancer and carries a considerable health risk.
• 1997 – Tobacco companies slammed with major lawsuits – ordered to spend billions of dollar
on anti-smoking campaigns over the next 25 years predominantly focused on educating the
young on dangers of smoking.
• 1997 – For the first time in history a tobacco company CEO admits on trial that cigarettes and
related tobacco products cause cancer. His name was Bennett Lebow.
• 1990 – 2000 – Bans on public smoking come into effect in most states in America, as well as in
other countries in the world.
https://tobaccofreelife.org/tobacco/tobacco-history/

18. Common Tobacco
Products
• Cigarette smoking  most common form
of tobacco use worldwide
• Other tobacco products include:
• Waterpipe tobacco - Hukkah
• Various smokeless tobacco products
• Cigars
• Cigarillos
• Roll-your-own tobacco
• Pipe tobacco
• Bidis
• Kreteks
https://www.fda.gov/consumers/consumer-updates/facts-fdas-new-tobacco-rule

20. https://ourworldindata.org/grapher/tobacco-production

21. Top 10 Smoking Nations in the World
1. Kiribati (52.40%)
2. Nauru (47.50%)
3. Greece (42.65%)
4. Serbia (41.65%)
5. Russia (40.90%)
6. Jordan (40.45%)
7. Indonesia (39.90%)
8. Bosnia And Herzegovina (38.60%)
9. Lebanon (38.20%)
10. Chile (38.00%)

26. Park, 2017

30. Novel and emerging nicotine and tobacco products
Heated tobacco products (HTPs)
• HTPs are like all other tobacco products, inherently toxic and
contain carcinogens  should be subjected to same policies
• HTPs produce aerosols containing nicotine and toxic chemicals
upon heating of the tobacco, or activation of a device
containing the tobacco
• Examples include
• iQOS
• Ploom
• glo
• PAX vaporizers
• The aerosols are inhaled by users during a process of sucking or
smoking involving a device  contains the highly addictive
substance nicotine, non-tobacco additives and are often
flavored
• In recent years, HTPs  promoted as ‘reduced harm’ products
and/or products that can help people quit conventional tobacco
smoking
• HTPs expose to toxic emissions  many cause cancer
• Currently there is not enough evidence to suggest that
• They are less harmful than conventional cigarettes
• What are the effects of second-hand emissions produced by HTPs
E-cigarettes
• E-cigarettes: Electronic nicotine delivery systems (ENDS) and
electronic non-nicotine delivery systems (ENNDS)  devices
which heat a liquid to create an aerosol which is then inhaled by
the user (± nicotine)
• The main constituents of the sol. /vol  propylene glycol (±
glycerol), and flavoring agents
• Particularly risky when used by children and adolescents 
Nicotine is highly addictive & youngsters’ brains affected
• ENDS use increases the risk of heart disease and lung disorders,
and pose risks to pregnant women by damaging growing fetus
• ENDS/ENNDS should not be promoted as a cessation aid until
adequate evidence is available
• Where ENDS and ENNDS are not banned  WHO recommends
that the products be regulated in accordance with four key
objectives:
• Prevent initiation of ENDS/ENNDS by non-smokers, minors and vulnerable
groups;
• Minimize health risks for ENDS/ENNDS users and protect non-users from
exposure to their emissions;
• Prevent unproven health claims being made about ENDS/ENNDS; and
• Protect tobacco control from all commercial and other vested interests related
to ENDS/ENNDS, including interests of the tobacco industry

32. WHO Response to Tobacco Control
• In 2003, WHO Member States unanimously adopted the WHO Framework Convention on
Tobacco Control (WHO FCTC)
• In force since 2005, it has currently 182 Parties covering >90% of the world's population
• The WHO FCTC is a milestone in the promotion of public health
• It is an evidence-based treaty that reaffirms the right of people to the highest standard of health,
provides legal dimensions for international health cooperation, and sets high standards for
compliance
• Strengthening implementation of the treaty is specifically included in the 2030 Agenda for
Sustainable Development Goals (SDG) as Target 3.a.
• Goal 3. Ensure healthy lives and promote wellbeing for all at all ages
• 3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil
pollution and contamination
• 3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all
countries, as appropriate
https://www.who.int/news-room/fact-sheets/detail/tobacco

34. Parts of the WHO Framework Convention on Tobacco
Control
Demand reduction
• Article 6. Price and tax measures to reduce the
demand for tobacco
• Article 7. Non-price measures to reduce the
demand for tobacco
• Article 8. Protection from exposure to tobacco
smoke
• Article 9. Regulation of the contents of tobacco
products
• Article 10. Regulation of tobacco product
disclosures
• Article 11. Packaging and labelling of tobacco
products
• Article 12. Education, communication, training
and public awareness
• Article 13. Tobacco advertising, promotion and
sponsorship
• Article 14. Demand reduction measures
concerning tobacco dependence and
cessation
Supply reduction
• Article 15. Illicit trade in tobacco products
• Article 16. Sales to and by minors
• Article 17. Provision of support for
economically viable alternative activities

35. Article 14
• The WHO FCTC directly speaks to the importance of reducing the number of current
tobacco users through cessation measures in Article 14 – Demand reduction measures
concerning tobacco dependence and cessation
• This Article states:
• “Each Party shall develop and disseminate appropriate, comprehensive and
integrated guidelines based on scientific evidence and best practices, taking into
account national circumstances and priorities, and shall take effective measures to
promote cessation of tobacco use and adequate treatment for tobacco
dependence.”

36. Article 14 – Demand reduction measures concerning
tobacco dependence and cessation
Towards this end, each Party shall endeavor to:
• Design and implement effective programs aimed at promoting the cessation of tobacco use, in
such locations as educational institutions, health care facilities, workplaces and sporting
environments;
• Include diagnosis and treatment of tobacco dependence and counselling services on cessation
of tobacco use in national health and education programs, plans and strategies, with the
participation of health workers, community workers and social workers as appropriate;
• Establish in health care facilities and rehabilitation centers, programs for diagnosing,
counselling, preventing and treating tobacco dependence; and
• Collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco
dependence including pharmaceutical products pursuant to Article 22. Such products and their
constituents may include medicines, products used to administer medicines and diagnostics when
appropriate

39. MPOWER
• In 2007, WHO introduced a practical, cost-effective way to scale up implementation of the
main demand reduction provisions of the WHO FCTC on the ground: MPOWER
• Each MPOWER measure corresponds to at least 1 provision of the WHO Framework
Convention on Tobacco Control.
• The 6 MPOWER measures are:
• Monitor tobacco use and prevention policies
• Protect people from tobacco use
• Offer help to quit tobacco use
• Warn about the dangers of tobacco
• Enforce bans on tobacco advertising, promotion and sponsorship
• Raise taxes on tobacco
• WHO has been monitoring MPOWER policies since 2007
• Brazil and Turkey are the only two countries to fully implement all the MPOWER measures
at the highest level of achievement

42. https://www.who.int/publications/i/item/WHO-NMH-PND-2019.5

43. https://www.who.int/publications/i/item/WHO-NMH-PND-2019.5

44. Increased proportion of people who abstain from smoking for 6
months or more due to a specific intervention
Source:Westetal(33)
aEachbarrepresentsthefindingsofameta-analysisandthestrengthofevidenceassociatedwitheachstudywillvary.
bThisrepresentsthe“projectedpercentagepointincreasein6–12monthabstinencecomparedwithnointervention”.Theauthorsadjustedthepublished
percentagepointincreasein6–12monthabstinencetoallowfordirectcomparisonbetweeneachinterventionwherethemeta-analysesdidnotusea
comparatorequivalentto“nointervention”.Assessmentswerebaseduponthepublishedeffectivenessofthecomparisoninterventionthroughaconsensuswew;l

45. increased proportion of people who abstain from smoking for 6
months or more due to a specific intervention
Source:Westetal(33)
aEachbarrepresentsthefindingsofameta-analysisandthestrengthofevidenceassociatedwitheachstudywillvary.
bThisrepresentsthe“projectedpercentagepointincreasein6–12monthabstinencecomparedwithnointervention”.Theauthorsadjustedthepublished
percentagepointincreasein6–12monthabstinencetoallowfordirectcomparisonbetweeneachinterventionwherethemeta-analysesdidnotusea
comparatorequivalentto“nointervention”.Assessmentswerebaseduponthepublishedeffectivenessofthecomparisoninterventionthroughaconsensuswew;l

46. World No Tobacco Day
• World No Tobacco Day is celebrated around the world every year on May 31
• This yearly celebration informs the public on the dangers of using tobacco, the business practices of
tobacco companies, what WHO is doing to fight the tobacco epidemic, and what people around the
world can do to claim their right to health and healthy living and to protect future generations
• World No Tobacco Day 2020:
#TobaccoExposed
• The global campaign will debunk myths and expose devious tactics employed by these industries,
by:
• Providing young people with the knowledge required to easily detect industry manipulation
• Equip them with the tools to rebuff such tactics, thereby empowering young people to stand up against them
• WHO calls on all young people to join the fight to become a tobacco-free generation
https://www.who.int/campaigns/world-no-tobacco-day/world-no-tobacco-day-2020

47. Tobacco Control in Pakistan
• Pakistan is a high-burden tobacco-use country implementing several of the best buy
(MPOWER) measures to reduce tobacco use, with two measures at the highest level of
achievement.
• The WHO is contributing to the implementation of MPOWER measures in Pakistan through:
• High-level strategic advocacy in support of smoke-free policies
• Providing technical support in the process of drafting tobacco control legislation
• Advocating for raising tobacco taxes to reduce demand
• High-level advocacy in support of strengthening restrictions on tobacco advertising
• The MPOWER measures Pakistan is implementing at highest level of achievement are:
• Monitoring tobacco use and prevention policies
• Protecting people from tobacco smoke
• The World Health Organization (WHO) and Pakistan’s health authorities are working closely to
reverse the country's tobacco epidemic. Collaborative activities include:
• Development of a national coordinating mechanism
• Establishment of a tobacco control cell
• Establishment of a federal enforcement committee
• Establishment of a technical advisory group
• Support for implementation of the Bloomberg Initiative Grants Programme in Pakistan
• The development of anti-tobacco legislation

48. Tobacco Control Cell, Ministry of National Health
Services, Regulations and Coordination, Pakistan
• After the devolution of Ministry of Health, Tobacco Control Cell has been placed with
Ministry of National Health Services, Regulations and Coordination
• This Ministry is thus responsible for taking necessary measures relating to tobacco control
• Tobacco Control Cell is currently headed by Dr Malik Muhammad Safi, Director General Health,
Ministry of National Health Services, Regulations and Coordination
• Tobacco Control Cell was established in July 2007, with aim to enhance tobacco control efforts
in Pakistan
• The Cell is accelerating tobacco control activities in Pakistan through multifaceted efforts
starting from planning, resource mobilization, institutional strengthening, public-private
partnership and monitoring

49. Tobacco Control Cell Implemented Mass Media
Campaigns
• Tobacco Control Cell implemented two national anti-tobacco mass media campaigns to
focus on the health harms of tobacco
• In first campaign, a 30 second Public Service Message called “Sponge” was designed to
turn tobacco users’ thoughts about quitting into active quit attempts by showing the real
health harms of smoking
• The second campaign featured a public service announcement (PSA) called “Tobacco Is
Hollowing You Out”, that graphically highlighted the many harmful illnesses caused by
tobacco use, including lung cancer, heart disease, stroke and oral cancers
• Sponge: https://www.youtube.com/watch?v=e2BSNKTt8qs&feature=youtu.be
• Tobacco Is Hollowing You Out: https://www.youtube.com/watch?v=NZCDP_shmM0

50. National Tobacco Cell – Policies in Pakistan
• Pakistan became party to the WHO Framework Convention on Tobacco Control (FCTC) in 2005.
• There are two main pieces of tobacco control legislation:
• The Cigarettes (Printing of Warning) Ordinance, 1979
• The Prohibition of Smoking in Enclosed Places and Protection of Non-smokers Health Ordinance, 2002
• Nearly twenty additional ordinances and amendments have been passed since 2002, clarifying and
strengthening tobacco control
• These national laws:
• Prohibit smoking in all places of public work or use, including public transport and outdoor waiting areas
for transport. Smoking is permitted in hotel guest rooms.
• Bans some advertising, including on domestic TV, radio, billboards, and in print media. Most other forms of
advertising and promotion are allowed.
• Require a pictorial and text health warning on 85% of smoked tobacco product packaging, with text on the
front in Urdu and text on the back in English. Warnings on smokeless tobacco products are not required.
• Allow sub-national regulations that are stricter than the national law

51. National Tobacco Cell – Pakistan
ACHIEVEMENTS:
• In 2008, The Union worked with the Ministry of Health in Pakistan to establish a government
Tobacco Control Cell responsible for tobacco control nationally
• The Union continues to work with the National Tobacco Control Cell and civil society (and with the
Ministry of Health at sub-national level) to improve graphic health warnings and expand bans on
advertising, promotion and sponsorship
• The Union is also supporting a project to implement Smoke-free Islamabad
CONTINUING WORK:
• The Tobacco Control Cell has formed a technical working group on tobacco taxation
• It includes representatives from The Union, WHO, World Bank and other stakeholders
• The working group has been tasked to review existing tobacco tax structure and devise a
mechanism to increase taxes on tobacco products in line with FCTC recommendations including
earmarking of tobacco tax revenues for tobacco control measures
• Tobacco Control Cell will be focal point for this initiative

53. Pakistan’s Key Achievements
• Notified Pictorial Health Warning of 85% size on both sides of cigarette packs and outers
• Ban on smoking in places of public work or use
• Ban on smoking in public service vehicles
• Ban on sale of cigarettes to minor
• Mandatory display of “No Smoking” signs at public places
• Ban on tobacco advertisements in Print and Electronic Media (through billboard a poster or banner
affixed outside a shop, kiosk, or mobile trolley etc.)
• Ban on import of shisha (tobacco and non-tobacco) and related substances
• Ban on manufacturing, importing and selling of cigarette packs having less than 20 cigarettes
• Ban on free samples, cash rebates, discounts and sponsorship of events
http://www.emro.who.int/pak/programmes/tobacco-free-initiative.html

54. http://www.emro.who.int/pak/programmes/tobacco-free-initiative.html

55. Alcohol
Goal 3. Ensure healthy lives and promote well being for all at all ages
3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug
abuse and harmful use of alcohol

65. Alcohol Consumption, Health Consequences and
Policy Responses Globally in 2016

66. Policy Options and Interventions for National Action
• Leadership, awareness and commitment
• Health services’ response
• Community action
• Drink-driving policies and countermeasures
• Availability of alcohol
• Marketing of alcoholic beverages
• Pricing policies
• Reducing the negative consequences of drinking and alcohol intoxication
• Reducing the public health impact of illicit alcohol and informally produced alcohol
• Monitoring and surveillance

67. POLICY AREA OPTIONS & INTERVENTIONS
Leadership,
awareness and
commitment
Ensuring broad access to information and effective education and public
awareness programs among all levels of society about the full range of
alcohol-related harm experienced in the country and the need for, and existence of, effective
preventive measures
Health services’
response
Increasing capacity of health and social welfare systems to deliver prevention,
treatment and care for alcohol-use and alcohol-induced disorders and co-morbid
conditions, including support and treatment for affected families and support for
mutual help or self-help activities and programs
Community action Mobilizing communities to prevent the selling of alcohol to, and consumption
of alcohol by, under-age drinkers, and to develop and support alcohol-free
environments, especially for youth and other at-risk groups
Drink-driving Policies
and
Countermeasures
Introducing and enforcing an upper limit for blood alcohol concentration, with a
reduced limit for professional drivers and young or novice drivers. Mandatory driver-education,
counselling and, as appropriate, treatment programs
Availability of alcohol Establishing, operating and enforcing an appropriate system to regulate production,
wholesaling and serving of alcoholic beverages that places reasonable limitations on the
distribution of alcohol and the operation of alcohol outlets in accordance with cultural
norms, by introducing, where appropriate, a licensing system on retail sales, or public
health-oriented government monopolies; regulating days and hours of retail sales

68. POLICY AREA OPTIONS & INTERVENTIONS
Marketing of alcoholic
beverages
Setting up regulatory or co-regulatory frameworks, preferably with a legislative basis, and
supported when appropriate by self-regulatory measures, for alcohol marketing; development
public agencies or independent bodies of effective systems of surveillance of marketing of
products
Pricing policies Establishing a system for specific domestic taxation on alcohol accompanied by an effective
enforcement system, which may take into account, as appropriate, the alcoholic content of the
beverage; establishing minimum prices for alcohol where applicable
Reducing the negative
consequences of drinking
and alcohol intoxication
Regulating the drinking context in order to minimize violence and disruptive behavior, including
serving alcohol in plastic containers or shatter-proof glass and management of alcohol-related
issues at large-scale public events; providing necessary care or shelter for severely intoxicated
people
Reducing the public
health impact of illicit
alcohol and informally
produced alcohol
Production and sale of informal alcohol are ingrained in many cultures and are often
informally controlled; thus, control measures could be different for illicit alcohol and
informally produced alcohol and should be combined with awareness raising and
community mobilization. Efforts to stimulate alternative sources of income are also
important.
Monitoring and
surveillance
establishing effective frameworks for monitoring and surveillance activities including periodic
national surveys on alcohol consumption and alcohol-related harm and a plan for exchange
dissemination of information

69. Illicit Drug Use

70. Definition
• Illicit drugs are drugs that have been prohibited under international drug control treaties.
• The main groups of illicit drugs used in international statistics are opioids, cocaine, amphetamines and
cannabis
• However, there is a range of other illicit drugs included in international drug control treaties, such as plant-
based and synthetic hallucinogens
• A full list of illicit drugs and classification can be found in the UNODC’s publication Terminology and
Information on Drugs
• Illicit drug use is – directly and indirectly – responsible for over 750,000 deaths per year
• Illicit drug use is responsible for 585,000 premature deaths by increasing the risk of particular disease and
injury
• Over 166,000 die from drug overdoses each year  >50% are <50 years old
• Opioids are responsible for the largest number of overdoses from illicit drugs
• It is estimated that around 1% of the world has a drug use disorder
• The US had the highest overdose rates from all three leading illicit drugs: opioids, amphetamine and cocaine

71. Illicit Drug Use – Diagnostic Criteria
A definite diagnosis of dependence should usually be made only if three or more of the following have been present
together at some time during the previous year:
• (a) a strong desire or sense of compulsion to take the substance;
• (b) difficulties in controlling substance-taking behavior in terms of its onset, termination, or levels of use;
• (c) a physiological withdrawal state when substance use has ceased or been reduced, as evidenced by the
characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the
intention of relieving or avoiding withdrawal symptoms;
• (d) evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve
effects originally produced by lower doses (clear examples of this are found in alcohol- and opiate-dependent
individuals who may take daily doses sufficient to incapacitate or kill nontolerant users);
• (e) progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased
amount of time necessary to obtain or take the substance or to recover from its effects;
• (f) persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver
through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related
impairment of cognitive functioning; efforts should be made to determine that the user was actually, or could be
expected to be, aware of the nature and extent of the harm.

79. Prevention & Control
• Cannabis is globally the most commonly used psychoactive substance under international
control
• In 2013, an estimated 181.8 million people aged 15-64 years used cannabis for
nonmedical purposes globally (uncertainty estimates 128.5–232.1 million) (UNODC, 2015)
• There is an increasing demand of treatment for cannabis use disorders and associated
health conditions in high- and middle-income countries, and there has been increased
attention to the public health aspects of cannabis use and related disorders in
international drug policy dialogues
• Different prevention and control strategies are given in next slide

80. Sector Actions
Regulation of the physical
and economic availability of
illicit psychoactive
substances
1) Law enforcement
2) International agreements
3) Crop eradication and/or substitution
4) Different legislative / policy frameworks
5) Venue Management
6) Precursor chemicals legislation
7) Assets legislation (e.g.: seizures)
Media 1) Mass media campaigns
2) Media advocacy
3) Advertising and advertising restrictions
Community Based Programs 1) “Top down” approaches
2) “Bottom up” approaches
3) Capacity building/sustainability/institutionalization of the intervention
School Based Programs 1) Peer education
2) Resiliency
3) Knowledge
4) Attitudes
5) Behaviors
6) Skills based
7) Interactive rather than didactic
8) Comprehensive vs classroom approaches