Understanding Substance Use: A health promotion perspective

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Health is a state of total well-being—physical, mental and social—helping us both survive and thrive in our everyday lives.

Health promotion, then, encourages us to embrace this idea of well-being and in the process increase our control over how we experience everyday life. It is therefore less about preventing disease than about helping us manage our life situation, whatever it may be, and reach our full potential.

But how does it work? Effective health promotion strikes a balance between personal choice and social responsibility, between people and their environments. In other words, it does not put the onus for good health on the individual alone.

This multi-lens perspective can be applied in a variety of settings, such as workplaces, neighbourhoods, cities, schools or campuses, to help promote ways we can improve our experiences in our everyday environments. Health promotion may also be applied to common but complex human behaviours such as substance use.

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How health promotion applies to substance use

Like food, sex and other “feel good” things in life, psychoactive substances (or drugs) change the way we feel. And just as food and sex help humans survive and thrive but can also get us into trouble—with our health, our relationships, our sense of self-worth—substance use has both benefits and the potential to lead us down an unhappy, unhealthy path. As a complex human behaviour, substance use requires that we look at it from a broad perspective that considers many factors, not just personal ones about wanting relief or to feel good.

Supply reduction: interventions that restrict access to a substance (particularly for populations considered vulnerable to harm)

Demand reduction: services to reduce the number of individuals who use substances, the amount they use or the frequency of use

Harm reduction: interventions that seek to reduce the harmful consequences even when use remains unchanged

Traditionally, the substance use field has focused simply on substance use and ways to measure, prevent and treat negative consequences. This has led to a continuum of laws, policies and services that runs from restricting supply to reducing demand and, for some, continuing on to harm reduction.

Various versions of this simple continuum have been used over time, all of them beginning with a focus on a disease or harm that must be avoided. While this may seem completely sensible at first glance, it makes less sense when considering that many people use psychoactive substances to promote physical, mental, emotional, social and/ or spiritual well-being. In other words, people use substances to promote health, yet substance use services focus on how drug use detracts from health.

Health promotion begins from a fundamentally different focus. Rather than primarily seeking to protect people from disease or harm, it seeks to enable people to increase control over their health whether they are using substances or not.

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A human approach

Human experience is complex. Helping people understand that complexity, and giving them skills to manage it, helps make them actors (rather than victims) in their own lives. That said, no one is completely autonomous. Our choices and behaviours are influenced by a variety of factors, including biology, physical and social environments and events throughout our life course.

These factors interact in complex ways to create unique sets of opportunities and constraints for each of us. Institutional and community cultures, as well as family and societal values, all influence our behaviour and the impact that behaviour might have on our total health.

Since many people use drugs often or in part to promote health and well-being, health promotion along these lines involves helping people manage their substance use in a way that maximizes benefit and minimizes harm. (Indeed, this is how we address other risky behaviours in our everyday lives, including driving and participating in sports.) It means giving attention to the full picture—the substances, the environments in which they are used and in which people live, and the individuals who use those substances and shape the environments.

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Substances: regulate supply to ensure the quality of substances and enact appropriate restrictions

Environments: promote social and physical contexts that encourage moderation and are stimulating and safe

Individuals: increase health capacity and resilience and develop active responsible citizens

People and drugs

Caffeine, alcohol and other psychoactive drugs tap into the wiring system of the human brain and influence the way nerve cells send, receive or process information. This has led some researchers to categorize drugs according to the type of effect they have on the central nervous system, though some may fit in more than one group.

Depressants decrease heart rate, breathing and mental processing—for example, alcohol and heroin

Stimulants increase heart rate, breathing and mental processing—for example, caffeine, tobacco or cocaine

Hallucinogens make things look, sound or feel different than normal—for example, magic mushrooms or LSD

People have been using a wide variety of psychoactive (or mind-altering) drugs for thousands of years to celebrate successes and to help deal with grief and sadness, to mark rites of passage and to pursue spiritual insight. Indeed, drug use is deeply embedded in our cultural fabric.

To feel good
Stimulants may lead to feelings of power, self-confidence and increased energy. Depressants tend to provide feelings of relaxation and satisfaction.

To feel better
People may use substances to reduce social anxiety or stress when building connections with others or to reduce symptoms associated with trauma or depression.

To do better
The increasing pressure to improve performance leads many people to use chemicals to “get going” or “keep going” or “make it to the next level.”

Curiosity or new experiences
Some people have a higher need for novelty and a higher tolerance for risk. These people may use drugs to discover new experiences, feelings or insights.

But the use of drugs involves risk. And risk can be associated with significant harm. Some of the harms relate to the short-term intoxicating properties of psychoactive drugs. These harms tend to be acute or immediate (e.g., injuries from car accidents, death from overdose). Other harms relate to chronic conditions (e.g., heart disease, cancers that emerge from longer term use). These vary depending on characteristics of the drug itself or the mode in which it is taken. For example, much of the chronic harm related to tobacco is from inhaling the smoke rather than from the drug (nicotine) itself.

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How and why risk rises and falls

The reasons we use a drug influence our pattern of use and risk of harmful consequences. If it is out of curiosity or another fleeting motive, only occasional or experimental use may follow. If the motive is strong and enduring (e.g., relieving a chronic sleep or mental health problem), then more long-lasting and intense substance use may follow. Motives for intense short-term use (e.g., to fit in, have fun or alleviate temporary stress) may result in risky behaviour with high potential for acute harm.

Certain places, times and activities also influence our substance use patterns and likelihood of experiencing harm. Unsupervised teen drinking, for example, tends to be a particularly high-risk activity. Being in a situation of social conflict or frustration while under the influence of alcohol or antianxiety drugs (e.g., benzodiazepines) can increase the likelihood of a conflict escalating to violence. And using drugs before or while driving, boating or hiking on dangerous terrain increases the risk of injury.

The overall social and cultural context surrounding our drug use is often more significant than we think. Consider, for example, the economic availability factor of different drugs: the cheaper and more available they are, the more likely they are to be used. Community norms also influence individual behaviour, and the degree of connection to family, friends and the wider community impact how much, how often, when, where and how we use different substances.

Personal factors, including our physical and mental health status, also affect our likelihood of using drugs in risky ways. If we struggle with anxiety or depression, for example, we may try to feel better by drinking alcohol. In some cases, difficult life experiences (e.g., physical, sexual or emotional abuse) may impact our physical or mental health as well as contribute directly to risky drug use. There is also evidence that genetic inheritance and personality or temperament may have an impact. For example, people with a tendency toward sensation-seeking are at higher risk of harm.

It goes without saying that certain things about a drug itself—its chemical composition and purity, the amount, frequency of use, method of consuming or administering it—influence the degree of risk and type of harm we might experience. Depressant drugs such as alcohol or heroin have elevated risks related to overdose, for example, whereas heavy use of stimulants can lead to psychotic behaviour. Another case in point: injecting concentrated forms of cocaine is much more risky than chewing coca leaves even though the same drug is involved.

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How risky use affects our brain

When our brain is repeatedly exposed to a drug, it may respond by making several adaptations to re-balance itself. But this balancing act comes at a price. Our brain may become less responsive to a particular chemical so that natural “feel good” sources—exercise, food, sex, fun hobbies, and so on—no longer provide any significant pleasure and we begin to feel flat, lifeless and depressed As a result, we may feel we need to use drugs just to feel normal and sometimes may need to take larger and larger amounts. Changes in the brain can also lead to impairment of our cognitive motor functioning.

Conditioning is another side effect of repeated drug use. It can lead us to link things in the environment with our drug experience. Exposure to those cues can later trigger powerful cravings. For example, we may associate drinking coffee with smoking, with one psychoactive substance triggering use of another. Or we might associate the end of a work day with going out for beer. Our minds and bodies can become so adapted to the pattern that we may struggle or be uncomfortable when we break the routine.

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A word about “addiction”

A common perception in our culture is that some drugs are intrinsically dangerous and possess the power to control human behaviour. According to this notion, a person takes a drug until, one day, the drug takes the person. Once this shift occurs, the person is characterized as “addicted” and powerless to control their substance use.

A convenient image that too often comes to mind when we think about addiction is a person who is overwhelmed by their substance use, unemployed, homeless and disconnected from family and friends. But how accurate can this stereotype be? Many of us know people who seem unable to control their drinking, drug use or other behaviour. We may, in fact, feel powerless ourselves in certain circumstances or at certain times. Does this feeling of powerlessness mean the drug or some other force is actually controlling us? If so, what are we to make of people who suddenly quit using a substance after years of habitual use? Many people, for example, successfully quit smoking simply by deciding one day not to buy any more cigarettes.

A more compassionate and logical perspective on substance use places the focus on the person rather than the drug. It considers the context and reasons why we start and continue to use drugs in the first place.

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How a “person first” approach works for all of us

From a “person first” point of view, risky and harmful substance use may be seen as a coping or adaptive response to a situation or condition. Using this approach can help us better explain reallife situations that do not fit neatly into a one-dimensional view of “addiction.” For instance, it helps us understand how some people who inject drugs to cope with trauma can and do continue to work and maintain close relationships. Or how some people use alcohol in ways that might be damaging their physical health while at the same time helping them to build or maintain business and social relationships.

One of the best reasons for adopting a “person first” perspective on substance use involves the issue of belonging and our calling as humans to reach out to others when we can. When we look at people as having a disease or being possessed by a power we do not understand, we tend to regard them as “broken” or “alien” and not like us. We label them as an “alcoholic” or “addict,” someone controlled by a substance.

But when we adopt a more balanced view which takes into account a range of human factors—from biological to environmental—we see instead a “thinking and feeling human being” who uses particular substances within certain contexts and for specific reasons. In other words, we see someone much more like us. We can begin to understand why some people may feel a sense of dependence on a substance—their only known means to cope—and why they may be reluctant to give it up.

Lewis Carroll

Keeping the focus on the person rather than the drug helps us in reaching out to a person who may appear to be “controlled” by their substance use and barely surviving. It also offers a way to support a well-functioning person who regularly uses drugs in harmful ways. In both cases, we affirm self-efficacy rather than seeing a person who use substances as a victim or inferior or somehow less human than others.

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Frogs in a pond

One way to visualize substance use from a health promotion perspective is to consider a “frogs in a pond” scenario. If the frogs in a pond started behaving strangely, our first reaction would not be to punish them or even to treat them. Instinctively, we would wonder what was happening in the pond—in the soil or water, or among the pond creatures— that was affecting the frogs.

This same ecological approach is necessary when we are thinking and talking about people and their relationships with substances, especially in our society where alcohol and other drug use is not only common and largely acceptable but often encouraged and rewarded. We need to keep in mind “the pond”—all of the factors that can contribute to a person’s choices about alcohol and other drugs.

All of us—our children, parents, friends, neighbours and coworkers— are influenced by a unique set of opportunities and constraints related to our biology, relationships and environment. These influences interact in different ways in each one of us. Indeed, we are complex beings and our behaviours are complex too.

Substance use is only one example of a complex behaviour that requires a look at “the pond.” Food and sex also fit this picture. Just as our eating and sexual behaviours are not only about food and sexuality, substance use is not just about substances. To illustrate this point, consider how people drink or don’t drink alcohol for a variety of reasons that have little to do with alcohol itself. Young people, for example, are influenced by the attitudes and behaviours of the key people in their lives, particularly their parents. And young and old alike in our culture are likely to find themselves in situations where they have to make decisions about whether to accept offers to drink or not and, if so, how much, how often, when, where, with whom and so on. These seemingly simple decisions may be based on too many socio-ecological factors to count.

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A socio-ecological model

Using a socio-ecological model helps us step back and look at the whole picture or the “ecosystem” in which people function. It highlights that each of us is influenced by a unique set of opportunities and constraints shaped by a complex interaction of biological, social and environmental factors that play out over our life course. In other words, it draws attention to the range of influences—from personal characteristics to broad social factors—that shape our behaviours, including those related to substance use.

While our personal role—the role of the individual—is always critical, the factors that influence health and wellness in ourselves and our community go far beyond individual choices or even individual capacities. For instance, the risk and protective factors that impact resilience, our ability to rise above or bounce back from adversity, do not reside only within ourselves. Many of the most important factors relate to our relationships (e.g., family, friends) and aspects of our community environment (e.g., norms, availability of alcohol and other drugs).

If we think of substance use within a socio-ecological frame, it takes the focus away from the substances. It involves attention to the health behaviours and skills of individuals seeking to manage their lives. But it also includes attention to the environments in which those behaviours and skills play out. A socio-ecological orientation provides a way to reflect on how individual, societal and environmental factors influence and feed back on one another.

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How our complexity affects our substance use, risk and harm

Many of the things that influence us interact with one another. So, under some conditions, a factor might have a different influence on us than it would under other conditions. For example, a chronically stressful family environment may influence the development of ineffective coping strategies and compromise the learning of healthy habits by children, which may in turn feed into their risky use of alcohol. However, community norms that promote moderation may mitigate risky alcohol consumption, and a mentor program may provide young people with an opportunity to learn positive coping strategies and healthy habits. But it can work the other way too. In a community where norms encourage risky drinking and where supports for individuals are absent, the outcomes for young people and their community may be very different.

An individual with poorly developed coping strategies may function quite well in a comfortable environment but suddenly become angry when confronted with normal demands in a situation that feels threatening. For example, a program in which clients are asked sensitive questions in a public space is more likely to experience confrontations than a program in which the same questions are explored in a comfortable private environment. The resulting behaviour is not just a matter of individual capacity. Environmental factors—institutional structures, policies and practices—influence immediate behaviours and can contribute to the development of future capacity.

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Early influences and their impact

The effects of biological, social and environmental factors play out over the life course. For example, the younger a person is when they start using drugs excessively or regularly, the more likely they are to experience harms or develop problematic substance use later in life. Similarly, people who experience repeated trauma early in life are more likely to experience a wide range of problems later on.

Life transitions (e.g., entering high school) can also increase vulnerability while secure attachment and access to supportive resources in early childhood can help us face challenges later in life.

Environments that encourage and support young people to make healthy choices can help to build individual capacity. So, for example, a school with clear expectations and restorative practices for dealing with students who break the rules will likely graduate a high level of resilient students with the knowledge and skills needed to thrive in life. On the other hand, overly regulated school environments may achieve short-term compliance but are less likely to build in young people the self-management capacity they need to survive and thrive in adulthood.

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People make places, and places make people

Our communities are social ecosystems where a variety of factors interact to influence the health of the environment and the people who live within it. Therefore, improving the health of our communities involves influencing our health actions, enhancing our health capacities and ensuring health opportunities for all individuals and institutions that make up our communities.

An obvious way we can work together to improve the health and well-being of our communities is to collectively recognize substance use as a complex human behaviour and then quickly move beyond this acceptance to focus on what really matters—managing risk and harm related to substance use.

Managing risk and harm is both an individual and a social responsibility. When used with care and in the right context, many psychoactive drugs can be beneficial. That is, the positive impact may outweigh the risks involved. When not used with care or in the wrong contexts, the risks can quickly outweigh the benefits.

Managing risk and reducing harm—whether it involves substance use or other common but risky human behaviours—require examination of the reasons or motivations for the behaviour and assessment of the risk and protective factors in play.

  • Individuals can engage in selfassessment and seek to maintain moderation (not too much, not too often) in their use of substances.

  • Communities can contribute to reducing the risks and harms related to drug use by promoting a culture of inclusivity and responsibility among citizens, and by addressing the social and economic conditions that might lead to risky drug use.

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Last word on language

Words have the potential to affect how we feel about ourselves and how we view other people. Anyone who has responsibility within a community (a family, a school, a social housing program, a drop-in centre) may have opportunities to help end the discriminatory views behind some terms we use, and help shape language that will help us speak clearly and promote inclusion rather than exclusion. Where do we begin?

Use simple, general language. Whenever possible, use broad language (e.g., substance use, substance-related harm).This does not label individuals and does not introduce emotionally-loaded judgments. Narrower language (e.g., substance use disorders) can be appropriately used when clearly required in the context.

Limit the use of negative language. Terms like “substance abuse” have moral overtones. Abuse connotes an action where there is an abuser and a victim. Substances cannot be victims and it is not clear who is experiencing the abuse. But the term suggests moral culpability of the person using the substance and this is inaccurate and unhelpful. Terms such as “problematic substance use,” while less judgmental, may still constrain the discussion and force attention toward the negative when a more balanced language may be more useful. So, for example, saying that problematic substance use by adults may influence the behaviour of young people fails to draw attention to the fact that any pattern of substance use may influence young people (some positively, others negatively).

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Health promotion in practice

People have been using psychoactive substances for centuries to promote health and well-being. Yet these same substances have caused—or have the potential to cause—harm to both individuals and communities. Therefore, health promotion must revolve around helping people manage their substance use as safely as possible in order for the approach to be meaningful and successful.

Ultimately, the goal of health promotion is healthy people in healthy communities.

In a healthy community, a high proportion of people are engaged in health-promoting actions, such as following low-risk drinking guidelines, avoiding smoking and adopting safer use techniques. Promoting health actions directly might involve a variety of motivational strategies and social marketing campaigns.

However, attention must also be given to building the capacity of people to engage in healthy actions. This requires a focus on health literacy to increase the number of people who have the knowledge and skills necessary to manage their personal health effectively and who are equipped to help others in the community. But healthy action requires more than knowledge and skills. It is not enough to teach people how to be healthy if the social or economic conditions in which they live undermine their ability or motivation to engage in health actions.

The third, and probably most important, element of a healthy community is a focus on health opportunity. This requires attention to social justice and health equity. It means advocating for policies and practices that acknowledge the complex circumstances that impact on people’s actions and abilities. It means seeking to create environments free from childhood trauma and other factors that increase the likelihood of substance use problems in youth and adulthood. It means promoting social connectedness that increases meaningful opportunities and reduces isolation and anti-social behaviour.

From a health promotion perspective, drug education should be more about developing health literacy (the knowledge and skills needed to manage substance use) than about lifestyle marketing. Prevention programs should focus on preventing harmful patterns of use rather than on drug use per se. And substance use treatment services should be designed to empower individuals to select their own goals and the services that meet their individual needs and develop their personal skills.

Across all services, the focus should be on developing individual and community capacities, giving adequate attention to both healthy public policy and community action, rather than on preventing or “fixing” problems that many of us mistakenly believe belong to the “other people” in society.

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