Commercial interests contribute to drug use and addiction

By Nora D. Volkow

Biomedical sciences are bringing increased focus to social determinants of health, which the World Health Organization (WHO) defines as “the conditions in which people are born, grow, work, live, and age, the systems put in place to deal with illness, and the wider set of forces and systems shaping the conditions of daily life.” Very often, commercial interests are intertwined with these social and environmental factors, which has led to the recognition by WHO and other agencies of the need to study and address so-called commercial determinants of health. Commercial interests are an important component of the social determinants of addictive behaviors and disorders. ?

Three of the four biggest industrial contributors to worldwide morbidity and mortality are alcohol, tobacco, and ultra-processed foods (the fourth being fossil fuels). The CDC estimates?that more than 178,000 people die in the United States each year from diseases attributable to excessive alcohol use, and more than 480,000 people die annually from causes attributable to tobacco use. According to the Center for Science in the Public Interest, approximately?678,000 people die annually from nutrition- and obesity-related diseases (including cancers, cardiovascular disease, and type 2 diabetes) caused by unhealthy diets. Considering that an estimated 3.27 million people die annually in the United States, the contribution to mortality from just these three commercial sectors is enormous. The societal and economic costs are also huge—over $300 billion annually, in the case of tobacco alone—and are largely deferred to other sectors like healthcare.

What these disease-causing products—including the highly refined foods that contribute to obesity— have in common is that they activate the brain’s reward system in ways that are highly reinforcing. The success of these industries is maximized by their products being able to trigger compulsive consumption, including consumption that results in addiction. Because of the well-understood role of reward in motivating our behaviors, existing industries are pushing novel products to activate the brain’s reward system, and new industry sectors are emerging to capitalize on our biological propensity to engage in reward-seeking behaviors.

Great progress has been made in reducing smoking in the United States, which has led to major improvements in health, but the rapidly growing vaping industry, if not properly regulated, could jeopardize this. The explosion in popularity of vaping in the last few years has led to a steep rise in nicotine exposure particularly among teenagers and young adults who are the most vulnerable to nicotine addiction. While recognized as less harmful than combustible tobacco products, nicotine vaping nonetheless has been associated with adverse health consequences, including increasing risk for tobacco initiation and dependence and pulmonary and vascular dysfunction. Vaping’s potential public health benefits as a harm-reduction alternative to tobacco smoking or as a therapeutic for smoking cessation must be balanced against these risks.?

The cannabis industry has presented new opportunities for commercial interests to drive drug consumption across all ages and demographics. Cannabis products are often sold in colorful packages that mimic kid-friendly snack foods, for example, making them appealing to children and to young people. Adolescents exposed to cannabis marketing have greater odds of using the drug. The legalization of cannabis by the states and the diversification of cannabis products have led to significant increases in the number of users and the amount of cannabis consumed by them in the US. Although people 18-30 years old have the highest prevalence of cannabis consumption, the age group with the fastest rate of increase is people 65 years or older. This older age group is being targeted with advertising touting cannabis’ alleged therapeutic benefits. As expected, the expanded use of cannabis and the higher doses used have resulted in an increase in the number of individuals suffering from adverse health consequences from these exposures.

Commercial determinants also play complex roles in the overdose crisis that currently claims 108,000 lives annually. First, it is well-known how some pharmaceutical companies were directly responsible for aggressively marketing powerful opioid analgesics with known addiction liability starting in the late 1990s. As access to legal opioids became more restricted, the illicit drug markets, including drug cartels with sophisticated business models, stepped in to efficiently supply highly purified forms of heroin and then, more recently, more powerful opioid drugs such as fentanyl.

The tech sector has also emerged as a contributor to addiction and addictive-like behaviors. Not only are licit and illicit drugs marketed on social media, but numerous studies have linked adolescent social media use to risky behaviors including substance use. Research from the Adolescent Brain Cognitive Development (ABCD) study shows associations between social media and other forms of screen time and worst mental health outcomes. Cyberbullying, which is experienced by nearly 1 in 10 adolescents, has been associated with increased risk of substance use. Also, just as tobacco companies realized in the last century, social media companies are incentivized to design their products to be used compulsively and to market those products toward young people who are poised to become lifetime users. Indeed, emerging evidence indicates that social media produces effects that are at least addiction-like, if not actually addictive.?

Potentially addictive online behavior is not confined to social media. Online gambling and sports betting are legal in an increasing number of states, with age limits of 18 or 21 and over depending on the jurisdiction. This has provided new opportunities for businesses to prey on individuals vulnerable to gambling addiction. The dangers of online gambling may be greater than those of traditional gambling in physical casinos and betting parlors. Research has shown that the largest risk factors for problem gambling are associated with gambling products that allow continuous play, a feature of many or most online gambling products.

How does Public Health “get out in front” of these industries, to mitigate the actual and potential harms they may cause? Policy interventions similar to those that have been successfully applied to tobacco and alcohol may be instructive. For instance, smoke-free workplace laws and restrictions on tobacco advertising have been effective at reducing smoking and its health impacts. Over 100 studies have shown that higher taxes on cigarettes produce significant reductions in smoking, especially among youth and lower-income individuals. And raising the minimum legal drinking age to 21 saved lives, for example, including through reduced vehicle crashes.

Research is needed to understand how the lessons learned from these successful policy interventions may be applied to other domains and to study the impact of policies already in place. For example, the U.S. Food and Drug Administration has taken steps to restrict the sale and marketing of flavored vapes, in part to limit their appeal to youth, while balancing these restrictions against the possible public health benefits for some adult cigarette smokers who use e-cigarettes to transition away from combustible tobacco products.

Lessons learned from alcohol and tobacco are also being applied to the sale, marketing, and taxation of cannabis products in states that have legalized the drug for adult use, but policies vary widely by state. A new analysis by the National Academies of Sciences, Engineering, and Medicine found that early legalization efforts have prioritized economic outcomes over public health. Needed is much more research to understand the potential risks and therapeutic applications of cannabis and to inform policy approaches that minimize cannabis’s harms, reduce the social and racial inequities associated with its criminalization, and ensure safe access for those who may benefit from it therapeutically.

How best to mitigate the health harms of social media and online gambling is an area about which much less is known, as the territory is even newer, and the changes are occurring more rapidly. A U.S. Surgeon General’s Advisory on the mental health impacts of social media recommends that policymakers develop health and safety standards for young users, including strengthening and enforcing age restrictions and ensuring that technology companies share data on the health impacts of their products. But we do not yet understand the full effects of different types of social media or the ways in which some might offer valuable protections or could be leveraged to do so through policy measures that incentivize tech companies to act in the public interest.

With the rapid rise in online gambling, research is just beginning to address possible harm-reduction approaches, such as age-restrictions, limitations on marketing of online gambling products, algorithms to detect problematic gambling, and linkage to therapeutic interventions, among others.[xxiv] But here too, much more research is needed to prevent gambling addiction from becoming a significant public health crisis.

History has shown that businesses often put profits over public health, too often with tragic consequences. As we confront the rapidly evolving landscape of addictive and potentially addictive products and technologies, it is imperative that we conduct research to understand how commercial interests affect public health and individual health and well-being. Such research can help guide policies as well as inform the development of evidence-based prevention and treatment interventions.

View Nora's blog on NIDA's website.