Prevention of Substance Abuse: Alcohol

Substance abuse is a major public health problem in the United States, The lifetime prevalence of alcohol abuse if approximately 18% whereas the lifetime prevalence of alcohol dependence is near 13%. Rates appear to be higher in men, whites, and younger and unmarried individuals. Approximately two-thirds of high school seniors are regular users of alcohol. Alcohol dependence often coexists with other disorders as well as with mood, anxiety, and personality disorders. Underdiagnosis and treatment of alcohol abuse is substantial, both because of patient denail and lack of detection of clinical clues. Treatment rates for alcohol dependence have slightly declined over the last several years.Only a quarter of alcohol dependent patients have ever been treated.

  As with cigarette use, clinicians identification and counseling about alcoholism may improve the chances of recovery.About 10% of all adults seen in medical practices are problem drinkers. An estimated 15-30% of hospitalized patients have problems with alcohol abuse of dependence, but the connection between patients' presenting complaints and their alcohol abuse is often missed. The CAGE test is both sensitive and specific for chronic alcoholism.However it is less sensitive in detecting heavy or binge drinking in elderly patients and has been criticized  for being less applicable to minority groups or to women. Others recommend asking three questions: (1) How many days per week do you drink (frequency)? (2) On a day when you drink, how many drinks do you have in one day (quantity)? (3) On how many occasions in the last month did you drink more than five drinks (binge drinking)? The alcohol use Disorder Identification Test (AUDIT) consists of questions on the quantity and frequency of alcohol consumption, on alcohol dependence symptoms, and on alcohol-related problems. The AUDIT questionnaire is a cost-effective and efficient diagnostic tool for routine screening of alcohol use disorders in primary care settings. Choice of therapy remains controversial. However, use of screening procedures and brief intervention methods can produce a 10-30% reduction in long-term alcohol use and alcohol-related problems. However, brief advice and counseling without regular follow-up and reinforcement cannot sustain significant long-term reductions in unhealthy drinking behaviors.

Cancer Prevention and Treatment

Primary Prevention

Mortality rates of cancer have begun to decrease in the past 2 years; part of this decrease results from reductions in tobacco use, since cigarette smoking is the most important preventable cause of cancer. Preventive health examinations and preventive gynecologic examinations are among the most common reasons for ambulatory care visits, although the use and content of these types of visits remains controversial. Primary prevention of skin cancer consists of restricting exposure to ultraviolet light by wearing appropriate clothing and use of sunscreens. In the past 2 decades, there has been a threefold increase in the incidence of squamous cell carcinoma and a fourfold increase in melanoma in the United States. Persons who engage in regular physical exercise and avoid obesity have lower rates of breast and colon cancer. Prevention of occupationally induced cancers involves minimizing exposure to carcinogenic substances such as asbestos, ionizing radiation, and benzene compounds. Chemo-prevention has been widely studied for primary cancer prevention. Hepatitis B vaccination can prevent hepatocellular carcinoma (HCC), and screening and vaccination programs may be cost-effective and useful in preventing HCC in high-risk groups such as Asians and Pacific Islanders. The use of HPV vaccine to prevent cervical cancer is discussed above in the Prevention of Infectious Disease section.

- Screening and Early Detection

Screening has been shown to prevent death from cancers of the breast, colon, and cervix. Current cancer screening recommendations from the United States Preventive Services Task Force.

   The appropriate form and frequency of screening for breast cancer is controversial.A large randomized trial of breast self-examination conducted among factory workers in shanghai found no benefit. A systematic review performed for the United States Preventive Services Task Force found that mammography was moderately effective in reducing breast cancer mortality for women 40-74 years of age. The absolute benefit was greater for older women and the risk of of false-positive results was high for all women. Digital mammography is more sensitive in women with dense breasts and younger women; however, studies exploring outcomes are lacking. Several organizations, including the American Cancer Society and the National Cancer Institute, recommend routine mammography screening, and changes in screening guidelines appear to impact women's belief about how frequently they should obtain screening.

  Screening for cervical cancer with a Papanicolaou smear is indicated in sexually active adolescents and in adult womens every 1-3 years. Screening for vaginal cancer with a Papanicolaou smear is not indicated in women who have undergone hysterectomies for benign disease with removal of the cervix---except in diethylstilbestrol (DES)-exposed women . Women over age 70 who have had normal results on three or more previous Papanicolaou smears may elect to stop screening.

  Observational clinical trials have revealed that chest CT is significantly more sensitive that chest radiography in identifying small asymptomatic lung cancers; however, there is no clear evidence that screening for lung cancer reduces mortality. Randomized controlled trials assessing the effect of low-dose CT (LDCT) on lung cancer mortality are underway.

Prevention of Overweight and Obesity

Obesity is now a true epidemic and public health crisis that both clinicians and patients must face. Normal body weight is defined as a body mass index (BMI), calculated as the weight in kilograms divided by the height in meter squared, of < 25 kg/m2; overweight is defined as a BMI = 25.0-29.9 kg/m2, and obesity as a BMI > 30 kg/m2. Over the last several years, the prevalence of obesity in the US population, the prevalence of obesity in the US population has increased dramatically. Among US adults, rates of obesity have risen from 15.9% in 1995 to 26.7% in 2008. Among men, the prevalence of obesity increased significantly between 1995 (16.5%) and 2008 ( 27.4%). A similar trend was seen among women between 1995 (14.7%) and 2008 (25.6%). There is a significant variation in rates of obesity by race. Between 2006 and 2008 blacks (35.7%) had 51% greater prevalence of obesity and Hispanics (28.7%) had 21% greater prevalence when compared with non Hispanic whites (23.7%). This trend has been linked both to declines in physical activity and to increased caloric intake in diets rich in fats and carbohydrates.

   Adequate levels of physical activity appear to be important for the preventation of weight gain and the development of obesity. Despite this, only 49% of Americans are physically active at a moderate level, and 20% at at a more vigorous level.In addition, only 3% of Americans meet four of the five recommendations for the intake of grains, fruits, vegetables, dairy products, and meat of the Food Guide Pyramid. Only one of four Americans eats the recommended five or more fruits and vegetables per day.

  Prevention of overweight and obesity involves both increasing physical activity and dietary modification to reduce caloric intake. Clinicians can help guide patients to develop personalized eating plans to reduce energy intake, particularly by recognizing the contributions of fat, concentrated carbohydrates, and large portion sizes. Patients typically underestimate caloric content, especially when consuming food away from home. Providing Patients with caloric and nutritional information may help address the current obesity epidemic. To prevent the long-term chronic disease sequelae of over weight or obesity, clinicians must work with patients to modify other risk factors, eg, by smoking cessation and strict glycemic and blood pressure control.

  Clinicians seem to share a general perception that almost no one succeeds in long-term maintenance of weight loss. However, research demonstrates that approximately 20% of overweight individuals are successful at long-term weight loss (defined as losing greater than 10% of initial body weight and maintaining the loss for greater than 1 year).The development and implementation of innovative public health strategies is essential in the fight against obesity, Lessons learned from smoking cessation campaigns may be helpful in the battle against this significant public health concern

Prevention of Osteoporosis

Osteoporosis, characterized by low bone mineral density, is common and associated with an increased risk of fracture, The lifetime risk of an osteoporotic fracture is approximately 50% for women and 30% for men. Osteoporotic fractures can cause significant pain and disability. As such, research has focused on means of preventing osteoprosis and related fractures, Primary prevention strategies include calcium suplementation, vitamin D supplementation, and exercise programs. A 2007 systematic review and meta analysis found that calcium supplementation of 1200 mg per day or more ( with or without vitamin D) could decrease fracture risk for adults ( mainly women were studied) over age 50.

Chemoprevention

Regular use of low-dose aspirin (810325mg) can reduce the incidence of myocardial infarction in men. Low-dose aspirin reduces stroke but not myocardial infarction in middle-aged women. Based on its ability to prevent cardiovascular events, aspirin use is cost-effective for men and women who are at increased cardiovascular risk, which can be defined as 10-year risk over 10%.

Prevention of Hypertension and Treatment

Over 43 million adults in the United States have hypertension, but 31% are unaware of their elevated blood pressure; 17% are aware but untreated; 29% are being treated but have not controlled their blood pressure (still greater than 140/90 mm Hg); and only 23% are well controlled.In every adult age group, higher values of systolic and diastolic blood pressure carry greater risks of stroke and congestive heart failure. Systolic blood pressure is a better predictor of morbid events than diastolic blood pressure. Home monitoring is better correlated with target organ damage than clinin-based values. Clinicians can apply specific blood pressure criteria, such as those of the Joint National Conference, along with consideration of the patient's cardiovascular risk, to decide at what levels should be considered in individual cases.

Lipid Disorders (Cholesterol) Treatment

Lipid Disorders Treatment

Higher low-density lipoprotein (LDL) cholesterol concentrations and lower high-density lipoprotein (HDL) lvels are associated with an increased risk of CHD. Cholesterol lowering therapy reduces the relative risk of CHD events, with the degree of reduction proportional to the reduction in LDL cholesterol achieved. The absolute benefits of screening for-and treating-abnormal lipid levels depend on the presence and number of other cardiovascular risk factors. 

Cigarette Smoking Causes and Care

Cigarette smoking remains the most important cause of preventable morbidity and early mortality. In 2000, there were an estimated 4.8 million premature deaths in the world attributable to smoking. 2.4 million in developing countries and 2 million in industrialized countries.More than three-quarters (3.8 Million) of these deaths were in men.The Leading causes of death from smoking were cardiovascular diseases (1.7 million deaths), chronic obstructive pulmonary disease (COPD) (1 million deaths), 

Prevention of Cardiovascular Disease

Cardiovascular diseases, including coronary heart disease (CHD) and stroke, represent two of the most important causes of morbidity and mortality in developed countries. Several risk factors increase the risk for coronary disease and stroke.These risk factors can be divided into those that are modifiable (eg, lipid disorders, hypertension, cigarette, smoking) and those that are not (eg, gender, age, family history of early coronary disease).Impressive declines in age-specific mortality rates from heart disease and stroke have been achieved in all age groups in North America during the past two decades, in large part through improvement of modifiable risk factors: reductions in cigarette smoking, improvements in lipid levels, and more aggressive detection and treatment of hypertension.

Prevention of Infectious Diseases

Much of the decline in the incidence and fatality rates of infectious diseases is attributable to public health measures - especially immunization, improved sanitation, and better nutrition.


Immunization remains the best means of preventing many of infections diseases. In the United States, childhood immunization has resulted in near elimination of measles. mumps, rubella, poliomyelitis, diphtheria, pertussis, and tetanus. Hemophiliacs influenza type b invasive disease has been reduced by more than 95% since the introduction of the first conjugate vaccines.