In a country like Israel, which is deeply committed to the main sources of infection, among them active foci achievement of an expanded immunization program, the still present in the neighboring territories. effort to reach this objective should be weighed within the national program aimed at elimination of the diseases References .................................. controlled by mass immunization. Analysis of present achievements clearly shows that measles, together with 1. Swartz, T. A., and Klingberg, W.: Routine measles immu- poliomyelitis and rubella, deserves to be included among nization in Israel: A three-year clinical and serologic follow- up. In International conference on application of vaccines the first priorities of a program whose objective is elim- against viral, rickettsial, and bacterial diseases of man, ination of clinical disease. Washington, D.C., 14-18 December 1970. Pan American Health Organization, Washington, D.C., 1971, pp. Conclusions 265-268. 2. Centers for Disease Control: Measles Surveillance Report No. 11, 1977-1981. Atlanta, Ga., September 1982. A 17-year-old immunization program has created the 3. Health and Welfare Canada: Measles in Canada. Canada basis for elimination of measles in Israel, provided that Diseases Weekly Report 9-25: 29-101 (1983). (a) the control policy is adapted to the seroepidemiology 4. World Health Organization: Measles surveillance. Weekly of the infection, and (b) a concentrated logistic effort is Epidemiol Record 58: 85-86 (1983). mounted in the period preceding the next expected epi- 5. Hopkins, D. R., Hinman, A. R., Kaplan, J. E, and Lane, J. M.: The case for global measles eradication. Lancet 1: demic. Under this effort: 1936-1938, June 19, 1982. 6. Public Health Laboratory Service: Goal to eliminate mea- * The nearly 90 percent vaccination coverage of each sles from the United States. Communicable Diseases Re- newborn cohort that has already been achieved should be port, No. 1: 1,4 (1979). maintained. 7. Yorke, J. A., Nathanson, N., Pianigiani, G., and Martin, J.: Seasonality and the requirements for perpetuation and erad- * A 97 percent immunization coverage should be aimed ication of viruses in populations. Am J Epidemiol 109: at for the target groups formed by preschool and elemen- 103-123, February 1979. tary school children who missed the routine immuniza- 8. Hethcote, H. W.: Measles and rubella in the United States. tion at age 1 year. Am J Epidemiol 117: 2-13, January 1983. * Similar coverage should be achieved by immunization 9. Centers for Disease Control: Classification of measles cases and categorization of measles elimination programs. of susceptible persons in selected groups of children, MMWR 31: 707-711 (1982). adolescents, and young adults at high risk. 10. World Health Organization: Measles surveillance in U.S.A. * The immunization program should be complemented Weekly Epidemiol Record 57: 367-368 (1982). by disease surveillance aimed at early identification of Substance Abuse by Adolescents in 1977 with 499 French adolescents. The overall order in the prevalence of use of legal and illegal drugs was In Israel and France: identical in both countries. Cigarettes and alcohol were A Cross-Cultural Perspective used by a larger proportion of young people than the illegal drugs; marijuana was used much morefrequently DENISE KANDEL, PhD than any other illicit drug. The same cumulative se- Dr. Kandel is professor of public health, Department of Psychia- quence of drug use appeared in the survey data for try, Columbia University, Box 20, 722 West 168th St., New York, French and Israeli adolescents as in comparative data N.Y. 10032. This paper is based on her presentation at the Second for adolescents in the United States-cigarette and alco- Binational Symposium: United States-Israel, held October 17-19, hol use preceded the use of illicit drugs. 1983, in Bethesda, Md. This research was partially supported by grant DA 01097 Scope E and by Research Scientist Award DA00081 from the National Striking cross-cultural differences appeared in the Institute on Drug Abuse. overall lifetime and current prevalences of use of all Tearsheet requests to Dr. Kandel. drugs, in the frequency of use, and in the age- and sex- specific rates for adolescents in Israel and in France. Synopsis .................................... French youths uniformly reported greater lifetime and current use of all alcoholic beverages, cigarettes, and Household surveys ofurban youths 14-18 years ofage illegal drugs, more extensive involvement, and smaller were conducted in 1979 with 609 Israeli adolescents and sex differences than the Israeli youths. May-June 1984, Vol. 99, No. 3 277 Prevalence of the use ofdrugs in a culture appears to sults suggest a relatively conservative position with re- be associated with four social processes: higher number gard to accessibility and availability of substances: re- of times each drug has been used; greater persistence of ducing availability may be one way to reduce individual involvement, as reflected by the proportions of current consumption by impinging not on individual persons users among those who ever tried a particular drug; directly but on society. earlier age offirst use; and a spread of the phenomenon throughout all groups in society that attenuates group differences in drug experiences. These cross-cultural re- CROSS-CULTURAL EPIDEMIOLOGIC DATA permit in- Methods sights into drug use behavior that cannot be gained with data for a single country. This is especially true when Two household surveys of urban youths 14-18 years there are great contrasts in drug use in the cultures being old were conducted (a) in the spring of 1979, with 609 compared. Data for a wide range of substances raise Israeli adolescents who resided in the four major urban provocative questions with important policy implica- centers in Israel-Jerusalem, Tel Aviv, Haifa, and tions: Beersheba, and (b) in the spring of 1977, with 499 French youths in the Paris metropolitan area. All inter- * What is the relationship between the overall consump- views were structured, and they were conducted in tion levels and the patterns of use of a substance in a homes. particular culture? Because the Israeli sample included a lower proportion * What are the implications of the use of one substance of 18-year-olds than the French sample (13 percent ver- for the use of other substances? How do stages of in- sus 26 percent), data were weighted to create a uniform volvement affect use of other drugs? distribution for each category in the age variable for each country. Cross-cultural studies in Israel and France were con- I focused on three dimensions of drug use: lifetime ducted to test specific hypotheses derived from earlier prevalence-that is, the proportion who had ever used work with American adolescents and to replicate in other each drug; current use, defined as use in the 30 days societies the epidemiologic and psychosocial studies of before the interview; and lifetime frequency of use for adolescents in the United States. Earlier analyses in the each drug. With certain exceptions, the same questions United States indicated that the uses of legal and illegal were asked for all drugs in both surveys. Adjustments drugs were closely interrelated and that illicit drug use were made in the alcoholic beverages listed in the ques- was preceded by the use of legal drugs, with alcohol use tions to reflect the range of beverages consumed in each a crucial step in this sequence (1,2a,3). An important country. In Israel, "white beer" was specified to avoid issue, therefore, is whether wide differences in the use of confusion with a nonalcoholic beverage known as "black alcoholic beverages between cultures affect the use of beer." I also distinguished ritualistic and nonritualistic other drugs in those cultures. uses of wine. My reporting will be confined to non- France and Israel were selected for comparative analy- ritualistic use. In France, questions were included about sis because of the striking differences in their patterns of cider, and "aperitifs" and "digestifs" were specified alcohol consumption, as documented by indirect con- among distilled spirits. sumption indicators such as alcohol sales volume and For comparative purposes, data will be drawn from the alcohol-related disabilities. According to these indica- 1979 national survey of high school seniors from tors, Israel had one of the lowest rates of alcoholism and Monitoring the Future, an ongoing study conducted by per capita consumption of alcohol and France had one of the University of Michigan on an annual basis since 1975 the highest rates in the world. On per capita consump- (8-9). The sample of high school seniors included over tion, France ranked 2nd out of 26 countries, Israel 15,000 17- and 18-year-olds from 130 high schools in ranked 26th and last, and the United States ranked 16th urban and nonurban areas. The questions in the Ameri- (4). can survey were phrased somewhat differently from those In contrast to the United States, there were almost no in the French and Israeli surveys. epidemiologic data in Israel and France on drug use- "Drug" is used through this paper to mean tobacco, whether tobacco, alcohol, or illicit drugs-by adoles- alcoholic beverages, and legal and illegal drugs. The cents or adults (5-7). term "legal drugs" indicates alcoholic beverages and 278 Public Health Reports tobacco. Illegal drugs include marijuana and/or hashish, psychedelics, heroin, and use on one's own of psycho- tropic drugs that can be medically prescribed, such as amphetamines, barbiturates, and tranquilizers. Results Epidemiologic trends. Striking cross-cultural dif- ferences for all drugs appeared in the proportions of those who had ever used them (lifetime prevalence), or were current users, in the frequency of use and in the age of onset of use. Lifetime and current use prevalences. For all drugs having used hashish or marijuana, a proportion similar to surveyed, the rates of reported use in France exceeded the 5 and 4 percent reported in 1971 and 1973 Israeli those in Israel.