United Nations Security Council Resolution 1566, defines terrorism as:

Criminal acts, including against civilians, committed with the intent to cause death or serious bodily injury, or taking of hostages, with the purpose to provoke a state of terror in the general public or in a group of persons or particular persons, intimidate a population or compel a government or an international organization to do or to abstain from doing any act [1].

Such violence scars thousands of people, sometimes many more. Among the onlookers and rescuers, some of the most painful scars are worn on the inside. These scars lead some people to misuse alcohol or other substances.

In the current issue, DiMaggio and colleagues provide a meta-analysis of studies exploring the rise of alcohol, tobacco and other substance use following terrorist incidents [2]. Although the evidence concerning behavioral persistence is weaker, some of the observed rise in substance use appears to be long-lasting. I presume that similar results would hold in other places where civilians are subject to mass trauma, sometimes on an even wider scale.

Perhaps the most important limitation concerned the nature of terrorist attacks on which reliable data have been collected and published. Seventy-seven per cent of the studies cited by DiMaggio et al. were undertaken in the aftermath of the 9/11 attacks in New York City and Washington, DC. Among the remaining studies, several concerned the aftermath of the Oklahoma City bombings and suicide bombings undertaken during the second Intifada. None of the studies cited were undertaken in the aftermath of sustained urban combat or strategic bombing, although such tactics harm civilians around the world. None explored the impact of large-scale natural disasters on substance use and on substance users.

Virtually every study cited concerned an archetypal terrorist attack that received widespread media coverage. These attacks were therefore experienced vicariously by a much greater number of people than those affected directly as victims, first-responders or witnesses close at hand. It is difficult to distinguish the direct and indirect effects of these attacks. Of course, the impact of terrorist attacks is likely to reflect local context and local practices regarding the use of intoxicating substances to cope with personal or collectively traumatic events.

In the case of 9/11, both direct and indirect effects were substantial. DiMaggio and colleagues report that ‘the unadjusted prevalence of increased cigarette smoking following a terrorist event’ was roughly 7%. In a city the size of New York, this represents tens of thousands of people. Given these figures, it is possible that the World Trade Center attacks will ultimately kill more people through smoking-related disease than died that September morning.

What should policy makers glean from the available literature on terrorist attacks, natural disasters and mass-casualty events? Some of the available literature suggests concrete guidance. Hurricane Katrina dispersed geographically based provider networks to which individuals turn for the treatment of substance use disorders [3,4]. This experience suggests that treatment providers should develop emergency-preparedness plans to meet the complex needs of current users (and of others). This is a daunting challenge, given the general shortage of substance abuse treatment in many jurisdictions.

Improved physical and mental health services for first-responders and for others in the wake of collective tragedies is also likely to prove fruitful [5,6]. After 9/11, the public health community became sensitized to physical health threats such as asthma [7]. Psychiatric disorders and substance use disorders may pose equally important threats to wellbeing [8,9].

Broader prevention measures may also be useful. Christopher Ruhm has advocated procyclical tobacco and alcohol excise taxes to address predictable public health threats [10]. Measures designed in a similar spirit may prove helpful in the aftermath of mass casualty events.

It is sad to say that more effective public health responses to terrorism are needed in much of today's world.

Declaration of interest