THINKING ABOUT HOW SOCIAL INEQUALITIES RELATE TO ALCOHOL AND DRUG USE AND PROBLEMS

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THINKING ABOUT HOW SOCIAL INEQUALITIES RELATE
TO ALCOHOL AND DRUG USE AND PROBLEMS

• Robin Room
• Centre for Social Research on Alcohol and Drugs
• Stockholm University
• Sveaplan, 106 91 Stockholm, Sweden
• robin.room_at_sorad.su.se
• 1st International Summer School on Inequalities
  and Addictions
• National Centre for Education and Training in
  Addictions
• 25-27 February, 2004
• Adelaide, South Australia

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Outline of the presentation

• Poverty or social class as social inequality, and
  its conceptual relation to substance use
• Marginalization and stigma in relation to social
  inequality and substance use
• Some issues in studying the relations of social
  inequality and substance use problems
• Putting social inequality, marginalization and
  substance use in a common frame
• Some directions for research

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The implicit model in general discussions of
health inequality
Socio-economic determinants Social class
other social differentiations
Health inequalities
Lifestyle determinants Including alcohol,
tobacco, drugs
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When psychoactive substances are brought into the
discussion of poverty ? ill-health
Psychosocial factors Including alcohol, tobacco,
drugs
Health inequalities
Socio-economic determinants Social class
other social differentiations
Material factors
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The meaning of social inequality in social
inequality and health

• (gender)
• (age)
• (ethnoreligious category)
• but mostly socio-economic differences
• Absolute vs. Relative differences
• Dimensions of conceptualization and measurement
• Occupational status
• Education
• Income
• Neighbourhood status

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The question of causal priority

• The causal arrow can be assumed for
• Social inequality ? Death
• More questionable for
• Social inequality ? Illness/disability
• -- since illness or disability can ? downward
  drift
• Even more for Social inequality ? mental illness
• There is an element of social definition in
  mental illness
• An aspect of the substance use
  addiction/dependence, harmful use,
  alcoholic/drug-induced psychosis is itself
  defined as an illness

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The dual nature of substance use and problems

• categories in the classification of health
  disorders
• dependence syndrome
• harmful use
• acute intoxication, etc. ...
• but also derogated moral categories
• slang a junkie, a drunk
• also official terms substance abuse/abuser
• Evidence from 14-country WHO study of
  cross-cultural applicability of disability
  assessments ratings by key informants of
  relative
• social disapproval/stigma on alcoholism, drug
  addiction
• disapproval of someone who is drunk, someone
  under influence of drugs appearing in public

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Degree of Social Disapproval/Stigma Relative
ordering from lowest to highest mean rating
within each country
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Reaction to appearing in public Ordering from
lowest to highest mean rating within each country
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Marginalization and the health system
utilization and attitudes among categories of the
disadvantaged living in poor districts in
Portugal (Santana, 2002)
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Poverty/ socioeconomic status (SES) vs.
Marginalization/stigma

• Relation between the two frames an interesting
  empirical question
• No necessary relation
• deserving vs. undeserving poor in Major
  Barbaras time (and now?)
• Two styles of research make conflation hard
• Positivist style for studies of social
  inequality one direction of causation and health
  status as outcome
• Phenomenological style emphasis on processes of
  social definition for studies of marginalization

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Issues in studying the relation of social
inequality with substance use and problems 1

• Patterns of use or problems by SES can vary with
  substance use measures used
• Heavy drinking measured one way rose with
  social class, measured another way fell (Room,
  1971)
• High-risk weekly drinking positively related to
  social class, no relation for frequent heavy
  drinking (Demers Kairouz, 2003)
• Patterns of use or problems by SES can vary with
  SES measures used
• Among 26-year-olds, no relation between income
  and average amount per drinking occasion, but
  less educated drink gt1½ times as much as more
  educated (Casswell et al., 2003)
• Low education, occupational status, unemployed ?
  smoking, but no relation with income (Siapush,
  2003)

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Issues in studying the relation of social
inequality with substance use and problems 2

• Income tends to have strongest positive (or
  least negative) relationship to regularity
  volume of consumption variables
• Psychoactive substance use competes with other
  demands on the resources of the poor
• Other components of inequality such as education
  and occupational status often relate to cultural
  differences as much as to resource differences
• For mortality and other serious substance-related
  problems, effects of different SES components may
  be additive
• Alcohol-specific deaths in Finland higher for
  each of lower education, occupational status
  (excluding farmers), personal and household
  income, living in rented housing (Mäkelä, 1999)

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Issues in studying the relation of social
inequality with substance use and problems 3

• The class position of a substance use pattern can
  vary within the same country
• Arab Israelis heavy drinking ? higher income,
  occupational status (but lower education)
  Jewish Israelis heavy drinking ? lower
  income, occ. status, education (Neumark et al.,
  2003)
• US 1960s abstention from alcohol among males
  ? higher SES in southern and prairie cities,
  ? lower SES in northeast
  Pacific coast cities

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Use-values of psychoactive substances physical
and symbolic

• Physical properties one or more or
• Mood modifier
• Intoxicant
• Medicine
• Thirst-quencher
• Nutrition
• Solvent
• Positive symbolic properties
• Of use
• Commensality and sharing
• Celebration
• Sacrament
• Of use or non-use
• Claim of autonomy, maturity
• Mark of distinction membership
• Negative symbolism
• Taboo on use, degraded market
• User or addict as lacking self-control
• Mark of marginality

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The two tracks Use vs. non-use
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The two tracks Frequent light use

• Moral valuation marks of honour or stigma

• Empirical connections with poverty SES

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The two tracks Intoxication/Getting
high/Bingeing
Moral valuation marks of honour or stigma
Empirical connections with poverty SES
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The two tracks Addicted (regular heavy) use
Moral valuation marks of honour or stigma
Empirical connections with poverty SES
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Social inequality, marginalization, and types of
alcohol drug problems

• Chronic health problems
• Extreme poverty limits substance use
• But common psychoactive substances (tobacco,
  alcohol) within reach of the poor in developed
  countries ? shift in class position of cirrhosis
• Poverty may increase the harm e.g., nutrition
  interacting with alcohol ? cirrhosis

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Social inequality, marginalization, and types of
alcohol drug problems (contd)

• Problems from a single occasion of use
• Overdoses, injuries (accidents, violence),
  infections
• Police arrests and other social reactions
• Poverty ? greater harm because less resources to
  buy protection
• Adverse social consequences of continuing use
• Family relations, friendships, work life
• Mixed results in US surveys on relation of
  alcohol problems to social class
• Marginalized often excluded from household surveys

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The two worlds of alcohol and drug problems

• General population surveys
• Include relatively stable poor populations
• Often exclude the marginalized
• Problems concentrated at ages 16-29
• Clinical populations those in alcohol drug
  treatment heavily marginalized
• Stockholm county
• lt 1/4 married or living with partner
• ½ living alone
• 30 homeless
• 30 unemployed
• ½ my mental health is a substantial or serious
  problem

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Processes of marginalization of alcohol and drug
users

• Intimate processes of social control and
  censure among family and friends
• frequently effective, but family and friends may
  eventually give up or push the user into
  treatment
• Decisions by social agents and agencies
• focused on the most problematic cases, amplifying
  their marginalization. Even actions intended as
  positive may have this effect if the case does
  not succeed.
• Policy decisions at the local or national
  level
• e.g., U.S. law to evict a family from public
  housing if any member is associated with drug
  dealing
• Policy decisions to be tough on drugs always
  carry the corollary of marginalizing those who do
  not conform.

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• In spite of two centuries of claims that
  addiction is a disease, and more recently that it
  is similar to other chronic diseases, the idea
  that addiction is rooted in repeated bad choices
  remains widely compelling.... Addicts remain
  unpopular political allies, even in disability
  rights circles.... A recent textbook on the
  disability rights movement avoids the subject of
  addiction altogether, even in its consideration
  of the movements problematic heterogeneity.
  (Baumohl et al., 2003)

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Some directions for further study 1

•   Attention to the relation of different
  components of social inequality to patterns and
  levels of psychoactive substance use in different
  populations. Moving beyond description to
  explanatory studies, qualitative and
  quantitative, of why and under what circumstances
  particular differences in substance use are
  found.
•    Interrelation of different components of
  social inequality, substance use patterns and
  levels, and different social and health problems
  related to substance use. How do different
  patterns of use intermediate the relationships
  between the social inequality indicators and the
  problems?

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Some directions for further study 2

• Quantitative qualitative studies are needed
  of the extent and mechanics of marginalization of
  substance use and problems in different societies
  and milieux. These studies should identify the
  patterns of reasoning and prejudice which
  underlie the stigmatization.
• Studies are needed in different societies and
  milieux of the relationship between components of
  social inequality and marginalization.
•   In the context of these general studies,
  specific attention needs to be paid to the
  interplay of social inequality and
  marginalization around substance use and problems.

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Some directions for further study 3

• Priority should be given to studies of what
  happens when some aspect of social inequality or
  marginalization changes. These studies can be at
  the aggregate or the individual level where
  possible at both either of planned experiments
  and interventions or of natural experiments
  when a policy changes.
• Thinking is needed about alternative
  conceptualizations and policies for substance use
  and problems which would diminish stigma and
  marginalization, particularly in the context of
  social inequality.