Robin Room

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

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@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

Outline of the presentation: 

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

The implicit model in general discussions of health inequality: 

The implicit model in general discussions of health inequality Socio-economic determinants Social class & other social differentiations Lifestyle determinants Including alcohol, tobacco, drugs Health inequalities

When psychoactive substances are brought into the discussion of poverty  ill-health: 

When psychoactive substances are brought into the discussion of poverty  ill-health Socio-economic determinants Social class & other social differentiations Psychosocial factors Including alcohol, tobacco, drugs Health inequalities Material factors

The meaning of “social inequality” in “social inequality and health”: 

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

The question of causal priority: 

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

The dual nature of substance use and problems: 

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

Degree of Social Disapproval/Stigma: Relative ordering from lowest to highest mean rating within each country: 

Degree of Social Disapproval/Stigma: Relative ordering from lowest to highest mean rating within each country

Reaction to appearing in public: Ordering from lowest to highest mean rating within each country : 

Reaction to appearing in public: Ordering from lowest to highest mean rating within each country

Marginalization and the health system: utilization and attitudes among categories of the disadvantaged living in poor districts in Portugal (Santana, 2002): 

Marginalization and the health system: utilization and attitudes among categories of the disadvantaged living in poor districts in Portugal (Santana, 2002)

Poverty/ socioeconomic status (SES) vs. Marginalization/stigma: 

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 Barbara’s 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

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

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 >1½ times as much as more educated (Casswell et al., 2003) Low education, occupational status, unemployed  smoking, but no relation with income (Siapush, 2003)

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

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)

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

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

Use-values of psychoactive substances: physical and symbolic: 

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

The two tracks: Use vs. non-use: 

The two tracks: Use vs. non-use

The two tracks: Frequent light use: 

The two tracks: Frequent light use Empirical connections with poverty & SES

Slide18: 

The two tracks: Intoxication/Getting high/Bingeing Moral valuation: marks of honour or stigma Empirical connections with poverty & SES

Slide19: 

The two tracks: Addicted (regular heavy) use Moral valuation: marks of honour or stigma Empirical connections with poverty & SES

Social inequality, marginalization, and types of alcohol & drug problems: 

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

Social inequality, marginalization, and types of alcohol & drug problems (cont’d): 

Social inequality, marginalization, and types of alcohol & drug problems (cont’d) 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

The “two worlds” of alcohol and drug problems: 

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: < 1/4 married or living with partner ½ living alone 30% homeless 30% unemployed ~½: “my mental health is a substantial or serious problem”

Processes of marginalization of alcohol and drug users: 

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.

Some directions for further study: 1: 

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?

Some directions for further study: 2: 

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.

Some directions for further study: 3: 

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.