THINKING ABOUT HOW SOCIAL INEQUALITIES RELATE TO
ALCOHOL AND DRUG USE AND PROBLEMS
Centre for Social Research on Alcohol and Drugs
My purpose in this paper is not to offer solutions, but rather to further our thinking about how social inequalities relate to alcohol and drug use and problems. The main emphasis here is on the social class dimension of social inequality. But, in the context of alcohol and drug use, I argue that it does not make sense to think about this kind of social inequality without also taking into account the overlapping area of marginalization or stigmatization. The paper begins by considering the conceptual relations of poverty or social class and of marginalization or stigmatization to substance use and to the relations between use and harm. The paper then considers some issues in studying the relation between poverty or social class and substance use and harm. Some attention is given to potential paths of connection between social inequality, on the one hand, and marginalization, on the other, and substance use and harm. Lastly, some directions for future research are suggested.
Poverty as social inequality and its conceptual relation to substance use
In the general context of public health, the main focus in discussions of health inequality is on poverty or social class and the adverse health experience of those who are poor. In this context, “socio-economic determinants” are one major class of determinants of health. Alongside this is another class, of “lifestyles and other behavioural determinants” of health (Beaglehole, 2002). Among the “lifestyle determinants”, alcohol, tobacco and drugs figure prominently (Green and Potvin, 2002). Reflecting this conceptual division, the literature on social inequality and health and that on psychoactive substance use and health tend until recently to have been rather separate.
When psychoactive substances are brought into the discussion of the relation between poverty and ill-health, they have been conceptualized as an intervening factor, as part of a class of “psychosocial factors” which, along with a class of “material factors”, potentially intermediate the relation. The model thus tends to start from the presumption of a greater use of the substances by the poor, which is often conceptualized as a response to the greater stress in poor people’s lives (Mackenbach, 2002). In this context, poverty is assumed to be causally prior, and ill health to be the final consequence. The model is implicitly built on tobacco smoking as the leading example, and relies on the undoubted fact that, in many developed societies today, regular tobacco smoking is commoner among those of lower than those of higher socio-economic status (e.g., Siapush, 2003). We shall return below to the issue of how well this model fits empirical findings for different psychoactive substances and circumstances.
In the literature on social inequality and health, there is discussion of the many different dimensions which social inequality could be seen as covering, and of the diversity of different potential operationalizations. While the term “social inequality” encompasses differences on other social differentiations such as gender, age or ethnoreligious category (Braveman & Gruskin, 2003), and the inequities of discrimination on such bases are certainly discussed in the public health literature (e.g., Olsen et al., 2003), the main emphasis in public health usage has been on socio-economic differentiations. Even here, it is well recognized that there are definitional and measurement choices to be made: poverty can be defined in absolute or in relative terms (Gwatkin, 2002); and the variables often included in measures of socio-economic status, such as education, income and occupational and neighbourhood status, differ both conceptually and also often in their relationship to health outcomes (e.g., Kelleher et al., 2003; Martikainen et al., 2003).
By and large, however, the public health literature takes the attribute of being disadvantaged as causally prior in considering its relation to lifestyle factors such as substance use and to health outcomes. There is a certain logic to this where the kind of outcome being considered is a death from heart attack, liver cirrhosis or AIDS. Even in the sphere of physical health, however, the model becomes more questionable when the outcome in question is shifted from death to illness or disability; the existence of the illness or disability may bring a downward drift in socioeconomic status (Green & Potvin, 2002). To the extent that the illness is caused by substance use, the causal arrow between the use and the socieconomic status is then potentially bidirectional.
When consideration extends beyond physical to include mental health, there are further complications. In the first place, an aspect of the substance use now becomes potentially the end-point, rather than an intermediator, in the form of alcohol and drug dependence and other substance use disorders. Second, with mental disorders the issue of the element of social definition in the end-point becomes inescapable. While there is an element of social construction and definition in all illness, the threshold of what becomes defined as a mental disorder is often set by the reactions of others to behaviours which they are defining as “strange and odd” (Room et al., 2001:265).
Marginalization and stigma in relation to social inequality and substance use
The element of social construction is particularly important when it comes to substance use disorders, and for that matter such partly medicalized social categories as “substance abuser”. Alcoholism and drug addiction are, on the one hand, from the perspective of medical nosology and public health, categories in the international classification of health disorders, under their professional names of alcohol and drug dependence. On the other hand, in social terms both alcoholism and drug addiction are thoroughly moralized and derogated categories. Both conditions ranked near the top, in terms of the degree of social disapproval or stigma reported by informants on 18 different characteristics, in nearly all of the 14 countries in a WHO study – in all but two countries, for instance, above being “dirty and unkempt”; in all but three being a drug addict was reported to be more disapproved or stigmatized than having a criminal record for burglary (Room et al., 2001:276).
An individual’s patterns of psychoactive substance use, in a great many societies, are thus not only a matter of public health interest, but are also a subject of social evaluation in terms of approval or disapproval, of honour or stigma, in everyday life. The evaluations attached to a particular pattern of substance use vary over time and between cultures, and often vary also within a culture according to circumstances and who is using. As in the case of drug use which is defined as illegal, disapproval may be expressed in the form of state sanctions, up to and including being deprived of life, liberty or property.
Whatever we may think of these moral evaluations, which may be positive and thus may encourage more and heavier drug use, or on the other hand may be negative and may add a heavy load of stigma and adverse consequences for the individual drug user, an analysis which takes into account social realities cannot ignore them.
In this sense, patterns of psychoactive substance use, particularly through the social evaluations of them, become involved in the creation of social inequality. But here the inequality in question is not so much about socioeconomic status directly, but rather has to do with marginalization, social exclusion and stigma.
This is a familiar territory for sociologists and criminologists. In sociological theories of labelling and deviance, the pattern of substance use becomes the “primary deviance”, the negative social evaluation of which initially potentially sets the user on the road to marginalization and exclusion (Knuttila, 2002). In the classic scenario, the marginalized users then find each other, and form a mutually supportive counterculture which cements its members into a further marginalization through “secondary deviance”. At the end-point of this process, the deviant substance user is fully marginalized and socially excluded, indeed extruded from respectable society.
The universality and inevitability of this scenario has been challenged empirically, at least for mental illness (Gove, 1982). But, by whatever mechanism, there is no doubt that some patterns of substance use – archetypally, the patterns of drinking which become defined as “alcoholism” – entail a process of social degradation and exclusion, a process described in classic Alcoholics Anonymous language as ending in the drinker the “hitting bottom”.
A glimpse of the processes of social devaluation directly relevant
to health outcome can be seen in the literature on public opinion about which
personal characteristics should be taken into account in setting health
priorities. Summarizing six studies from
The nature and extent of the relation between the two phenomena of social marginalization and stigma, on the one hand, and poverty or low socioeconomic status (SES), on the other, is an interesting empirical question, though it is beyond our scope here. Addressing the question is complicated by the drift in the literature towards incorporating “social exclusion” into the conceptualization of poverty and social inequality. Social exclusion, as Micklewright and Stewart (2001) remark, is a “slippery concept”; it could reflect active processes of derogation at the individual level, but is more commonly operationalized as Micklewright and Stewart do, in terms of conditions such as unemployment, where the exclusion may be more structural and impersonal. For the sake of clarity, we shall not use “social exclusion” here, but rather poverty or low SES, to describe a socio-economic position in society, and marginalization or stigmatization to describe social processes which apply to statuses which are specifically derogated and discredited.
There is no necessary relation between stigmatization and poverty: the processes by which one ends up poor and by which one ends up marginalized may have little relationship to one another. The empirical overlap between those who are marginalized and those who are poor has long been recognized to be partial; Shaw’s distinction between the “deserving” and the “undeserving poor” in Major Barbara reflected the common social welfare distinction of the time (one that has come back into favour in our neoliberal times -- Loury, 2001). On the other hand, it is also possible to be rich and stigmatized and marginalized, although the affluent ipso facto are better able to purchase protection from this.
What is important for our present purposes is to recognize that there are two main frames in which to view the relation between social inequality and psychoactive substance use, one focused on SES and poverty, and the other on marginalization and stigma. A different style of research tends to have been associated with each frame, although there is no necessary reason for this. Studies of social inequality have tended to be in a more positivist style of research and analysis, with one-directional causal arrows and with health status as the outcome, while studies of marginalization tend to have been more in a style of phenomenological research and analysis of processes of social definition, with recursive causal arrows. The different orientations of these research traditions have meant that their findings are not easily conflated.
There is by now a considerable tradition of empirical studies of the relationships of social class or social inequality with substance use and problems. It is clear from the literature that the relationships are not simple and unidirectional; a simple model of poverty resulting in more substance use which in turn causes greater rates of illness will often not be sustained empirically. Let us consider some examples of the complications that have been found. The examples will primarily come from alcohol studies, but the general points apply across substances.
1. Patterns of use or problems by social class can vary with the measure of use or problems utilized. Indeed the social class relation can be reversed. This has been shown for measures of heavy drinking, which has been measured in different studies with a variety of measures. A comparison of the findings by social class (using a 4-category version of Hollingshead’s ISP, based on education and occupational status) among San Francisco males 40-59 interviewed in 1962 found that, for Knupfer’s F/Q measure of heavy drinking, the rate rose fairly evenly from 22% in the lowest category to 30% in the highest. On the other hand, with a measure of frequent heavy drinking (drinking 5 or more drinks on an occasion at least once a week), the rate declined fairly evenly from 13% in the lowest class category to 4% in the highest (Room, 1971).
In the same vein, Demers and Kairouz (2003:210, model 2), analyzing 1993 and 1998 surveys of adults in Québec, Canada, and using as an indicator of SES a measure of “income adequacy” derived from household income and size, found substantial differences in the strength of the relationship with different measures of drinking. The frequency of heavy drinking showed essentially no relation to social class. On the other hand, high-risk weekly drinking and volume of drinking showed a significant positive relationship with social class, and frequency of drinking an even stronger one.
2. Patterns of use or problems by social class can vary with the measure
of social class utilized. For
instance, studying a cohort of 26-year-olds in
The same general pattern was found for having a cigarette smoker in the household in a 1998-99 Australian national sample (Siapush, 2003). There was no relation of having a smoker in the household to household income, but strong negative relations with education and occupational status, and a positive relation to one or more household members being unemployed.
heavy drinking occasions (5+ drinks in the last month) in a 1995 national
In contrast to the previous examples, in a sample of U.S. adults interviewed in 1992 (Henderson et al., 2004), those with a low education level (less than 9 years schooling) reported a much lower rate than others of an indicator of alcohol problems – answering positively to any of the criteria for alcohol dependence – among both men and women. The relationship of this indicator to income was slightly curvilinear for both genders, with those with the lowest family income reporting the highest rate, and those with the highest family income the second-highest rate.
3. All else being equal, income tends to have the strongest positive relation of any inequality indicator to consumption variables, particularly to volume of consumption. The previous examples at least partly illustrate the generalization that, of all indicators of social class or inequality, income tends to have the most positive relationship to regular substance use, and particularly to the volume of use. For poor people, psychoactive substance use competes with other demands on their limited resources, even though those among the poor who are using a substance tend to spend a higher proportion of their income on it than richer users. In considerable part, the relation with income reflects the fact that psychoactive substances are commodities, in most circumstances with a price which it is harder for the poor to pay. When income is included in a combined measure of SES, the relationship with a volume measure, at least for alcohol, tends to be positive. A study of the German general population 18+ (Burger et al., 2003) which uses volume of drinking as its alcohol indicator is illustrative of this. It found a positive relationship with SES (constructed from education, occupational level and household income) at all ages: among males, the median consumption in grams of ethanol per day was 13.5 for high SES, 10.4 for middle, and 8.8 for low SES; the corresponding figures for females were 5.6, 2.2 and 0.9.
4. For serious substance-related problems such
as mortality, the effects of different components of social class may be
additive. This is the finding of a detailed study of 21,922 deaths in
An additive relationship was also found in an analysis of Finnish alcohol-specified male mortality for another aspect of social class: the tendency for class position to be handed down across generations. Analyzing the deaths 1991-1998 of those born 1956-1960, Pensola and Martikainen (2003) found that, in comparison to the reference category where both the decedent and the head of his childhood household had had a higher-status job (not manual labour), alcohol-specified deaths were 1½ times more likely where the head of household but not the decedent had had a manual job, 4 times as likely where the decedent but not the head of household had had a manual job, and almost 5 times as likely where both had had a manual job.
5. The class position of a substance use
pattern can vary within the same country. This point is illustrated by the
findings for Arab and Jewish Israelis (2 above). Examples can also be found in
cases with less obvious cultural divergences.
For instance, a different social class location for abstention as
against drinking was found in a comparison of patterns in cities in a 1964
Thinking about social inequality, marginalization and substance use in a common frame
The physical properties of psychoactive drugs result in use-values for human consumption. An amphetamine pill or a caffeine drink has a stimulant effects and that is an important reason for their use. For some substances, notably alcohol, the range of physical properties is broad: alcohol is a thirst-quencher, a source of calories, a medicine, a solvent, and of course a mood modifier and an intoxicant (see Mäkelä, 1983). Of course, the physical property psychoactive substances have in common is their psychoactivity. This is a major attraction for them, but at the same time it carries potential problems in its wake, varying with the particular substance – physical health problems for tobacco and alcohol, injuries for alcohol and other depressants, and so on.
As we have mentioned, psychoactive substances also take on symbolic use-values, and for that matter symbolism around abstaining from use. The substance may become a sacrament (as with wine in the Christian communion). Very often it becomes a commensal symbol of comradeship and celebration, symbolizing the sharing of the occasion as well as the substance itself (e.g., Dubinskas, 1992). For teenagers and young adults, use may be a claim of autonomy and maturity, and also may be a mark of distinction and membership in a particular social group (Salasuo & Seppälä, forthcoming).
But what carries a positive symbolic value to one audience may carry an extremely negative one to another. The disapproval may be expressed in informally and normatively, or it may take the official form of restrictions or a ban. If a demand nevertheless exists for a banned substance, it is usually served to a greater or lesser extent by an illicit market.
All these aspects of substance use and its
meanings potentially play a role in the interrelations of substance use,
poverty and marginalization. That the
substances are valued commodities means that poorer people typically have less
access to them, or that they gain access through disapproved or extralegal
means. When there is an illicit market,
its retail level is typically staffed by poorer people. On the one hand, the lack of access to a
valued substance may cost the poor in terms of social standing. On the other
hand, participation in an illicit market may bring social discredit and
marginalization. Legal punishments for
illicit substance use – for instance, the
In Table 1, further consideration is given to some connections between substance use and poverty and social inequality, on the one hand, and marginalization and stigmatization, on the other.
Thinking about social inequality, marginalization and alcohol and drug problems in a common frame
Some problems from alcohol and drug use
a direct physiological effect of the accumulation of use – usually relatively
heavy use -- over a long time. These
notably include chronic physical harm such as liver cirrhosis or lung
cancer. The relation here may be
relatively uncomplicated by the social evaluation of the behaviour, so that
marginalization and stigma may play only a small role. More important in the relation between
poverty and the harm may be market factors in terms of the price and promotion
of products containing the substance. As
the very poor in
Even for chronic health problems, however, poverty may increase the harm from a given level of substance use. For example, nutritional deficiencies may interact with alcohol in raising the risk of cirrhosis. Social evaluations may also play a role in the handling and chances of the individual case. An example is the conditions which the medical system may set for a liver transplant for cirrhosis or a lung transplant for lung cancer. Abstinence from alcohol for a considerable time is usually a precondition for one and abstinence from nicotine for the other, under conditions which cannot be justified on purely medical grounds, and which clearly include a moral element (Rehm et al., 2003). The poor and particularly the marginalized are likely to be disadvantaged in these processes.
Other problems from alcohol and drug
use are a result of a single occasion of substance use. These include overdoses, injuries from
accidents or violence, and infections, as well as such social reactions as
police arrests. Here poverty is likely
to play a part in increasing the risk of harm from a given occasion of
use. A poor drinker or drug user will
have fewer resources to reduce risks by hiring a taxi or buying an unused
needle, and often will be less secluded or protected from risks in the
environment and the reactions from others.
However, it is surprisingly difficult to find comparable data which
quantifies the effects of social inequality on the harm resulting from
equivalent behaviour. Studies in the
Table 1. Some connections of particular patterns of substance use with social inequality and marginalization
Empirical connections with poverty and SES
Moral valuation: marks of honour or stigma
Use vs. non-use
Cost associated with use, whether monetary or in terms of effort in growing or preparing, often deters the poor from use. This will vary with the local nonmarket availability and market price of the substance.
Whether greater or lesser use by unemployed than by employed is influenced by the extent of unemployment support.
Using heroin in the
Non-use of alcohol is potentially slightly stigmatizing, something to explain, in much of the developed world (Paton-Simpson, 2001).
Use as a positive status symbol in some circles: tobacco and alcohol as symbols of emancipation for young women in 1920s U.S. (Fass, 1979); in developing countries, lager beer as a relatively cheap symbol of cosmopolitanism (Room et al., 2002:65-66)
Abstinence as a positive
status symbol in others (alcohol for Moslems in a multifaith society; as a
signal of ambition for poor men in 19th-century
Frequent light use
Frequent use by the very poor
common only if the substance is part of the diet (wine in southern
Where main use value is as an
intoxicant (alcohol in northern and eastern
Cigarette use much lighter (fewer per day) among poor people in poor societies than in richer societies.
Frequent light use takes on a moral valuation in some circles. Life becomes a pilgrim’s progress of self-control, which in one version one demonstrates regularly by drinking always in a controlled fashion. (Room, 1998)
Subcultures of socially integrated illicit drug users are often scornful both of non-users and of those whose drug use is seen as having got out of control (Salasuo & Seppälä, forthcoming).
Sporadic intoxication/getting high is characteristic of young adults, particularly young males, in a number of cultural circumstances and for different drugs; e.g., fiesta drinking in Mexico; weekend or holiday drug use by participants in western European club cultures.
A pattern of sporadic
intoxication is more affordable than regular use for the poor; influenced by
how cheap the substance is.
Intoxication as the “cheapest way out of
Public intoxication was
stigmatized and criminalized in northern
Public or private intoxication on drugs stigmatized when it became known.
Stigmatization stronger for women, as intoxication seen as meaning sexually availability.
No stigma, typically, for intoxication by privileged youth, particularly males (university students; upper class)
Drunk driving increasingly stigmatized in developed societies.
Strong stigma on use if there are adverse consequences from it.
Addicted (regular heavy) use
Social class location of addiction/very heavy use influenced by price of substance. For an expensive substance, poor addicts necessarily turn to crime and other marginalized activities.
Heavy stigmatization, including by other users.
“Secondary deviance”: formation of heavy using contracultures, often organized around procuring and using substance, but strongly socially excluded.
A third class of problems are adverse social consequences of the substance use – effects of drinking in such areas as family relationships, friendships, and work performance and standing. Both specific occasions of use and the cumulation of a use pattern over time are likely to be involved in the occurrence of these problems, although it is clear that the likelihood of the problems occurring is much greater when enough use to get high or intoxicated is involved (e.g., Room et al., 1995). Some general population surveys have found that the ratio of adverse consequences to heavy drinking rates is greater for those of lower SES than for those of higher SES. Thus Cahalan and Room (1974:91) found that the rate of adverse consequences was almost twice the rate of those with heavy drinking but no consequences in the lowest social class group, but about two-thirds the rate in the two upper social class groups. On the other hand, Hilton (1991:202-3) did not find such a great discrepancy in a later U.S. survey, and Harford et al. (1991) actually found some reverse effects of education (a greater ratio of consequences to intoxication for the more educated) in regression analyses of the same data. Again, the results will be influenced by what is used as the measure of social class or position and what constitutes the measure of social problems from drinking.
These results come from surveys of those living in households. Those who are really at the margins of a society – the homeless, those temporarily staying with friends or family, some of those living in group quarters – are typically not included in the sample for such surveys. General population surveys provide a relatively good frame for studying the effects of social inequalities for relatively stable poor populations, those living in families and with some regularity of employment or social support. But a household-based sample is not a good frame for studying the marginalized and socially excluded.
Conversely, those in treatment for alcohol or drug problems are certainly more often than not poor. But what is most striking about them is their high degree of marginalization. In this they differ considerably from those identified as having alcohol or drug problems in general population studies. The clinical populations have heavier use habits and a much more diverse range of personal and social problems from their substance use than all but a small fraction of those in general population samples. Particularly for alcohol problems, the average age of clinical populations is older than the average age of those with problems in the general population. Beyond this, the clinical population “is much more likely to be unemployed or to be in marginal jobs, and to be divorced or separated…. One-half of all clients in US alcoholism treatment facilities are separated or divorced, and about 60 per cent are currently not employed” (Room, 1980). In a variation on these statistics, a recent study of those entering alcohol or drug treatment in Stockholm County found that less than one-quarter of the clients were currently married or living with a partner, about 50% lived alone, about 30% were homeless, about 30% were unemployed, and almost half thought that their mental health was a “substantial” or more serious problem (unpublished figures from Room et al., 2003).
These divergences between the pictures from general population studies and from clinical populations led me to suggest that we can talk of the “two worlds of alcohol problems” (Room, 1977). The salient feature of the clinical picture is the marginalization of many of the clients – the high rates of “spare and awkward people” (Room, 1980), without ties to a family, a continuing home, or a steady job. “We may suspect that the process of entering treatment is to some extent a process of extrusion from the general population, that many clients come to treatment after having exhausted their moral credit with employers and families.” (Room, 1980)
The years since this sketchy account was written have seen a number of studies which fill in more of the picture, but we still know too little about what goes on in the hinterland between the two worlds – about how and under what circumstances some of those with heavy substance use and occasional problems from it move on into the more marginalized world of the clinical populations.
We can conceive of the marginalization as proceeding from three main sources:
1. There are the intimate processes of social control and censure among family and friends (e.g., Holmila, 1988; Room, 1996) which are frequently effective, but which may also result at length in the family and friends becoming fed up and giving up or pushing the user into treatment (Room et al., 1996; Wiseman, 1991).
2. There are the decisions by social agents and agencies, which tend to focus attention on the most problematic cases and to amplify their marginalization (Nilsson et al., 2001). Even official actions intended as positive steps toward social reintegration may result in marginalization if the case does not “succeed” (e.g., Brune et al., 2003).
There are also policy decisions
at the local or national level which result in marginalization. For example, the
Marginalization of those defined as having alcohol or drug problems is thus a process which can have both elements which are personal and interactional and elements which are institutional and structural. Underlying the process is the heavy moralization of substance use which is defined as problematic – not least, often, by other substance users, who often define themselves in contrast to the problematic category (Salasuo & Seppälä, forthcoming). “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” (Baumohl et al., 2003)
1. Greater attention needs to be paid to the relation of different components of social inequality to patterns and levels of psychoactive substance use in different populations. The literature should seek to move beyond description to explanatory studies, both qualitative and quantitative, which contribute to our understanding of why and under what circumstances particular differentiations on psychoactive substance use are found.
2. Studies are needed of the interrelation of different components of social inequality, substance use patterns and levels, and different social and health problems related to substance use. At a minimum, we need to know the extent to which different patterns of use intermediate the relationships between the social inequality indicators and the problems. In these studies, attention is needed to the effects of potentially interacting or confounding factors on the relationships.
3. Quantitative as well as qualitative studies are needed of the extent and mechanics of marginalization and social stigmatization of substance use and problems in different societies and milieux. These studies should seek identify the patterns of reasoning and prejudice which underlie the stigmatization.
4. General studies are needed in different societies and milieux of the relationship between components of social class and social inequality, on the one hand, and of marginalization and stigmatization, on the other. Again, both quantitative and qualitative studies are needed.
5. 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.
6. Priority should be given to studies of what happens when some aspect or component of social inequality or marginalization changes. These studies can be at the aggregate or the individual level; wherever possible, they should include both levels of change. Along with planned experiments and interventions, these studies can include when policies change and longitudinal studies in the individual life-course and “natural experiments” when a relevant policy changes.
7. Some clear thinking is needed, involving philosophers and ethicists as well as social scientists, about the options for alternative conceptualizations and policies for substance use and problems which would diminish stigmatization and marginalization, and particularly their potential connection with social inequality.
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