Stigma, social inequality and alcohol and drug use

Drug and Alcohol Review, (March 2005), 24, 143 – 155 Stigma, social inequality and alcohol and drug use ROBIN ROOM Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm, Sweden Abstract A heavy load of symbolism surrounds psychoactive substance use, for reasons which are discussed. Psychoactive substances can be prestige commodities, but one or another aspect of their use seems to attract near–universal stigma and marginalization. Processes of stigmatization include intimate process of social control among family and friends; decisions by social and health agencies; and governmental policy decisions. What is negatively moralized commonly includes incurring health, casualty or social problems, derogated even by other heavy users; intoxication itself; addiction or dependence, and the loss of control such terms describe; and in some circumstances use per se. Two independent literatures on stigma operate on different premises: studies oriented to mental illness and disability consider the negative effects of stigma on the stigmatized, and how stigma may be neutralized, while studies of crime generally view stigma more benignly, as a form of social control. The alcohol and drug literature overlap both topical areas, and includes examples of both orientations. Whole poverty and heavy substance use are not necessary related, poverty often increases the harm for a given level of use. Marginalization and stigma commonly add to this effect. Those in treatment for alcohol or drug problems are frequently and disproportionately marginalized. Studies of social inequality and substance use problems need to pay attention also to processes of stigmatization and marginalization and their effect on adverse outcomes. [Room R. Stigma, social inequality and alcohol and drug use. Drug Alcohol Rev 2005;24:143 – 155] Key words: stigma, marginalization, social inequality, alcohol problems, drug problems, social control, moralization Introduction This paper discusses stigma and marginalization in connection with psychoactive substance use, and how these affect patterns by social class and other social inequalities. The paper starts from the point that adverse outcomes (such as mortality) from heavy alcohol and drug use are much more strongly related to lower social class position [1] than the patterns of heavy alcohol and drug use themselves. As will be discussed, there are certainly mechanisms by which poor people can suffer worse outcomes than more affluent people for the same behaviour. My argument is that, in the case of alcohol and drug problems, an extra factor has been relatively neglected: that alcohol and drug use and problems are heavily moralized territories, often resulting in stigma and marginalization, and that these factors are important in the adverse outcomes. In a substance use context, poverty and marginalization are not necessarily causally prior While the term ‘social inequality’ encompasses differences on other social differentiations such as gender, age or ethnoreligious category [2], 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 [3]; and the variables often included in measures of socio-economic status, such as education, income and occupational and neighbourhood status, differ both Robin Room, Professor and Director, Centre for Social Research on Alcohol and Drugs, Stockholm University, S-106 91 Stockholm, Sweden. Email: robin.room@sorad.su.se. Prepared for presentation at an Exploratory Workshop on Alcohol, Illicit Drugs and Addiction Research, Academy of Finland, Helsinki, 14 December, 2004. Parts of it draw on a paper, ‘Thinking about how social inequalities relate to alcohol and drug use and problems’, presented at a conference on Inequalities and Addictions at the National Centre for Education and Training in Addictions, 25 – 27 February, 2004, Adelaide, South Australia. Received 8 December 2004; accepted for publication 20 January 2005. ISSN 0959-5236 print/ISSN 1465-3362 online/05/020143–13 # Australian Professional Society on Alcohol and Other Drugs DOI: 10.1080/09595230500102434 144 R. Room conceptually and also often in their relationship to health outcomes (e.g. [4,5]). By and large, the public health literature takes the attribute of being disadvantaged as causally prior in considering its relation to life-style 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 [6]. To the extent that the illness is caused by substance use, the causal arrow between the use and the socio-economic 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. Secondly, 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’ [7]. 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’. More generally, the use of alcohol and drugs is strongly moralized, and those transgressing moral norms are subject to stigma and social marginalization. Stigma, poverty and alcohol and drug problems We may take as a working definition of stigma, in the context of alcohol and drug use, the one used in the law of a US state, Wisconsin: ‘Stigma’ means disqualification from social acceptance, derogation, marginalization and ostracism encountered by. . . persons who abuse alcohol or other drugs as the result of societal negative attitudes, feelings, perceptions, representations and acts of discrimination [8]. Those who are stigmatized or marginalized are often poor, and otherwise lacking social resources; but there is no necessary relation between stigmatization and poverty or other social inequalities. 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 [9]). On the other hand, it is also possible to be rich and stigmatized and marginalized, although the affluent are ipso facto better able to purchase protection from this. There is also no necessary relation between psychoactive substance use and stigma or marginalization. In the developed countries today this is most obvious for alcohol, where drinking is closely associated with many positively valued and highprestige activities and statuses—we have only to mention champagne for a wedding reception, or complimentary drinks for first-class passengers. It is also now true, at least in some youth subcultures, for some forms of illicit substance use—e.g. ecstasy at a rave, or cannabis at a student party. On the other hand, as we shall discuss, some aspects of psychoactive substance use seem to attract near-universal stigma and marginalization. Sources of social value and derogation What are the properties of psychoactive substances which are relevant to social valuation or derogation? In the first place, psychoactive substances are valued physical goods. Their status as physical goods renders them subject to commodification, and indeed globalization in use and trade. Given their positive valuation, possession and use has often been a symbol of power and domination [10], or at least of access to resources beyond subsistence. Secondly, using psychoactive substances is a behaviour, and very often a social behaviour. There are thus many social and cultural associations, mostly positive, around the use of the substance. Toasting in champagne as a symbol of celebration, the cannabis joint passing around the circle of users, the wine circulating at a family holiday meal, the sense of community that may be engendered at a rave, are all contemporary images which conjure up the social meanings which become attached to the use and which extend beyond the psychoactive effect per se of the substance. Use of the substances socially means that the use often serves to demarcate the boundaries of inclusion and exclusion in a social grouping [11]—so that the use of a psychoactive substance in itself can signal social exclusion and marginalization. Thirdly, psychoactive substance use is a peculiarly intimate behaviour, in that the substance is taken into the body. Any such substance is a potential source of contamination and poison, as well as of nutrition, pleasure or solace. In this respect, psychoactive substances are a part of the more general category of foodstuffs and drinks, and carry at least their share of Table 1. Degree of social disapproval or stigma – relative ordering from lowest to highest mean rating within each countr Country Condition (ordering in total sample; 1 = least stigma) China Egypt Greece India Japan Luxembourg Netherlands Nigeria Romania Spain Tunisia Turkey UK Wheelchair bound (1) Blind (2) Inability to read (3) Borderline intelligence (4) Obese (5) Depression (6) Dementia (7) Facial disfigurement (8) Cannot hold down a job (9) Homeless (10) Chronic mental disorder (11) Leprosy (12) Dirty and unkempt (13) Does not take care of their children (14) Alcoholism (15) Criminal record for burglary (16) HIV positive (17) Drug addiction (18) 2 1 6 3 9 5 4 7 10 16 12 11 15 18 8 13 14 17 3 5 6 4 1 2 8 7 11 9 13 16 14 10 12 17 18 15 1 2 3 4 5 10 7 8 12 6 11 9 13 16 15 17 14 18 5 2 3 7 1 4 6 8 10 9 12 15 11 14 13 16 18 17 2 4 1 5 3 6 9 8 10 7 14 13 12 11 15 16 17 18 5 9 2 7 1 15 10 3 4 12 17 11 8 6 14 13 16 18 2 1 5 3 4 6 9 7 8 13 10 11 12 16 15 17 14 18 2 1 3 4 7 6 8 10 9 15 8 11 12 14 16 17 13 18 1 3 2 5 4 9 7 6 11 8 15 18 12 10 13 17 14 16 3 1 5 7 4 2 8 6 10 16 9 13 12 11 14 18 15 17 2 1 4 5 6 3 7 8 11 10 9 14 13 15 12 16 18 17 1 2 5 7 3 12 4 9 11 8 10 6 13 17 14 15 16 18 1 3 2 6 14 5 9 8 7 12 10 13 11 4 17 15 16 18 2 1 6 4 11 3 5 7 10 8 12 9 14 17 15 16 13 18 n of key informants 15 15 16 15 47 18 16 13 15 15 18 15 15 12 Source: Room et al., 2001:276. Stigma, social inequality and alcohol and drug use Canada 145 146 R. Room the complex of prescriptions and taboos which surround what is ingested [12,13]. Fourthly, by definition psychoactive substances affect thinking and feeling, and are often expected to affect behaviour—even to the extent that the substance may be seen as possessing the user, submerging the true self [14]. The psychoactive qualities of the substances is what makes them both ‘prized’ and feared as ‘dangerous’, as Steele & Josephs [15] put it. The psychoactivity accounts both for much of the positive valuation on the substances and for much of the moral loading that commonly surrounds their use. For all these reasons, a heavy load of symbolism thus often attaches to the use or non-use of psychoactive substances. The use may be a positive signal of power or status, may be heavily derogated or stigmatized, or may simply be an expression of difference without strong implications for power or status. Psychoactive substances and social institutions and rubrics Psychoactive substance use and its risks are influenced or governed by social institutions and professions. In many countries, for instance, alcohol can only be sold with a government licence, carrying with it limits on the circumstances of sale. By international agreement, some psychoactive substances are available only when permitted by a prescription from a physician, with a licensed pharmacist usually actually providing the substance. Use of psychoactive substances results in a variety of social and health consequences, both immediate and chronic. Included are not only chronic and acute health consequences to the substance user, but also injury and other harm to others and problems in work and family roles. The full range of social institutions and professions which respond to and handle health, casualty and social problems are involved in responding to psychoactive substance problems. Each of the professions and institutions tends to be associated with a particular governing image or rubric of the problems with which it deals. Physician and hospitals deal with illness, psychiatrists and mental illness clinics specifically with mental illness, police and judges with crime, welfare workers and social welfare with disability or destitution, priests and churches with sin. Problems from alcohol or drugs sometimes fall between these jurisdictions, but more commonly fall into areas of shared jurisdiction. It is thus not obvious which institutional system should be assigned the primary jurisdiction, and there are considerable differences from one society to another, and sometimes from one substance to another, in this. Thus the health system has primary jurisdiction for alcohol problems in Italy and Denmark, while the welfare system has traditionally had primary responsibility in Sweden and Finland. In Denmark, on the other hand, drugs are handled by the welfare system. Responsibility can be shifted between systems, sometimes abruptly; thus, for a couple of years in California in the late 1960s, alcoholism was shifted from being a health disorder to being a vocational disability [16]; for that period, if a Californian did not need help with getting or keeping work, he or she was not eligible for alcoholism treatment. A primarily US-based sociological literature, using ‘deviance’ as its general term for problems considered to need social handling, has emphasized a general shift in the 20th century from crime to illness models of deviance. On the other hand, the literature has acknowledged that the trend had been in the opposite direction in the first half of the 20th century for illicit drugs in the United States [17]. The general perception, in a US context, has been that more stigma is associated with crime or vice than with disease, so that the alcoholism movement, for instance, dedicated itself to persuading the society that changing the conceptualization of alcohol problems from vice or crime to illness would diminish the stigmatization of those with the problems [18]. The generalized and ubiquitous stigma of alcoholism and addiction The question of how much the stigmatization of those with a particular problem is affected by changing its rubric, or even its social handling procedures, remains open. For one thing it has long been recognized that, in the minds of many in the general population, the rubrics are not mutually exclusive: those who subscribe to a disease model of alcoholism are also ready to think of it as a vice or moral weakness [18]. Thus the intent of the alcoholism movement in putting forward the disease concept of alcoholism, that it should replace the ‘old moral model’, has not been realized. As a recent US discussion put it, ‘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’ [19]. 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 ‘alcoholism’ and ‘drug addiction’ ranked near the top, in terms of degree of social disapproval or stigma reported by local key informants, in a list of 18 conditions ranked for 14 Stigma, social inequality and alcohol and drug use 147 Table 2. Marginalization and the health system: health status, utilization and attitudes among categories of the disadvantaged living in poor districts in Portugal (in percentage) Alcohol addicts Hard drug users Homeless Ex-prisoners Single mothers Poor elderly 100 15 96 35 100 12 90 20 87 35 99 58 42 31 50 29 28 26 Health5‘good’ Used health services Bad opinion of health services Source: Santana, 2002. different countries in a WHO study (Table 1)—in all but two countries, for instance, above being ‘dirty and unkempt’; while in all but three being a drug addict was reported to be more disapproved or stigmatized than having a criminal record for burglary [7, p. 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. 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, 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 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 [20]. 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 [21]. However, 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 ‘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 Britain, the United States and Australia, Olsen et al. [23] report that respondents felt that tobacco smokers, ‘high’ alcohol users and illegal drug users should all receive less priority in health care. Often the justification given is the belief that the users’ behaviour contributed to their own illness. Along the same lines, the 14-country WHO study found that, in responses on scenarios involving alcohol or heroin problems, the ‘theme of personal responsibility became vividly apparent’ [7, p. 260]. Studies in health services show that the care given is in fact likely to be inferior if the patient is seen as a skid-row drinker or a similarly derogated category (e.g. [24,25]). Santana [26] found that among nine categories of ‘disadvantaged people’ interviewed in a population sample in deprived districts in Portugal, those identified as alcoholics were, along with the homeless, the least likely to have used health services, despite 100% having less than good health, and the most likely to have a ‘bad’ or ‘very bad’ opinion of the health services (see Table 2). To the extent access to good health care affects health status, these findings illustrate a direct path by which exclusion and marginalization can affect health status. Sources and objects of substance use-related stigmatization If we focus on processes in an ongoing society, we can conceive of stigmatization and marginalization as proceeding from three main sources: There are the intimate processes of social control and censure among family and friends (e.g. [27,28]) which are frequently effective, but which may also result at length in the family and friends becoming fed up and pushing the user out of the family or into treatment [29,30]. There are the decisions by social agents and agencies, which tend to focus attention on the most problematic 148 R. Room Table 3. Percentage of informants responding ‘People would think it was wrong’ for a person to appear in public, by country Country Condition Total % Canada China Egypt Greece India Japan Luxembourg Netherlands Nigeria Romania Spain Tunisia Turkey UK A woman in her 8th month of pregnancy Someone who is blind A person in a wheelchair An obese person A person who is intellectually ‘slow’ Someone with a face disfigured from burns Someone with a chronic mental disorder who ‘acts out’ Someone who is dirty and unkempt Someone who is visibly drunk Someone who is visibly under the influence of drugs 2 3 2 12 7 6 15 0 7 0 20 7 0 0 0 0 0 7 0 33 33 0 0 0 13 0 6 0 0 0 13 7 0 0 20 4 6 7 6 4 0 17 0 0 0 19 23 0 12 0 0 0 31 0 12 19 0 0 0 8 0 0 17 7 7 0 13 13 20 13 0 13 0 0 0 0 27 0 0 0 17 0 0 22 0 0 0 0 14 13 0 7 0 0 20 33 7 0 0 0 0 8 8 0 17 25 46 58 20 13 20 27 27 57 69 88 100 20 27 40 17 46 67 0 6 M 44 81 56 8 8 17 47 80 64 40 73 67 17 50 56 43 79 79 0 14 M 33 50 M n of key informants 245 15 15 16 15 47 18 16 13 15 15 18 15 15 12 Source: Room et al., 2001:281. Note: The question was ‘Please indicate how people in this society would react to a person with the health condition appearing in public’. ‘Think it was wrong’ refers to responses: ‘People would think it was wrong, and might say something about it’ and ‘People would think it was wrong and try to stop it’. M = question not asked. Stigma, social inequality and alcohol and drug use cases and to amplify their marginalization [31]. Even official actions intended as positive steps toward social reintegration may result in marginalization if the case does not ‘succeed’ (e.g. [32]). There are also policy decisions at the local or national level which result in marginalization. For example, the US law that a family should be evicted from public housing if any member of the family is associated with drug dealing has the result of increasing marginalization. More generally, policy decisions to be ‘tough on drugs’ always carry the potential to stigmatize and marginalize those who do not conform. 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 and stigmatization of substance use which is defined as problematic—not least by other substance users, who often define themselves in contrast to the problematic category [33]. The underlying determinant of what is problematic is the occurrence of problems which are ascribed to the substance use: illness, violence, casualties, and failure in major social roles, particularly at work and in the family. Part of modernity, starting in the early 19th century [34], seems to have been an increased willingness to see first alcohol, and later other psychoactive substances, as causal agents in these calamities and failures in responsibility. From the point of view of the substance user, this fundamental and minimum level of moralization of substance use operates in terms of ‘getting caught’. In the company of other heavy drinkers, there may be little or no moral loading on the drinking behaviour itself. The ideal of the ‘competent drinker’, as Gusfield [35, pp. 124 – 5] describes it among the heavy drinkers he studied, is not defined in terms of characteristics of the drinking behaviour, but instead simply in terms of the drinker’s ‘self-judgement of his state of risk acceptance’, i.e. the ability to handle himself without adverse consequences. But if the drinker misjudges—or if he simply gets caught out in a situation where the risk may have been low but not zero—then moral disapproval descends on him, not only from society in general but also from other heavy drinkers, to whom he now appears as an incompetent drinker, one who has ‘let the side down’. Similar conceptual mechanisms can be seen at work for use of other drugs, for instance in Slavin’s study [36] of socially integrated methedrine injectors, who—far out on the distribution of drug use as they themselves were—distinguished themselves from ‘junkies’ in terms of their own sense of ‘control’ of their risks. Slavin notes his own discomfort at the ‘pejorative language’ of his informants concerning the ‘junkies’, but also notes that the distinction they make 149 ‘works in some ways to reduce drug related harms for these men and keep them ‘‘functional’’. We may see three other areas of moralization and stigmatization built on this fundamental understanding of adverse events and consequences of the substance use. The first is the moralization of intoxication itself. At a minimum, to be stoned or drunk in specific circumstances—e.g. when about to drive a car, or as a parent looking after small children—is unacceptable to nearly everyone [37]. For those who do accept getting intoxicated or high at all, it should be in periods and circumstances of ‘time out’ [38], when the risks are limited and those in attendance are presumably assuming the attached risks. But acceptance of intoxication as a desirable or morally acceptable state is rare in ‘serious’ public discourse in many modern societies, inhabiting instead the realm of literary and other artistic works (e.g. [39,40]). Table 3 shows the proportion of key informants in each of 14 countries reporting that ‘people would think it was wrong’ for a person with each of 10 named conditions to appear in public. Overall, the conditions most likely to be socially excluded were ‘someone who is visibly drunk’ and ‘someone who is visibly under the influence of drugs’. The moralization of intoxication means that advocates of the argument that alcohol problems are best controlled by integration of drinking in cultural practices specify carefully that they do not include intoxication, however culturally integrated it may be. Thus, for instance, Morris Chafetz, long a leading exponent of this position, specified that anyone who ‘has been intoxicated four times in a year’ should be considered a problem drinker [41]. Similarly, those touting the advantages of drinking have been careful to specify that it is moderate drinking, and not intoxication, which they favour: ‘Citizens for Moderation [represents] the interests of [those] who consume responsibly and in good health’ [42]. Conflating intoxicated bad behaviour with addiction, and arguing for a ‘moral vision of addiction’, Stanton Peele [43] called for inculcating ‘values that are incompatible with addiction and with drug- and alcohol-induced misbehaviour’, contrasting ‘values toward health, moderation and selfcontrol’ with ‘the immorality of addictive behaviour’. Those on the ‘wetter’ side of debates about drinking practices and policies have thus been at pains to differentiate controlled or moderate drinking from intoxication, and to assign opposite moral valences to them—negative for intoxication, but positive for controlled or moderate drinking. Intoxication has thus remained morally reprehensible or at least questionable in most public discourse throughout the modern period. The stigma on intoxication is so taken for granted that what exactly is wrong with it is not often spelled out. There seem to be three 150 R. Room related elements. A person under the influence of alcohol or drugs is seen as unpredictable, and thus anxiety-provoking for those in the vicinity. The intoxication is seen as disinhibiting, and thus as potentially resulting in bad or injurious behaviour [14]. And to be intoxicated is also to abandon the norm of ‘sober attention as the normative mode of consciousness for every waking minute’, in the modern world of exacting machinery and intellectual work [44]. A second area of moralization and stigmatization is in terms of addiction or dependence. We have already noted above the high level of stigma around alcoholism and addiction (see Table 1). A loss of control—over the substance use and over one’s life—has always been the central element in modern cultural understandings of the nature of alcoholism and addiction, so that they have often been characterized as ‘diseases of the will’ [45]. Half a century ago, Edwin Lemert collected a number of statements of American attitudes toward the alcoholic, and noted that the ‘general theme underlying’ them ‘has to do with lack of self-control on the part of the drinker’. Lemert went on to note the stigmatization that this theme inevitably involved: ‘This societal symbolism of the deviation as a sign of character weakness is one of the most vivid and isolating distinctions which can be made in a culture which attributes morality, success, and respectability to the power of a disciplined will’ [46]. A third potential area of moralization and stigmatization is less universally applied: stigmatization in terms of substance use per se. For alcohol, the general stigmatization applies only in certain cultural milieux, e.g. for Mormons or for Moslems, although there are statuses or circumstances—a pregnant woman or an on-duty bus driver, for instance—where any use tends to be stigmatized. For tobacco, cigarette smoking has increasingly taken on a somewhat stigmatized status [47]; as might be predicted, it is lung cancer patients, those who have been ‘caught’ in adverse consequences from the smoking, who feel the stigma most keenly [48]. The aim of ‘just say no’ policies on drugs is generally to render use of the drugs socially unacceptable, that is to stigmatize use, and users in fact report that they do experience some stigma [49]. Studying stigma There are two literatures on stigma, operating on very different premises. One literature, oriented primarily around illness, mental illness and disability, focuses on those who are already in a stigmatized status or condition; stigma is taken for given as a discriminatory social evil. The studies often consider the negative effects of stigma on the stigmatized person or on the professional – patient interaction (e.g. [50,51]), from the perspective of how the stigma or these effects can be neutralized (e.g. [52,53]. Aligned with this literature are substantial public policy initiatives, like the Wisconsin legislation quoted at the start of this paper, which provides that the state agency may ‘develop and implement a comprehensive strategy to reduce stigma of and discrimination against persons with mental illness, alcoholics and drug dependent persons’ [8]. The other literature, oriented primarily around crime, generally views stigmatization as a form of social control [54], either as an aspect of judicial punishment of crime [55 – 57], or as social norms which potentially deter even without formal punishment (e.g. [58,59]). In the context of this literature, stigma is often viewed benignly, as an effective way of deterring bad corporate conduct [55], or as a less harsh alternative to punishment by the state [58]. The argument against harsh punishments too liberally applied becomes that they lose their effectiveness through ‘stigma saturation’, i.e. a reduction in their power to stigmatize [56]. Aligned with this literature, too, are public policy initiatives, including those which frequently justify their provisions by the need to ‘send a message’ about what is and is not considered tolerable behaviour. The two literatures thus examine two ends of a common process. One considers the deterrent value of stigma as a means of social control—where the ideal result might be universal primary deterrence so that no one was actually stigmatized. The other considers the real-life circumstance where the ideal has not been attained, and the effects of stigma on those who have not been successfully deterred. In general, the studies of stigma as a means of social control recognize that the result may not in fact always be social control and conformity. As mentioned above, a whole sociological literature on ‘secondary deviance’ is devoted to studying processes which may be construed as failures of stigma to result in conformity. In contrast, the literature on stigmatization and mental health seems generally to be less alive to the possibility that efforts to reduce stigma may also have unintended effects. One example where this was found, however, is the classic evaluation of the effects of a positive mental health campaign in the 1950s, Closed Ranks [60], which found that efforts to persuade a community to see mental health was a continuum, as opposed to seeing mental illness as a separate state, were strongly resisted, putatively because the continuum model threatened the community’s toleration of its more ‘eccentric’ citizens. As discussed above, the alcohol and drug field falls into and overlaps the field both of mental health and of crime. Some parts of the field are usually considered under a crime rubric—drinking driving is a good example—and easily subsumed in the stigma-associal-control literature. Thus Blume [54] discusses ‘stigmatizing drunk drivers’ in approving terms in his concluding argument. On the other hand, cases under Stigma, social inequality and alcohol and drug use treatment for alcohol and drug problems are easily subsumed into discussions of stigma and mental illness, as in the Wisconsin legislation quoted above. However, as a matter of cultural politics, it is difficult to extend either framing of stigma to cover the whole alcohol and drug field. On the one hand, it is unusual nowadays to find direct arguments for the stigmatization of those who have a history of alcohol or drug problems, but who are now sober. For that matter, to the extent alcohol or drug addiction is construed as a disease, it is legally impermissible as ‘cruel and unusual punishment’ in the United States to punish an addict for exhibiting the signs of the disease [61]. On the other hand, policies against stigma usually carefully exclude from their scope those who are at the time under the influence of alcohol or using drugs [62]. Discussions of stigma in the alcohol and drug field have primarily been clinically-orientated considerations of the stigma on those treated for alcohol or drug problems, from the perspectives of stigma as a barrier to coming to treatment (e.g. [63]), managing the stigma posttreatment (e.g. [64]), or documenting or decrying public attitudes (e.g. [65]). One study considers empirical evidence on the adverse effects of posttreatment stigma [22]. Thinking about social inequality, marginalization and alcohol and drug problems in a common frame Some problems from alcohol and drug use are 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 China move into the cash economy, cigarettes become available to them as a regular consumption item for the first time; the eventual result will be rising rates of lung cancer at the bottom as well as top of the socio-economic ladder in China [66]. Similarly, the relatively high taxes on alcohol in the United Kingdom for most of the 20th century meant that liver cirrhosis used to be a disease of the relatively well-off in Britain [67]. The fall in the price of alcoholic beverages relative to spending power has now put cirrhosis within reach of the poor in Britain; thus the index of inequality in male cirrhosis mortality by social class in England and Wales rose from 0.88 in 1961 (i.e. fewer cirrhosis deaths in lower social classes) to 1.40 in 1981 (a 40% excess of deaths in lower social classes [68]). An analogous shift was 151 found in Sweden from the 1960s to the 1990s in the relative class positions for heavier drinking and for alcohol-specific hospitalizations [69]. 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. Moral considerations and stigma 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 [70]. 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 United States looking for police bias by social class or race in drinking-driving arrests, for instance, have not necessarily found it (e.g. [71,72]). A Stockholm County study gives a sense of the combined effect for chronic and acute alcohol-specific harms to health. Comparing rates of relatively heavy drinking among manual workers in 1984 with those among higher level non-manual workers, the rates for manual workers were about 1.5 times higher for men, and about equal for women. But hospitalization rates for alcohol-specific causes were more skewed between the social classes: rates for manual workers in the county in 1980 – 84 were 3.6 times as high for men and 2.5 times as high for women as for the higher level nonmanual workers (recalculated from Romelsjö & Lundberg [69, Tables 2 and 4]). 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. [73]. 152 R. Room 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 [74, p. 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 [75, pp. 202 – 3] did not find such a great discrepancy in a later US survey, and Harford et al. [76] 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. The results of such analyses are 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. 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’ [77]). 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 [78]). 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’ [79]. The salient feature of the clinical picture is the marginalization of many of the clients— the high rates of ‘spare and awkward people’ [77], 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’ [77]. 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 and stigmatized world of the clinical populations. Some conclusions about research directions Psychoactive substance use occurs in a highly charged field of moral forces. Outlawing a drug and punishing those caught using it may be intended to ‘send a message’ about standards of behaviour. Alcohol and drug use can serve as a demonstration to the user and to others about highly valued personal qualities such as self-control. Adverse consequences of use can be regarded as evidence of moral iniquity. Entering treatment for alcohol or drug problems is potentially humiliating evidence of failure in self-management. In these and many other ways, substance use can serve as an instrument of social inclusion or social exclusion. In terms of social exclusion the user may be stigmatized, and the result may be social marginalization. These processes are separate from issues of the division of resources in society and social inequality. On the other hand, access to resources gives the user greater opportunities to insulate behaviour from social reactions and from potential stigma and marginalization. Social inequality, stigmatization and marginalization around substance use interact in complex ways, which need to be better understood. There is a high degree of marginalization and stigmatization among those who end up in treatment for alcohol or drug problems, even in well-developed welfare societies. Improving the social reintegration of such treated populations, or implementing effective interventions short of tertiary treatment, will require a better understanding of how and under what conditions the marginalization and stigmatization happens. Quantitative and qualitative studies are needed of the extent and mechanics of marginalization and social Stigma, social inequality and alcohol and drug use stigmatization of substance users and those with substance use problems in different societies and milieux. These studies should include attention to the potential preventive effects of stigmatization, on one hand, and to the potential deviance-amplifying and other adverse effects on the other hand. General studies are needed in different societies and milieux of the relationship between components of social class and social inequality and, conversely, of marginalization and stigmatization. Again, both quantitative and qualitative studies are needed. 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. 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. 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