Epidemiology of substance abuse among Latinos.

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Journal of Ethnicity in Substance Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wesa20

Epidemiology of Substance Abuse Among Latinos a

Sherry Lipsky & Raul Caetano a

b

University of Washington , Seattle, Washington

b

School of Public Health and Southwestern School of Health Professions, University of Texas , Dallas, Texas Published online: 18 Aug 2009.

To cite this article: Sherry Lipsky & Raul Caetano (2009) Epidemiology of Substance Abuse Among Latinos, Journal of Ethnicity in Substance Abuse, 8:3, 242-260, DOI: 10.1080/15332640903110435 To link to this article: http://dx.doi.org/10.1080/15332640903110435

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Journal of Ethnicity in Substance Abuse, 8:242–260, 2009 Copyright # Taylor & Francis Group, LLC ISSN: 1533-2640 print=1533-2659 online DOI: 10.1080/15332640903110435

Epidemiology of Substance Abuse Among Latinos

Downloaded by [Washington University in St Louis] at 07:26 23 December 2014

SHERRY LIPSKY University of Washington, Seattle, Washington

RAUL CAETANO School of Public Health and Southwestern School of Health Professions, University of Texas, Dallas, Texas

The importance of conducting substance abuse research among ethnic minorities is underscored by findings that members of many ethnic minorities in the United States report higher rates of heavy drinking and alcohol-related problems than do Whites and have increased rates of illicit drug use, abuse, and dependence. It is important to better understand ethnic-specific substance use from a public health perspective. Recent data suggest that the prevalence of past month alcohol use and heavy alcohol use among Hispanics is lower than and the prevalence of binge drinking and alcohol abuse or dependence is comparable to that of non-Hispanic Whites. These estimates vary among Hispanic subgroups and across gender and age groups. The prevalence of past month illicit drug use is also lower among Hispanics than that of several other groups, including non-Hispanic Whites. These trends are consistent among both men and women, although the prevalence for men is nearly twice that of women in nearly all subgroups. Conversely, the prevalence of illicit drug abuse or dependence among Hispanics is slightly higher than that of non-Hispanic Whites. This article describes national level epidemiological data on the prevalence of alcohol and illicit drug use, abuse, and dependence among Latinos=Hispanics in the United States in comparison to other race and ethnic groups. Previous findings in the literature

Address correspondence to Sherry Lipsky, Ph.D., MPH, Department of Psychiatry & Behavioral Sciences, University of Washington at Harborview Medical Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations (CHAMMP), Box 359911, 325 Ninth Ave, Seattle, WA 98104-2499. E-mail: [email protected] 242


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will be reviewed and new analyses using the 2002 National Survey on Drug Use and Health will be presented. Given the heterogeneity of Hispanics in the United States, data for Hispanics will be broken down by national groups whenever possible. KEYWORDS substance abuse, ethnic minorities, epidemiology


EPIDEMIOLOGY OF SUBSTANCE ABUSE AMONG LATINOS Considerable advances have been made in the past several decades in substance abuse research among ethnic minorities in the United States. The importance of conducting alcohol research, in particular, among ethnic minorities is underscored by findings that members of many ethnic minorities in the United States report higher rates of heavy drinking and alcohol-related problems than do Whites (Caetano & Clark, 1998a, 1998b). Increased rates of illicit drug use, abuse, and dependence are also found in certain ethnic minority groups (National Institute on Drug Abuse, 2003). It is important from a public health perspective, then, to better understand ethnic-specific substance use. Several theories or hypotheses have been proposed to explain differences or disparities that ethnic minorities may experience in health outcomes and health behaviors such as substance use and misuse. We will briefly discuss three main theories here: social-structural, acculturation, and gender roles and family structure. Social-structural theories related to health generally refer to the effect of the social environment on health status, including factors such as socioeconomic status, physical surroundings, social relations, and political factors. Specifically, health disparities can be linked to such issues as access to care, discrimination and racism at individual and institutional levels, and availability of resources. Acculturation, broadly defined as the extent to which ethnic group members participate in the cultural traditions, values, and practices of the dominant society (Snowden & Hines, 1998), may also influence substance use. Acculturation stress, a concept closely related to acculturation, occurs when the acculturation process causes problems for individuals (i.e., problems arising from conflicts between the immigrant culture and that of the host society) (Berry, 2003; Born, 1970). Gender roles and family structure are thought to influence health behaviors differentially among ethnic groups and can be affected via the acculturation process. Gender roles change fairly rapidly as individuals become more acculturated, which usually reflects a modification of traditional values and an approach toward those of the host culture (Marıń & Gamba, 2003). Familialism, an especially important cultural value among Latinos, is related to a strong identification and attachment with nuclear


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S. Lipsky and R. Caetano

and extended families and with feelings of loyalty, reciprocity, and solidarity (Marıń & Gamba, 2003). Certain aspects of familialism, such as the power of family members as referents, may diminish as acculturation progresses. This article describes the epidemiology of alcohol and illicit drug use, abuse, and dependence among Hispanics (Latinos) in the United States, with the majority of data derived from general population studies. In addition, the role of acculturation, gender, and other sociodemographic factors will be examined. Hispanics are one of the fastest growing minority groups in the United States and are expected to triple in population over the next 50 years (U.S. Census Bureau, 2004b). Hispanics are younger than non-Hispanic Whites, with 34.4% of the population younger than 18 years compared to 22.8% among non-Hispanic Whites. Hispanics are also the poorest ethnic minority in the United States despite having the highest rate of participation in the labor force (Huerta, 2003). Hispanics come from diverse racial backgrounds and countries of origins, however, and have different patterns of immigration across time. Approximately 64% of Hispanics are of Mexican descent, 9.6% are Puerto Rican, 7.2% are Central American, 5.5% are South American, 3.6% are of Cuban descent, and 7.6% are of other Hispanic origins (U.S. Census Bureau, 2004a). Hispanics experience various levels of acculturation and may or may not speak English. In fact, according to the U.S. Census Bureau, 40% of Hispanics are foreign born, and 70% of all Hispanics speak a language other than English at home. It is even more important, then, to take into account the heterogeneity within Hispanic ethnic groups in the examination of substance use, where the data allow.

Alcohol The history of alcohol research among Hispanics in the United States exemplifies the difficulties in studying a heterogeneous ethnic minority population. Most analyses have treated Hispanics as a single group despite the fact that traditional alcohol use patterns vary among Hispanics with different countries of origin. In general, those studies that have examined Hispanic subgroups suggest that Mexican Americans exhibit more frequent, heavy, or binge drinking and more alcohol-related problems compared to Cuban Americans and Puerto Ricans (Caetano, 1988, 1989; Nielsen, 2000). Lee, Markides, and Ray (1997) found that the prevalence of past (ever) heavy drinking was highest in Mexican American and Puerto Ricans with little variation across age groups. Nielsen (2000) examined drinking patterns among Hispanic subgroups by age and gender and found significant age-related differences only among Cubans; 18 to 29 year olds had the largest percentage of frequent heavy drinking compared to the other age groups. Cuban men and women were generally less likely to abstain. Among Mexican Americans, Puerto Ricans, and ‘‘other Hispanics,’’ women were

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more likely to abstain and men were more likely to report higher rates of frequent heavy drinking. The most recent data from the National Survey on Drug Use and Health (NSDUH) (Office of Applied Studies, 2004b), previously called the National Household Survey on Drug Abuse (NHSDA), using the years 2003–2004 combined, indicate that the prevalence of current (past month) alcohol use among adult Hispanics is 44.6% compared to 58.4% among non-Hispanic Whites (Table 1). This gap remained constant for past year and lifetime alcohol use as well. Among Hispanic subgroups, the highest prevalence of current alcohol use is among those of Cuban descent, followed by those of Puerto Rican, Mexican, and Central or South American descent. Mexican Americans were the only subgroup with a significantly different change in prevalence from the time periods 2002 to 2003 and 2003 to 2004; the rate actually decreased from 45.6% to 43.4%. The prevalence of binge alcohol use among adult Hispanics (26.2%), however, is comparable to that of non-Hispanic Whites (24.8%) (Table 1). The prevalence of heavy alcohol use among Hispanics (5.8%) is lower than that of non-Hispanic Whites (8.3%). The pattern among Hispanic subgroups for binge and heavy alcohol use was similar, with the highest prevalence among those of Puerto Rican and Mexican descent and the lowest prevalence among those of Central and South American descent. Cuban Americans had intermediate values. There were no significant differences in alcohol use or binge or heavy drinking trends between 2002 to 2003 and 2003 to 2004 for either group or among subgroups. The prevalence of alcohol abuse (4.6%) and alcohol dependence (3.7%) in 2004 among adults is the same for Hispanics and non-Hispanic Whites (Office of Applied Studies, 2004a). The only significant difference in prevalence between 2003 and 2004 was in alcohol dependence among non-Hispanic Whites (3.2% and 3.7%, respectively). In contrast, prevalence data from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions TABLE 1 Alcohol Use and Misuse by Ethnicity and Hispanic Subgroupa Variables Past month useb Past year useb Lifetime useb Binge drinkingb Heavy alcohol useb Alcohol abusec Alcohol dependencec a

Non-Hispanic Puerto Central=South White Hispanic Mexican Rican Cuban American 58.4 72.7 91.0 24.8 8.3 20.2 13.7

44.6 60.8 78.6 26.2 5.8 – –

43.4 59.8 78.0 26.9 6.1 12.1 9.8

46.2 65.7 78.8 30.1 7.8 11.5 7.0

56.1 64.8 83.3 23.7 4.9 6.2 4.0

41.7 58.0 77.5 21.5 3.0 – –

Dashes indicate the data are unavailable; all values reported are percentages. National Survey on Drug Use and Health 2003–2004 data combined (Office of Applied Studies, 2004b). c 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (Alegria et al., 2006). b


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(NESARC) reveal higher rates among adults in both groups (Grant et al., 2004). The prevalence of alcohol abuse among Hispanics was 6.2% compared to 7.5% among non-Hispanic Whites (Table 1). Similarly, the prevalence for alcohol dependence was 5.9% and 5.4%, respectively. However, patterns of alcohol abuse and dependence among Hispanic subgroups varied (Alegria, Canino, Stinson, & Grant, 2006; Grant, Stinson, et al., 2004). The prevalence of alcohol abuse and alcohol dependence was highest among Mexican Americans, followed by Puerto Ricans and Cuban Americans. Gender Differences. Alcohol consumption and drinking patterns also differ among Hispanic subgroups for men and women. Data from the 1997–1998 NHSDA demonstrated similar prevalence rates for past month alcohol use among men across Hispanic subgroups. however Findings from both the NSHDA (National Institute on Drug Abuse, 2003; Nielsen, 2000) and the Hispanic Health and Nutrition Examination Survey (HHANES) (AguirreMolina & Caetano, 1994; Lee et al., 1997) suggest that Mexican American and Puerto Rican men have higher rates of heavy drinking than Cuban American men. Other studies have found that although Mexican American men had higher rates of abstention than other Hispanic men, they also had the highest rate of frequent heavy drinking (Caetano, 1988; Gilbert & Cervantes, 1986). Overall, Cuban American men drink more frequently but more moderately in terms of volume, although recent Cuban immigrants appear to exhibit patterns of consumption and alcohol problems similar to Mexican Americans and Puerto Ricans (Black & Markides, 1994). Alcohol consumption is consistently lower among women than men within each Hispanic subgroup. The 1997–1998 NHSDA data illustrate this with prevalence rates of past month alcohol use among women ranging from 29.6% among Mexican Americans to 39.4% among Puerto Ricans, compared to rates among males ranging from 49.2% among Cubans to 57.5% among Central Americans (Table 2). Prevalence of heavy drinking TABLE 2 Prevalence of Past Month Alcohol Use and Misuse by Gendera Men Ethnicity Hispanic Puerto Rican Mexican Cuban Central American South American Other

Women

Alcohol use

Heavy alcohol use

Alcohol use

Heavy alcohol use

55.2 51.7 56.1 49.2 57.5 56.4 51.4

10.4 8.6 12.4 3.0 6.6 6.2 7.9

32.2 39.4 29.6 35.1 35.6 32.8 34.7

2.1 4.3 2.2 0.6 1.2 1.5 0.1

a Data are from 1997–1998 National Household Survey on Drug Abuse (National Institute on Drug Abuse, 2003); values reported are percentages.



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is also substantially lower among women compared to men and differs somewhat in pattern from women’s past month alcohol use. Puerto Rican women have the highest heavy drinking prevalence rate and Cuban women the lowest rate next to women in the ‘‘other Hispanic’’ subgroup. Similar to the NHSDA findings, data from the HHANES revealed that Puerto Rican and Mexican American women consume a higher volume of alcohol and are more likely to report heavy drinking than Cuban American women (Black & Markides, 1993). However, in other studies, Mexican American women had higher rates of both abstinence and frequent heavy drinking compared to other Hispanic subgroups (Aguirre-Molina & Caetano, 1994; Lee et al., 1997). Moreover, the prevalence of alcohol dependence has been shown to be higher among U.S.-born Mexican American women than among Puerto Rican and immigrant Mexican American women (Canino, Burnam, & Caetano, 1992). Acculturation and Alcohol Use. Acculturation has been associated with health-related risk behaviors including alcohol and other drug use (Caetano & Clark, 2003). Acculturation appears to have a more consistent effect on alcohol use and drinking patterns of women than men (Polednak, 1997). Some studies indicate a positive association between acculturation and alcohol consumption among men (Caetano & Clark, 2003), whereas other studies suggest the opposite (Neff, Prihoda, & Hoppe, 1991). In a multigenerational study of Mexican Americans, investigators discovered that drinking levels were highest among less acculturated, second generation men (Neff, Hoppe, & Perea, 1987). Other studies have found age to be an important factor in the relationship between acculturation and drinking (Black & Markides, 1994; Caetano & Medina-Mora, 1986; Markides, Ray, StroupBenham, & Trevi~ no, 1990) with a negative relationship for middle-aged men (Markides, Krause, & Mendes de Leon, 1988). Black and Markides (1994) found aging and cohort differences in men among Hispanic subgroups as well. Mexican American and Puerto Rican men had increasing proportions of former drinkers and decreasing proportions of current drinkers across age cohorts, but the proportion of abstainers remained fairly constant. Cuban American men, on the other hand, evidenced cohort effects; levels of former drinkers and abstainers remained relatively constant across age cohorts whereas younger cohorts were more likely to be current drinkers. Acculturation among Hispanic women, on the other hand, has been positively associated with alcohol consumption and alcohol-related problems (Black & Markides, 1993; Caetano, 1987, 1994; Caetano & Medina-Mora, 1988; Gilbert & Cervantes, 1986; Markides et al., 1990; Zemore, 2004, 2005), although immigration from Mexico to the United States has been shown not to change drinking patterns among women (Burnam, 1989; Caetano & Medina-Mora, 1988). In the study by Caetano and Medina-Mora (1988), the majority of women born in Mexico were abstainers, and the


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proportion did not decline with length of time in the United States; few of these women were highly acculturated. Conversely, most of the women born in the United States were highly acculturated and the abstention rate was comparatively low (32% vs. 61%). The latter results suggest that acculturation-related drinking patterns among women pertain primarily to those who were born in the United States. It is also possible that acculturation affects women who were born abroad but came to the United States at an early age and who therefore did not grow up in societies that are more restrictive of drinking by women than the United States. Acculturation has also been linked to several alcohol-related problems, including alcohol dependence. Neff et al. (1987) found that Mexican American men who scored in the middle of the acculturation scale were the most likely to experience alcohol-related problems. Burnam, Hough, Karno, Escobar, and Telles (1987), however, found that lifetime prevalence of alcohol abuse and dependence in Mexican Americans was greater among those in the high acculturation group. Furthermore, the prevalence of alcohol abuse and dependence was significantly greater (P < .05) among immigrant Mexican Americans with high acculturation (17.7%) compared to those with low acculturation (11.3%). Among native-born Mexican Americans, the prevalence of alcohol abuse and dependence was comparable in high and low acculturation groups (24.9% and 24.3%, respectively). Grant, Stinson, et al. (2004) and Alegria et al. (2006) examined nativity as a factor for alcohol abuse and dependence using the NESARC data. U.S.-born non-Hispanic Whites were significantly more likely to be alcohol abusers or dependent compared to U.S.-born or foreign-born Mexican Americans, and U.S.-born Mexican Americans were more likely than foreign born Mexican Americans to be alcohol abusers or dependent after adjusting for sociodemographic factors (Grant, Stinson, et al., 2004). Similar patterns were found in comparing U.S.-born non-Hispanic Whites to U.S.-born and island-born Puerto Ricans, but nativity was not a factor when comparing U.S.-born and island-born Puerto Ricans (Alegria et al., 2006). U.S.-born non-Hispanic Whites were more likely to be alcohol abusers or dependent compared to foreign-born Cuban Americans. In contrast to Puerto Ricans, nativity was a factor among Cuban Americans, with those born in the United States more likely to be alcohol abusers or dependent (Alegria et al., 2006). Furthermore, trends in drinking patterns among Hispanics have varied by acculturation over time. In the National Alcohol study, Caetano and Clark (1998a, 1998b) found that frequent heavy drinking among men decreased in the low acculturation group, increased in the medium acculturation group, and remained stable in the high acculturation group between 1984 and 1995. Men in all acculturation levels also had higher levels of abstinence. Rates of frequent heavy drinking among women were low across acculturation groups in both years, and women in the medium acculturation group were significantly more likely to be abstainers. In an analysis examining

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the predictors of abstention versus drinking at least one drink in the previous 12 months, men were more likely to drink than women, and Cubans and Cuban Americans were more likely to drink than Mexicans and Mexican Americans. Caetano and Clark (1998a, 1998b) also found that alcohol-related problems remained mostly stable for men in the low- and high-acculturation groups but increased for men in the medium acculturation group over time. Alcohol-related problems remained stable over all acculturation groups for women. In separate analyses, risk factors for frequent heavy drinking included being born in the United States, in the medium acculturation group, and male; Puerto Rican or Cuban heritage or being older decreased the risk. In multivariate analysis, risk factors for alcohol-related problems included being born in the United States, in the medium acculturation group, and male; being older and Puerto Rican were protective factors.

Illicit Drugs A popular belief persists that Hispanic Americans are substantially more likely to be involved in illegal drug use than are non-Hispanic Whites. Estimates from the 2003–2004 NSDUH tend to challenge this notion (Office of Applied Studies, 2004b). The prevalence of past month illicit drug use among adult Hispanics (7.1%) was, in fact, slightly lower than that of non-Hispanic Whites (7.9%) (Table 3) and several other race and ethnic groups. Past year illicit drug use followed similar patterns among groups, with the prevalence among Hispanics still lower than that of non-Hispanic Whites. Further, the only race or ethnic group with a statistically significant change between 2003 and 2004 was Hispanics (13.6 vs. 11.8%, respectively). Similarly, lifetime use was substantially lower among Hispanics compared to non-Hispanic Whites. Among Hispanic subgroups, the highest prevalence of illicit drug use in all three categories (past month, past year, and lifetime use) in 2003–2004 were found among Puerto Ricans and Mexican Americans. The lowest rates were found among Cuban Americans and Central=South Americans. Mexican Americans were the only subgroup with statistically

TABLE 3 Prevalence of Illicit Drug Use by Ethnicity and Hispanic Subgroupa Use Past month Past year Lifetime use

Non-Hispanic Puerto Central=South White Hispanic Mexican Rican Cuban American 7.9 14.2 51.1

7.1 12.7 37.1

6.8 12.8 37.0

10.8 15.6 48.6

6.4 12.3 35.0

5.5 9.0 29.2

a Data are from the 2003–2004 National Survey on Drug Use and Health (Office of Applied Studies, 2004b); values reported are percentages.


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significant changes between 2002–2003 and 2003–2004 in the rates of illicit drug use, with a decrease in both lifetime and past year use. It is possible that these survey results are influenced by under-reporting of drug use by Hispanics more so than by Whites. However, although some level of under-reporting occurs, there is no evidence that it is much higher among ethnic minority groups than Whites. A more detailed analysis of past month illicit drug use from the 1997–1998 NHSDA found similar trends among Hispanic subgroups (National Institute on Drug Abuse, 2003). Although the number of Hispanic respondents (n ¼ 6,795) was unusually high in 1998, the findings should be viewed with caution because the estimates are not as precise with smaller numbers in each subgroup and with divisions in each group such as age. The highest prevalence of past month illicit drug use was among ‘‘other Hispanics’’ (8.2%) followed by those of Puerto Rican (6.9%) and Mexican (6.2%) heritage. The lowest estimates were observed for those of South American (2.1%) and Cuban (3.4%) heritage. These trends were consistent among both men and women, although the prevalence for men is nearly twice that of females in each subgroup with the exception of South Americans; the prevalence among males (2.3%) of South American descent is similar to that of their female counterparts (2.0%). These patterns are generally consistent with sex-specific estimates for other racial=ethnic minority groups. Although Hispanics are surpassed by other race=ethnicity groups in past month prevalence of marijuana use (e.g., 8% among American Indians= Alaska Natives, 6.6% among Blacks, and 5.4% in Whites vs. 4.5% in Hispanics), Hispanics as a group are on par with Blacks and American Indians=Alaska Natives in terms of past month cocaine use (1.3%, 1.3%, and 1.4%, respectively); the prevalence among non-Hispanic Whites is 0.7% (National Institute on Drug Abuse, 2003). The use of these drugs among Hispanic subgroups generally follows the trend evidenced for illicit drug use overall. Again, these prevalence rates are consistently higher among males across Hispanic subgroups with the exception of cocaine use among South Americans, where the prevalence among women (1.2%) exceeds that of men (0.2%). Age is also clearly a factor in illicit drug use. The prevalence of past month illicit drug use among Hispanics is highest among those aged 18 to 25 years (11.1%) and decreases as age increases (National Institute on Drug Abuse, 2003). The prevalence among those 26 to 34 years of age decreases by one-half (5.4%) and is further reduced in those aged 35 years or more (3.5%). This trend is even more dramatic among subgroups. For example, although the prevalence for those of Puerto Rican descent is highest in the 18 to 25 year old group (15.7%), it is only 2.2% in the oldest age group (35 years and older). In comparison, the prevalence among Mexican Americans is 10.4% in the 18 to 25 year old group and decreases by more



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than one-half in the 26 to 34 year old group (4.2%), but remains at 4.1% in the oldest age group. This age distribution of illicit drug use among Hispanics does not differ substantially from that among Whites. The most recent NSDUH data available (Office of Applied Studies, 2005) reveal that the prevalence of illicit drug abuse or dependence among Hispanic adults aged 18 years or older is slightly higher than that of Whites (3.0% and 2.6%, respectively) and lower than the rate among Blacks (3.6%) and American Indian=Alaska Natives (7.3%). There were no statistically significant changes in the rates of abuse or dependence for any racial or ethnic group between 2002 and 2003 and between 2003 and 2004. Prevalences for Hispanic subgroups were not reported in the NSDUH data. Grant, Stinson, et al. (2004) and Alegria et al. (2006) analyzed the 2001–2002 NESARC data to detect differences in the prevalence of drug abuse and dependence among Cuban Americans, Mexican Americans, and Puerto Ricans compared to non-Hispanic Whites. The prevalence of drug abuse for each Hispanic subgroup (3.8%, 4.3%, and 5.2%, respectively) was lower than that of non-Hispanic Whites (8.5%); the prevalence of drug dependence among the Cuban American and Mexican American groups (1% and 1.8%, respectively) was lower than that of non-Hispanic Whites (2.7%) but was higher among Puerto Ricans (3.3%). Although the estimates from NESARC are higher than those of the NHSDA=NSDUH, it is clear that differences exist among Hispanic subgroups.

Acculturation and Illicit Drug Use Few studies have examined the effects of acculturation on illicit drug use, abuse and dependence. In a California study, Vega, Alderete, Kolody, and Alguilar-Gaxiola (1998) examined illicit drug use among Mexicans and Mexican Americans in a primarily agricultural region. English language preference, U.S. nativity, and urban residence were risk factors for lifetime illicit drug use; the combined effect of these factors was greater among women than among men. National data also suggest that higher acculturation, as reflected in English language use, is associated with higher rates of illicit drug use (Amaro, Whitaker, Coffman, & Heeren, 1990; Wagner-Echeagaray, Schutz, Chilcoat, & Anthony, 1994). Amaro et al. (1990) found preferred language use significantly associated with marijuana use and cocaine use among Mexican Americans and Puerto Ricans in the HHANES data. Speaking English was more strongly associated with a higher rate of marijuana use among Mexican American women compared to their male counterparts. Speaking English also was more strongly associated with a higher rate of cocaine use among U.S.-born Mexican Americans and among Puerto Rican men as well as Puerto Ricans born on the island. In an analysis of NSDUH data, Wagner-Echeagaray et al. (1994) found English as the chosen language for the interview to be significantly associated with smoking crack cocaine.


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These findings were stronger among Mexican Americans than among other Hispanic groups. Burnam et al. (1987) found that U.S.-born Mexican Americans in Los Angeles who were highly acculturated had a higher lifetime prevalence of drug and alcohol abuse=dependence than Mexico-born subjects. In the NESARC (Grant, Stinson, et al., 2004), drug abuse and dependence were also significantly higher among U.S.-born Mexican Americans compared to foreign-born Mexican Americans after adjusting for sociodemographic factors. However, U.S.-born non-Hispanic Whites were more likely to be drug abusers or dependent than U.S.-born or foreign-born Mexican Americans. In a further analysis of these data, Alegria et al. (2006) demonstrated an increased risk of drug abuse among U.S.-born non-Hispanic Whites compared to foreign-born Cuban Americans. The risk of drug dependence was not significantly increased when comparing U.S.-born non-Hispanic Whites to Cuban Americans, regardless of nativity. Alegria et al. (2006) also compared Puerto Ricans and non-Hispanic Whites. U.S.-born non-Hispanic Whites were at increased risk of drug abuse and dependence compared to island-born Puerto Ricans, but not compared to U.S.-born Puerto Ricans. On the other hand, U.S.-born Puerto Ricans were significantly more likely to be drug abusers but not alcohol dependent compared to island-born Puerto Ricans.

Risk Factors To assess independent risk factors for alcohol and illicit drug use and abuse=dependence among the three major race=ethnicity groups in the United States and among Hispanics specifically, we utilized the 2002 NSDUH public file (Office of Applied Studies, 2004a). The NSDUH is a cross-sectional survey conducted each year by the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration. The survey methodology has been reported in detail elsewhere (Office of Applied Studies, 2003). Briefly, data are obtained from a representative sample of the noninstitutionalized civilian population of the United States through face-to-face interviews at their place of residence employing computer-assisted administration of the questionnaire. The current analysis included non-Hispanic White, non-Hispanic Black, and Hispanic respondents aged 18 years and older.

Measures Outcome Measures. The alcohol outcome measures were (1) binge drinking (5 or more drinks in a couple of hours on one or more days in the past month), (2) heavy drinking (5 or more drinks in a couple of hours on 5 or more days in the past month; includes binge drinkers), and (3) alcohol abuse



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or dependence. Abuse and dependence are defined using the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994). The illicit drug outcome measures included (1) illicit drug use and (2) illicit drug abuse or dependence. Illicit drug use is defined as any use of the following in the previous 12 months: cocaine, crack cocaine, heroin, hallucinogens, inhalants, marijuana, or prescription drug use (defined as any use of pain relievers, tranquilizers, stimulants, or sedatives not prescribed for the subject or taken ‘‘only for the experience or feeling it caused’’). Drug abuse and dependence are defined using the criteria listed in the DSM-IV (American Psychiatric Association, 1994). Control Variables. Sociodemographic measures include respondent’s self-identified race=ethnicity (non-Hispanic White, Black, or Hispanic); age group (18 to 25, 26 to 34, and 35 to 49 years); marital status (married vs. not married [never married, separated, divorced, widowed); education level (less than 12 years, 12 years, or more than 12 years); employment status in the past week (full-time [35 hours=week or more], part-time [less than 35 hours=week], unemployed, other=not in workforce); and household income (less than $20,000, $20,000 to $39,999, $40,000 to $74,999, and $75,000 or more). Acculturation among Hispanics is measured as nativity (U.S. born vs. foreign born) and years lived in or born in the United States (less than 5 years, 5 to 9 years, 10 or more years, or born in the United States). Additional control variables used in the alcohol analyses included age at first drink, average number of drinks per week in the past month, and illicit drug use. Additional control variables used in the illicit drug analyses included heavy alcohol use and alcohol abuse=dependence.

Data Analysis Logistic regression analyses were performed to examine the risk factors for each outcome variable, computing adjusted odds ratios (AOR) and 95% confidence intervals (CI). Each model included all of the sociodemographic factors and relevant substance use factors as described above. For number of drinks per week, the original values were divided by 5 so that each unit increase in the odds ratio represents the odds of the outcome for every 5 drinks consumed per week. Separate models were also constructed for Hispanics and both acculturation measures were tested in each model. If an acculturation measure was significant (Wald test P .10) after all other factors were included in the model, the variable was retained in the model. All analyses were conducted with the Software for Survey Data Analysis (SUDAAN 9.01; Research Triangle Institute, Research Triangle Park, NC). SUDAAN takes into account the complex multistage sampling design

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to more accurately estimate the standard errors. The data are weighted to correct for the probability of selection into the sample, for nonresponse, and to adjust the sample to known population distributions. The original records were randomly subsampled for the public use file to ensure confidentiality and the remaining sample was adjusted to the known totals from the full file to increase precision. The sample sizes for the total sample analyses were 33,072 for alcohol use and 34,172 for illicit drug use. In the Hispanic subsample analyses, the sample sizes were 4,122 and 4,336, respectively.

RESULTS In the total sample, significant risk factors for binge drinking included male gender, marital status (not married), younger age, employment status (higher levels of employment), lower educational level, younger age at first drink, greater number of drinks per week, and illicit drug use (Table 4). Although race=ethnicity was not significant in this model, the risk for binge drinking was slightly increased for Hispanics compared to non-Hispanic Whites (AOR ¼ 1.15, 95% CI ¼ 0.98, 1.36). Risk factors for heavy drinking were similar to those found in the binge drinking model plus race=ethnicity (Black) and income. Risk factors for binge and heavy drinking among Hispanics were more limited (data not shown). Significant factors associated with binge drinking were male gender, marital status (not married), employment (employed), greater number of drinks per week, and illicit drug use. Acculturation, TABLE 4 Factors Associated With Drinking Patterns Among Non-Hispanic Whites, Blacks, and Hispanics: 2002 National Survey on Drug Use and Healtha Binge drinking (N ¼ 33,072) Variables Race Black Hispanic White Alcohol use Age at first use Average number of drinks per weekb Illicit drug use

Heavy drinking (N ¼ 33,072)

AOR

(95% CI)

AOR

(95% CI)

1.06 1.15 1.00

(0.89, 1.26) (0.98, 1.36)

0.51 0.76 1.00

(0.34, 0.77) (0.56, 1.05)

0.97 6.63

(0.95, 0.99) (5.75, 7.63)

0.95 2.62

(0.92, 0.98) (2.35, 2.91)

1.91

(1.68, 2.17)

2.16

(1.80, 2.59)

AOR ¼ adjusted odds ratio; CI ¼ confidence ratio. a All models adjusted for gender, marital status, age, family income, employment status, and education level. b Each unit increase in the odds ratio represents the odds of the outcome for every 5 drinks consumed per week.

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however, was not associated with binge drinking. For heavy alcohol use, marital status (not married), younger age at first drink, greater number of drinks per week, and illicit drug use were significant risk factors. In addition, Hispanics born in the United States were nearly twice as likely to be heavy drinkers compared to their foreign-born counterparts (AOR ¼ 1.89, 95% CI ¼ 0.97, 3.66). In the total sample, Hispanic ethnicity was a protective factor for illicit drug use (Table 5). Heavy alcohol use and alcohol abuse=dependence were positively associated with illicit drug use. Male gender, marital status (not married), younger age, low income, unemployment, and lower education levels were also found to be independent risk factors for illicit drug use (data not shown). The model for drug abuse=dependence found similar risk factors with a few exceptions: Black race, but not Hispanic ethnicity, was associated with drug abuse=dependence and income was not a significant independent risk factor for drug abuse=dependence. Among Hispanics, factors associated with illicit drug use included younger age, heavy drinking, and alcohol abuse=dependence (data not shown). Both nativity (born in the United States) (AOR ¼ 2.20, 95% CI ¼ 1.35, 3.57) and years lived in the United States were significantly associated with illicit drug use. Hispanics who had lived in the United States for 5 to 9 years were at decreased risk of illicit drug use (AOR ¼ 0.32, 0.32, 95% CI ¼ 0.13, 0.84) compared to those living in the United States for 10 or more years (including those born in the United States). Living in the United States for less than 5 years was not a risk factor (AOR ¼ 0.96, 95% CI ¼ 0.38, 2.41). Risk factors for drug abuse=dependence varied slightly, with male gender, younger age, lower education levels, and alcohol

TABLE 5 Factors Associated With Illicit Drug Use and Abuse=Dependence Among Non-Hispanic Whites, Blacks, and Hispanics: 2002 National Survey on Drug Use and Healtha Illicit drug use (N ¼ 34,172)

Illicit drug abuse=Dependence (N ¼ 34172)

Variables

AOR

(95% CI)

AOR

(95% CI)

Race Black Hispanic White Heavy alcohol use Alcohol abuse=dependence

0.96 0.53 1.00 3.03 2.61

(0.81, 1.13) (0.43, 0.66)

1.37 0.90 1.00 1.38 5.49

(1.07, 1.74) (0.66, 1.21)

(2.64, 3.47) (2.27, 2.99)

(1.10, 1.73) (4.41, 6.82)

AOR ¼ adjusted odds ratio; CI ¼ confidence ratio. a All models adjusted for gender, marital status, age, family income, employment status, and education level.

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abuse=dependence increasing the risk. Acculturation risk factors followed a similar pattern to that of illicit drug use.


CONCLUSIONS The importance of conducting research on substance use among ethnic minorities is underscored by the findings reviewed in this article. Overall, studies reveal comparable, if not lower, rates of alcohol and illicit drug use, abuse, and dependence among Hispanics compared to non-Hispanic Whites. Although the estimates from NESARC are higher than those of the NHSDA=NSDUH, the prevalence of both alcohol abuse and dependence was greater in both Hispanics and non-Hispanic Whites. Further, the 2002 NSDUH analysis reported herein demonstrated that although race=ethnicity was not significantly associated with binge drinking after controlling for sociodemographics and illicit drug use, Black race was independently associated with heavy drinking. Hispanic ethnicity was a protective factor for illicit drug use, and Black race was positively associated with drug abuse=dependence. The studies reviewed in this article further illustrate the necessity and the difficulties of examining differences among ethnic subgroups. Several studies examined differences in alcohol use among Hispanic subgroups but less is known about drug use. Although the findings vary to a certain degree, Puerto Rican and Mexican Americans appear to have higher rates of alcohol and illicit drug misuse, abuse, and dependence than other Hispanic subgroups. The NESARC data demonstrated a reversal in this pattern for drug abuse and dependence, with higher rates among Puerto Ricans and Mexican Americans compared to Cuban Americans. Data from other national surveys, however, did not report on drug abuse and dependence by subgroup. The relationship between acculturation and substance use is a complex one and not readily summed up. Higher levels of acculturation are generally associated with risky drinking and alcohol abuse and dependence, although some studies have shown a relationship with medium acculturation as well. In our analyses of the NSDUH data, acculturation (nativity) was associated with heavy drinking but not binge drinking. Acculturation appears to have a more consistent effect on alcohol use and drinking patterns of women than of men. Acculturation-related drinking patterns among women may be related to nativity (U.S.-born); however, early age at immigration to the United States may also increase risky drinking patterns secondary to extended exposure to less restrictive social norms. Less is known about acculturation and illicit drug use, but national data suggest that higher acculturation is associated with higher rates of illicit drug use, particularly nativity. Nativity and,



257

to a lesser extent, years lived in the United States were significantly associated with illicit drug use and abuse=dependence in our NSDUH analysis. In addition to acculturation, it is clear that several other risk factors are associated with risky drinking. For example, male gender, marital status, employment status, younger age at first drink, alcohol volume, and illicit drug use were independently associated with either binge or heavy drinking among Hispanics in the 2002 NSDUH analysis. Likewise, factors associated with illicit drug use among Hispanics included younger age, heavy drinking, and alcohol abuse=dependence. In addition to these factors, male gender and lower education levels were associated with drug abuse=dependence. Similar but more extensive risk factors were found in the alcohol and illicit drug analyses of the total sample, although this may be the result of a smaller sample size of Hispanics. There are several limitations in comparing study findings. Differences in estimates between studies may be the result of many factors, including small sample sizes, particularly among ethnic subgroups, the use of different alcohol and illicit drug measures, the use of different acculturation measures, and sampling techniques. Furthermore, most national surveys have not addressed important factors such as social norms and attitudes among race=ethnic groups or among ethnic subgroups. One exception is the National Alcohol Survey, in which the data suggest that liberal drinking norms and attitudes are positively related to higher levels of acculturation (Caetano & Clark, 2003; Zemore, 2005). These associations may vary by other factors, such as levels of drinking, age, and gender. Zemore (2005), for instance, found that gender-specific drinking norms mediate the association between acculturation and volume consumed among female drinkers. These aspects of race=ethnicity and acculturation can further our understanding of substance use and misuse. Future research must be directed toward understanding not only the differences in substance use among ethnic groups, but also the effect of the complex, multidimensional process of acculturation on substance use among ethnic minorities. The process of acculturation differs by culture of origin, socioeconomic status, gender, age, generation, and language use, among other factors, and must be considered in our attempt to better elucidate the relationship of ethnicity and substance use among Latinos.

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