J. DRUG EDUCATION, Vol. 42(4) 413-424, 2012
YOUNG ADULTS’ PERCEPTIONS OF AN ADOLESCENT’S USE OF MARIJUANA AND ALCOHOL* LAURA A. NABORS MICHAEL D. BRUBAKER SARAH HOFFMAN HALLEY SHIPLEY JORDAN PANGALLO AMANDA STRONG University of Cincinnati, Ohio
ABSTRACT
Adolescent substance use is a serious problem often invoking negative reactions. The current study extends the literature in this area. A total of 425 college students read one of five vignettes, each of which described an adolescent who used marijuana, hard liquor, or drank an occasional beer (control) and who had received or not received treatment. Participants responded to questions assessing acceptance, willingness to help, and beliefs about the adolescent’s academic functioning. Students provided higher acceptance of the adolescent who drank an occasional beer compared to the one who had received treatment for alcohol use and the one who was using marijuana, but did not receive treatment. Results differed based on question type, suggesting that interpretation of stigma is complex and that context plays a role in understanding perceptions. Future research, focusing on reasons for differences in judgments across contexts, will provide new information.
*The authors declare no conflicts of interest. 413 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/DE.42.4.c http://baywood.com
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Alcohol and marijuana are drugs that are commonly used by adolescents in the United States. In an annual survey of substance use among students in the eighth to twelfth grades, 10% to 26% of students reported participating in heavy alcohol drinking, defined as five alcoholic drinks in a row in the past two weeks (Goldstein, 2011). Marijuana use is also common, with as many as 24.5% of teens reporting usage in the last year (Johnston, O’Malley, Bachman, & Schulenberg, 2011; Sterling, Weisner, Hinman, & Parthasarathy, 2010). Substance use is associated with accidents that harm the self and others, decline in school performance, and delinquent behaviors, all of which is indicative of the serious risk for negative outcomes for youth who abuse alcohol and drugs (Goldstein, 2011). Persons with substance use problems often face many barriers to treatment, including stigma and worries about being perceived negatively by others if it is known that they have received treatment for a substance abuse problem (Room, 2005). Additionally, researchers have suggested that more information is needed to understand college students’ perceptions of drug use (Hatgis, Friedmann, & Wiener, 2008). The present study adds to the literature by providing information about college students’ attitudes toward adolescents who use marijuana or alcohol and who may or may not have received treatment for using either of these substances. Specifically, the current study investigated perceptions of an individual using substances described in vignettes, with participants randomly assigned to read one of five vignettes describing an adolescent who either abused marijuana, abused alcohol, abused marijuana and received treatment, abused alcohol and received treatment, or drank an occasional beer at a party (control condition). Individuals typically hold negative attitudes toward persons who engage in substance use (Pescosolido, Monahan, Link, Stueve, & Kikuzawa, 1999; Rasinski, Woll, & Cooke, 2005). These negative perceptions can lead to stigmatized or negative reactions toward persons who abuse different types of drugs, which can alternately become a barrier to accessing treatment (Sirey, Bruce, Alexopoulous, Perlick, Friredman, & Meyers, 2001). Goffman (1963) described stigma as being caused by a negative characteristic or behavior. Negative perceptions toward those with discrediting attributes can lead to rejection and isolation on the part of those who have the characteristics (Galea, Nandi, & Vlahov, 2004). Stigmatized views of persons with substance use problems also may result in societal contempt that reduces interest in developing treatment programs, as those who abuse substances may be viewed as dishonest (Luoma, Twohig, Waltz, Hayes, Roget, Padilla, et al., 2007) or unable to change (Corrigan, Lurie, Goldman, Slopen, Medasani, & Phelan, 2000). Substance use is viewed by many as a choice to fail, and those who do this are viewed as being responsible for their condition and even morally corrupt (Adlaf, Hamilton, Wu, & Noh, 2009). Those engaging in substance abuse are often viewed as being less capable of important decisionmaking, being unable to care for others, and are often more feared and avoided socially than others (Byrne, 2000; Pescosolido et al., 1999). Negative views of
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substance users can be internalized by persons with these problems (Antonak & Livneh, 2000). These negative views can become a barrier to seeking treatment (Adlaf et al., 2009). Perceptions of marijuana use may be an exception to the notion of negative perceptions being associated with substance use. To illustrate, Plancherel, Bolognini, Stéphan, Laget, Chinet, Bernard, et al. (2005) reported that adolescents and young adults viewed others who were regular users of marijuana as being less dangerous than regular users of alcohol. Similarly, Hatgis et al. (2008) determined that college students’ viewed marijuana as being less addictive than alcohol or other substances. These misperceptions of the risk for abuse and negative outcomes related to marijuana use may place college students at risk. Research assessing perceptions of those receiving treatment for marijuana use are lacking, as are studies comparing perceptions of marijuana users who participated in treatment to those who used alcohol and participated in treatment. If those who have received treatment are perceived negatively, this may be a barrier for entering treatment. Another variable that needs further study is participation in treatment. Research shows that individuals who have participated in treatment might be viewed negatively by others, because they were once “addicted” and could not control their substance use (Link, Struening, Rahov, Phelan, & Nuttbrock, 1997; Room, 2005). Luoma et al. (2007) surveyed 197 adults who were currently receiving treatment for substance use problems to determine the impact of stigma. Results indicated that participants had experienced negative reactions from others related to their substance use. They also reported that they felt others would not trust a person who had received treatment for substance use problems to work with young children. Luoma and colleagues did not specifically examine perceptions of treatment as being a factor that impacted stigmatized reactions, which was a goal of the current study. Characteristics of the perceivers themselves may be related to their perceptions of persons with substance use problems. Gender is a perceiver characteristic that may influence young adults’ perceptions of an individual who engages in substance abuse. For instance, Corrigan and Watson (2007) assessed how the gender of perceivers was related to perceptions of persons with different mental and physical illnesses, including schizophrenia, drug dependence, or emphysema. Their findings indicated that women were less likely to have negative attitudes toward those depicted in the vignettes than males did. However, these researchers assessed general views of “drug dependence.” Thus, it was not evident what participants were thinking when making judgments of the substance-dependent individual portrayed in the vignette. Hatgis et al. (2008) assessed college students’ views of males and females who had used marijuana, alcohol, cocaine, and heroin. Their findings showed that males held more negative opinions of male drug users compared to females, showing a similar gender bias to the one reported by Corrigan and Watson. Based on the findings reported by Hatgis et al. (2008),
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it was expected that males would hold more negative opinions of a male using substances than females would. The current study contributes to the literature by examining adults’ perceptions of vignettes describing an adolescent who was using marijuana, one who was using marijuana and had received treatment, one who was using alcohol, and one who was using alcohol and had received treatment. It was hypothesized that college students would report more positive perceptions of an adolescent who drank an occasional beer at parties compared to the adolescents in the other conditions who abused substances (Pescosolido et al., 1999; Rasinski et al., 2005). Moreover, it was hypothesized that perceptions of the adolescent who used alcohol would be more negative than perceptions of the adolescent who used marijuana (Plancherel et al., 2005). Based on previous literature showing that stigma does not necessarily abate after treatment (Link et al., 1997; Luoma et al., 2007), we hypothesized that the null hypothesis would be supported, such that there were no differences in perceptions based on whether adolescents had received treatment, irrespective of whether they were using marijuana or alcohol. Finally, it was expected that females would report more positive perceptions of a male engaging in substance use compared to males, irrespective of type of substance used and whether the individual had received treatment (Hatgis et al., 2008). We assessed stigma for three different questions—liking, helping the person, and academic functioning—in order to assess affective reactions (liking), behaviors (helping), and estimates of the cognitive abilities of the individual. We expected stigma to operate similarly across the three questions. Participants, who read vignettes describing drinking and marijuana use, also provided written responses about their ideas of how the adolescent in the vignette could impact his or her ability to receive treatment. METHOD Participants A total of 425 college students participated—248 females and 177 males. Students were between the ages of 18 and 60, with 53% between the ages of 18 and 20 years and 41% between the ages of 21 and 30 years. Some 83% were Caucasian, 9% were African American, 1% were Hispanic, and 1% were Asian, with the remaining self-identifying as “Other.” About 19% were freshman, 24% were sophomores, 28% were juniors, 26% were seniors, and 3% were either “nonmatriculating” or reported “Other.” Only 11 students identified themselves as a “recovering addict,” and 90% of the participants reported that the descriptions in the vignettes were realistic. Procedures The current study was approved by a university-based institutional review board and was part of an ongoing study assessing perceptions of stigma and
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barriers to treatment for those engaging in substance use (Hoffman, Brubaker, Pangallo, Shipley, Scherzinger, O’Bryan, et al., 2012). Participants read an information form before agreeing to participate. After giving consent, they read one of five vignettes, which were assigned at random. The vignettes were adapted from Corrigan and Watson (2007). Vignettes were similar to these authors’ vignettes in that they were brief, describing the age and drug dependence status of the main character. Corrigan and Watson compared a description of general “drug dependence” to other problems (e.g., schizophrenia). However, the current study focused on comparison of alcohol and marijuana use as well as whether or not youth using these substances had received treatment. There also was a comparison condition, describing a youth who drank occasionally (see Table 1). Next, participants completed questions assessing their liking of, desire to help, and beliefs about the adolescent’s academic progress. They responded to these questions on 7-point Likert scales (with a rating of “1” indicating less positive views scores, such as not wanting to help, and “7” indicating more positive perceptions, such as positive perceptions about academic skills). They also wrote their responses to a series of questions examining factors that would either facilitate or stop treatment seeking by the adolescent. A question of interest for
Table 1. Five Vignettes Type of vignette
Script
Typical
John Smith is 16 years of age and drinks a beer occasionally at parties, but he does not use any other substances.
Drinks too much
John Smith is 16 years of age and has difficulties because of using hard liquor. This has disrupted his life significantly. John has not received treatment.
Drinks too much and has received treatment
John Smith is 16 years of age and has difficulties because of using marijuana. This has disrupted his life significantly. John has received treatment several times.
Uses marijuana
John Smith is 16 years of age and has difficulties because of using marijuana. This has disrupted his life significantly. John has not received treatment.
Uses marijuana and has received treatment
John Smith is 16 years of age and has difficulties because of using marijuana. This has disrupted his life significantly. John has received treatment several times.
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the current study was participants’ perceptions of how the adolescent in the vignette would impact his or her own ability to receive treatment. Students’ responses to this question were analyzed by two research assistants using a memoing technique that allowed for comparative analyses of key themes in participants’ responses (Corbin & Strauss, 2008).
RESULTS A 5 (script) × 2 (gender) MANOVA was conducted with liking, wanting to help, and academic progress as the three dependent variables. Results indicated that type of vignette influenced ratings, Wilks’ Lambda = .820, F(12, 415) = 7.084, p < .001. This yielded a hr2 = .064. Gender also was significant, Wilks’ Lambda = .933, F(3, 415) = 9.913, p < .001. This yielded a hr2 = .067. The interaction term was not significant. Exploratory analyses indicated no significant effects for ethnic or age groups of participants. 1 Follow-up ANOVAs for the three dependent variables for the vignettes were significant (p < .001). The F and hr2 values for the three dependent variables were as follows: liking, F(4, 415) = 7.36, hr2 = .066; wanting to help, F(4, 415) = 6.07, hr2 = .055; and academic progress F(4, 415) = 14.67, hr2 = .124. This indicated medium effect sizes for liking and wanting to help the adolescent in the vignette and a large effect size for differences in ratings of academic progress. The means and standard errors for each of the vignettes by dependent variable are presented in Table 2. Tukey’s follow-up tests for the liking question indicated that the adolescent who drank occasionally received higher liking ratings than the adolescent who drank too much and received treatment and the adolescent who used marijuana. Also, the adolescent who used marijuana and had received treatment received higher liking ratings than the adolescent who drank too much and received treatment. The adolescent who used marijuana and received treatment received higher liking ratings than the one who used marijuana. The students’ ratings showed that they provided higher ratings for wanting to help the adolescent when he drank too much and received treatment or used marijuana compared to ratings for the individual drinking occasionally. For the question about academic progress, students reported that the adolescent who drank occasionally would make better progress than the adolescent when he drank too much and received treatment or when he used marijuana. They rated the adolescent who used marijuana and had received treatment as making better academic progress compared to when he drank too much, drank too much and had received treatment, or when he used marijuana. 1 Post hoc analyses were conducted to examine the responses of the 11 participants who were self-identified as recovering addicts. Results were not appreciably different for these participants when compared to other college students in the sample.
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Table 2. Means and Standard Errors for Student Ratings by Vignette for the Three Dependent Variables
Dependent variable Vignette Typical
Liking
Wanting to help
M
SE
M
4.006a
.137
4.584d
SE
Academic progress M
SE
.144 3.935e
.144 .146
Drinks too much
3.523
.139
5.470
.146
2.801f
Drinks too much and has received treatment
3.324a,b
.138
5.276d
.145
2.783e,g
.146
Uses marijuana
3.208a,c
.140
5.328d
.147 2.982e,h
.148
Uses marijuana and has received treatment
4.016b,c
.142
4.941
.149
3.794f,g,h
.150
Note: Superscripts indicate a significant difference between mean scores at p < .01 to .001 using Tukey follow-up tests.
Follow-up ANOVAs to explore gender differences were significant for all three dependent variables, including liking, F(1, 415) = 9, p = .003, hr2 = .021; wanting to help, F(1, 415) = 19.24, p = .001, hr2 = .044; academic progress, F(1, 415) = 7.05, p = .008, hr2 = .017. Means and standard errors are presented in Table 3. Females reported a stronger desire to help compared to males, irrespective of the type of vignette they read. In contrast, males reported higher liking ratings and expectations for academic progress than females did. Qualitative analysis of students’ responses about how the adolescent would impact his own ability to get treatment revealed that participants viewed marijuana and alcohol use differently. Marijuana use was seen as a less “severe” problem. For example, one student (male or female), who read the vignette about a student using marijuana, wrote that, “In my opinion, there are not any existing substance abuse treatment (SAT) programs that would impact the adolescent’s ability to receive SAT services. Marijuana isn’t as big of a ‘problem’ to people compared to cocaine or alcohol.” Students also wrote about other difficulties inherent in existing programs. They reported that services might be hard to access, because they were costly or designed for adults rather than teenagers. For instance, one participant wrote that, “Most substance abuse programs are geared more toward adult abusers.” Overcrowded programs also were seen as a barrier to treatment. Most did report believing that treatment would help an adolescent (e.g., “I believe a substance abuse program would positively affect this young man. Hope will be given to solve his difficulties.”).
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Table 3. Means and Standard Errors for Gender Differences in Ratings for the Three Dependent Variables Dependent variable Liking
Wanting to help
Academic progress
M
SE
M
SE
M
SE
Males
3.802
.095
4.833
.100
3.433
.100
Females
3.428
.080
5.407
.084
3.085
.085
Gender
DISCUSSION Results provided partial support for study hypotheses. Our findings painted a complex picture of variables to consider when assessing attitudes toward substance use and support the notion that substance use is a discrediting characteristic (Goffman, 1963; Luoma et al., 2007). College students’ perceptions of adolescents using substances varied based on perceiver gender, and characteristics of the target described in the vignette, such as type of substance used and whether the adolescent had received treatment. Results also varied based on our dependent variables (e.g., liking, academic performance). Findings lend support to the notion that stigma is a multifaceted construct that is complex to conceptualize, as reactions vary based on type of attribute and question asked about the individual (Link & Phelan, 2001). Despite the complexity of our construct, it is noteworthy that a general pattern did emerge, showing that the individual using alcohol who had received treatment and the one using marijuana were perceived as being less liked, performing more poorly academically, and wanting to receive help, potentially because they were viewed as having significant substance use problems. The question about “liking” was considered a proxy variable for acceptance of the adolescent. Study findings indicated that college students provided the higher liking ratings for the typical youth who drank occasionally compared to the youth who drank too much and received treatment and the one who used marijuana. Based on study hypotheses and our literature review, it was expected that the youth who drank occasionally would receive higher liking ratings than the youth in the four other vignette conditions (Pescosolido et al., 1999; Rasinski et al., 2005, Sirey et al., 2001). Perhaps this did not occur because only the youth who abused marijuana and the one who used alcohol and received treatment were viewed as being “addicted” to these substances and having a substance use problem. As marijuana is an illegal substance, it may have been assumed that the marijuana user in treatment was mandated for legal reasons rather than social problems related to dependence, and this idea influenced participants’ ratings. As expected, college students’ perceptions were more negative toward an
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adolescent engaging in alcohol misuse who had received treatment compared to an adolescent who was abusing marijuana. This showed partial support for the notion that attitudes would be more positive for marijuana as opposed to alcohol use (Hatgis et al., 2008; Plancherel et al., 2005). It could be that students believed that treatment for marijuana use is effective, while treatment of substance use is less effective. Although this argument is plausible, it is speculative in nature, and future studies will need to confirm whether this is the case. The results for wanting to help the adolescent indicated that participants provided more positive ratings for wanting to help the adolescent who drank alcohol and received treatment and the one who used marijuana more than the adolescent who drank a beer occasionally. Effect sizes were in the medium range, suggesting that relationships were moderate (Cohen, 1988, 1992). If reactions uniformly indicated a stigmatized reaction, then one would have expected lower ratings for wanting to help those engaging in substance use. However, the opposite occurred, indicating that participants may have been expressing support for treatment of and assistance for those with substance use problems. It could also be the case that participants were providing socially desirable responses, but the pattern of responses for liking and academic functioning were not consistent with this notion. It may be that participants were experiencing either pity or sympathy for those struggling with substance use. In future research, questions assessing these ideas will provide additional information to answer these questions. Inspection of the means in Table 2 suggested that college students believed that the adolescents who drank too much would have poorer academic performance than the occasional drinker or those that had used marijuana. Effect sizes were in the large range, suggesting strong relationships (Cohen, 1988, 1992). This finding provided more support for the notion that participants perceived marijuana use as having less severe effects than alcohol use (Hatgis et al., 2008; Plancherel et al., 2005). Specifically, follow-up tests showed that those assigned the vignette of the adolescent who drank too much and had received treatment reported lower academic performance compared to those who read the vignette describing the adolescent who used marijuana and had received treatment. Participants’ ratings demonstrated that drinking too much, irrespective of whether treatment was received, was perceived as being related to lower academic performance than using marijuana and receiving treatment. Finally, using marijuana was related to lower ratings of academic performance than using marijuana when having received treatment. In general, participants appeared to have a more positive outlook for those receiving treatment for marijuana use than treatment for alcohol use. Findings for ratings made by males and females were contrary to our hypotheses. Males provided higher liking ratings and higher ratings for academic performance of the male adolescent described in the vignettes compared to females. This occurred irrespective of the substance being used. This contrasts with literature suggesting that males would provide less positive ratings (Corrigan
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& Watson, 2007). On the other hand, women were more likely to want to help the adolescent, which aligns with literature showing that females hold more positive attitudes. This suggests that the specific question or construct being rated is an important variable to consider when assessing attitudes of those with substance use problems. Qualitative analysis of written responses demonstrated positive views of treatment, although accessing treatment was seen as difficult given the overcrowding and lack of programs for adolescents. Most were optimistic that treatment would work if adolescents were able to find a bed and were able to stay long enough to benefit from therapy and the therapeutic milieu. In contrast, results from quantitative analyses revealed that treatment was associated with stigma, especially for those with alcohol use problems. Both methods shed light on different aspects of participants’ views of this complexity of young adults’ perceptions of substance abuse treatment and its ability to have positive effects on adolescent functioning. Future research, focusing on participants’ ideas of how to improve access and reduce barriers to treatment access, may provide direction for those developing treatment programs. Several factors limited the generalizability of study findings. For example, reasons for liking, helping, and academic performance ratings were not assessed, which will be a key variable to assess in future studies. Moreover, we did not examine perceptions of responsibility or blame for substance use problems, which could be a critical variable impacting ratings across the different questions (Hatgis et al., 2008). Our study was cross-sectional in nature, which means that we did not assess the changing nature of perceptions over time. This will be important to assess, since stigmatized reactions are variable and a construct that is impacted by many factors. Questions for this study assessed attitudes, and it can be the case that attitudes do not translate into behaviors. Thus, in future studies, it will be critical to assess behavioral intentions and behaviors toward those who have received treatment and are in need of treatment for substance use problems. Study findings suggested that assessing differences in opinions for different affective responses and behaviors will be critical, as perceptions may vary according to context. Stigma is a complex construct, operating in many ways and influenced by situational factors, characteristics of the perceived (the person engaging in substance use), and characteristics of the perceiver (the individual making judgments). Researchers will need to consider all of these factors in order to paint an accurate picture of adults’ attitudes toward adolescents engaging in substance use. For instance, young adult’s perceptions may be influenced by their experiences with adults in their own families as well as general societal norms about abuse of substances and addiction. Therefore, perceptions of stigma are influenced by myriad factors, including familial, social, and environmental. The impact of these variables and interactions among them bear further investigation. Also, participating in treatment did not always have a positive influence on stigma, and this is an important consideration for those providing treatment and aftercare
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services. Discussing ways that those in the general public as well as friends and family can help those having difficulty with substance use may be a way to describe common ground that people feel they can work from to engage and assist those with substance use problems. Research aimed at examining whether providing ideas for helping individuals with substance use problems is related to increased positive reactions toward these individuals will improve knowledge about the impact of helping on perceptions held by the “helper.” ACKNOWLEDGMENTS The authors would like to thank the Counseling Program Research Subcommittee in the School of Human Services, in the College of Education, Criminal Justice, and Human Services, at the University of Cincinnati as well as the undergraduates who assisted with this project. REFERENCES Adlaf, E. M., Hamilton, H. A., Wu, F., & Noh, S. (2009). Adolescent stigma towards drug addiction: Effects of age and drug use behavior. Addictive Behaviors, 34(4), 360-364. Antonak, R. F., & Livneh, H. (2000). Measurement of attitudes towards persons with disabilities. Disability and Rehabilitation, 22, 211-224. Byrne, P. (2000). Stigma of mental illness and ways of diminishing it. Advances in Psychiatric Treatment, 6, 65-72. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum. Cohen, J. (1992). Quantitative methods in psychology: A power primer. Psychological Bulletin, 112(1), 155-159. Corbin, J., & Strauss, A. (2008). Basics of qualitative research (3rd ed.). Thousand Oaks, CA: Sage. Corrigan, P. W., Lurie, B. D., Goldman, H. H., Slopen, N., Medasani, K., & Phelan, S. (2000). How adolescents perceive the stigma of mental illness and alcohol abuse. Psychiatric Services, 56(5), 544-550. Corrigan, P. W., & Watson, A. C. (2007). The stigma of psychiatric disorders and the gender, ethnicity, and education of the perceiver. Community Mental Health Journal, 43(5), 439-458. Galea, S., Nandi, A., & Vlahov, D. (2004). The social epidemiology of substance abuse. Epidemiologic Reviews, 26(1), 36-52. Goffman, E. (1963). Stigma: Notes on the management of a spoiled identity. Englewood Cliffs, NJ: Prentice-Hall. Goldstein, M. A. (2011). Adolescent substance abuse. The Mass General Hospital for Children Adolescent Medicine Handbook, 3,155-165. Hatgis, C., Friedmann, P. D., & Wiener, M. (2008). Attributions of responsibility for addiction: The effects of gender and type of substance. Substance Use and Misuse, 43, 700-708. Hoffman, S., Brubaker, M. D., Pangallo, J., Shipley, H., Scherzinger, S., O’Bryan, E., et al. (2012). Stigma and overcoming barriers to treatment for youth with substance abuse
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problems. In C. O. Logan & M. I. Hodges (Eds.), The psychology of attitudes. Hauppauge, NY: NOVA Science Publishers. Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2011). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2010. Ann Arbor, MI: Institute for Social Research, University of Michigan. Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363-385. Link, B. G., Struening, E. L., Rahov, M., Phelan, J. C., & Nuttbrock, L. (1997). On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance use. Journal of Health and Social Behavior, 38(2), 177-190. Luoma, J. B., Twohig, M. P., Waltz, T., Hayes, S. C., Roget, N., Padilla, M., et al. (2007). An investigation of stigma in individuals receiving treatment for substance abuse. Addictive Behaviors, 32, 1331-1346. Pescosolido, B. A., Monahan, J., Link, B., Stueve, A., & Kikuzawa, S. (1999). The public’s views of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health, 89(9), 1339-1345. Plancherel, B., Bolognini, M., Stéphan, P., Laget, J., Chinet, L., Bernard, M., et al. (2005). Adolescents’ beliefs about marijuana use: A comparison of regular users, past users, and never/occasional users. Journal of Drug Education, 35(2), 131-146. Rasinski, K., Woll, P., & Cooke, A. (2005). Stigma and substance use disorders. On the stigma of mental illness: Practical strategies for research and social change. Washington, DC: American Psychological Association. Room, R. (2005). Stigma, social inequality, and alcohol and drug use. Drug and Alcohol Review, 24(2), 143-155. Sirey, A. J., Bruce, M. L., Alexopoulos, G. S., Perlick, D. A., Friedman, S. J., & Meyers, B. S. (2001). Stigma as a barrier to recovery: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatric Services, 52(2), 1615-1620. Sterling, S., Weisner, C., Hinman, A., & Parthasarathy, S. (2010). Access to treatment for adolescents with substance use and co-occurring disorders: Challenges and opportunities. Journal of the American Academy of Child and Adolescent Psychiatry, 49(7), 637-646.
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YOUNG ADULTS’ PERCEPTIONS OF AN ADOLESCENT’S USE OF MARIJUANA AND ALCOHOL* LAURA A. NABORS MICHAEL D. BRUBAKER SARAH HOFFMAN HALLEY SHIPLEY JORDAN PANGALLO AMANDA STRONG University of Cincinnati, Ohio
ABSTRACT
Adolescent substance use is a serious problem often invoking negative reactions. The current study extends the literature in this area. A total of 425 college students read one of five vignettes, each of which described an adolescent who used marijuana, hard liquor, or drank an occasional beer (control) and who had received or not received treatment. Participants responded to questions assessing acceptance, willingness to help, and beliefs about the adolescent’s academic functioning. Students provided higher acceptance of the adolescent who drank an occasional beer compared to the one who had received treatment for alcohol use and the one who was using marijuana, but did not receive treatment. Results differed based on question type, suggesting that interpretation of stigma is complex and that context plays a role in understanding perceptions. Future research, focusing on reasons for differences in judgments across contexts, will provide new information.
*The authors declare no conflicts of interest. 413 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/DE.42.4.c http://baywood.com
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Alcohol and marijuana are drugs that are commonly used by adolescents in the United States. In an annual survey of substance use among students in the eighth to twelfth grades, 10% to 26% of students reported participating in heavy alcohol drinking, defined as five alcoholic drinks in a row in the past two weeks (Goldstein, 2011). Marijuana use is also common, with as many as 24.5% of teens reporting usage in the last year (Johnston, O’Malley, Bachman, & Schulenberg, 2011; Sterling, Weisner, Hinman, & Parthasarathy, 2010). Substance use is associated with accidents that harm the self and others, decline in school performance, and delinquent behaviors, all of which is indicative of the serious risk for negative outcomes for youth who abuse alcohol and drugs (Goldstein, 2011). Persons with substance use problems often face many barriers to treatment, including stigma and worries about being perceived negatively by others if it is known that they have received treatment for a substance abuse problem (Room, 2005). Additionally, researchers have suggested that more information is needed to understand college students’ perceptions of drug use (Hatgis, Friedmann, & Wiener, 2008). The present study adds to the literature by providing information about college students’ attitudes toward adolescents who use marijuana or alcohol and who may or may not have received treatment for using either of these substances. Specifically, the current study investigated perceptions of an individual using substances described in vignettes, with participants randomly assigned to read one of five vignettes describing an adolescent who either abused marijuana, abused alcohol, abused marijuana and received treatment, abused alcohol and received treatment, or drank an occasional beer at a party (control condition). Individuals typically hold negative attitudes toward persons who engage in substance use (Pescosolido, Monahan, Link, Stueve, & Kikuzawa, 1999; Rasinski, Woll, & Cooke, 2005). These negative perceptions can lead to stigmatized or negative reactions toward persons who abuse different types of drugs, which can alternately become a barrier to accessing treatment (Sirey, Bruce, Alexopoulous, Perlick, Friredman, & Meyers, 2001). Goffman (1963) described stigma as being caused by a negative characteristic or behavior. Negative perceptions toward those with discrediting attributes can lead to rejection and isolation on the part of those who have the characteristics (Galea, Nandi, & Vlahov, 2004). Stigmatized views of persons with substance use problems also may result in societal contempt that reduces interest in developing treatment programs, as those who abuse substances may be viewed as dishonest (Luoma, Twohig, Waltz, Hayes, Roget, Padilla, et al., 2007) or unable to change (Corrigan, Lurie, Goldman, Slopen, Medasani, & Phelan, 2000). Substance use is viewed by many as a choice to fail, and those who do this are viewed as being responsible for their condition and even morally corrupt (Adlaf, Hamilton, Wu, & Noh, 2009). Those engaging in substance abuse are often viewed as being less capable of important decisionmaking, being unable to care for others, and are often more feared and avoided socially than others (Byrne, 2000; Pescosolido et al., 1999). Negative views of
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substance users can be internalized by persons with these problems (Antonak & Livneh, 2000). These negative views can become a barrier to seeking treatment (Adlaf et al., 2009). Perceptions of marijuana use may be an exception to the notion of negative perceptions being associated with substance use. To illustrate, Plancherel, Bolognini, Stéphan, Laget, Chinet, Bernard, et al. (2005) reported that adolescents and young adults viewed others who were regular users of marijuana as being less dangerous than regular users of alcohol. Similarly, Hatgis et al. (2008) determined that college students’ viewed marijuana as being less addictive than alcohol or other substances. These misperceptions of the risk for abuse and negative outcomes related to marijuana use may place college students at risk. Research assessing perceptions of those receiving treatment for marijuana use are lacking, as are studies comparing perceptions of marijuana users who participated in treatment to those who used alcohol and participated in treatment. If those who have received treatment are perceived negatively, this may be a barrier for entering treatment. Another variable that needs further study is participation in treatment. Research shows that individuals who have participated in treatment might be viewed negatively by others, because they were once “addicted” and could not control their substance use (Link, Struening, Rahov, Phelan, & Nuttbrock, 1997; Room, 2005). Luoma et al. (2007) surveyed 197 adults who were currently receiving treatment for substance use problems to determine the impact of stigma. Results indicated that participants had experienced negative reactions from others related to their substance use. They also reported that they felt others would not trust a person who had received treatment for substance use problems to work with young children. Luoma and colleagues did not specifically examine perceptions of treatment as being a factor that impacted stigmatized reactions, which was a goal of the current study. Characteristics of the perceivers themselves may be related to their perceptions of persons with substance use problems. Gender is a perceiver characteristic that may influence young adults’ perceptions of an individual who engages in substance abuse. For instance, Corrigan and Watson (2007) assessed how the gender of perceivers was related to perceptions of persons with different mental and physical illnesses, including schizophrenia, drug dependence, or emphysema. Their findings indicated that women were less likely to have negative attitudes toward those depicted in the vignettes than males did. However, these researchers assessed general views of “drug dependence.” Thus, it was not evident what participants were thinking when making judgments of the substance-dependent individual portrayed in the vignette. Hatgis et al. (2008) assessed college students’ views of males and females who had used marijuana, alcohol, cocaine, and heroin. Their findings showed that males held more negative opinions of male drug users compared to females, showing a similar gender bias to the one reported by Corrigan and Watson. Based on the findings reported by Hatgis et al. (2008),
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it was expected that males would hold more negative opinions of a male using substances than females would. The current study contributes to the literature by examining adults’ perceptions of vignettes describing an adolescent who was using marijuana, one who was using marijuana and had received treatment, one who was using alcohol, and one who was using alcohol and had received treatment. It was hypothesized that college students would report more positive perceptions of an adolescent who drank an occasional beer at parties compared to the adolescents in the other conditions who abused substances (Pescosolido et al., 1999; Rasinski et al., 2005). Moreover, it was hypothesized that perceptions of the adolescent who used alcohol would be more negative than perceptions of the adolescent who used marijuana (Plancherel et al., 2005). Based on previous literature showing that stigma does not necessarily abate after treatment (Link et al., 1997; Luoma et al., 2007), we hypothesized that the null hypothesis would be supported, such that there were no differences in perceptions based on whether adolescents had received treatment, irrespective of whether they were using marijuana or alcohol. Finally, it was expected that females would report more positive perceptions of a male engaging in substance use compared to males, irrespective of type of substance used and whether the individual had received treatment (Hatgis et al., 2008). We assessed stigma for three different questions—liking, helping the person, and academic functioning—in order to assess affective reactions (liking), behaviors (helping), and estimates of the cognitive abilities of the individual. We expected stigma to operate similarly across the three questions. Participants, who read vignettes describing drinking and marijuana use, also provided written responses about their ideas of how the adolescent in the vignette could impact his or her ability to receive treatment. METHOD Participants A total of 425 college students participated—248 females and 177 males. Students were between the ages of 18 and 60, with 53% between the ages of 18 and 20 years and 41% between the ages of 21 and 30 years. Some 83% were Caucasian, 9% were African American, 1% were Hispanic, and 1% were Asian, with the remaining self-identifying as “Other.” About 19% were freshman, 24% were sophomores, 28% were juniors, 26% were seniors, and 3% were either “nonmatriculating” or reported “Other.” Only 11 students identified themselves as a “recovering addict,” and 90% of the participants reported that the descriptions in the vignettes were realistic. Procedures The current study was approved by a university-based institutional review board and was part of an ongoing study assessing perceptions of stigma and
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barriers to treatment for those engaging in substance use (Hoffman, Brubaker, Pangallo, Shipley, Scherzinger, O’Bryan, et al., 2012). Participants read an information form before agreeing to participate. After giving consent, they read one of five vignettes, which were assigned at random. The vignettes were adapted from Corrigan and Watson (2007). Vignettes were similar to these authors’ vignettes in that they were brief, describing the age and drug dependence status of the main character. Corrigan and Watson compared a description of general “drug dependence” to other problems (e.g., schizophrenia). However, the current study focused on comparison of alcohol and marijuana use as well as whether or not youth using these substances had received treatment. There also was a comparison condition, describing a youth who drank occasionally (see Table 1). Next, participants completed questions assessing their liking of, desire to help, and beliefs about the adolescent’s academic progress. They responded to these questions on 7-point Likert scales (with a rating of “1” indicating less positive views scores, such as not wanting to help, and “7” indicating more positive perceptions, such as positive perceptions about academic skills). They also wrote their responses to a series of questions examining factors that would either facilitate or stop treatment seeking by the adolescent. A question of interest for
Table 1. Five Vignettes Type of vignette
Script
Typical
John Smith is 16 years of age and drinks a beer occasionally at parties, but he does not use any other substances.
Drinks too much
John Smith is 16 years of age and has difficulties because of using hard liquor. This has disrupted his life significantly. John has not received treatment.
Drinks too much and has received treatment
John Smith is 16 years of age and has difficulties because of using marijuana. This has disrupted his life significantly. John has received treatment several times.
Uses marijuana
John Smith is 16 years of age and has difficulties because of using marijuana. This has disrupted his life significantly. John has not received treatment.
Uses marijuana and has received treatment
John Smith is 16 years of age and has difficulties because of using marijuana. This has disrupted his life significantly. John has received treatment several times.
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the current study was participants’ perceptions of how the adolescent in the vignette would impact his or her own ability to receive treatment. Students’ responses to this question were analyzed by two research assistants using a memoing technique that allowed for comparative analyses of key themes in participants’ responses (Corbin & Strauss, 2008).
RESULTS A 5 (script) × 2 (gender) MANOVA was conducted with liking, wanting to help, and academic progress as the three dependent variables. Results indicated that type of vignette influenced ratings, Wilks’ Lambda = .820, F(12, 415) = 7.084, p < .001. This yielded a hr2 = .064. Gender also was significant, Wilks’ Lambda = .933, F(3, 415) = 9.913, p < .001. This yielded a hr2 = .067. The interaction term was not significant. Exploratory analyses indicated no significant effects for ethnic or age groups of participants. 1 Follow-up ANOVAs for the three dependent variables for the vignettes were significant (p < .001). The F and hr2 values for the three dependent variables were as follows: liking, F(4, 415) = 7.36, hr2 = .066; wanting to help, F(4, 415) = 6.07, hr2 = .055; and academic progress F(4, 415) = 14.67, hr2 = .124. This indicated medium effect sizes for liking and wanting to help the adolescent in the vignette and a large effect size for differences in ratings of academic progress. The means and standard errors for each of the vignettes by dependent variable are presented in Table 2. Tukey’s follow-up tests for the liking question indicated that the adolescent who drank occasionally received higher liking ratings than the adolescent who drank too much and received treatment and the adolescent who used marijuana. Also, the adolescent who used marijuana and had received treatment received higher liking ratings than the adolescent who drank too much and received treatment. The adolescent who used marijuana and received treatment received higher liking ratings than the one who used marijuana. The students’ ratings showed that they provided higher ratings for wanting to help the adolescent when he drank too much and received treatment or used marijuana compared to ratings for the individual drinking occasionally. For the question about academic progress, students reported that the adolescent who drank occasionally would make better progress than the adolescent when he drank too much and received treatment or when he used marijuana. They rated the adolescent who used marijuana and had received treatment as making better academic progress compared to when he drank too much, drank too much and had received treatment, or when he used marijuana. 1 Post hoc analyses were conducted to examine the responses of the 11 participants who were self-identified as recovering addicts. Results were not appreciably different for these participants when compared to other college students in the sample.
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Table 2. Means and Standard Errors for Student Ratings by Vignette for the Three Dependent Variables
Dependent variable Vignette Typical
Liking
Wanting to help
M
SE
M
4.006a
.137
4.584d
SE
Academic progress M
SE
.144 3.935e
.144 .146
Drinks too much
3.523
.139
5.470
.146
2.801f
Drinks too much and has received treatment
3.324a,b
.138
5.276d
.145
2.783e,g
.146
Uses marijuana
3.208a,c
.140
5.328d
.147 2.982e,h
.148
Uses marijuana and has received treatment
4.016b,c
.142
4.941
.149
3.794f,g,h
.150
Note: Superscripts indicate a significant difference between mean scores at p < .01 to .001 using Tukey follow-up tests.
Follow-up ANOVAs to explore gender differences were significant for all three dependent variables, including liking, F(1, 415) = 9, p = .003, hr2 = .021; wanting to help, F(1, 415) = 19.24, p = .001, hr2 = .044; academic progress, F(1, 415) = 7.05, p = .008, hr2 = .017. Means and standard errors are presented in Table 3. Females reported a stronger desire to help compared to males, irrespective of the type of vignette they read. In contrast, males reported higher liking ratings and expectations for academic progress than females did. Qualitative analysis of students’ responses about how the adolescent would impact his own ability to get treatment revealed that participants viewed marijuana and alcohol use differently. Marijuana use was seen as a less “severe” problem. For example, one student (male or female), who read the vignette about a student using marijuana, wrote that, “In my opinion, there are not any existing substance abuse treatment (SAT) programs that would impact the adolescent’s ability to receive SAT services. Marijuana isn’t as big of a ‘problem’ to people compared to cocaine or alcohol.” Students also wrote about other difficulties inherent in existing programs. They reported that services might be hard to access, because they were costly or designed for adults rather than teenagers. For instance, one participant wrote that, “Most substance abuse programs are geared more toward adult abusers.” Overcrowded programs also were seen as a barrier to treatment. Most did report believing that treatment would help an adolescent (e.g., “I believe a substance abuse program would positively affect this young man. Hope will be given to solve his difficulties.”).
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Table 3. Means and Standard Errors for Gender Differences in Ratings for the Three Dependent Variables Dependent variable Liking
Wanting to help
Academic progress
M
SE
M
SE
M
SE
Males
3.802
.095
4.833
.100
3.433
.100
Females
3.428
.080
5.407
.084
3.085
.085
Gender
DISCUSSION Results provided partial support for study hypotheses. Our findings painted a complex picture of variables to consider when assessing attitudes toward substance use and support the notion that substance use is a discrediting characteristic (Goffman, 1963; Luoma et al., 2007). College students’ perceptions of adolescents using substances varied based on perceiver gender, and characteristics of the target described in the vignette, such as type of substance used and whether the adolescent had received treatment. Results also varied based on our dependent variables (e.g., liking, academic performance). Findings lend support to the notion that stigma is a multifaceted construct that is complex to conceptualize, as reactions vary based on type of attribute and question asked about the individual (Link & Phelan, 2001). Despite the complexity of our construct, it is noteworthy that a general pattern did emerge, showing that the individual using alcohol who had received treatment and the one using marijuana were perceived as being less liked, performing more poorly academically, and wanting to receive help, potentially because they were viewed as having significant substance use problems. The question about “liking” was considered a proxy variable for acceptance of the adolescent. Study findings indicated that college students provided the higher liking ratings for the typical youth who drank occasionally compared to the youth who drank too much and received treatment and the one who used marijuana. Based on study hypotheses and our literature review, it was expected that the youth who drank occasionally would receive higher liking ratings than the youth in the four other vignette conditions (Pescosolido et al., 1999; Rasinski et al., 2005, Sirey et al., 2001). Perhaps this did not occur because only the youth who abused marijuana and the one who used alcohol and received treatment were viewed as being “addicted” to these substances and having a substance use problem. As marijuana is an illegal substance, it may have been assumed that the marijuana user in treatment was mandated for legal reasons rather than social problems related to dependence, and this idea influenced participants’ ratings. As expected, college students’ perceptions were more negative toward an
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adolescent engaging in alcohol misuse who had received treatment compared to an adolescent who was abusing marijuana. This showed partial support for the notion that attitudes would be more positive for marijuana as opposed to alcohol use (Hatgis et al., 2008; Plancherel et al., 2005). It could be that students believed that treatment for marijuana use is effective, while treatment of substance use is less effective. Although this argument is plausible, it is speculative in nature, and future studies will need to confirm whether this is the case. The results for wanting to help the adolescent indicated that participants provided more positive ratings for wanting to help the adolescent who drank alcohol and received treatment and the one who used marijuana more than the adolescent who drank a beer occasionally. Effect sizes were in the medium range, suggesting that relationships were moderate (Cohen, 1988, 1992). If reactions uniformly indicated a stigmatized reaction, then one would have expected lower ratings for wanting to help those engaging in substance use. However, the opposite occurred, indicating that participants may have been expressing support for treatment of and assistance for those with substance use problems. It could also be the case that participants were providing socially desirable responses, but the pattern of responses for liking and academic functioning were not consistent with this notion. It may be that participants were experiencing either pity or sympathy for those struggling with substance use. In future research, questions assessing these ideas will provide additional information to answer these questions. Inspection of the means in Table 2 suggested that college students believed that the adolescents who drank too much would have poorer academic performance than the occasional drinker or those that had used marijuana. Effect sizes were in the large range, suggesting strong relationships (Cohen, 1988, 1992). This finding provided more support for the notion that participants perceived marijuana use as having less severe effects than alcohol use (Hatgis et al., 2008; Plancherel et al., 2005). Specifically, follow-up tests showed that those assigned the vignette of the adolescent who drank too much and had received treatment reported lower academic performance compared to those who read the vignette describing the adolescent who used marijuana and had received treatment. Participants’ ratings demonstrated that drinking too much, irrespective of whether treatment was received, was perceived as being related to lower academic performance than using marijuana and receiving treatment. Finally, using marijuana was related to lower ratings of academic performance than using marijuana when having received treatment. In general, participants appeared to have a more positive outlook for those receiving treatment for marijuana use than treatment for alcohol use. Findings for ratings made by males and females were contrary to our hypotheses. Males provided higher liking ratings and higher ratings for academic performance of the male adolescent described in the vignettes compared to females. This occurred irrespective of the substance being used. This contrasts with literature suggesting that males would provide less positive ratings (Corrigan
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& Watson, 2007). On the other hand, women were more likely to want to help the adolescent, which aligns with literature showing that females hold more positive attitudes. This suggests that the specific question or construct being rated is an important variable to consider when assessing attitudes of those with substance use problems. Qualitative analysis of written responses demonstrated positive views of treatment, although accessing treatment was seen as difficult given the overcrowding and lack of programs for adolescents. Most were optimistic that treatment would work if adolescents were able to find a bed and were able to stay long enough to benefit from therapy and the therapeutic milieu. In contrast, results from quantitative analyses revealed that treatment was associated with stigma, especially for those with alcohol use problems. Both methods shed light on different aspects of participants’ views of this complexity of young adults’ perceptions of substance abuse treatment and its ability to have positive effects on adolescent functioning. Future research, focusing on participants’ ideas of how to improve access and reduce barriers to treatment access, may provide direction for those developing treatment programs. Several factors limited the generalizability of study findings. For example, reasons for liking, helping, and academic performance ratings were not assessed, which will be a key variable to assess in future studies. Moreover, we did not examine perceptions of responsibility or blame for substance use problems, which could be a critical variable impacting ratings across the different questions (Hatgis et al., 2008). Our study was cross-sectional in nature, which means that we did not assess the changing nature of perceptions over time. This will be important to assess, since stigmatized reactions are variable and a construct that is impacted by many factors. Questions for this study assessed attitudes, and it can be the case that attitudes do not translate into behaviors. Thus, in future studies, it will be critical to assess behavioral intentions and behaviors toward those who have received treatment and are in need of treatment for substance use problems. Study findings suggested that assessing differences in opinions for different affective responses and behaviors will be critical, as perceptions may vary according to context. Stigma is a complex construct, operating in many ways and influenced by situational factors, characteristics of the perceived (the person engaging in substance use), and characteristics of the perceiver (the individual making judgments). Researchers will need to consider all of these factors in order to paint an accurate picture of adults’ attitudes toward adolescents engaging in substance use. For instance, young adult’s perceptions may be influenced by their experiences with adults in their own families as well as general societal norms about abuse of substances and addiction. Therefore, perceptions of stigma are influenced by myriad factors, including familial, social, and environmental. The impact of these variables and interactions among them bear further investigation. Also, participating in treatment did not always have a positive influence on stigma, and this is an important consideration for those providing treatment and aftercare
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services. Discussing ways that those in the general public as well as friends and family can help those having difficulty with substance use may be a way to describe common ground that people feel they can work from to engage and assist those with substance use problems. Research aimed at examining whether providing ideas for helping individuals with substance use problems is related to increased positive reactions toward these individuals will improve knowledge about the impact of helping on perceptions held by the “helper.” ACKNOWLEDGMENTS The authors would like to thank the Counseling Program Research Subcommittee in the School of Human Services, in the College of Education, Criminal Justice, and Human Services, at the University of Cincinnati as well as the undergraduates who assisted with this project. REFERENCES Adlaf, E. M., Hamilton, H. A., Wu, F., & Noh, S. (2009). Adolescent stigma towards drug addiction: Effects of age and drug use behavior. Addictive Behaviors, 34(4), 360-364. Antonak, R. F., & Livneh, H. (2000). Measurement of attitudes towards persons with disabilities. Disability and Rehabilitation, 22, 211-224. Byrne, P. (2000). Stigma of mental illness and ways of diminishing it. Advances in Psychiatric Treatment, 6, 65-72. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum. Cohen, J. (1992). Quantitative methods in psychology: A power primer. Psychological Bulletin, 112(1), 155-159. Corbin, J., & Strauss, A. (2008). Basics of qualitative research (3rd ed.). Thousand Oaks, CA: Sage. Corrigan, P. W., Lurie, B. D., Goldman, H. H., Slopen, N., Medasani, K., & Phelan, S. (2000). How adolescents perceive the stigma of mental illness and alcohol abuse. Psychiatric Services, 56(5), 544-550. Corrigan, P. W., & Watson, A. C. (2007). The stigma of psychiatric disorders and the gender, ethnicity, and education of the perceiver. Community Mental Health Journal, 43(5), 439-458. Galea, S., Nandi, A., & Vlahov, D. (2004). The social epidemiology of substance abuse. Epidemiologic Reviews, 26(1), 36-52. Goffman, E. (1963). Stigma: Notes on the management of a spoiled identity. Englewood Cliffs, NJ: Prentice-Hall. Goldstein, M. A. (2011). Adolescent substance abuse. The Mass General Hospital for Children Adolescent Medicine Handbook, 3,155-165. Hatgis, C., Friedmann, P. D., & Wiener, M. (2008). Attributions of responsibility for addiction: The effects of gender and type of substance. Substance Use and Misuse, 43, 700-708. Hoffman, S., Brubaker, M. D., Pangallo, J., Shipley, H., Scherzinger, S., O’Bryan, E., et al. (2012). Stigma and overcoming barriers to treatment for youth with substance abuse
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problems. In C. O. Logan & M. I. Hodges (Eds.), The psychology of attitudes. Hauppauge, NY: NOVA Science Publishers. Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2011). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2010. Ann Arbor, MI: Institute for Social Research, University of Michigan. Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363-385. Link, B. G., Struening, E. L., Rahov, M., Phelan, J. C., & Nuttbrock, L. (1997). On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance use. Journal of Health and Social Behavior, 38(2), 177-190. Luoma, J. B., Twohig, M. P., Waltz, T., Hayes, S. C., Roget, N., Padilla, M., et al. (2007). An investigation of stigma in individuals receiving treatment for substance abuse. Addictive Behaviors, 32, 1331-1346. Pescosolido, B. A., Monahan, J., Link, B., Stueve, A., & Kikuzawa, S. (1999). The public’s views of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health, 89(9), 1339-1345. Plancherel, B., Bolognini, M., Stéphan, P., Laget, J., Chinet, L., Bernard, M., et al. (2005). Adolescents’ beliefs about marijuana use: A comparison of regular users, past users, and never/occasional users. Journal of Drug Education, 35(2), 131-146. Rasinski, K., Woll, P., & Cooke, A. (2005). Stigma and substance use disorders. On the stigma of mental illness: Practical strategies for research and social change. Washington, DC: American Psychological Association. Room, R. (2005). Stigma, social inequality, and alcohol and drug use. Drug and Alcohol Review, 24(2), 143-155. Sirey, A. J., Bruce, M. L., Alexopoulos, G. S., Perlick, D. A., Friedman, S. J., & Meyers, B. S. (2001). Stigma as a barrier to recovery: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatric Services, 52(2), 1615-1620. Sterling, S., Weisner, C., Hinman, A., & Parthasarathy, S. (2010). Access to treatment for adolescents with substance use and co-occurring disorders: Challenges and opportunities. Journal of the American Academy of Child and Adolescent Psychiatry, 49(7), 637-646.
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