comparing the stigma of substance disorders in an undergraduate population

7/29/2019 Comparing the Stigma of Substance Disorders in an Undergraduate Population

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Running head: COMPARING SUBSTANCE DEPENDENCE STIGMA

Comparing the Stigma of Substance Dependence Disorders in an Undergraduate Population

Matthew D. Machnik

University of Wisconsin-Green Bay


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COMPARING SUBSTANCE DEPENDENCE STIGMA 2

Abstract

Stigma is a social phenomenon that involves the endorsement of negative attitudes toward

certain groups, such as those diagnosed with mental illness. One such group that falls within the

purview of mental illness is people diagnosed with substance dependence disorders. However,

research into the stigma associated with these disorders is scarce, and even less work has been

done on comparisons of the stigma associated with individual substance dependence disorders.

Thus, the aim of the current study was to expand the knowledge base on this topic by comparing

the stigma associated with nicotine, alcohol, and cocaine dependence. This was accomplished by

examining the stigmatizing beliefs held by a group of undergraduate students at a Midwestern

university. Participants were asked to read one of three vignettes describing an individual

diagnosed with one of the aforementioned conditions, after which they completed two measures

regarding stigma, as well as one regarding familiarity with substance dependence disorders.

Results indicate that cocaine and alcohol dependence were generally rated as having similar

amounts of stigma associated with them, with nicotine dependence being rated as having the

lowest ratings of stigma. Additional results, their potential implications, and limitations of the


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Comparing the Stigma of Substance Dependence Disorders in an Undergraduate Population

Although the conceptualization of stigma is debated, it is proposed that the development

of stigmatizing attitudes involves holding negative and prejudicial beliefs toward members of a

specific group (Link & Phelan, 2001). This can occur based upon general acceptance of

stereotypes held by large groups (Ben-Zeev, Young, & Corrigan, 2010), and can result in

discrimination and status loss (Link & Phelan, 2001). Stigma carries with it a number of

implications for mentally ill individuals, such as stereotyping and prejudice, loss of self-esteem,

and hesitance to seek treatment (Ben-Zeev et al., 2010). The impact of negative stigma on mental

health is so great, advocacy groups, such as the National Alliance on Mental Illness [NAMI],

have undertaken the responsibility of educating the public about mental illness in an attempt to

reduce stigmatizing beliefs held by large groups (NAMI, 2011).

Types of Stigma

Ben-Zeev et al. (2010) take the conceptualization of stigma by Link and Phelan (2001)

further by suggesting that stigma can occur in a number of ways. Specifically, they describe

three different types, including public stigma, self-stigma, and label avoidance (Ben-Zeev et al.,


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Second, it can be thought of as how a person believes that others hold stigmatizing attitudes,

such as when an individual perceives others as believing that drug users are not to be trusted

(Palamar, et al., 2011).

Self-stigma occurs when a person internalizes the stigmatizing beliefs held by the public

(Ben-Zeev et al., 2010), which are then applied by the individual to a stigmatized characteristic

that he or she possesses (Bathje & Pryor, 2011). This internalization can lead to loss of both self-

esteem and self-efficacy (Bathje & Pryor, 2011). As a result, self-stigmatizing individuals may

experience decreased confidence regarding the completion of everyday tasks, as well as

hesitance to seek treatment (Ben-Zeev et al., 2010).

Finally, label avoidance occurs when a person engages in behavior aimed at avoiding the

application of a stigmatized label applied to him or her (Ben-Zeev et al., 2010). For example, a

person may choose to not seek treatment for his or her mental illness due to the impact of being

labeled as a mental health patient (Ben-Zeev et al., 2010). Based on the conceptualizations

provided by Ben-Zeev et al. (2010), label avoidance could be the product of either public or self-

stigma. In other words, a person may want to avoid a label that was applied either by the public,


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employers may be hesitant to hire individuals diagnosed with mental illness, while landlords may

not lease to them out of concern for tenant safety (Ben-Zeev et al., 2010). This, it would seem,

may result from the perception that persons with mental illness are inherently dangerous (Link &

Phelan, 2001). In addition, stigmatized individuals can experience a greater desire for social

distance by others (Dietrich et al., 2004), which can impair social relationships. If these

stigmatizing beliefs are internalized, they may be hesitant to engage in social situations, leading

to outright social avoidance (Ben-Zeev et al., 2010). Thus, it is apparent that developing an

understanding of stigma is imperative, as stigma can discourage treatment, create economic

disadvantages, and lead to a lower quality of life among those diagnosed with mental illness.

Two of the most commonly studied disorders in regard to mental illness stigma are

schizophrenia and depression. Studies have been conducted that suggest stigma associated with

schizophrenia exists on a variety of levels, including publically (Smith, Reddy, Foster, Asbury,

& Brooks, 2011), and self-directed among diagnosed individuals (Kleim et al., 2008). Interviews

conducted with persons diagnosed with schizophrenia suggest that these stigmatizing beliefs can

lead to social isolation and discrimination, being perceived as dangerous, and receiving


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Stigma and Substance Use

Stigmatizing beliefs have also been studied in regard to substance abuse disorders,

although this particular group has received less attention than others. This lack of attention may

be a point of concern, since substance disorders are regarded as being highly destructive to the

individual (Geppert & Bogenschutz, 2009). The desire to avoid labeling may discourage these

individuals from seeking treatment (Ben-Zeev et al., 2010), however, which can allow the

destructive behavior to continue. In addition, the results of a study conducted by Luoma et al.

(2007) suggest that people who seek treatment for substance related disorders are often aware of

their stigmatization, which may decrease the likelihood of treatment success. Thus, not only is

stigma a barrier to seeking treatment, but it may also act as a source of discouragement after

treatment has begun.

Stigma has also been examined regarding specific substance types and their related

disorders. Stigma associated with nicotine use, cigarette smoking in particular, has become an

area of interest recently, as legislation has begun to prohibit smoking in public areas (Kim &

Shanahan, 2003). Although the objective of this process is to encourage current smokers to quit,


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work supervisors as being lower on job performance and dependability (Gilbert, Hannan, &

Lowe, 1998). Furthermore, in a study conducted by Stuber & Galea (2009), a strong relationship

was found between negative perceptions of the social acceptability of smoking, and reluctance to

discuss smoking habits with primary care physicians. Therefore, when considering the impact of

anti-smoking campaigns and legislation on stigma, the possibility exists that increases in stigma

may actually deter smoking cessation efforts.

Another area that has received a considerable amount of attention is stigma associated

with alcohol use. Studies have been conducted to confirm the presence of publically held

stigmatizing beliefs about people who abuse alcohol across different cultures (Piza Peluso, &

Blay, 2008; Fortney et al., 2004). Similar to other disorders, the perceived shame resulting from

stigma associated with seeking treatment for alcohol related disorders can deter individuals from

finding care (Gray, 2010). The results of a study conducted by Fortney et al. (2004) suggest that

these stigmatizing beliefs can occur regardless of treatment venue, whether it is specialized or

through primary care.

Moreover, research has examined the public stigma associated with alcohol dependence.


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racial differences in perceptions of former alcoholics. The results of the study indicate that White

respondents reported holding fewer stigmatizing beliefs toward former alcoholics when

compared with minority group members (Smith et al., 2010). Interestingly, a study conducted by

Fortney et al. (2004) found that African-American individuals were less likely to feel stigmatized

upon seeking treatment for alcohol abuse when compared to Caucasians.

The results of the aforementioned studies provide interesting insight into the stigma held

by different racial groups. Specifically, even though African-American individuals hold more

stigmatizing beliefs about alcohol use (Smith et al., 2010), they are less likely to feel stigmatized

for seeking treatment (Fortney et al., 2004). The inverse appears to be true for White/Caucasian

individuals (Smith et al., 2010; Fortney et al., 2004). Although one can speculate on what might

cause these seemingly paradoxical findings, it is difficult to infer what might cause this

relationship. Therefore, it seems that additional research is needed to explain these results.

Nevertheless, both studies have provided information demonstrating the complex nature of

stigma as it relates to substance abuse.

A thorough search of the relevant literature yielded no information pertaining solely to


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Currently, there is a lack of information in the literature pertaining to comparisons of

substance dependence and other mental illnesses. However, existing research does provide some

insight into this issue. For instance, studies conducted by Corrigan et al. (2000) and Crespo et al.

(2008) made use of similar measures of stigma, and found that cocaine use was consistently rated

as holding more stigma than psychosis and depression. One potential explanation for this finding

comes from a vignette study conducted by Link, Phelan, Bresnahan, Stueve, and Pescosolido

(1999), in which results suggest that persons diagnosed with substance dependence disorders

were perceived as being more likely to exhibit violent behavior when compared with persons

diagnosed with depression. In addition, a vignette study conducted by Pescosolido et al. (2010)

found that alcohol dependence was a more stigmatized condition than schizophrenia. Thus,

although specific research into this area is rare, it would appear that substance abuse is

considered to be a more stigmatized condition than some other forms of mental illness.

One explanation for these results involves examining other perceptions of mental illness

and substance disorders. For example, Link et al. (1999) found that participants were less likely

to rate cocaine or alcohol dependence as a mental illness when compared to depression or


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Comparison of Substance Related Stigma

Another gap in our knowledge base pertains to comparisons of the stigma of individual

substance disorders. However, the small amount of existing research on this topic can provide

limited insight. For example, Link et al. (1999) examined the stigmatizing attitudes toward a

number of different psychiatric and medical conditions. Although this study was mentioned

previously, it is unique in that it included multiple substance use disorders in its comparison,

whereas others limited their inclusion to a single substance related disorder. Therefore, the study

conducted by Link et al. (1999) is one of few that can provide information related to

comparisons of substance use stigma.

Utilizing a nationwide, representative sample of American adults (N=1444), Link et al.

(1999) presented participants with a number of different vignettes. Each vignette was written to

represent an individual diagnosed with a specific condition, such as cocaine dependence, alcohol

dependence, or schizophrenia, with each disorder being representative of the diagnostic criteria

in the DSM-IV (Link et al., 1999). In addition, baseline measurements of stigma were derived

from a vignette describing a troubled individual who was not diagnosed with any condition (Link


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A number of different results were obtained regarding the stigma of cocaine and alcohol

dependence. Specifically, persons described as being diagnosed with cocaine dependence were

perceived as being more likely to be violent when compared with persons diagnosed with alcohol

dependence (Link et al., 1999). Similarly, participants responded as desiring greater amounts of

social distance from an individual diagnosed with cocaine dependence when compared to an

individual diagnosed with alcohol dependence (Link et al., 1999). Therefore, one can conclude

that, according to the results of Link et al. (1999), cocaine dependence as a diagnosed condition

is more stigmatized than alcohol dependence.

A more thorough approach to comparing stigmatizing beliefs about substance use was

conducted by Cunningham, Sobell, and Chow (1993). The researchers utilized a participant pool

of 606 adults, aged 19 to 76, who were recruited locally. The researchers departed from other

research methods by using vignettes describing a general substance use scenario, rather than

basing the vignettes on DSM-IV criteria (Cunningham et al., 1993). In constructing the vignettes,

the researchers described a male individual who engaged in one of three types of substance use,

including cigarette smoking, alcohol consumption, or cocaine use (Cunningham et al., 1993). In


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marital aspects, and two for interpersonal (Cunningham et al., 1993). This allowed comparisons

to be made across the different aspects of stigma, which offered insight into whether a substance

type was stigmatized more greatly in one area as opposed to another. Finally, the researchers

collected information regarding substance abuse treatment, and how it pertained to the individual

in the vignette (Cunningham et al., 1993). Specifically, the questions assessed impressions of

likelihood of treatment success, which types of treatment programs they would suggest, whether

or not the individual could successfully cease substance use by abstaining, and whether or not

participants would believe the individual described if he admitted to successfully ceasing his

substance use (Cunningham et al., 1993).

The researchers reported a number of significant findings. In regard to treatment, cocaine

and alcohol users were rated as being less likely to succeed in treatment when compared to

cigarette smokers (Cunningham et al., 1993). Across all three substance types, individuals

utilizing abstinence for cessation of use were rated as being more likely to succeed than those

undertaking non-abstaining methods (Cunningham et al., 1993). Finally, cigarette smokers were

rated as being more likely to succeed in cessation of use without treatment when compared to


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by Cunningham et al. (1993), it would appear that cigarette smokers are subjected to lower levels

of stigma when compared to cocaine or alcohol users.

The researchers provided a number of potential explanations for their results.

Specifically, in regard to cigarette smoking being rated as less likely to cause problems across all

elements of stigma, the authors suggest that this finding may have originated from participants

belief that cigarette smoking is not a legitimate substance abuse problem (Cunningham et al.,

1993). This may be so, given the less stringent restrictions placed on tobacco when compared to

cocaine or alcohol use. In addition, this perception may also be supported by the notion that

tobacco use is seemingly associated with fewer intoxicating and behavior influencing effects

than the other two substance types used.

The researchers were surprised by the finding that cocaine and alcohol use were rated as

having similar amounts of legal stigma (Cunningham et al., 1993). They suggest that this

perception may have come about by participants considering the legal ramifications associated

with each, such as drunk driving and arrests (Cunningham et al., 1993). Though this certainly

seems plausible, the result also carries with it a potential implication for stigma and the legal


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similarities exist, certain differences do as well. For example, in both studies, individuals using

cocaine were rated as being highly stigmatized (Link et al., 1999; Cunningham et al., 1993).

However, whereas cocaine dependence was associated with a higher degree of stigmatization

than alcohol dependence in Link et al. (1999), cocaine users were ascribed a similar level of

stigmatization when compared to alcohol users in Cunningham et al. (1993). Thus, the results of

the two studies suggest that cocaine and alcohol use carry similar levels of stigma in some

populations, but not others.

Observations of methodological differences between the two studies may provide a

potential explanation for their differing results. First, both studies made use of different

populations. Specifically, the participant pool used in Link et al. (1999) was comprised of adults

who participated in a survey that was administered throughout the United States, whereas the

study conducted by Cunningham et al. (1993) was completed using adults recruited locally in

Toronto, Canada. Therefore, given the different countries of origin for both samples, one

potential explanation for the different results regarding cocaine and alcohol related stigma is that

they represent different culturally held beliefs. While this suggestion is certainly debatable, it


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Cunningham et al. (1993) were constructed to describe patterns of substance use not

corresponding to a diagnosed condition. The presentation of different behaviors in both studies

may play a role in affecting how participants view the individuals described in the vignettes, and

may account for the differences present. Therefore, it may be prudent to suggest that researchers

hoping to make comparisons between obtained and previous results use similar criteria for

presenting behaviors.

A final difference is present in the types of measurements used. For example, the measure

used in Cunningham et al. (1993) focused on the social consequences of substance use, such as

problems in regard to work, legal, marital, and interpersonal issues. However, the measure used

in Link et al. (1999) assessed perceptions of dangerousness, as well as desire for social distance.

Thus, differences in the aspects of stigma that were assessed in the two studies may have

contributed to the differences in the results.

The Current Study

The current investigation served as a partial conceptual replication of the study conducted

by Cunningham et al. (1993). This is because, similar to Cunningham et al. (1993), the intention


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al. (1993). The population used in the current research contained a number of distinct differences

when compared to the original study. For example, it was comprised entirely of undergraduate

students at a local university, was located in a different country and state of origin, and had a

distinct prevalence rate of substance use (Wisconsin Department of Health Services [WDHS],

2010). Specifically, Wisconsin has the highest rates of overall alcohol consumption, binge

drinking, and drinking and driving in the United States (WDHS, 2010). It was hypothesized that

these differences would have a cumulative effect that influenced the results obtained. For

example, given the high prevalence of alcohol consumption in this region, it was proposed that

stigmatizing attitudes about alcohol use may be lower due to the seemingly high social

acceptability of this behavior.

In addition, the population used in the current research was more representative of

undergraduate students. For example, average participant age was 19.66 (SD=3.05), whereas the

population used in Cunningham et al. (1993) was reported as having an average age of 29.1

(SD=9.3). Furthermore, all of the participants will have attained some level of college education,

whereas only 58.1% (N=579) of the population in Cunningham et al. (1993) reported having


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seem unlikely that the brief questionnaire used in Cunningham et al. (1993) is adequate in

forming a clear understanding of stigma. This may be especially true, since three of the four

elements were assessed using only a single question. In addition, researchers have proposed that

different types of stigma may exist, including public and self-stigma, as well as label avoidance

(Ben-Zeev et al., 2010). These types of stigma can be broken down further to include concepts

such as dangerousness, helping or rejection behaviors, and ideas regarding segregation of the

mentally ill (Corrigan et al., 2003a). Therefore, advances in the understanding of stigma have

seemingly rendered the measure used by Cunningham et al. (1993) inadequate, in that it does not

address the different facets of stigma that have been proposed. These same limitations could be

applied to the measure used in Link et al. (1999), who limited their assessment of stigma to

perceptions of dangerousness and desire for social distance. Therefore, the current study

attempted to overcome the limitations of both Cunningham et al. (1993) and Link et al. (1999) by

including assessments for two different types of public stigma, including the specific beliefs held

by the participants, as well as how participants believe others view mentally ill persons.

Finally, the current study utilized vignettes derived from the DSM-IV-TR criteria for


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use, whereas this behavior is not present in the vignette for alcohol dependence (Link et al.,

1999). Thus, it is possible that participants ratings of stigma may have been influenced by the

behaviors presented, such as theft, as opposed to the disorder described. Therefore, the current

study attempted to overcome this limitation by keeping the descriptions of behavior consistent

throughout each of the vignettes. By doing so, it was proposed that participants ratings would be

more indicative of the attitudes held toward the different substance dependence disorders rather

than the behaviors described.

The present study tested three different hypotheses. First, it was hypothesized that

nicotine dependence would carry with it the lowest ratings of stigma. This is based upon the

notion that participants may associate nicotine use with fewer intoxicating effects and legal

ramifications. Second, it was hypothesized that alcohol dependence would be rated as having

more stigma than nicotine dependence, but less stigma than cocaine dependence. Although this

stands in contrast to the results obtained by Cunningham et al. (1993), it was proposed that the

characteristics of the population being used will contribute to decreased amounts of stigma

associated with alcohol. Finally, it was hypothesized that cocaine dependence would be


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N=143) were in their first or second year of undergraduate schooling. Ethnically, the vast

majority of the population identified as White/Caucasian (N=145; 89.5%). However, other

ethnicities were represented, including Asian/Pacific Islander (N=7; 4.3%), Black/African-

American (N=2; 1.2%), Hispanic/Mexican/Puerto Rican (N=3; 1.9%), Native American (N=3;

1.9%), and 2 participants (1.2%) identifying as other. Finally, 32 different undergraduate majors

were represented, with 44 participants (27.2%) responding undecided, and 7 (4.3%) providing

no information regarding their majors. The three most commonly represented majors in the

sample were Human Biology (N=19; 11.7%), Nursing (N=12; 7.4%), and Human Development

(N=11; 6.8%).

Although the total number of respondents was 163 individuals, one was eliminated from

data analysis for reporting an age less than 18 years, which resulted in the final sample size of

162. Furthermore, only 160 students signed up in advance to participate in the study, which was

the only way to receive the web link to the surveys. That means some may have taken the

surveys twice. All of the participants were recruited using the Experiential Research Learning

Program [ERLP], a computer-based program designed at the university where the study took


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Data collection was completed over the Internet using Qualtrics survey software. Upon

signing up for the study in ERLP, each participant was provided with a link to the study website.

Use of this method allowed each participant to complete the survey at a time and place of his or

her choosing. Once at the study website, each of the participants was asked to read a consent

form (see Appendix A). Consent was obtained on this form using a forced-choice checkbox

which, if not checked, would not allow students to progress past this point. If they consented,

they were then asked to provide demographic information, including age, gender, ethnicity,

major, and year in school (see Appendix B). Next, following a between-subjects design,

participants were randomly assigned to read one of three vignettes developed by the researcher.

Randomization was accomplished using a setting within the Qualtrics survey software, which

allowed each vignette to be distributed a proportionate number of times throughout the entire

participant pool. After reading the vignette, participants were asked to complete three different

questionnaires regarding their attitudes toward the person in the vignette, as well as their

familiarity with substance dependence disorders.

After completing each of the surveys, the responses were saved, and participants were


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(see Appendix D). The three disorders used were derived from theDiagnostic and Statistical

Manual of Mental Disorders, 4th

Edition, Text Revision [DSM-IV-TR], and consisted of alcohol

dependence, cocaine dependence, and nicotine dependence (American Psychiatric Association,

2000). The final number of participants exposed to each vignette was as follows: cocaine

dependence (N=53), alcohol dependence (N=55), and nicotine dependence (N=54). Within the

nicotine dependence vignette, cigarette smoking was described as the preferred means of

nicotine administration. Each of the vignettes contained similar descriptions of behavior, and the

manipulation was the type of substance dependence with which the person was diagnosed.

Questionnaires.

Attribution Questionnaire. This measure was developed by Corrigan et al. (2003a), and

was used in the current research to assess the stigmatizing attitudes held by each participant (see

Appendix E). The questionnaire included six different subscales which were designed to assess a

number of different components of stigma, including personal responsibility beliefs (3 items),

pity (3 items), anger (3 items), fear (4 items), coercion-segregation (4 items), and willingness to

help (4 items) (Corrigan et al., 2003a). Each of the 21 items was scored using a nine-point Likert


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fear = .96; helping = .88; and coercion/segregation = .89 (Corrigan et al., 2003a). Normative data

was provided for four of the six subscales: personal responsibility (M=4.32, SD=2.14); pity

(M=5.55, SD=1.94); anger (M=3.77, SD=2.19); fear (M=5.07, SD=2.49).

DUSS. The DUSS was developed by Palamar et al. (2011), and was used to assess

participants beliefs regarding perceptions of stigma held by others (see Appendix F). The 10

items in the DUSS were designed to measure several different facets of public stigma, including

dangerousness, trust, and likelihood of finding employment (Palamar et al., 2011). Participants

were asked to rate how much they agreed with each item using a five-point Likert scale (Palamar

et al., 2011). An overall score of stigma was formed by adding the responses, and dividing the

sum by the total number of items (score range = 1 to 5; Palamar et al., 2011). In addition to

providing a measure of public stigma, the DUSS addressed the possibility that participants may

be more comfortable ascribing stigmatizing beliefs to others.

The psychometric properties of the DUSS were assessed using a sample of 1,048 adults

[mean age=20.31 (SD=1.9); 43.6% identified as White; 46.4% had some college education;

Palamar et al., 2011]. However, the only psychometric information obtained was in regard to the


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the 7 items were modified, with the authors permission, to reflect familiarity with substance

dependence disorders. Participants were asked to provide a yes or no response. Responses were

summed together, with yes responses adding one point to the overall total, and no responses

being marked as zero (Corrigan et al., 2003a). This method produced a familiarity index that

ranged from a minimum of zero points, to a maximum of seven (Corrigan et al., 2003a). This

measure was found to have acceptable reliability ( = .62) , and was normed using the same

sample as the Attribution Questionnaire, with a mean score of familiarity being reported as 2.17

(SD=1.63; Corrigan et al., 2003a).

Results

Data were analyzed using IBM SPSS 19 Statistics software. Before the dependent

variables were analyzed, the demographic distribution of each experimental condition was

examined. A one-way ANOVA was used to determine the means and standard deviations for the

age and year in school variables across the three experimental conditions. Furthermore, a Chi-

Square analysis was performed to determine if the distribution of gender and ethnicity were

different across the experimental conditions as well. No statistically significant differences were


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.001), coercion-segregation (p < .001), and personal responsibility (p < .01) subscales of the

Attribution Questionnaire, as well as on the DUSS (p < .001). Differences between conditions on

the pity and anger subscales of the Attribution Questionnaire, as well as the familiarity

questionnaire, were not statistically significant. In addition, a post hoc Tukey HSD Comparison

was run to further examine differences between conditions on scores of stigma and familiarity,

and a number of significant results were obtained (see Table 3).

A bivariate correlation analysis was run to determine the relationships between the

summed scores for the six subscales of the Attribution Questionnaire, DUSS, and familiarity

questionnaire. Numerous statistically significant relationships emerged, but perhaps the most

noteworthy are the relationships found between familiarity scores and the measures of stigma.

With the exception of the personal responsibility subscale, all other measures of stigma were

significantly correlated with familiarity in such a way that overall stigmatizing beliefs were

reduced as familiarity increased. The correlation matrix associated with this analysis is provided

in Table 4.

Finally, analyses were run to determine whether any significant differences were present


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analysis was run to examine any potential relationships between age, year in school, and summed

scores on the stigma and familiarity questionnaires. The only significant relationship to emerge

was between age and the personal responsibility subscale (r= -.16,p < .05), suggesting that

perceptions of personal responsibility tended to decrease as age increased. Since the average age

was relatively similar between each of the three conditions, it is not likely that this relationship

had a significant effect on comparisons of mean ratings of personal responsibility between

conditions.

Discussion

The purpose of the current study was to compare ratings of stigma associated with

cocaine, alcohol, and nicotine dependence disorders. Results of the data analysis supported the

hypothesis that nicotine dependence would, in relation to the other substance types, carry the

lowest levels of stigma within the population studied. Specifically, nicotine dependence was

associated with lesser degrees of fear and coercion-segregation beliefs, lower scores of perceived

stigmatizing beliefs of others, and an increased willingness to help. However, nicotine

dependence was rated as having a higher degree of personal responsibility, suggesting that


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dependence may suggest social acceptability of the behavior. This, in turn, could create a

situation in which nicotine dependent persons feel less social pressure to cease nicotine use.

Thus, while stigma has been noted to have the effect of creating hesitance to seek mental health

treatment (Ben-Zeev et al., 2010), it may be the case that individuals with less stigmatized

conditions may perceive less social pressure to seek treatment for cessation of use. One potential

direction for future research may be to examine the relationship between a lack of perceived

stigma in regard to substance dependence and willingness to cease substance use.

The results regarding the second and third hypotheses were mixed. It was proposed that

cocaine dependence would be associated with the highest ratings of stigma, while alcohol

dependence would be less stigmatized than cocaine dependence, but more stigmatized than

nicotine dependence. While cocaine dependence was associated with higher levels of stigma in

regard to fear and personal responsibility, relatively similar ratings of stigma for cocaine and

alcohol dependence were found in regard to helping, coercion-segregation beliefs, and the

perceived beliefs of others. Thus, while support was obtained for hypotheses two and three, this

support is fairly limited.


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potentially be attributed to the increased prevalence of alcohol consumption in the current

sample, it cannot be known for certain. One suggestion for future research would be to perform

studies of substance dependence stigma using similar methodologies. For example, a number of

studies done using the same measures, and in different geographic locations, could then be

compared to determine whether the differences in scores of stigma could be attributed to

population differences. From this, it could be determined if a regions prevalence of substance

use could affect stigmatizing attitudes.

One result that was particularly troublesome was the strong negative correlation between

helping behaviors and the perceived stigmatizing beliefs of others. This carries the important

implication that an individuals willingness to engage in helping behaviors (e.g., sharing a car

pool or offering a job interview) toward persons diagnosed with substance dependence disorders

may be influenced by the stigmatizing attitudes that he or she believes others hold. However, a

more positive result was found when comparing familiarity with substance dependence disorders

and scores of stigma. Specifically, stigmatizing beliefs were reduced as increased familiarity was

reported. Thus, while the correlations were not particularly strong in this regard, they were


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is needed to determine how to effectively increase familiarity with substance dependent

individuals. For example, one way to possibly increase familiarity could be through live lectures

or videos of personal testimonials. These methods, however, are different from the examples of

exposure described in the familiarity questionnaire, which makes their ability to increase

familiarity questionable. Nevertheless, future research may want to examine these methods as a

potential means of increasing familiarity with persons diagnosed with substance dependence

disorders, since, as the results of this study would suggest, increasing familiarity could reduce

stigmatizing attitudes.

One particularly intriguing result was in regard to the pity and anger subscales of the

Attribution Questionnaire, in that the mean responses for each deviated from the trends present

in the remaining four subscales, as well as the DUSS. Specifically, the trend involved cocaine

and alcohol dependence being rated as having relatively similar levels of stigma on three scales,

with alcohol dependence having slightly lower ratings of stigma on two scales. In deviating from

this trend, alcohol dependence was rated as having higher mean scores of pity and anger than

both cocaine and nicotine dependence. In other words, participants reported feeling more


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While the measures used in this study were intended to provide a thorough measurement

of stigma, there are additional variables not accounted for which could have affected scores. Onesuch variable is the influence of the legal status of a substance. For example, cocaine is currently

an illicit substance, while alcohol and nicotine products are legally obtainable. Although it is

possible that the current research may provide some insight into this issue, the methodology of

the study makes it difficult to understand directly the contributions of legal status to stigma.

Thus, it would seem that researchers hoping to develop a better understanding of stigma may

want to pursue this specific topic of inquiry.

Additionally, due to ethical reasons, the participants own habits of drug use were not

recorded. One could assume that if, for example, one of the participants was a frequent user of

any of the substances mentioned in this study, he or she may be less likely to give higher ratings

of stigma. Furthermore, participants with different patterns of substance use, such as binge

drinking or heavy consumption, could result in different ratings of stigma within each of the

substance types used. For this reason, it is suggested that any future research on the subject of

substance dependence stigma include measures of personal substance use, and examine patterns


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make these comparisons. Nevertheless, this brief and informal comparison is able to provide

some insight into where substance dependence stands in regard to mental illness stigma.Several limitations are present within the current study. First, the vignettes that were used

only addressed stigmatizing attitudes directed toward males with substance dependence

disorders. Therefore, future studies of this type should include both male and female characters

in vignettes to determine any differences that may exist based on gender. Second, the measure

developed by Palamar et al. (2011) was designed specifically to assess stigmatizing attitudes

toward people who use illicit substances. Therefore, although reliability and validity information

was available regarding its use measuring the stigma of cocaine dependence, its ability to

measure the stigma of both nicotine and alcohol dependence is questionable. Thus, the

measurements obtained regarding nicotine and alcohol dependence may not be entirely accurate.

It is suggested the psychometric properties of the scale developed by Palamar et al. (2011) be

investigated further, as it may serve as a powerful measure of stigma directed toward users of

non-illicit substances. Third, the sample used in the study was predominantly White/Caucasian.

Therefore, the results may not be generalizable to undergraduate populations with greater


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beliefs develop, in that comparisons of stigma across populations with different characteristics,

such as substance use prevalence rates, can possibly identify factors that contribute to increasedor decreased stigma. It is hoped that this study will inspire others to follow suit, and help build a

better understanding of public stigma.


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References

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American Psychiatric Association. (2000).Diagnostic and Statistical Manual of Mental

Disorders (4th ed., text rev.). Washington, DC: Author.

Barney, L. J., Griffiths, K. M., Jorm, A. F., & Christensen, H. (2006). Stigma about depression

and its impact on help-seeking intentions.Australian and New Zealand Journal of

Psychiatry, 40, 51-54. doi:10.1111/j.1440-1614.2006.01741.x

Bathje, G. J., & Pryor, J. B. (2011). The relationships of public and self-stigma to seeking mental

health services.Journal of Mental Health Counseling, 33, 161-177. Retrieved from

http://www.amhca.org/news/journal.aspx

Ben-Zeev, D., Young, M., & Corrigan, P. (2010). DSM-V and the stigma of mental illness.

Journal of Mental Health, 19, 318-327. doi:10.3109/09638237.2010.492484

Cockerham, W. C. (2003). Sociology of Mental Disorder(6th ed.). Upper Saddle River, NJ:

Prentice Hall.


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Perceptions of discrimination among persons with serious mental illness. Psychiatric

Services, 54, 1105-1110. doi: 10.1176/appi.ps.54.8.1105Crespo, M., Perez-Santos, E., Munoz, M., & Guillen, A. (2008). Descriptive study of stigma

associated with severe and persistent mental illness among the general population of

Madrid (Spain). Community Mental Health Journal, 44, 393-403. doi: 10.1007/s10597-

008-9142-y

Cunningham, J. A., Sobell, L. C., & Chow, V. M. (1993). What's in a label? The effects of

substance types and labels on treatment considerations and stigma. Journal of Studies on

Alcohol, 54, 693-699. Retrieved from http://www.jsad.com/

Dietrich, S., Beck, M., Bujantugs, B., Kenzine, D., Matschinger, H., & Angermeyer, M. C.

(2004). The relationship between public causal beliefs and social distance toward

mentally ill people.Australian and New Zealand Journal of Psychiatry, 38, 348-354.

doi:10.1111/j.1440-1614.2004.01363.x

Fortney, J., Mukherjee, S., Curran, G., Fortney, S., Xiaotong, H., & Booth, B. M. (2004). Factors

associated with perceived stigma for alcohol use and treatment among at-risk drinkers.


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A qualitative study with focus group. Social Psychiatry and Psychiatric Epidemiology,42, 14-23. doi:10.1007/s00127-006-0126-3

Gray, R. (2010). Shame, labeling and stigma: Challenges to counseling clients in alcohol and

other drug settings. Contemporary Drug Problems: An Interdisciplinary Quarterly, 37,

685-703. Retrieved from http://www.federallegalpublications.com/contemporary-drug-

problems

Kim, S., & Shanahan, J. (2003). Stigmatizing smokers: Public sentiment toward cigarette

smoking and its relationship to smoking behaviors.Journal of Health Communication,

8, 343-367. doi:10.1080/10810730305723

Kleim, B., Vauth, R., Adam, G., Stieglitz, R., Hayward, P., & Corrigan, P. (2008). Perceived

stigma predicts low self-efficacy and poor coping in schizophrenia.Journal of Mental

Health, 17, 482-491. doi:10.1080/09638230701506283

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(2007). An investigation of stigma in individuals receiving treatment for substance abuse.

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Health Support, Education and Advocacy. Retrieved from http://www.nami.org/

Palamar, J. J., Kiang, M. V., & Halkitis, P. N. (2011). Development and psychometric evaluation

of scales that assess stigma associated with illicit drug users. Substance Use & Misuse,

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Appendix APlease print this form for your records.

Informed Consent*

Please read the following information carefully:

Title: College Students Attitudes about Substance Dependence

Principal Investigator: Dr. Kristin Vespia; [email protected]; (920) 465-2746

Research Assistant: Matthew D. Machnik

Purpose of Research: To gain knowledge pertaining to students attitudes toward persons diagnosed withsubstance dependence disorders. This research is taking place under the supervision of Dr. Kristin Vespia,a faculty member in Human Development and Psychology, and is part of an Honors Project beingconducted by Matthew D. Machnik, a UWGB student.

Participation: Participation will involve reading a vignette and completing four brief surveys, whichshould take about 15 minutes in total. The first survey will collect demographic information, includingage, gender, ethnicity, major, and year in school. Two questionnaires will ask about personal and publicperceptions related to substance dependence disorders. A final measure will include items aboutparticipants familiarity with substance dependence disorders.

Benefits: Participants will receive 1 ERLP point for their participation.

Risks: The only foreseeable risks involved with this study will be the minimal risk typically associatedwith survey research that encountering survey items on a topic that somehow relates to your own

background could potentially, for example, lead you to think more about that background as a result.Please stop your participation and contact the research supervisor if you experience any distress.

Safeguards: All survey information provided will be anonymous and will be kept confidential Although


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Appendix B

1. Age ______

2. Gender: (Please circle one)

Male Female

3. Which of the following best describes your ethnic affiliation: (Please check one)

___ Asian/Pacific Islander

___ Black/African-American

___ Hispanic/Mexican/Puerto Rican

___ Native American

___ White/Caucasian

4. Current major: ____________________________

5. Year in school: (Please check one)


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Appendix C

If you did not already print the consent form, please take this opportunity to print the followinginformation for your records.

Thank you for participating in the study! The following information reiterates the purpose of the

study in which you just participated, and provides the contact information for the researchers

involved should you have any questions.

Title: College Students Attitudes about Substance Dependence

Purpose of Research: To gain knowledge pertaining to students attitudes toward persons

diagnosed with substance dependence disorders. This research is taking place under the

supervision of Dr. Kristin Vespia, a faculty member in Human Development and Psychology,

and is part of an Honors Project being conducted by Matthew D. Machnik, a UWGB student.

Posting of Results: The results of the study will be posted on the ERLP website once data

collection is complete. If you have questions regarding the study, or would like to be notified

about the results individually, please contact Dr. Kristin Vespia; [email protected]; (920) 465-

2746.


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Appendix D

Cocaine Dependence:

Thomas has been using cocaine for the past 18 months. During the past 12 months, he has

needed to increase the amount of cocaine he uses in order to achieve the desired effect. He finds

that when he is unable to use cocaine, he experiences significant cocaine withdrawal symptoms.

In order to overcome the withdrawal, he feels he needs to use cocaine on a continual basis. Hehas noticed a marked decline in his overall health, and has all but given up the recreational

activities he used to enjoy. Even though he is aware of the effects his cocaine use is having on

his life, he continues to use it. Over the past 12 months, he has tried to quit using cocaine several

times, but has been unsuccessful. As a result, Thomas has been diagnosed by a Psychologist as

having cocaine dependence.

Alcohol Dependence:

Thomas has been drinking alcohol for the past 18 months. During the past 12 months, he has

needed to increase the amount of alcohol he drinks in order to achieve the desired effect. He


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Appendix D (continued)

Nicotine Dependence:Thomas has been smoking cigarettes for the past 18 months. During the past 12 months, he has

needed to increase the number of cigarettes he smokes in order to achieve the desired effect. He

finds that when he is unable to smoke cigarettes, he experiences significant nicotine withdrawal

symptoms. In order to overcome the withdrawal, he feels he needs to smoke cigarettes on a

continual basis. He has noticed a marked decline in his overall health, and has all but given up

the recreational activities he used to enjoy. Even though he is aware of the effects his cigarette

smoking is having on his life, he continues to smoke. Over the past 12 months, he has tried to

quit smoking cigarettes several times, but has been unsuccessful. As a result, Thomas has been

diagnosed by a Psychologist as having nicotine dependence.


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Appendix E

Personal Responsibility Beliefs1. I would think that it were Thomass own fault that he is in the present condition. (1 = No, not

at all; 9 = Yes, absolutely so)

2. How controllable, do you think, is the cause of Thomass present condition? (1 = Not at all

under personal control; 9 = Completely under personal control)

3. How responsible, do you think, is Thomas for his present condition? (1 = Not at all

responsible; 9 = Very much responsible)

Pity

1. I would feel pity for Thomas. (1 = None at all; 9 = Very much)

2. How much sympathy would you feel for Thomas? (1 = None at all; 9 = Very much)

3. How much concern would you feel for Thomas? (1 = None at all; 9 = Very much)

Anger

1. I would feel aggravated by Thomas. (1 = None at all; 9 = Very much)

2. How angry would you feel at Thomas? (1 = None at all; 9 = Very much)


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Appendix E (continued)

Helping1. If I were an employer, I would interview Thomas for a job. (1 = Not likely; 9 = Very likely)

2. I would share a car pool with Thomas each day. (1 = Not likely; 9 = Very likely)

3. How certain would you feel that you would help Thomas? (1 = Not at all certain; 9 =

Absolutely certain)

4. If I were a landlord, I probably would rent an apartment to Thomas. (1 = Not likely; 9 = Very

likely)

Coercion-Segregation

1. I think Thomas poses a risk to his neighbors unless he is hospitalized. (1 = Not at all; 9 = Very

much)

2. I think it would be best for Thomass community if he were put away in a psychiatric hospital.

(1 = Not at all; 9 = Very much)

3. How much do you think an asylum, where Thomas can be kept away from his neighbors, is

best? (1 = Not at all; 9 = Very much)


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Appendix F

For all items, 1 = Strongly disagree; 5 = Strongly agree

1. Most people would believe Thomas cannot be trusted.

2. Most people would believe that Thomas is dangerous.

3. Most people would not accept Thomas as a close friend.

4. Most people feel that Thomass drug use is a sign of personal failure.

5. Most people would take Thomass opinion less seriously.

6. Most people think less of Thomas.

7. Most people would treat Thomas just as they would treat anyone else.

8. Most employers would not hire Thomas.

9. Most people would not accept Thomas as a teacher of young children in public schools.

10. Most young women would not date Thomas.


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Appendix G

1. My job involves providing services/treatment for persons with substance dependence

disorders. (Yes/No)

2. I have observed, in passing, a person I believe may have had a substance dependence disorder.

(Yes/No)

3. I have observed persons with substance dependence disorders on a frequent basis. (Yes/No)

4. I have worked with a person who had a substance dependence disorder at my place of

employment. (Yes/No)

5. A friend of the family has a substance dependence disorder. (Yes/No)

6. I have a relative who has a substance dependence disorder. (Yes/No)

7. I live with a person who has a substance dependence disorder. (Yes/No)


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Table 1

Age and Year in School Distribution between Conditions

Cocaine Alcohol Nicotine

M SD M SD M SD

Age 20.04 4.53 19.51 2.23 19.42 1.61

Year in School 1.51 1.07 1.58 1.05 1.39 0.79

Note. No statistically significant differences were found between conditions.


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Table 2

Gender and Ethnicity Distribution between Conditions


N N N

Gender

Male 12 12 13

Female 40 43 41

Other 1 0 0

Ethnicity

Asian/Pacific Islander 2 4 1

Black/African-American 0 0 1

Hispanic/Mexican/Puerto Rican 1 2 0

Native American 2 0 1

White/Caucasian 47 48 50

Other 1 1 1


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Table 3

Means and Standard Deviations of Measures with Tukey HSD Comparison Significance Levels


Measures M SD M SD M SD

Attribution Questionnaire

Pity 4.82 1.62 5.18 1.6 4.58 1.74

Anger 4.77 2.15 5.28 2.08 4.76 2.13

Fear 4.51 c. ** 1.71 4.13 c. **

1.74 2.73 a. ** b. ** 1.59

Helping 3.39 c. ** 1.42 3.32 c. ** 1.14 4.48 a. ** b. ** 1.7

Coercion-Segregation 3.76 c. ** 1.52 3.14 c. * 1.46 2.4 a. ** b. * 1.42

Personal Responsibility 5.98 c. * 1.68 6.1 1.39 6.75 a. * 1.17

DUSS 3.96 c. ** 0.46 3.99 c. ** 0.49 3.08 a.** b. ** 0.67

Familiarity Questionnaire 2.42 1.66 2.78 1.77 2.65 1.78

Note. Only statistically significant relationships are reported. a. = compared to cocaine dependence, b.= compared to alcohol

dependence, c. = compared to nicotine dependence, * = p < .05, ** =p < .001


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Table 4

Correlations between Summed Scores on all Measures

Measures 1 2 3 4 5 6 7 8

1 Personal Responsibility --- ***-.34 ***.37 .11 *-.16 .10 -.01 -.13

2 Pity --- *-.16 .01 ***.30 *-.17 -.03 *.17

3 Anger --- ***.36 -.12 ***.31 .14 *-.17

4 Fear --- **-.23 ***.63 ***.44 *-.18

5 Helping --- **-.21 ***-.50 *.18

6 Coercion-Segregation --- ***.40 ***-.26

7 DUSS --- **-.23

8 Familiarity ---

Note. * =p < .05, ** =p < .01, *** =p < .001

comparing the stigma of substance disorders in an undergraduate population

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