The social epidemiology of substance use.

Tobacco, alcohol, and illicit substance use continue to result in substantial morbidity and mortality and significant societal economic costs despite considerable efforts to minimize use of licit substances and prevent use of illicit substances. Each year, more than 400,000 Americans die from cigarette smoking, and one in every five deaths in the United States is believed to be smoking related (1). Consequences of alcohol and illicit substance abuse include, among others, cirrhosis, job loss, and criminal behavior related to the acquisition and sale of illicit drugs. The economic costs of addiction were estimated as $400 billion yearly in the United States in 1999 (2). Substance use is associated with a wide range of risk behaviors. For the more commonly used substances, risk behavior includes symptoms of both dependence (e.g., reducing important activities because of use of the substance) and abuse (e.g., driving a car more than once while intoxicated, getting into trouble with superiors or co-workers because of intoxication). For example, in 2002, 4.7 percent of the population reported driving under the influence of an illicit drug and 14.2 percent reported driving under the influence of alcohol at least once during the past year (3). Several academic disciplines, including, among others, sociology, psychology, anthropology, and epidemiology, have studied substance use behavior. To some extent, each of these disciplines has considered substance use through its own analytic lens. For example, although individual psychological factors are frequently explored in the psychological substance use literature, these constructs are not commonly discussed in the psychiatric epidemiologic literature that concerns itself with the determinants of substance abuse and dependence. However, in sum, evidence from these different fields of inquiry strongly suggests that the etiology of substance use and abuse is multifactorial and that genetic, psychological, and social factors are all determinants of substance use. Why, then, should we concern ourselves with the social epidemiology of substance use? In some ways, all epidemiology is social; people are biologic and social organisms, and few biologic processes or behaviors are unmediated by their social context. This may be particularly true and important of behaviors in general and of substance use in particular. The experience of substance use has always been rooted in the social context (4). For example, despite the well-recognized consequences of alcohol abuse and dependence, alcohol drinking enjoys social sanction and is a common feature of both formal and informal social gatherings in the United States. Therefore, in many disciplines, substance use is seldom studied in isolation from the relevant social context considered, at least implicitly, to affect substance use patterns. Although this reinforces the importance of the social context as a determinant of substance use, it provides little help in understanding the specific social determinants empirically associated with substance use behavior. The social epidemiology of substance use explicitly considers the social factors that shape the population distribution of substance use behavior. As a distinct area of research, the social epidemiology of substance use is nascent, and, as such, most of the work that has contributed to the body of knowledge that may be called the social epidemiology of substance use has frequently been carried out with a different primary focus. For example, much work has investigated the two “psychosocial” factors—psychological and social—that may be associated with substance use, often studying both (5, 6). This review systematically summarizes the key epidemiologic literature that has studied social (or exogenous) factors that may shape substance use behavior. We conclude our review with a note about methodological issues in studies dealing with the social epidemiology of substance use.