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

COMPARING SUBSTANCE DEPENDENCE STIGMA 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 current study are included.

COMPARING SUBSTANCE DEPENDENCE STIGMA 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., 2010). Public stigma involves the endorsement of stereotypes by large groups (Ben-Zeev et al., 2010), such as when one ethnic group holds disdainful attitudes about other ethnicities (Cockerham, 2003). These stereotypes and attitudes can also be applied to persons with mental illness, and can manifest themselves behaviorally as discrimination and prejudice (Ben-Zeev et al., 2010). The idea of public stigma can be broken down further, such that it may be perceived in two distinct ways. First, it can be the stigmatizing attitudes that a person holds about others (Palamar, Kiang, & Halkitis, 2011), such as when an individual believes that people with mental illness are inherently dangerous (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003a).

COMPARING SUBSTANCE DEPENDENCE STIGMA 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 selfesteem 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 selfstigma. In other words, a person may want to avoid a label that was applied either by the public, or by him- or herself. Therefore, this type of stigma is focused upon the labels applied to mental illness, rather than the illness itself. Stigma and Mental Illness Stigma, as it pertains to mental illness, can negatively influence the quality of life for members of stigmatized groups (Link, Struening, Rahav, Phelan, & Nuttbrock, 1997; Ahern, Stuber, & Galea, 2007). This finding carries with it implications that extend across a variety of contexts. For example, stigmatized persons often experience discrimination in regards to employment, housing, and dealings with law enforcement (Corrigan et al., 2003b). Specifically,

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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 inadequate health care (Gonzlez-Torres, Oraa, Arstegui, Fernndez-Rivas, & Guimon, 2007). Among persons diagnosed with depressive disorders, self-stigma has been associated with lower quality of life (Yen et al., 2009), while self-stigma and public stigma were found to be associated with moderate degrees of embarrassment, and reluctance to seek treatment (Barney, Griffiths, Jorm, & Christensen, 2006). The aforementioned studies provide only a small sample of the existing research pertaining to mental illness stigma. However, their results demonstrate the importance of understanding this phenomenon, as it can have a variety of detrimental effects for members of stigmatized groups.

COMPARING SUBSTANCE DEPENDENCE STIGMA 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, as well as limit the amount of potential harm to people exposed to second-hand smoke, it can also encourage the stigmatization of individuals who smoke cigarettes (Kim & Shanahan, 2003). As a result of anti-smoking legislation and campaigns, cigarette smoking in America has been labeled as a public enemy, leading to an increase in negative attitudes toward cigarette smokers (Kim & Shanahan, 2003). Although the intentions of the anti-smoking movement seem honest, especially considering the widely noted adverse health effects of smoking, the stigma it creates has the potential to produce a number of problems. For example, cigarette smokers have been rated by

COMPARING SUBSTANCE DEPENDENCE STIGMA 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. A vignette study conducted by Piza Peluso and Blay (2008) found that participants perceived alcohol dependent persons as being more likely to commit violent acts, and felt that knowledge of the disorder leads to increased social distancing. Additionally, a vignette study conducted by Pescosolido et al. (2010) found that 74% of respondents (N=630) would be unwilling to work closely with the individual, while 79% would not allow an alcohol dependent person marry into their family. Additional research into alcohol-related stigma has made comparisons across racial and ethnic groups. A study conducted by Smith, Dawson, Goldstein, and Grant (2010) examined

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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 the stigma associated with cocaine. For the sake of comparison, information was also sought regarding other relatively serious street drugs, such as crack or heroin. All of the research located was determined to be outside of the focus of the present study. Despite this, other studies were located which compared the stigma of cocaine use and dependence to other mental and medical disorders (Crespo, Perez-Santos, Munoz, & Guillen, 2008; Corrigan et al., 2000; Ronzani, Higgins-Biddle, & Furtado, 2009). Thus, it would seem that research regarding the stigma attached to cocaine use, as well as other street drugs, is needed. Comparisons of Stigma between Mental Illness and Substance Abuse

COMPARING SUBSTANCE DEPENDENCE STIGMA 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 schizophrenia. This perception may result from ideas about whether or not the person has control over his or her disorder. The results of Corrigan et al. (2000) would suggest that substance use, specifically cocaine use, is considered to be under greater perceived control of the individual when compared to other forms of mental illness. Furthermore, substance dependence may be considered more likely to be the result of bad character than other neurobiological causes, such as a chemical imbalance (Pescosolido et al., 2010). Therefore, by associating substance disorders with character flaws and greater perceived controllability, members of the public may be more likely to stigmatize them when compared to other mental illnesses.

COMPARING SUBSTANCE DEPENDENCE STIGMA 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,

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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 et al., 1999). Attitudes about stigma were determined by gathering participants perceptions of dangerousness, as well as desire for social distance (Link et al., 1999). In regard to dangerousness, participants were questioned as to how strongly they believed the individual in the vignette would be violent towards others (Link et al., 1999). For social distance, the researchers asked participants a number of questions involving a variety of hypothetical social situations, such as socializing, making friends, or working with the individual described in the vignette (Link et al., 1999).

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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 addition, two labels were applied to each substance users level of dependence (Cunningham et al., 1993). For example, in regard to alcohol use, the labels alcoholic or heavy drinker were used to designate high dependence and moderate dependence, respectively (Cunningham et al., 1993). This was done while keeping the described amounts of consumption consistent across the different label types (Cunningham et al., 1993). Cunningham et al. (1993) conceptualized stigma as including a number of elements, such as perceived work, legal, marital, and interpersonal problems. These four different elements were then used to construct a five-item assessment, with one question each for the work, legal, and

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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 cocaine and alcohol users (Cunningham et al., 1993). A number of findings regarding stigma were also noted. Across all four elements of stigma, cigarette smokers had a lower stigma rating attached to them when compared to both alcohol and cocaine users (Cunningham et al., 1993). In addition, both cocaine and alcohol users were rated as having similar degrees of stigma attached to them, particularly in regard to perceived legal problems (Cunningham et al., 1993). Furthermore, cigarette smokers admissions of cessation of use were more likely to be believed than those of alcohol or cocaine users (Cunningham et al., 1993). Thus, when making general assumptions about the findings obtained

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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 status of a substance. It seems almost counterintuitive to suggest that an illicit substance would be perceived as carrying similar amounts of legal stigma compared to one that is legally obtainable. Therefore, the finding obtained by Cunningham et al. (1993) seems to suggest that, when compared to legal status, participants may put greater emphasis on the negative legal consequences of substance use when forming impressions of users. Even though a limited amount of research exists regarding the relative state of stigmatizing beliefs regarding substance use, comparisons can still be made. What is intriguing about the results of Link et al. (1999) and Cunningham et al. (1993) is that, while certain

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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 offers an interesting direction for present and future research. Specifically, comparisons of culturally held stigmatizing beliefs may assist in understanding how these beliefs develop. Although further comparisons of participant characteristics could provide insight into how the different results were achieved, Link et al. (1999) did not include the demographic composition of the participants used, thus making such comparisons impossible. Second, the vignettes used in both studies involved different methods of construction. Specifically, the vignettes used in Link et al. (1999) were written to correspond with DSM-IV criteria for both alcohol and cocaine dependence. The vignettes from the study conducted by

COMPARING SUBSTANCE DEPENDENCE STIGMA 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

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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 was to assess any potential differences in participants stigmatizing attitudes held toward nicotine, alcohol, and cocaine users. Although significant methodological differences exist, the findings of the current study expand upon the results of Cunningham et al. (1993) in a number of ways. First, a significant amount of time has passed the since the study conducted by Cunningham et al. (1993) was published. Thus, it is possible that public attitudes toward alcohol, cocaine, and nicotine users may have since changed. Second, by utilizing a different population, the current investigation increased the generalizability of the results obtained by Cunningham et

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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 acquired some college education. Therefore, the results of the current investigation will be more generalizable to college undergraduate populations, as well as younger adults in general. A third difference between the current investigation and the work of Cunningham et al. (1993) was the types of participant attitudes assessed. As previously noted, the measure of stigma used in the study by Cunningham et al. (1993) consisted of five questions designed to measure four proposed elements of stigma. Although this method did provide insight into the topic, certain limitations exist. For example, research into the topic of stigma has shown that it is a complex construct (e.g., Ben-Zeev et al., 2010; Link & Phelan, 2001). Therefore, it would

COMPARING SUBSTANCE DEPENDENCE STIGMA 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

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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 cocaine, alcohol, and nicotine dependence. This stands in contrast to Cunningham et al. (1993), who described general substance use scenarios without the inclusion of mental illness diagnoses. Thus, an advantage to the vignettes used in the current study is that they not only present specific substance dependence behaviors, but also address the attitudes participants may have toward substance abuse as a mental illness. In addition, the vignettes expand upon those used in Link et al. (1999). Although the vignettes used in Link et al. (1999) were also written based upon DSMIV criteria, the types of behavior they present are not consistent. For example, the vignette describing cocaine dependence implied that the individual was stealing to support his or her drug

COMPARING SUBSTANCE DEPENDENCE STIGMA 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

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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 associated with the highest level of stigma. Method Participants The sample consisted of 162 undergraduate students from a mid-size public university in the upper Midwest. It was comprised of 124 women (76.5%), 37 men (22.8%), and one individual identifying as other (0.6%), and had an age range of 18 to 45 (M=19.66, SD=3.05). One important consideration is that 87.5% (N=140) of the sample was aged below the legal limit for alcohol consumption in the state where the study was conducted. Most participants (88.3%;

COMPARING SUBSTANCE DEPENDENCE STIGMA 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/AfricanAmerican (N=2; 1.2%), Hispanic/Mexican/Puerto Rican (N=3; 1.9%), Native American (N=3;

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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 place. The program is used with students enrolled in introductory Psychology and Human Development courses. Students can choose studies in which to participate based on provided descriptions, and alternatives to research participation, such as writing research summaries or attending presentations, are available. Participation in these experiences is part of the requirements for both of the aforementioned courses, though the amount of credit needed to be earned is small compared to the requirements for course completion. Procedure

COMPARING SUBSTANCE DEPENDENCE STIGMA Data collection was completed over the Internet using Qualtrics survey software. Upon

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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 directed to a page which allowed them to provide their name. The purpose of the name collection was to ensure that each student was properly awarded credit for their participation. Participants names and survey results were stored in different data files within the Qualtrics server, so the names provided could not be linked to the individual results. After providing their name, participants were directed to a debriefing form (see Appendix C). Materials Vignettes. Each of the three vignettes was a written representation of an individual who was described as being diagnosed with one of three different substance dependence disorders

COMPARING SUBSTANCE DEPENDENCE STIGMA (see Appendix D). The three disorders used were derived from the Diagnostic and Statistical

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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 scale, with a score of one representing the minimum, and a score of nine representing the maximum as it related to each item (Corrigan et al., 2003a). Each subscale was assessed individually. Scores were determined by summing the responses for the items in each subscale, and dividing the sum by the total number of items (score range = 1 to 9) (Corrigan et al., 2003a). The psychometric properties of the instrument were assessed using a sample of 542 students from a Midwestern community college, with the majority of participants identifying as White and female (Corrigan et al., 2003a). The reliability of each subscale was assessed, and the following alpha coefficients were obtained: personal responsibility = .70; pity = .74; anger = .89;

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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 measure of stigma associated with cocaine (Palamar et al., 2011). Reliability of the DUSS as a measure of stigma associated with cocaine was found to be high ( = .79; Palamar et al., 2011). Additionally, the mean score of perceived public stigma of cocaine users obtained during scale development was 3.66 (SD=0.68; Palamar et al., 2011). Familiarity Questionnaire. A third questionnaire was used to assess the familiarity of the participant with individuals having substance dependence disorders (see Appendix G). The specific set of items that was used was derived from Corrigan et al. (2003a), and was originally designed to assess an individuals familiarity with mental illness. For the purposes of this study,

COMPARING SUBSTANCE DEPENDENCE STIGMA the 7 items were modified, with the authors permission, to reflect familiarity with substance

23

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 ChiSquare 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 found between experimental groups in regard to the aforementioned demographic variables, and each of the demographic variables was relatively equally distributed throughout each condition. The demographic distribution between groups is provided in Tables 1 and 2. A one-way ANOVA was then used to compare participants average ratings on each of the measures of stigma by substance type. Specifically, each vignette was coded with a unique identifier within SPSS, which was then used to examine the differences between the six subscales of the Attribution Questionnaire, DUSS, and familiarity questionnaire. Between conditions, statistically significant differences were found within the fear (p < .001), helping (p <

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

24

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 between the demographic variables and scores on each of the measures. A one-way ANOVA was run to compare the gender, major, and ethnicity variables with mean scores on the stigma and familiarity questionnaires. The only significant difference to emerge from this analysis pertained to gender and familiarity. Specifically, females (M=3.22, SD=1.86) reported higher familiarity with substance dependence disorders than males (M=2.46, SD=1.67; p < .05). However, no significant differences were noted in the distribution of females between each of the three conditions. Thus, it is not likely that the relationship between gender and familiarity had an effect on comparisons of mean scores of stigma. In addition, a bivariate correlation

COMPARING SUBSTANCE DEPENDENCE STIGMA

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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 participants believed the person described in the nicotine dependence vignette was more responsible for his condition than the persons described in the alcohol or cocaine vignettes. One potential explanation for this result may be a public misperception that nicotine is not a drug. Without the knowledge that nicotine is a drug, people may be more likely to assume that its use is purely within the control of the user, and the inability to stop using it may be a lack of willpower, as opposed to actual drug addiction. The lower levels of stigma associated with nicotine dependence may have an unintended side effect. Specifically, the relatively lower levels of stigma associated with nicotine

COMPARING SUBSTANCE DEPENDENCE STIGMA 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.

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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. These results were particularly intriguing, as it had been proposed that the increased prevalence of alcohol consumption in the geographic region of the study would result in overall decreased levels of stigma regarding alcohol dependence. This notion was based on a comparison with Cunningham et al. (1993), who found that cocaine and alcohol use were rated as having similar degrees of stigma. In the current study, alcohol dependence was less stigmatized than cocaine dependence in regard to fear and personal responsibility. However, the methodological differences that exist between the current study and Cunningham et al. (1993) make recognizing the cause of these differences difficult. Thus, while the differences could

COMPARING SUBSTANCE DEPENDENCE STIGMA potentially be attributed to the increased prevalence of alcohol consumption in the current

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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 statistically significant, and demonstrate that increased exposure to persons with substance dependence disorders can possibly reduce stigmatizing beliefs. The items in the familiarity questionnaire shared a commonality, in that they all examined participants own personal experiences with substance dependent individuals. Thus, familiarity was based upon participants own personal interactions and observations rather than general knowledge of the disorders described. The results would suggest that familiarity based on this mode of exposure has the possibility to decrease stigmatizing attitudes. While this result could potentially suggest a new method to be used in anti-stigma efforts, it would seem research

COMPARING SUBSTANCE DEPENDENCE STIGMA is needed to determine how to effectively increase familiarity with substance dependent

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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 sympathy for, and more anger toward, the person described in the alcohol dependence vignette when compared with the person described in cocaine and nicotine dependence vignettes. In addition, the pity and anger subscales were the only measures of stigma whose results were not statistically significant different from nicotine. This result poses an interesting question about what makes feelings of pity and anger directed at alcohol dependent individuals different from the other beliefs examined in this study. One suggestion for future research is that these two beliefs be examined further to better understand their contribution to stigmatizing attitudes.

COMPARING SUBSTANCE DEPENDENCE STIGMA

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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. One such 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 of use rather than amounts used. The results of the current study can be compared to Corrigan et al. (2003a) to examine the stigmatization of substance dependence as a mental illness. In their study, Corrigan et al. (2003a) used the Attribution Questionnaire to obtain participants attitudes regarding an individual diagnosed with schizophrenia. When comparing their results with those obtained in the current research, the three substance dependence disorders represented were regarded as being associated with higher degrees of personal responsibility and anger, but lower degrees of pity and fear. However, it should be noted that no tests of statistical significance were run to

COMPARING SUBSTANCE DEPENDENCE STIGMA 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.

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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 amounts of diversity. Finally, the possibility exists that some participants may have taken the surveys twice, although this number was very small, so it is likely that the effect on scores was negligible. In conclusion, although studies have examined the stigma related to substance use, few comparisons have been made regarding the stigma associated with different substance types. Developing a better understanding of this topic seems crucial, as any differences that are found could have implications for both mental health professionals and the population they serve. Furthermore, additional comparative research could provide further insight into how stigmatizing

COMPARING SUBSTANCE DEPENDENCE STIGMA beliefs develop, in that comparisons of stigma across populations with different characteristics,

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

COMPARING SUBSTANCE DEPENDENCE STIGMA References Ahern, J., Stuber, J., & Galea, S. (2007). Stigma, discrimination and the health of illicit drug

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users. Drug & Alcohol Dependence, 88, 188-196. doi:10.1016/j.drugalcdep.2006.10.014 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. Corrigan, P. W., River, L. P., Lundin, R. K., Uphoff Wasowski, K., Campion, J. Mathisen, J., . . . Gagnon, C. (2000). Stigmatizing attributions about mental illness. Journal of Community Psychology, 28, 91-102. doi: 10.1002/(SICI)1520-6629(200001)28:1<91::AIDJCOP9>3.0.CO;2-M Corrigan, P., Markowitz, F. E., Watson, A., Rowan, D., & Kubiak, M. (2003a). An attribution model of public discrimination towards persons with mental illness. Journal of Health and Social Behavior, 44, 162-179. doi:10.2307/1519806 Corrigan, P., Thompson, V., Lambert, D., Sangster, Y., Noel, J., & Campbell, J. (2003b).

COMPARING SUBSTANCE DEPENDENCE STIGMA Perceptions of discrimination among persons with serious mental illness. Psychiatric Services, 54, 1105-1110. doi: 10.1176/appi.ps.54.8.1105 Crespo, 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

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Madrid (Spain). Community Mental Health Journal, 44, 393-403. doi: 10.1007/s10597008-9142-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. Journal of Behavioral Health Services & Research, 31, 418-429. doi: 10.1007/BF02287693 Geppert, C., & Bogenschutz, M. (2009). Ethics in substance use disorder treatment. Psychiatric Clinics of North America, 32, 283-297. doi:10.1016/j.psc.2009.03.002 Gilbert, G., Hannan, E., & Lowe, K. (1998). Is smoking stigma clouding the objectivity of employee performance appraisal?. Public Personnel Management, 27, 285-300. Retrieved from http://www.ipma-hr.org/node/21487 Gonzlez-Torres, M., Oraa, R., Arstegui, M., Fernndez-Rivas, A., & Guimon, J. (2007).

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Stigma and discrimination towards people with schizophrenia and their family members: 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-drugproblems 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 Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363-385. doi:10.1146/annurev.soc.27.1.363 Link, B. G., Phelan, J. C., Bresnahan, M., Stueve, A., & Pescosolido, B. A. (1999). Public conceptions of mental illness: Labels, causes, dangerousness, and social distance. American Journal of Public Health, 89, 1328-1333. doi:10.2105/AJPH.89.9.1328 Link, B., Struening, E., Rahav, M., Phelan, J., & Nuttbrock, L. (1997). On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. Journal of Health and Social Behavior, 38, 177-190. doi: 10.2307/2955424 Luoma, J. B., Twohig, M. P., Waltz, T., Hayes, S. C., Roget, N., Padilla, M., & Fisher, G.

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(2007). An investigation of stigma in individuals receiving treatment for substance abuse. Addictive Behaviors, 32, 1331-1346. doi:10.1016/j.addbeh.2006.09.008 National Alliance on Mental Illness (2011). NAMI: National Alliance on Mental Illness Mental 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, 46, 1457-1467. doi:10.3109/10826084.2011.596606 Pescosolido, B., Martin, J., Long, J., Medina, T., Phelan, J., & Link, B. (2010). "A disease like any other"? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. American Journal of Psychiatry, 167, 1321-1330. doi:10.1176/appi.ajp.2010.09121743 Piza Peluso, ., & Blay, S. (2008). Public perception of alcohol dependence. Revista Brasileira De Psiquiatria, 30, 19-24. doi:10.1590/S1516-44462008000100004 Ronzani, T., Higgins-Biddle, J., & Furtado, E. (2009). Stigmatization of alcohol and other drug users by primary care providers in Southeast Brazil. Social Science & Medicine, 69, 1080-1084. doi:10.1016/j.socscimed.2009.07.026 Smith, S. M., Dawson, D. A., Goldstein, R. B., & Grant, B. F. (2010). Examining perceived alcoholism stigma effect on racial-ethnic disparities in treatment and quality of life among alcoholics. Journal of Studies on Alcohol and Drugs, 71, 231-236. Retrieved from http://www.jsad.com/ Smith, V., Reddy, J., Foster, K., Asbury, E. T., & Brooks, J. (2011). Public perceptions, knowledge, and stigma towards people with schizophrenia. Journal of Public Mental Health, 10, 45-56. doi:10.1108/17465721111134547

COMPARING SUBSTANCE DEPENDENCE STIGMA Stuber, J., & Galea, S. (2009). Who conceals their smoking status from their health care provider?.Nicotine & Tobacco Research, 11, 303-307. doi:10.1093/ntr/ntn024 Wisconsin Department of Health Services, Population Health Information Section, Division of

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Public Health. (2010). Wisconsin epidemiological profile on alcohol and other drug use, 2010 (P-45718-10). Retrieved from http://www.dhs.wisconsin.gov/publications/P4/P45718.pdf Yen, C., Chen, C., Lee, Y., Tang, T., Ko, C., & Yen, J. (2009). Association between quality of life and self-stigma, insight, and adverse effects or medication in patients with depressive disorders. Depression and Anxiety, 26, 1033-1039. doi:10.1002/da.20413

COMPARING SUBSTANCE DEPENDENCE STIGMA Appendix A

Please 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; vespiak@uwgb.edu; (920) 465-2746 Research Assistant: Matthew D. Machnik

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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. Participation: Participation will involve reading a vignette and completing four brief surveys, which should take about 15 minutes in total. The first survey will collect demographic information, including age, gender, ethnicity, major, and year in school. Two questionnaires will ask about personal and public perceptions related to substance dependence disorders. A final measure will include items about participants 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 associated with 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 your name will be collected to ensure proper awarding of credit, it will be collected using a different electronic link and process than the one for completing the surveys. Your name will, therefore, be stored separately from your survey, and there should be no way to identify your individual survey responses. You will not be asked to provide your name, ID number, or any other information that would personally identify you on the survey instruments themselves. Your participation in this study is purely voluntary, and you have the right to cease participation at any time without penalty, as well as to choose not to answer specific survey items. Although it is not anticipated, if at any point you should experience any discomfort while completing the research materials, please stop and contact the principal investigator. You can also contact the campus Health and Counseling Center at 465-2380. If you have questions regarding the study, please contact Dr. Kristin Vespia using the information provided above. All materials used in the study have been reviewed by the University of Wisconsin-Green Bay Institutional Review Board. If you have any questions regarding research participant rights, please contact James Marker, current Chair of the Institutional Review Board, at markerj@uwgb.edu or (920) 465-2230. *Some information borrowed from the sample consent form provided on the UWGB IRB website (http://www.uwgb.edu/irb)

COMPARING SUBSTANCE DEPENDENCE STIGMA Appendix B 1. Age ______

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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) ___ Freshman ___ Sophomore ___ Junior ___ Senior ___ Super-Senior ___ Other: ___________________

COMPARING SUBSTANCE DEPENDENCE STIGMA Appendix C

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If you did not already print the consent form, please take this opportunity to print the following information 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; vespiak@uwgb.edu; (920) 4652746.

If you have any questions regarding research participant rights, please contact James Marker, current Chair of the Institutional Review Board, at markerj@uwgb.edu or (920) 465-2230.

COMPARING SUBSTANCE DEPENDENCE STIGMA Appendix D Cocaine Dependence: Thomas has been using cocaine for the past 18 months. During the past 12 months, he has

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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. 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 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 finds that when he is unable to drink alcohol, he experiences significant alcohol withdrawal symptoms. In order to overcome the withdrawal, he feels he needs to drink alcohol 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 alcohol use is having on his life, he continues to drink. Over the past 12 months, he has tried to quit drinking alcohol several times, but has been unsuccessful. As a result, Thomas has been diagnosed by a Psychologist as having alcohol dependence.

COMPARING SUBSTANCE DEPENDENCE STIGMA Appendix D (continued) Nicotine Dependence:

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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.

COMPARING SUBSTANCE DEPENDENCE STIGMA Appendix E Personal Responsibility Beliefs

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1. 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) 3. How irritated would feel by Thomas? (1 = None at all; 9 = Very much) Fear 1. How dangerous would you feel Thomas is? (1 = None at all; 9 = Very much) 2. I would feel threatened by Thomas? (1 = No, not at all; 9 = Yes, very much) 3. How scared of Thomas would you feel? (1 = None at all; 9 = Very much) 4. How frightened of Thomas would you feel? (1 = None at all; 9 = Very much)

COMPARING SUBSTANCE DEPENDENCE STIGMA Appendix E (continued) Helping 1. 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)

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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) 4. If I were in charge of Thomass treatment, I would force him to live in a group home. (1 = Not at all; 9 = Very much)

COMPARING SUBSTANCE DEPENDENCE STIGMA 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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COMPARING SUBSTANCE DEPENDENCE STIGMA Appendix G 1. My job involves providing services/treatment for persons with substance dependence disorders. (Yes/No)

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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)

COMPARING SUBSTANCE DEPENDENCE STIGMA Table 1 Age and Year in School Distribution between Conditions Cocaine M Age Year in School 20.04 1.51 SD 4.53 1.07 M 19.51 1.58 Alcohol SD 2.23 1.05 M 19.42 1.39 Nicotine SD 1.61 0.79

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Note. No statistically significant differences were found between conditions.

COMPARING SUBSTANCE DEPENDENCE STIGMA Table 2 Gender and Ethnicity Distribution between Conditions Cocaine N Gender Male Female Other Ethnicity Asian/Pacific Islander Black/African-American Hispanic/Mexican/Puerto Rican Native American White/Caucasian Other 2 0 1 2 47 1 4 0 2 0 48 1 1 1 0 1 50 1 12 40 1 12 43 0 13 41 0 Alcohol N Nicotine N

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Note. No statistically significant differences were found between conditions.

COMPARING SUBSTANCE DEPENDENCE STIGMA

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Table 3 Means and Standard Deviations of Measures with Tukey HSD Comparison Significance Levels Cocaine Measures Attribution Questionnaire Pity Anger Fear Helping Coercion-Segregation Personal Responsibility DUSS Familiarity Questionnaire 4.82 4.77 4.51 c. ** 3.39 c. ** 3.76 c. ** 5.98 c. * 3.96 c. ** 2.42 1.62 2.15 1.71 1.42 1.52 1.68 0.46 1.66 5.18 5.28 4.13 c. ** 3.32 c. ** 3.14 c. * 6.1 3.99 c. ** 2.78 1.6 2.08 1.74 1.14 1.46 1.39 0.49 1.77 4.58 4.76 2.73 a. ** b. ** 4.48 a. ** b. ** 2.4 a. ** b. * 6.75 a. * 3.08 a.** b. ** 2.65 1.74 2.13 1.59 1.7 1.42 1.17 0.67 1.78 M SD M Alcohol SD M Nicotine SD

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

COMPARING SUBSTANCE DEPENDENCE STIGMA Table 4 Correlations between Summed Scores on all Measures Measures 1 Personal Responsibility 2 Pity 3 Anger 4 Fear 5 Helping 6 Coercion-Segregation 7 DUSS 8 Familiarity Note. * = p < .05, ** = p < .01, *** = p < .001 1 --2 ***-.34 --3 ***.37 *-.16 --4 .11 .01 ***.36 --5 *-.16 ***.30 -.12 **-.23 ---

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6 .10 *-.17 ***.31 ***.63 **-.21 ---

7 -.01 -.03 .14 ***.44 ***-.50 ***.40 ---

8 -.13 *.17 *-.17 *-.18 *.18 ***-.26 **-.23 ---