Drug and Alcohol Review, (March 2005), 24, 143 – 155

Stigma, social inequality and alcohol and drug use

ROBIN ROOM

Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm, Sweden

Abstract
A heavy load of symbolism surrounds psychoactive substance use, for reasons which are discussed. Psychoactive substances can
be prestige commodities, but one or another aspect of their use seems to attract near–universal stigma and marginalization.
Processes of stigmatization include intimate process of social control among family and friends; decisions by social and health
agencies; and governmental policy decisions. What is negatively moralized commonly includes incurring health, casualty or
social problems, derogated even by other heavy users; intoxication itself; addiction or dependence, and the loss of control such
terms describe; and in some circumstances use per se. Two independent literatures on stigma operate on different premises: studies
oriented to mental illness and disability consider the negative effects of stigma on the stigmatized, and how stigma may be
neutralized, while studies of crime generally view stigma more benignly, as a form of social control. The alcohol and drug
literature overlap both topical areas, and includes examples of both orientations. Whole poverty and heavy substance use are not
necessary related, poverty often increases the harm for a given level of use. Marginalization and stigma commonly add to this
effect. Those in treatment for alcohol or drug problems are frequently and disproportionately marginalized. Studies of social
inequality and substance use problems need to pay attention also to processes of stigmatization and marginalization and their
effect on adverse outcomes. [Room R. Stigma, social inequality and alcohol and drug use. Drug Alcohol Rev
2005;24:143 – 155]

Key words: stigma, marginalization, social inequality, alcohol problems, drug problems, social control, moralization

Introduction often resulting in stigma and marginalization, and that

This paper discusses stigma and marginalization in
connection with psychoactive substance use, and how
these affect patterns by social class and other social
inequalities. The paper starts from the point that
adverse outcomes (such as mortality) from heavy
alcohol and drug use are much more strongly related
to lower social class position [1] than the patterns of
heavy alcohol and drug use themselves. As will be
discussed, there are certainly mechanisms by which
poor people can suffer worse outcomes than more
affluent people for the same behaviour. My argument is
that, in the case of alcohol and drug problems, an extra
factor has been relatively neglected: that alcohol and
drug use and problems are heavily moralized territories,
these factors are important in the adverse outcomes.
In a substance use context, poverty and
marginalization are not necessarily causally prior
While the term ‘social inequality’ encompasses differ-
ences on other social differentiations such as gender,
age or ethnoreligious category [2], the main emphasis
in public health usage has been on socio-economic
differentiations. Even here, it is well recognized that
there are definitional and measurement choices to be
made: poverty can be defined in absolute or in relative
terms [3]; and the variables often included in measures
of socio-economic status, such as education, income
and occupational and neighbourhood status, differ both

Robin Room, Professor and Director, Centre for Social Research on Alcohol and Drugs, Stockholm University, S-106 91 Stockholm, Sweden. E-
mail: robin.room@sorad.su.se.
Prepared for presentation at an Exploratory Workshop on Alcohol, Illicit Drugs and Addiction Research, Academy of Finland, Helsinki, 14
December, 2004. Parts of it draw on a paper, ‘Thinking about how social inequalities relate to alcohol and drug use and problems’, presented at a
conference on Inequalities and Addictions at the National Centre for Education and Training in Addictions, 25 – 27 February, 2004, Adelaide,
South Australia.

Received 8 December 2004; accepted for publication 20 January 2005.

ISSN 0959-5236 print/ISSN 1465-3362 online/05/020143–13 # Australian Professional Society on Alcohol and Other Drugs
DOI: 10.1080/09595230500102434
144 R. Room
conceptually and also often in their relationship to
health outcomes (e.g. [4,5]).
By and large, the public health literature takes the
attribute of being disadvantaged as causally prior in
considering its relation to life-style factors such as
substance use and to health outcomes. There is a
certain logic to this, where the kind of outcome being
considered is a death from heart attack, liver cirrhosis
or AIDS. Even in the sphere of physical health,
however, the model becomes more questionable when
the outcome in question is shifted from death to
illness or disability; the existence of the illness or
disability may bring a downward drift in socio-
economic status [6]. To the extent that the illness
is caused by substance use, the causal arrow between
the use and the socio-economic status is then
potentially bidirectional.
When consideration extends beyond physical to
include mental health, there are further complications.
In the first place, an aspect of the substance use now
becomes potentially the end-point, rather than an
intermediator, in the form of alcohol and drug
dependence and other substance use disorders.
Secondly, with mental disorders the issue of the
element of social definition in the end-point becomes
inescapable. While there is an element of social
construction and definition in all illness, the threshold
of what becomes defined as a mental disorder is often
set by the reactions of others to behaviours which they
are defining as ‘strange and odd’ [7]. The element of
social construction is particularly important when it
comes to substance use disorders, and for that matter
such partly medicalized social categories as ‘substance
abuser’. More generally, the use of alcohol and drugs
is strongly moralized, and those transgressing moral
norms are subject to stigma and social marginaliza-
tion.
Stigma, poverty and alcohol and drug problems
We may take as a working definition of stigma, in the
context of alcohol and drug use, the one used in the law
of a US state, Wisconsin:
‘Stigma’ means disqualification from social accep-
tance, derogation, marginalization and ostracism
encountered by. . . persons who abuse alcohol or other
drugs as the result of societal negative attitudes,
feelings, perceptions, representations and acts of dis-
crimination [8].
Those who are stigmatized or marginalized are often
poor, and otherwise lacking social resources; but there
is no necessary relation between stigmatization and
poverty or other social inequalities. The empirical
overlap between those who are marginalized and those
who are poor has long been recognized to be partial;
Shaw’s distinction between the ‘deserving’ and the
‘undeserving poor’ in Major Barbara reflected the
common social welfare distinction of the time (one
that has come back into favour in our neoliberal times
[9]). On the other hand, it is also possible to be rich
and stigmatized and marginalized, although the
affluent are ipso facto better able to purchase protec-
tion from this.
There is also no necessary relation between
psychoactive substance use and stigma or margin-
alization. In the developed countries today this is
most obvious for alcohol, where drinking is closely
associated with many positively valued and high-
prestige activities and statuses—we have only to
mention champagne for a wedding reception, or
complimentary drinks for first-class passengers. It is
also now true, at least in some youth subcultures, for
some forms of illicit substance use—e.g. ecstasy at a
rave, or cannabis at a student party. On the other
hand, as we shall discuss, some aspects of psychoac-
tive substance use seem to attract near-universal
stigma and marginalization.
Sources of social value and derogation
What are the properties of psychoactive substances
which are relevant to social valuation or derogation? In
the first place, psychoactive substances are valued
physical goods. Their status as physical goods renders
them subject to commodification, and indeed globali-
zation in use and trade. Given their positive valuation,
possession and use has often been a symbol of power
and domination [10], or at least of access to resources
beyond subsistence.
Secondly, using psychoactive substances is a beha-
viour, and very often a social behaviour. There are thus
many social and cultural associations, mostly positive,
around the use of the substance. Toasting in cham-
pagne as a symbol of celebration, the cannabis joint
passing around the circle of users, the wine circulating
at a family holiday meal, the sense of community that
may be engendered at a rave, are all contemporary
images which conjure up the social meanings which
become attached to the use and which extend beyond
the psychoactive effect per se of the substance. Use of
the substances socially means that the use often serves
to demarcate the boundaries of inclusion and exclusion
in a social grouping [11]—so that the use of a
psychoactive substance in itself can signal social
exclusion and marginalization.
Thirdly, psychoactive substance use is a peculiarly
intimate behaviour, in that the substance is taken into
the body. Any such substance is a potential source of
contamination and poison, as well as of nutrition,
pleasure or solace. In this respect, psychoactive
substances are a part of the more general category of
foodstuffs and drinks, and carry at least their share of
Table 1. Degree of social disapproval or stigma – relative ordering from lowest to highest mean rating within each countr

Country

Condition (ordering in total sample; Canada China Egypt Greece India Japan Luxem- Nether- Nigeria Romania Spain Tunisia Turkey UK
1 = least stigma) bourg lands

Wheelchair bound (1) 2 3 1 5 2 5 2 2 1 3 2 1 1 2

Blind (2) 1 5 2 2 4 9 1 1 3 1 1 2 3 1
Inability to read (3) 6 6 3 3 1 2 5 3 2 5 4 5 2 6
Borderline intelligence (4) 3 4 4 7 5 7 3 4 5 7 5 7 6 4
Obese (5) 9 1 5 1 3 1 4 7 4 4 6 3 14 11
Depression (6) 5 2 10 4 6 15 6 6 9 2 3 12 5 3
Dementia (7) 4 8 7 6 9 10 9 8 7 8 7 4 9 5
Facial disfigurement (8) 7 7 8 8 8 3 7 10 6 6 8 9 8 7
Cannot hold down a job (9) 10 11 12 10 10 4 8 9 11 10 11 11 7 10
Homeless (10) 16 9 6 9 7 12 13 15 8 16 10 8 12 8
Chronic mental disorder (11) 12 13 11 12 14 17 10 8 15 9 9 10 10 12
Leprosy (12) 11 16 9 15 13 11 11 11 18 13 14 6 13 9
Dirty and unkempt (13) 15 14 13 11 12 8 12 12 12 12 13 13 11 14

Stigma, social inequality and alcohol and drug use

Does not take care of their children (14) 18 10 16 14 11 6 16 14 10 11 15 17 4 17
Alcoholism (15) 8 12 15 13 15 14 15 16 13 14 12 14 17 15
Criminal record for burglary (16) 13 17 17 16 16 13 17 17 17 18 16 15 15 16
HIV positive (17) 14 18 14 18 17 16 14 13 14 15 18 16 16 13
Drug addiction (18) 17 15 18 17 18 18 18 18 16 17 17 18 18 18

n of key informants 15 15 16 15 47 18 16 13 15 15 18 15 15 12

Source: Room et al., 2001:276.

145
146 R. Room
the complex of prescriptions and taboos which
surround what is ingested [12,13].
Fourthly, by definition psychoactive substances affect
thinking and feeling, and are often expected to affect
behaviour—even to the extent that the substance may
be seen as possessing the user, submerging the true self
[14]. The psychoactive qualities of the substances is
what makes them both ‘prized’ and feared as ‘danger-
ous’, as Steele & Josephs [15] put it. The psychoactivity
accounts both for much of the positive valuation on the
substances and for much of the moral loading that
commonly surrounds their use.
For all these reasons, a heavy load of symbolism
thus often attaches to the use or non-use of
psychoactive substances. The use may be a positive
signal of power or status, may be heavily derogated or
stigmatized, or may simply be an expression of
difference without strong implications for power or
status.
Psychoactive substances and social institutions
and rubrics
Psychoactive substance use and its risks are influenced
or governed by social institutions and professions. In
many countries, for instance, alcohol can only be sold
with a government licence, carrying with it limits on the
circumstances of sale. By international agreement,
some psychoactive substances are available only when
permitted by a prescription from a physician, with a
licensed pharmacist usually actually providing the
substance.
Use of psychoactive substances results in a variety of
social and health consequences, both immediate and
chronic. Included are not only chronic and acute health
consequences to the substance user, but also injury and
other harm to others and problems in work and family
roles. The full range of social institutions and profes-
sions which respond to and handle health, casualty and
social problems are involved in responding to psy-
choactive substance problems.
Each of the professions and institutions tends to be
associated with a particular governing image or rubric
of the problems with which it deals. Physician and
hospitals deal with illness, psychiatrists and mental
illness clinics specifically with mental illness, police and
judges with crime, welfare workers and social welfare
with disability or destitution, priests and churches with
sin. Problems from alcohol or drugs sometimes fall
between these jurisdictions, but more commonly fall
into areas of shared jurisdiction. It is thus not obvious
which institutional system should be assigned the
primary jurisdiction, and there are considerable differ-
ences from one society to another, and sometimes from
one substance to another, in this. Thus the health
system has primary jurisdiction for alcohol problems in
Italy and Denmark, while the welfare system has
traditionally had primary responsibility in Sweden and
Finland. In Denmark, on the other hand, drugs are
handled by the welfare system. Responsibility can be
shifted between systems, sometimes abruptly; thus, for
a couple of years in California in the late 1960s,
alcoholism was shifted from being a health disorder to
being a vocational disability [16]; for that period, if a
Californian did not need help with getting or keeping
work, he or she was not eligible for alcoholism
treatment.
A primarily US-based sociological literature, using
‘deviance’ as its general term for problems considered
to need social handling, has emphasized a general shift
in the 20th century from crime to illness models of
deviance. On the other hand, the literature has
acknowledged that the trend had been in the opposite
direction in the first half of the 20th century for illicit
drugs in the United States [17]. The general percep-
tion, in a US context, has been that more stigma is
associated with crime or vice than with disease, so that
the alcoholism movement, for instance, dedicated itself
to persuading the society that changing the conceptua-
lization of alcohol problems from vice or crime to
illness would diminish the stigmatization of those with
the problems [18].
The generalized and ubiquitous stigma of
alcoholism and addiction
The question of how much the stigmatization of those
with a particular problem is affected by changing its
rubric, or even its social handling procedures, remains
open. For one thing it has long been recognized that, in
the minds of many in the general population, the
rubrics are not mutually exclusive: those who subscribe
to a disease model of alcoholism are also ready to think
of it as a vice or moral weakness [18]. Thus the intent of
the alcoholism movement in putting forward the
disease concept of alcoholism, that it should replace
the ‘old moral model’, has not been realized. As a
recent US discussion put it, ‘in spite of two centuries of
claims that addiction is a disease, and more recently
that it is similar to other chronic diseases, the idea that
addiction is rooted in repeated bad choices remains
widely compelling’ [19]. Alcoholism and drug addic-
tion are, on the one hand, from the perspective of
medical nosology and public health, categories in the
international classification of health disorders, under
their professional names of alcohol and drug depen-
dence. On the other hand, in social terms both
alcoholism and drug addiction are thoroughly mor-
alized and derogated categories. Both ‘alcoholism’ and
‘drug addiction’ ranked near the top, in terms of degree
of social disapproval or stigma reported by local key
informants, in a list of 18 conditions ranked for 14

Table 2. Marginalization and the health system: health status, utilization and attitudes among categories of the disadvantaged
living in poor districts in Portugal (in percentage)
Alcohol addicts Hard drug users Homeless
Health5‘good’ 100 96 100
Used health ser- 15 35 12
vices
Bad opinion of 42 31 50
health services
Source: Santana, 2002.
different countries in a WHO study (Table 1)—in all
but two countries, for instance, above being ‘dirty and
unkempt’; while in all but three being a drug addict was
reported to be more disapproved or stigmatized than
having a criminal record for burglary [7, p. 276].
An individual’s patterns of psychoactive substance
use, in a great many societies, are thus not only a matter
of public health interest, but are also a subject of social
evaluation in terms of approval or disapproval, of
honour or stigma, in everyday life. The evaluations
attached to a particular pattern of substance use vary
over time and between cultures, and often vary also
within a culture according to circumstances and who is
using. Disapproval may be expressed in the form of
state sanctions, up to and including being deprived of
life, liberty or property.
Whatever we may think of these moral evaluations,
an analysis which takes into account social realities
cannot ignore them. In this sense, patterns of psy-
choactive substance use, particularly through the social
evaluations of them, become involved in the creation of
marginalization, social exclusion and stigma. This is a
familiar territory for sociologists and criminologists. In
sociological theories of labelling and deviance the
pattern of substance use becomes the ‘primary
deviance’, the negative social evaluation of which
initially potentially sets the user on the road to
marginalization and exclusion [20]. In the classic
scenario, the marginalized users then find each other,
and form a mutually supportive counterculture which
cements its members into a further marginalization
through ‘secondary deviance’. At the end-point of this
process, the deviant substance user is fully marginalized
and socially excluded, indeed extruded from respect-
able society.
The universality and inevitability of this scenario has
been challenged empirically, at least for mental illness
[21]. However, by whatever mechanism, there is no
doubt that some patterns of substance use—archety-
pally, the patterns of drinking which become defined as
‘alcoholism’—entail a process of social degradation and
exclusion, a process described in classic Alcoholics
Anonymous language as ending in the drinker ‘hitting
bottom’.
Stigma, social inequality and alcohol and drug use 147
Ex-prisoners Single mothers Poor elderly
90 87 99
20 35 58
29 28 26
A glimpse of the processes of social devaluation
directly relevant to health outcome can be seen in the
literature on public opinion about which personal
characteristics should be taken into account in setting
health priorities. Summarizing six studies from Britain,
the United States and Australia, Olsen et al. [23] report
that respondents felt that tobacco smokers, ‘high’
alcohol users and illegal drug users should all receive
less priority in health care. Often the justification given
is the belief that the users’ behaviour contributed to
their own illness. Along the same lines, the 14-country
WHO study found that, in responses on scenarios
involving alcohol or heroin problems, the ‘theme of
personal responsibility became vividly apparent’ [7, p.
260]. Studies in health services show that the care given
is in fact likely to be inferior if the patient is seen as a
skid-row drinker or a similarly derogated category (e.g.
[24,25]). Santana [26] found that among nine cate-
gories of ‘disadvantaged people’ interviewed in a
population sample in deprived districts in Portugal,
those identified as alcoholics were, along with the
homeless, the least likely to have used health services,
despite 100% having less than good health, and the
most likely to have a ‘bad’ or ‘very bad’ opinion of the
health services (see Table 2). To the extent access to
good health care affects health status, these findings
illustrate a direct path by which exclusion and margin-
alization can affect health status.
Sources and objects of substance use-related
stigmatization
If we focus on processes in an ongoing society, we can
conceive of stigmatization and marginalization as
proceeding from three main sources:
There are the intimate processes of social control and
censure among family and friends (e.g. [27,28]) which
are frequently effective, but which may also result at
length in the family and friends becoming fed up and
pushing the user out of the family or into treatment
[29,30].
There are the decisions by social agents and agencies,
which tend to focus attention on the most problematic
 148
R. Room
Table 3. Percentage of informants responding ‘People would think it was wrong’ for a person to appear in public, by country

Country

Condition Total % Canada China Egypt Greece India Japan Luxembourg Netherlands Nigeria Romania Spain Tunisia Turkey UK

A woman in her 8th month of pregnancy 2 0 0 0 0 4 0 0 0 7 0 0 0 7 0

Someone who is blind 3 7 0 0 0 6 0 0 0 7 13 0 0 0 0
A person in a wheelchair 2 0 0 0 13 7 0 0 0 0 0 0 0 0 0
An obese person 12 20 7 13 7 6 19 31 8 13 0 17 0 20 8
A person who is intellectually ‘slow’ 7 7 0 0 0 4 23 0 0 13 0 0 14 33 8
Someone with a face disfigured from burns 6 0 33 6 0 0 0 12 0 20 0 0 13 7 0
Someone with a chronic mental disorder who ‘acts 15 0 33 0 20 17 12 19 17 13 27 22 0 0 17
out’
Someone who is dirty and unkempt 25 20 27 69 20 17 0 44 8 47 40 17 43 0 33
Someone who is visibly drunk 46 13 27 88 27 46 6 81 8 80 73 50 79 14 50
Someone who is visibly under the influence of drugs 58 20 57 100 40 67 M 56 17 64 67 56 79 M M

n of key informants 245 15 15 16 15 47 18 16 13 15 15 18 15 15 12

Source: Room et al., 2001:281.

Note: The question was ‘Please indicate how people in this society would react to a person with the health condition appearing in public’. ‘Think it was wrong’ refers to
responses: ‘People would think it was wrong, and might say something about it’ and ‘People would think it was wrong and try to stop it’. M = question not asked.

cases and to amplify their marginalization [31]. Even
official actions intended as positive steps toward social
reintegration may result in marginalization if the case
does not ‘succeed’ (e.g. [32]).
There are also policy decisions at the local or national
level which result in marginalization. For example, the
US law that a family should be evicted from public
housing if any member of the family is associated with
drug dealing has the result of increasing marginaliza-
tion. More generally, policy decisions to be ‘tough on
drugs’ always carry the potential to stigmatize and
marginalize those who do not conform.
Marginalization of those defined as having alcohol or
drug problems is thus a process which can have both
elements which are personal and interactional and
elements which are institutional and structural.
Underlying the process is the heavy moralization and
stigmatization of substance use which is defined as
problematic—not least by other substance users, who
often define themselves in contrast to the problematic
category [33]. The underlying determinant of what is
problematic is the occurrence of problems which are
ascribed to the substance use: illness, violence, casual-
ties, and failure in major social roles, particularly at
work and in the family. Part of modernity, starting in
the early 19th century [34], seems to have been an
increased willingness to see first alcohol, and later other
psychoactive substances, as causal agents in these
calamities and failures in responsibility.
From the point of view of the substance user, this
fundamental and minimum level of moralization of
substance use operates in terms of ‘getting caught’. In
the company of other heavy drinkers, there may be little
or no moral loading on the drinking behaviour itself.
The ideal of the ‘competent drinker’, as Gusfield [35,
pp. 124 – 5] describes it among the heavy drinkers he
studied, is not defined in terms of characteristics of the
drinking behaviour, but instead simply in terms of the
drinker’s ‘self-judgement of his state of risk accep-
tance’, i.e. the ability to handle himself without adverse
consequences. But if the drinker misjudges—or if he
simply gets caught out in a situation where the risk may
have been low but not zero—then moral disapproval
descends on him, not only from society in general but
also from other heavy drinkers, to whom he now
appears as an incompetent drinker, one who has ‘let the
side down’. Similar conceptual mechanisms can be
seen at work for use of other drugs, for instance in
Slavin’s study [36] of socially integrated methedrine
injectors, who—far out on the distribution of drug use
as they themselves were—distinguished themselves
from ‘junkies’ in terms of their own sense of ‘control’
of their risks. Slavin notes his own discomfort at the
‘pejorative language’ of his informants concerning the
‘junkies’, but also notes that the distinction they make
Stigma, social inequality and alcohol and drug use 149
‘works in some ways to reduce drug related harms for
these men and keep them ‘‘functional’’.
We may see three other areas of moralization and
stigmatization built on this fundamental understanding
of adverse events and consequences of the substance
use. The first is the moralization of intoxication itself.
At a minimum, to be stoned or drunk in specific
circumstances—e.g. when about to drive a car, or as a
parent looking after small children—is unacceptable to
nearly everyone [37]. For those who do accept getting
intoxicated or high at all, it should be in periods and
circumstances of ‘time out’ [38], when the risks are
limited and those in attendance are presumably
assuming the attached risks. But acceptance of
intoxication as a desirable or morally acceptable state
is rare in ‘serious’ public discourse in many modern
societies, inhabiting instead the realm of literary and
other artistic works (e.g. [39,40]). Table 3 shows the
proportion of key informants in each of 14 countries
reporting that ‘people would think it was wrong’ for a
person with each of 10 named conditions to appear in
public. Overall, the conditions most likely to be
socially excluded were ‘someone who is visibly drunk’
and ‘someone who is visibly under the influence of
drugs’.
The moralization of intoxication means that advo-
cates of the argument that alcohol problems are best
controlled by integration of drinking in cultural
practices specify carefully that they do not include
intoxication, however culturally integrated it may be.
Thus, for instance, Morris Chafetz, long a leading
exponent of this position, specified that anyone who
‘has been intoxicated four times in a year’ should be
considered a problem drinker [41]. Similarly, those
touting the advantages of drinking have been careful to
specify that it is moderate drinking, and not intoxication,
which they favour: ‘Citizens for Moderation [repre-
sents] the interests of [those] who consume responsibly
and in good health’ [42]. Conflating intoxicated bad
behaviour with addiction, and arguing for a ‘moral
vision of addiction’, Stanton Peele [43] called for
inculcating ‘values that are incompatible with addiction
and with drug- and alcohol-induced misbehaviour’,
contrasting ‘values toward health, moderation and self-
control’ with ‘the immorality of addictive behaviour’.
Those on the ‘wetter’ side of debates about drinking
practices and policies have thus been at pains to
differentiate controlled or moderate drinking from
intoxication, and to assign opposite moral valences to
them—negative for intoxication, but positive for con-
trolled or moderate drinking.
Intoxication has thus remained morally reprehensible
or at least questionable in most public discourse
throughout the modern period. The stigma on intox-
ication is so taken for granted that what exactly is wrong
with it is not often spelled out. There seem to be three
150 R. Room
related elements. A person under the influence of
alcohol or drugs is seen as unpredictable, and thus
anxiety-provoking for those in the vicinity. The
intoxication is seen as disinhibiting, and thus as
potentially resulting in bad or injurious behaviour
[14]. And to be intoxicated is also to abandon the
norm of ‘sober attention as the normative mode of
consciousness for every waking minute’, in the modern
world of exacting machinery and intellectual work [44].
A second area of moralization and stigmatization is in
terms of addiction or dependence. We have already
noted above the high level of stigma around alcoholism
and addiction (see Table 1). A loss of control—over the
substance use and over one’s life—has always been the
central element in modern cultural understandings of
the nature of alcoholism and addiction, so that they
have often been characterized as ‘diseases of the will’
[45]. Half a century ago, Edwin Lemert collected a
number of statements of American attitudes toward the
alcoholic, and noted that the ‘general theme under-
lying’ them ‘has to do with lack of self-control on the
part of the drinker’. Lemert went on to note the
stigmatization that this theme inevitably involved: ‘This
societal symbolism of the deviation as a sign of
character weakness is one of the most vivid and
isolating distinctions which can be made in a culture
which attributes morality, success, and respectability to
the power of a disciplined will’ [46].
A third potential area of moralization and stigmatiza-
tion is less universally applied: stigmatization in terms
of substance use per se. For alcohol, the general
stigmatization applies only in certain cultural milieux,
e.g. for Mormons or for Moslems, although there are
statuses or circumstances—a pregnant woman or an
on-duty bus driver, for instance—where any use tends
to be stigmatized. For tobacco, cigarette smoking has
increasingly taken on a somewhat stigmatized status
[47]; as might be predicted, it is lung cancer patients,
those who have been ‘caught’ in adverse consequences
from the smoking, who feel the stigma most keenly
[48]. The aim of ‘just say no’ policies on drugs is
generally to render use of the drugs socially unaccep-
table, that is to stigmatize use, and users in fact report
that they do experience some stigma [49].
Studying stigma
There are two literatures on stigma, operating on very
different premises. One literature, oriented primarily
around illness, mental illness and disability, focuses on
those who are already in a stigmatized status or
condition; stigma is taken for given as a discriminatory
social evil. The studies often consider the negative
effects of stigma on the stigmatized person or on the
professional – patient interaction (e.g. [50,51]), from
the perspective of how the stigma or these effects can be
neutralized (e.g. [52,53]. Aligned with this literature
are substantial public policy initiatives, like the Wis-
consin legislation quoted at the start of this paper,
which provides that the state agency may ‘develop and
implement a comprehensive strategy to reduce stigma
of and discrimination against persons with mental
illness, alcoholics and drug dependent persons’ [8].
The other literature, oriented primarily around
crime, generally views stigmatization as a form of social
control [54], either as an aspect of judicial punishment
of crime [55 – 57], or as social norms which potentially
deter even without formal punishment (e.g. [58,59]). In
the context of this literature, stigma is often viewed
benignly, as an effective way of deterring bad corporate
conduct [55], or as a less harsh alternative to punish-
ment by the state [58]. The argument against harsh
punishments too liberally applied becomes that they
lose their effectiveness through ‘stigma saturation’, i.e.
a reduction in their power to stigmatize [56]. Aligned
with this literature, too, are public policy initiatives,
including those which frequently justify their provisions
by the need to ‘send a message’ about what is and is not
considered tolerable behaviour.
The two literatures thus examine two ends of a
common process. One considers the deterrent value of
stigma as a means of social control—where the ideal
result might be universal primary deterrence so that no
one was actually stigmatized. The other considers the
real-life circumstance where the ideal has not been
attained, and the effects of stigma on those who have
not been successfully deterred. In general, the studies
of stigma as a means of social control recognize that the
result may not in fact always be social control and
conformity. As mentioned above, a whole sociological
literature on ‘secondary deviance’ is devoted to study-
ing processes which may be construed as failures of
stigma to result in conformity. In contrast, the literature
on stigmatization and mental health seems generally to
be less alive to the possibility that efforts to reduce
stigma may also have unintended effects. One example
where this was found, however, is the classic evaluation
of the effects of a positive mental health campaign in the
1950s, Closed Ranks [60], which found that efforts to
persuade a community to see mental health was a
continuum, as opposed to seeing mental illness as a
separate state, were strongly resisted, putatively because
the continuum model threatened the community’s
toleration of its more ‘eccentric’ citizens.
As discussed above, the alcohol and drug field falls
into and overlaps the field both of mental health and of
crime. Some parts of the field are usually considered
under a crime rubric—drinking driving is a good
example—and easily subsumed in the stigma-as-
social-control literature. Thus Blume [54] discusses
‘stigmatizing drunk drivers’ in approving terms in his
concluding argument. On the other hand, cases under

treatment for alcohol and drug problems are easily
subsumed into discussions of stigma and mental illness,
as in the Wisconsin legislation quoted above. However,
as a matter of cultural politics, it is difficult to extend
either framing of stigma to cover the whole alcohol and
drug field. On the one hand, it is unusual nowadays to
find direct arguments for the stigmatization of those
who have a history of alcohol or drug problems, but
who are now sober. For that matter, to the extent
alcohol or drug addiction is construed as a disease, it is
legally impermissible as ‘cruel and unusual punish-
ment’ in the United States to punish an addict for
exhibiting the signs of the disease [61]. On the other
hand, policies against stigma usually carefully exclude
from their scope those who are at the time under the
influence of alcohol or using drugs [62]. Discussions of
stigma in the alcohol and drug field have primarily been
clinically-orientated considerations of the stigma on
those treated for alcohol or drug problems, from the
perspectives of stigma as a barrier to coming to
treatment (e.g. [63]), managing the stigma post-
treatment (e.g. [64]), or documenting or decrying
public attitudes (e.g. [65]). One study considers
empirical evidence on the adverse effects of post-
treatment stigma [22].
Thinking about social inequality, marginalization
and alcohol and drug problems in a common
frame
Some problems from alcohol and drug use are a direct
physiological effect of the accumulation of use—usually
relatively heavy use—over a long time. These notably
include chronic physical harm such as liver cirrhosis or
lung cancer. The relation here may be relatively
uncomplicated by the social evaluation of the beha-
viour, so that marginalization and stigma may play only
a small role. More important in the relation between
poverty and the harm may be market factors in terms of
the price and promotion of products containing the
substance. As the very poor in China move into the cash
economy, cigarettes become available to them as a
regular consumption item for the first time; the
eventual result will be rising rates of lung cancer at
the bottom as well as top of the socio-economic ladder
in China [66]. Similarly, the relatively high taxes on
alcohol in the United Kingdom for most of the 20th
century meant that liver cirrhosis used to be a disease of
the relatively well-off in Britain [67]. The fall in the
price of alcoholic beverages relative to spending power
has now put cirrhosis within reach of the poor in
Britain; thus the index of inequality in male cirrhosis
mortality by social class in England and Wales rose
from 0.88 in 1961 (i.e. fewer cirrhosis deaths in lower
social classes) to 1.40 in 1981 (a 40% excess of deaths
in lower social classes [68]). An analogous shift was
Stigma, social inequality and alcohol and drug use 151
found in Sweden from the 1960s to the 1990s in the
relative class positions for heavier drinking and for
alcohol-specific hospitalizations [69].
Even for chronic health problems, however, poverty
may increase the harm from a given level of substance
use. For example, nutritional deficiencies may interact
with alcohol in raising the risk of cirrhosis. Moral
considerations and stigma may also play a role in the
handling and chances of the individual case. An
example is the conditions which the medical system
may set for a liver transplant for cirrhosis or a lung
transplant for lung cancer. Abstinence from alcohol for
a considerable time is usually a precondition for one
and abstinence from nicotine for the other, under
conditions which cannot be justified on purely medical
grounds, and which clearly include a moral element
[70]. The poor and particularly the marginalized are
likely to be disadvantaged in these processes.
Other problems from alcohol and drug use are a
result of a single occasion of substance use. These
include overdoses, injuries from accidents or violence,
and infections, as well as such social reactions as police
arrests. Here poverty is likely to play a part in increasing
the risk of harm from a given occasion of use. A poor
drinker or drug user will have fewer resources to reduce
risks by hiring a taxi or buying an unused needle, and
often will be less secluded or protected from risks in the
environment and the reactions from others. However, it
is surprisingly difficult to find comparable data which
quantifies the effects of social inequality on the harm
resulting from equivalent behaviour. Studies in the
United States looking for police bias by social class or
race in drinking-driving arrests, for instance, have not
necessarily found it (e.g. [71,72]).
A Stockholm County study gives a sense of the
combined effect for chronic and acute alcohol-specific
harms to health. Comparing rates of relatively heavy
drinking among manual workers in 1984 with those
among higher level non-manual workers, the rates for
manual workers were about 1.5 times higher for men,
and about equal for women. But hospitalization rates
for alcohol-specific causes were more skewed between
the social classes: rates for manual workers in the
county in 1980 – 84 were 3.6 times as high for men and
2.5 times as high for women as for the higher level
nonmanual workers (recalculated from Romelsjö &
Lundberg [69, Tables 2 and 4]).
A third class of problems are adverse social con-
sequences of the substance use—effects of drinking in
such areas as family relationships, friendships, and work
performance and standing. Both specific occasions of
use and the cumulation of a use pattern over time are
likely to be involved in the occurrence of these
problems, although it is clear that the likelihood of
the problems occurring is much greater when enough
use to get high or intoxicated is involved (e.g. [73].
152 R. Room
Some general population surveys have found that the
ratio of adverse consequences to heavy drinking rates is
greater for those of lower SES than for those of higher
SES. Thus Cahalan and Room [74, p. 91] found that
the rate of adverse consequences was almost twice the
rate of those with heavy drinking but no consequences
in the lowest social class group, but about two-thirds
the rate in the two upper social class groups. On the
other hand, Hilton [75, pp. 202 – 3] did not find such a
great discrepancy in a later US survey, and Harford et
al. [76] actually found some reverse effects of education
(a greater ratio of consequences to intoxication for the
more educated) in regression analyses of the same data.
The results of such analyses are influenced by what is
used as the measure of social class or position and what
constitutes the measure of social problems from
drinking.
These results come from surveys of those living in
households. Those who are really at the margins of a
society—the homeless, those temporarily staying with
friends or family, some of those living in group
quarters—are typically not included in the sample for
such surveys. General population surveys provide a
relatively good frame for studying the effects of social
inequalities for relatively stable poor populations, those
living in families and with some regularity of employ-
ment or social support; but a household-based sample
is not a good frame for studying the marginalized and
socially excluded.
Conversely, those in treatment for alcohol or drug
problems are certainly more often than not poor.
What is most striking about them is their high degree
of marginalization. In this they differ considerably
from those identified as having alcohol or drug
problems in general population studies. The clinical
populations have heavier use habits and a much more
diverse range of personal and social problems from
their substance use than all but a small fraction of
those in general population samples. Particularly for
alcohol problems, the average age of clinical popula-
tions is older than the average age of those with
problems in the general population. Beyond this, the
clinical population ‘is much more likely to be
unemployed or to be in marginal jobs, and to be
divorced or separated. . .. One-half of all clients in US
alcoholism treatment facilities are separated or di-
vorced, and about 60 per cent are currently not
employed’ [77]). In a variation on these statistics, a
recent study of those entering alcohol or drug
treatment in Stockholm County found that less than
one-quarter of the clients were currently married or
living with a partner, about 50% lived alone, about
30% were homeless, about 30% were unemployed and
almost half thought that their mental health was a
‘substantial’ or more serious problem (unpublished
figures from [78]).
These divergences between the pictures from general
population studies and from clinical populations led me
to suggest that we can talk of the ‘two worlds of alcohol
problems’ [79]. The salient feature of the clinical
picture is the marginalization of many of the clients—
the high rates of ‘spare and awkward people’ [77],
without ties to a family, a continuing home, or a steady
job. ‘We may suspect that the process of entering
treatment is to some extent a process of extrusion from
the general population, that many clients come to
treatment after having exhausted their moral credit with
employers and families’ [77].
The years since this sketchy account was written have
seen a number of studies which fill in more of the
picture, but we still know too little about what goes on
in the hinterland between the two worlds—about how
and under what circumstances some of those with
heavy substance use and occasional problems from it
move on into the more marginalized and stigmatized
world of the clinical populations.
Some conclusions about research directions
Psychoactive substance use occurs in a highly charged
field of moral forces. Outlawing a drug and punishing
those caught using it may be intended to ‘send a
message’ about standards of behaviour. Alcohol and
drug use can serve as a demonstration to the user and
to others about highly valued personal qualities such
as self-control. Adverse consequences of use can be
regarded as evidence of moral iniquity. Entering
treatment for alcohol or drug problems is potentially
humiliating evidence of failure in self-management. In
these and many other ways, substance use can serve as
an instrument of social inclusion or social exclusion.
In terms of social exclusion the user may be
stigmatized, and the result may be social margin-
alization.
These processes are separate from issues of the
division of resources in society and social inequality.
On the other hand, access to resources gives the user
greater opportunities to insulate behaviour from social
reactions and from potential stigma and marginaliza-
tion. Social inequality, stigmatization and marginaliz-
ation around substance use interact in complex ways,
which need to be better understood.
There is a high degree of marginalization and
stigmatization among those who end up in treatment
for alcohol or drug problems, even in well-developed
welfare societies. Improving the social reintegration of
such treated populations, or implementing effective
interventions short of tertiary treatment, will require a
better understanding of how and under what conditions
the marginalization and stigmatization happens.
Quantitative and qualitative studies are needed of the
extent and mechanics of marginalization and social

stigmatization of substance users and those with
substance use problems in different societies and
milieux. These studies should include attention to the
potential preventive effects of stigmatization, on one
hand, and to the potential deviance-amplifying and
other adverse effects on the other hand.
General studies are needed in different societies and
milieux of the relationship between components of
social class and social inequality and, conversely, of
marginalization and stigmatization. Again, both quan-
titative and qualitative studies are needed.
In the context of these general studies, specific
attention needs to be paid to the interplay of social
inequality and marginalization around substance use
and problems. Priority should be given to studies of
what happens when some aspect or component of social
inequality or marginalization changes. These studies
can be at the aggregate or the individual level; wherever
possible, they should include both levels of change.
Along with planned experiments and interventions,
these studies can include longitudinal studies in the
individual life-course and ‘natural experiments’ when a
relevant policy changes.
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