Hispanic drug abuse in an evolving cultural context: An agenda for research

Drug and Alcohol Dependence 84S (2006) S8–S16

Hispanic drug abuse in an evolving cultural context: An agenda for research Lynn A. Warner a,∗ , Avelardo Valdez b , William A. Vega c , Mario de la Rosa d , R. Jay Turner e , Glorisa Canino f a

School of Social Welfare, University at Albany, State University of New York, 135 Western Avenue, Albany, NY 12222, USA b University of Houston, 237 Social Work Building, Houston, TX 77204-4013, USA c University of Medicine and Dentistry, New Jersey, Room 3717, 151 Centennial Ave., Piscataway, NJ 08854, USA d School of Social Work, Florida International University, University Park Campus, DM-463 11200 S.W. Eighth Street, Miami, FL 33199, USA e Center for Demography and Population Health, Florida State University, 617 Bellamy Building, Tallahassee, FL 32306, USA f University of Puerto Rico, Medical Sciences Campus, PO Box 365067, San Juan 00936-5067, Puerto Rico

Abstract Drug abuse in the U.S. Hispanic population appears to be in a dynamic state of acceleration, although there are differences in drug use patterns between U.S.-born and foreign-born Hispanics, and across Hispanic subgroups (i.e., Mexican, Cuban, Puerto Rican, and Central or South American). An understanding of the consequences of cultural adjustments for drug use is needed to effectively anticipate the scope and dimensions of illicit drug use in the largest, rapidly growing, minority group in the U.S. This paper provides an epidemiologic overview of current Hispanic drug use, summarizes research on the relationship between culture change and drug use, organized according to individual, social (i.e., family and peer group), and community level influences on drug use, and offers a systematic agenda for future research. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Hispanics; Substance use disorder; Epidemiology; Acculturation

1. Introduction Hispanics are the largest minority group in the U.S. with a population of 40 million people (U.S. Census Bureau, 2005), constituting 13.4% of the population. Due to high fertility and immigration rates, this group is rapidly growing and projected to comprise at least 25% of the population by 2050 (U.S. Census Bureau, 2004). The Hispanic population is youthful (e.g., 40% of the population is under the age of 21), and disproportionately low-income (e.g., 23% below the federal poverty line), with limited educational attainment (e.g., more than half of Hispanics over the age of 25 have not graduated from high school) (Ramirez and de la Cruz, 2002). Overall, the demographic profile suggests that Hispanics are substantially socioeconomically disadvantaged in ways that may increase individual vulnerability to substance abuse. The purpose of this article is to identify social science research initiatives that will yield data relevant

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Corresponding author. Tel.: +1 518 591 8734; fax: +1 518 442 5380. E-mail address: [email protected] (L.A. Warner).

0376-8716/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.drugalcdep.2006.05.003

for policies and programs to effectively anticipate the scope and dimensions of drug use in this rapidly growing minority group, and identify culturally relevant interventions. The agenda was developed by reviewing epidemiologic data on the scope of substance use and disorder among Hispanics in the U.S. and research on risk and protective factors. To provide a context for the reader, this article summarizes studies that highlight issues unique to Hispanics and were most influential in our decisions about needed research. At the outset it is important to note that the review was more extensive than can be captured here. For example, “drug use” includes alcohol, tobacco, and other licit and illicit substances, each with its own set of epidemiologic surveillance systems and literatures. Although most Hispanics with substance use disorders have comorbid alcohol use disorders (Vega et al., 2003), the reverse is not true. Thus, studies focused on alcohol dependence cannot accurately capture drug use patterns. Further, stigma is associated with any type of substance abuse, but persons who use illicit substances are likely to experience stigma in different ways, many of which stem from involvement in criminal activity, and stereotypes about “addicts”. Consequently, results from studies

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on alcohol use among Hispanics may not be uniformly generalizeable to substance abuse, and whenever possible we include here studies that focused on illicit substances, or reported findings separately for alcohol and other substances. (For a review of alcohol studies that serves as a useful companion to this study of illicit substances, see Galvan and Caetano, 2003). A second criterion for including studies in this paper derives from our assumption that it is unlikely that Hispanic drug-use patterns are defined by factors that have not previously been identified in the extensive body of research on risk and protective factors. Rather, we predict that there are powerful reciprocal influences between cultural adaptation and known personal, family, peer, and environmental factors. An overriding challenge for research on the etiology of drug abuse among Hispanics is to identify how acculturation and assimilation dynamics interact with key variables at all levels of analysis. Here, too, research on alcohol use was instructive (e.g., Caetano, 1987). Additionally, the current agenda was influenced by reviews of culture change among Hispanics that have been conducted by mental health researchers (Escobar et al., 2000; Escobar and Vega, 2000). The review is organized into two main sections. The first section is a brief overview of the current epidemiology of illicit drug use and disorder among Hispanics in the U.S. It emphasizes the demographic correlates of nativity (e.g., immigrant or U.S.-born), ethnicity (person’s or parents’ country of birth), gender, and age-related patterns of drug-use. The second section presents studies that speak to the interplay between culture change and drug abuse etiology, organized around individual, social (peer and family), and community levels of influence. Because of epidemiologic shifts in Hispanic drug use identified in section one, studies that speak to gender and age-related risks are emphasized. Important considerations for conducting research with Hispanics and interpreting findings are identified in both sections. Specific suggestions for future research are presented separately in the final section. 2. Epidemiology Annual data from respondents (persons age 12 years and older) to the National Survey on Drug Use and Health (NSDUH), and its precursor, the National Household Survey on Drug Abuse (NHDSA) show that Hispanics consistently report lower rates of lifetime illicit substance use than non-Hispanic blacks and nonHispanic whites, and higher rates than Asian Americans. For example, in 1997, the lifetime rate for Hispanics was 25.9%, whereas the rates for blacks and whites were 31.1% and 38.2%, respectively (SAMHSA, 1998). As of 2003, rates had increased for all groups, although the relative ranking of lifetime use by race-ethnicity did not change: 37% for Hispanics, 44.6% for blacks, and 49.2% for whites (SAMHSA, 2004). With other measures of drug use, such as current use or substance use disorder, there tends to be little difference between the groups, or higher rates among Hispanics than the other two groups. The rates of illicit substance use in the past month were similar across the main ethnic groups: 8.0% of Hispanics, 8.3% of whites, and 8.7% of blacks reported current illicit substance use in 2003. With the most serious measure of drug use, substance

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use or dependence in the last year, Hispanics had the highest rate (9.8%), followed by whites (9.2%) and blacks (8.1%). Although the lifetime rate of substance use disorder was estimated to be lower for Hispanics (22.9%) than whites (29.5%) in the National Comorbidity Survey (which focuses on a more limited age range (persons ages 15–54 years) than the NSDUH and also excluded Spanish speakers), the groups did not differ from each other in the persistence of disorder (Breslau et al., 2005). Substance use disorder in the past year among those with a lifetime disorder was 23.3% for Hispanics and 23.6% for non-Hispanic whites. National surveys restricted to adolescent populations suggest that the younger the respondents, the more likely Hispanics have higher rates of illicit substance use compared to whites and blacks. Among eighth grade respondents in the Monitoring the Future study, Hispanics reported the highest rates of illicit drug use in the past year since 1992 (Johnston et al., 2004). In 2002, one fifth of eighth grade Hispanics had used an illicit substance. Roughly one-third of Hispanic and white tenth graders reported illicit substance use, which is greater than the proportion of black peers in the same grade, and the substance use rate of Hispanic high school seniors falls between the rate of whites and blacks. Similar patterns were found in data from the 2003 Youth Risk Behavior Surveillance Survey: among males, for example, the rate of lifetime marijuana use among Hispanics (46.7%) fell between the rate reported by whites (40.5%) and Blacks (49.0%), as did the rate of current marijuana use; lifetime and current cocaine use was highest among Hispanics (Centers for Disease Control and Prevention, 2004). Data on the U.S. Hispanic population as a whole obscures within-group variation. Hispanics are heterogeneous: About two-thirds of the population is Mexican, followed by Central and South American (14.3%), Cuban (3.7%), Puerto Rican (8.6), and other (6.5%) (Ramirez and de la Cruz, 2002). Within these groups there are further variations by nativity status, length of stay in the U.S. and languages spoken (Borrell, 2005). Population-based studies have only recently been fielded to yield sample sizes sufficient to estimate rates by national origin. Data from the NHSDA show that rates of past month illicit drug use in the Hispanic population ranged from 10.1% for Puerto Ricans to 3.7% for Cuban Americans, with rates for Mexicans and Central or South Americans at 5.5% and 4.1%, respectively (SAMHSA, 2002). On some indicators the relative ranking by national origin changes when analyses are restricted to adolescents. For example, data from the Monitoring the Future surveys indicate that Cuban adolescents have the highest reported 12 month illicit drug use rates of any ethnic group in the U.S. (Wallace et al., 2002). 2.1. Nativity A consistent finding in Hispanic drug use research has been that the U.S.-born report higher rates of experimental drug use, abuse, and dependence than immigrants do (Amaro et al., 1990; Boles et al., 1994; Burnam et al., 1987; Ortega et al., 2000; Vega et al., 1998). In these studies, as well as in this review, it is important to note that although persons born in Puerto Rico are U.S.

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citizens, and thus are not technically foreign-born, island-born Puerto Ricans are treated analytically as foreign-born. Data from the National Epidemiologic Survey on Alcohol and Related Conditions underscore the importance of studying place of birth as a correlate of substance abuse within groups defined by national origin (Grant et al., 2004). In that study, 6.1% of Mexican-origin persons had any lifetime drug use disorder, which reflects a rate of 1.7% among foreign-born Mexican Americans and 12.0% among U.S.-born Mexican Americans. However, there is suggestive evidence that differences by nativity are not significant when samples are comprised of adolescents. Turner and Gil (2002) reported no difference in substance use disorder rates between U.S.-born and foreign-born Cuban adolescents. 2.2. Age at onset Adolescence is the period in the life course when substance use experimentation is most likely to occur, and extensive empirical findings confirm that the younger a person is when substances are first used, the greater the likelihood of drug use problems in later adolescence and early adulthood (Ellickson et al., 1992; Newcomb and Bentler, 1986). However, little is known about interactions between nativity and age with regard to progression to substance dependence. A longitudinal community study of males provides a noteworthy contribution along these dimensions; substance use during early adolescence was associated with substance use disorder during young adulthood, but the risk was greatest for African Americans and foreign-born Hispanics, the groups who reported the lowest rates of early use (Gil et al., 2004). An extensive set of studies also suggests that the order in which different types of drugs are used is related to the probability of ever using illicit drugs such as cocaine or heroin (Ellickson et al., 1992; Kandel, 1985; Newcomb and Bentler, 1986). Most of this research shows that individuals who ever used an illicit substance followed a typical pattern, whereby alcohol or tobacco use (“gateway” substances) preceded marijuana use and dependence (e.g., Kandel, 2002), and marijuana use preceded illicit drug use and dependence (Vega and Gil, 2005). The use of an illicit substance before a licit substance is considered to be a breach of the normative sequence, although etiological studies have not focused on the consequences of breaches for the development of substance use disorder. Studies that have examined initiation patterns among different ethnic groups have not generated consistent findings. Vega and Gil (1998) found a greater likelihood of illicit drug use experimentation before gateway drug use among Hispanics, while others found no difference in the patterns across ethnic groups (Brook et al., 1998b). Yamaguchi and Kandel (2002) found that blacks and Hispanics were more likely to have non-distinct, random patterns than whites. Further complexity in sequencing has been reported based on analyses of Youth Risk Behavior Survey data stratified by ethnicity and gender (Guerra et al., 2000). Controlling for other factors, the use of illicit substances before licit substances was more likely to occur for black male and Hispanic female youth, compared to white youth.

2.3. Gender Most population-based studies among adults have found that the prevalence of substance use, abuse and dependence is significantly higher among males than females (Anthony et al., 1994; Hughes et al., 1997; Warner et al., 1995), and the male to female ratio is often substantially greater among Hispanics than non-Hispanic whites (Bachman et al., 1991; Canino et al., 1993; Vega et al., 1998). The higher sex ratio difference among Hispanics compared to whites has been attributed to negative sanctions against female substance use in the traditional Latino family (Oetting and Beauvais, 1990), and relatively more stigma against Hispanic female compared to white female drug users (Valdez et al., 2000). The extent to which family processes correspond with traditional customs is likely to vary by national origin, which may help explain why Puerto Rican women tend to report higher rates of illicit drug use than other Hispanic women (Amaro et al., 1990). Gender also appears to interact with nativity and age at immigration. For example, substance abuse rates were seven times higher among U.S.-born Mexican American women compared to Mexican immigrant women in Fresno (Vega et al., 1998). Recent research shows that substance use disorder prevalence is low for immigrants arriving in adulthood, and exceptionally lower among Hispanic women who were older when they moved to the U.S. (Vega et al., 2004). Although the links between societal changes and drug use patterns have yet to be elaborated, secular changes in gender role expectations overall may explain why recent studies of adolescents in most race/ethnicity groups either do not find a gender gap in drug abuse rates (Khoury et al., 1996), or find higher rates among females than males (Kandel et al., 1997; Sloboda, 2002). According to data from combined 2002 and 2003 NSDUH surveys, rates of past month illicit drug use were similar for male (11.5%) and female (10.1%) Hispanic youths aged 12–17 years (Office of Applied Studies, 2004), and Warner et al. (2001) found no significant gender differences in rates of substance use disorders between older adolescents either in the U.S. mainland or Puerto Rico. 2.4. Summary of substance use epidemiology Caution in comparing substance use prevalence estimates across studies, regardless of the population, is warranted. Research can be based on a range of definitions of use or disorder, a range of drugs (e.g., marijuana, cocaine or both), and non-comparable age groups (e.g., 12–15 years or 11–17 years). Among Hispanics, the languages used to collect data have consequences for participation and reliability of reporting. For comparisons within Hispanic groups, the preceding overview reinforces the need to interpret prevalence estimates in light of sample characteristics such as national origin, nativity, gender and age. Research by Lillie-Blanton et al. (1993) illustrated the importance of adjusting rates according to community context; blacks and whites had similar cocaine use rates when they were matched by neighborhood, but black had higher rates according to unmatched analyses.

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With these caveats in mind, the epidemiologic data suggest that drug abuse in the U.S. Hispanic population appears to be in a dynamic state of acceleration. Older Hispanics report lower substance use rates compared to same-age non-Hispanic whites, but rates among Hispanic adolescents are similar to or greater than rates among non-Hispanic white adolescents. Gender differences in drug use rates are notable among older Hispanics, but not younger; and, at least for some Hispanic subgroups, substance abuse prevalence among U.S.-born adolescents is no different from foreign-born adolescents. 3. Drug abuse risk and protective factors in evolving cultural context Risk and protective factors for drug use are not necessarily the same as those for drug abuse or dependence. In general, situational and environmental factors are likely to be more influential in initial substance use (U.S. Congress, Office of Technology Assessment, 1994), whereas affective, cognitive and behavioral dysregulation are implicated in the progression from drug use to abuse or dependence (Dawes et al., 2000). As stated in the Introduction, it is unlikely that Hispanic drug-use patterns are defined by factors that have not previously been identified in the extensive body of research on risk and protective factors, some of which evaluates the role of culture. (See the article on prevention research in this volume for additional coverage of culture and drug use). Notable shifts in Hispanic demographics and substance use patterns point to culture change as a key area to study. Various definitions of culture change (i.e., acculturation, assimilation and adaptation) have been included in Hispanic drug abuse research, and have consistently been found to be positively associated with substance abuse (Gil et al., 2000; Ortega et al., 2000; Vega et al., 1998; Zapata et al., 1998). However, acculturation may operate differently for Hispanic subgroups; based on analyses of three national surveys, acculturation was associated with crack use for Mexican Americans but no other Hispanic group (Wagner-Echeagaray et al., 1994). Also, the salient features of culture change may differ for the approximately 40% of the U.S. Hispanic population that is foreign-born (Ramirez and de la Cruz, 2002), and Hispanics born in the U.S. but who live in families and communities with strong cultural connections. Generally, acculturation is a developmental process by which an individual assimilates the practices and values of the dominant culture, rather than the attainment of a status (i.e., one has adopted the host culture or not) (Coatsworth et al., 2005; De la Rosa, 2002; LaFromboise et al., 1993). Culture change is challenging to operationalize (for a critique of acculturation as it has been used in Hispanic health research, see Hunt et al., 2004), with place of birth and number of years living in the United States often used as proxy measures. Moreover, acculturation is not only an individual-level process but occurs at peer, family and community levels as well (Weigers and Sherraden, 2001), yet how culture change operates at these other levels, and the conditions under which it is adaptive or not, are not well understood. In each of the following subsections, we describe facets of social and cultural adjustment that are theoretically linked

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to individual, family and peer, and environmental correlates of substance use, and identify research that speaks to the influence of culture change on drug use patterns. 3.1. Individuals, culture change, and drug use For individuals, culture change can influence values, preferences, and attitudes about normative behavior (Betancourt and Lopez, 1993). Weakened ethnic and cultural identity (Vega et al., 2002), lower levels of ethnic pride (Felix-Ortiz et al., 1998), and predominate use of English rather than Spanish (Epstein et al., 2001; Marsiglia and Waller, 2002) have been identified as correlates of substance use. Additionally, tolerance of deviance and positive attitudes toward drug use have been found to increase with number of years in the U.S. (Velez and Ungemack, 1995). Individuals’ stress exposure and coping responses are also theoretically linked with culture change (De la Rosa, 2002). In this area, research on mental illness is particularly instructive and relevant, given strong evidence that psychiatric disorders are implicated in the etiology of drug use disorders (Biederman et al., 1997; Kessler et al., 1996; McGee et al., 2000). For example, lower rates of mental illness among foreign-born compared to U.S. born Hispanics have been interpreted as an “immigrant paradox”. Despite adversities posed by moving and living in situations that may be particularly stressful (e.g., high crime, high poverty rates), foreign-born Hispanics have better outcomes than U.S.-born Hispanics (e.g., Escobar et al., 2000; Ortega et al., 2000; Vega et al., 1998). One explanation for the finding is a selection effect: healthy people migrate, yielding a group of immigrants who are much less vulnerable to psychosocial stressors. Research on rates of drug use prior to exiting one’s home country is not widely available, but data on age at onset of drug use suggest foreign-born Hispanics are not likely to have used drugs prior to leaving their countries (Vega et al., 2002). Others have argued that foreign-born Hispanics have lower risk for negative outcomes because they have relatively modest expectations about what success means, whereas the U.S.-born experience more distress given barriers to their substantially higher expectations of attaining the American dream (Burnam et al., 1987). According to a study of Hispanic middle school students, immigrants viewed their current lives in comparison with life in their home countries, where economic and social conditions were often worse, but U.S.-born Hispanics were more likely to compare themselves with their peers in the United States and to conclude they had fewer resources (Suarez-Orozco and Suarez-Orozco, 1995). The investigators suggested that as a result of the different frames of reference, U.S.-born Hispanic youth experience more distress. Substance use could be a way of coping with this distress, or a way to gain entrance to a social network that is perceived to be better off. Culture change processes, if associated with exposure to negative life events, may also factor into the development of substance abuse. Turner and Lloyd (2003) demonstrated that lifetime cumulative exposure to major negative life events significantly increases risk for the subsequent onset of drug dependence among Hispanics, as among other groups. Because the study was conducted in South Florida where Hispanics are a

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majority rather than a minority group, and half of those studied were from the relatively privileged Cuban background, the results may not be generalizable to other Hispanics. It has been suggested that stress associated with exposure to violence among Central American refugees and immigrants might increase the need for mental health care in this group (U.S. Department of Health and Human Services, 2001). It is reasonable to question if traumas or losses surrounding immigration have distinct consequences for drug use and dependence as well, particularly with regard to substance use as self-medication. 3.2. Families and peer groups, culture change, and drug use Families and peers, as conduits of social control and social learning, have important influences on drug use. In Hispanic cultures “familism” has been identified as a uniquely defining trait (Chandler et al., 1999; De la Rosa, 1988). Even though positive parent–child relationships are protective against drug use across ethnicities, some evidence suggests family-related factors are potentially more salient for Hispanics than other groups. For example, parental involvement in adolescents’ lives had a greater inhibiting effect against drug use among Hispanic adolescents than African-American and non-Hispanic white adolescents (Smith and Krohn, 1995). In light of the evidence demonstrating the protective effects of familism, it is not particularly surprising that substance use increases when acculturation erodes traditional family values, including “respeto” (respect for parents), family support and family pride (Vega and Gil, 1998). The acculturation gap hypothesis identifies a mechanism that may contribute to the erosion of familism (Szapocznik, 1979). Because attachment to cultural prerogatives is likely to vary across successive generations in a household (Perez and Padilla, 2000), youths’ drug use and other negative behavior may reflect the strains engendered when children have greater levels of acculturation than parents. A recent study in which a mother’s level of acculturation was a protective factor for Hispanic adolescents’ antisocial behavior (Eamon and Mulder, 2005), supports the notion that minimization of acculturation gaps across the generations may be beneficial. On the other hand, caution is warranted if parents themselves increase their substance use as part of their acculturation. To the extent that acculturation weakens any prohibitions against divorce, or against unmarried women having children, the impact on youths’ drug use may be substantial. Studies show that Hispanic youth living in two parent households are significantly less likely to use substances than those living in single parent households or with neither parent (Gil et al., 1998, 2000; Krohn et al., 1996). Additionally, Hispanic youth from single parent households were more likely to use alcohol or drugs than African-American and white non-Hispanic counterparts from single parent households (Krohn et al., 1996). There is some evidence that the influence of family structure on drug use varies by Hispanic subgroup: Mexican and Puerto Rican adolescents in single versus two parent families had higher drug use, but no such association was found for Cuban American adolescents (Sokol-Katz and Ulbrich, 1992). Because female-headed households are disproportionately poor, estimates of the influence of

family structure on between- and within-group drug use patterns require studies that control for socioeconomic status. The culture-related strains in parent–child relationships may also shape opportunities for Hispanic youths to associate with deviant peers. For example, a series of studies of Puerto Rican, Colombian and African American adolescents shows poor relationships with parents are related to youths’ development of unconventional attitudes and rebelliousness, which in turn increased youths’ vulnerability to deviant peers and drug use (Brook et al., 1998a; Chappin and Brook, 2001). Other research on linguistic acculturation (e.g., youths’ use of English to communicate with parents) identified that peers’ drinking norms mediated the relationship between acculturation and polydrug use (Epstein et al., 2003). Research on peer networks supports the hypothesis in the previous section that substance use may be a way to gain entrance to a more desirable social network. Krohn et al. (1996) showed that Hispanic alcohol users were less likely to have friends from their own ethnic groups than non-alcohol users, lending support to the argument that greater acculturation, vis-`a-vis greater numbers of friendships with non-Hispanic youth than Hispanic youth, may be related to increased substance use in Hispanic youth. The impact of acculturation on Hispanic women’s traditional roles within the family, and related consequences for women’s drug use patterns are more difficult to predict. On one hand, women who use drugs are severely stigmatized because of culturally embedded gender norms (Mora, 2002) that may not readily change. On the other hand, the stressors associated with acculturation might establish countervailing pressures toward drug use. Pressure to use drugs might also come from male partners, given research that points to the influential role that males play in women’s initiation and persistent use of drugs (Amaro and Hardy-Fanta, 1995). (See the article on drug abuse treatment in this issue for other concerns related to gender, culture, and drug use). 3.3. Communities, culture change, and drug use Family and social networks are embedded in larger community contexts, and there has been increasing attention to the influence of these contextual factors on health. Some studies estimate the association between individuals’ perceptions of social capital in the community, such as collective efficacy, and public health outcomes (e.g., Kawachi et al., 1999). Evidence suggests that social capital may be relatively higher in predominately Hispanic communities, and thus may be a particularly important focus for future studies of Latino drug use. For example, the pernicious effects of poverty in some neighborhoods may be neutralized by high levels of residential stability and homeownership in low-income Hispanic communities (Ross et al., 2000). Other studies have focused on the neighborhood as the unit of analysis, and examined the way characteristics, such as level of poverty, may predict outcomes that are correlated with drug abuse, such as depression (Wight et al., 2005), but not drug abuse per se. For example, a study that included multi-level measures found that marital status of parents, immigrant generation

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and dimensions of neighborhood social context accounted for the differences in rates of violence between black, white, and Hispanic youth (Sampson et al., 2005). Given the relatively recent gains that have been made in our understanding of contextual influences on health, it is not surprising that changes in social context have yet to be examined in any consistent way. Similarly, change in the cultural context of communities or neighborhoods, and its association with drug use patterns, is unexplored. Studies conducted along the U.S.-Mexico border support the assumption that culture change processes at the community level relate to drug use. For example, according to a survey of primarily Mexican adolescents in schools on both sides of the Texas-Mexico border, rates of depressive symptoms, drug use, and suicide were high in both settings, but youth residing in Texas reported more current illicit drug use than youth residing in Mexico (Swanson et al., 1992). Case studies of drug abuse and community capital, like those conducted by Valdez et al. (1997) in Laredo, Texas, promise to be an important methodology for developing hypotheses about communities in transition, and their vulnerability to drug abuse. 4. Research agenda The last several years have witnessed substantial advances in research on drug abuse among Hispanics in the U.S., including federal support for studies that oversample minority groups, and thus allow for sufficient sample size to investigate within group profiles, and design strategies that improve data reliability, such as Spanish-language interview protocols and measures (e.g., Alegr´ıa et al., 2004a,b). Understanding the complex interactions between culture change processes and drug use identified in this review requires commitment to a research agenda that crosses geographic borders, includes researchers from multiple disciplines, and relies on multiple scientific methods. Each component of the research agenda is described in more detail below, and specific questions are offered. 4.1. Crossing borders Research must have the capacity to manage variations in drug-use patterns among Hispanics who live in different regions and different geographic areas (e.g., rural and small towns, border areas, and densely populated metropolitan areas) and represent different national origins. Multi-site studies, and replication studies conducted in Hispanic communities with diverse characteristics are needed. Closer collaboration with researchers in countries from which Hispanics typically emigrate is particularly important for at least two reasons. First, a substantial proportion of Hispanics were not born in the U.S. Consequently the epidemiology of drug use in this country is structured to some extent by prevailing drug use patterns in the countries of origin, as well as social norms and attitudes about gender- and age-appropriate behavior. Tests of hypotheses about the stresses and consequences of culture change could be more rigorous with epidemiological data from the sending countries. Second, Hispanics who come to the U.S. to work, but do not intend to stay, constitute a unique and pos-

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sibly highly vulnerable sub-group. It is possible that drug use problems acquired in the U.S. may follow some of these persons back to their nations of origin, with unknown consequences for indigenous populations (Vega et al., 1998). 4.2. Input from multiple disciplines Immigration and culture change processes are likely to be extremely sensitive to chronological age insofar as it is a proxy for developmental level and exposure to life stress. Expertise from multiple disciplines is needed to evaluate the components of that statement. Cultural anthropologists, psychologists and sociologists have unique perspectives on development within context, and discipline-specific models of stress and coping. In a collaboration across disciplines, the relative contribution to drug abuse of such things as values, norms, role functioning, deviance, abnormal development, and stigma can be systematically evaluated. A related line of inquiry focuses on the interplay between exposure to stressors, psychiatric illness and drug dependence. There is a pressing need for research to evaluate variations in stress exposure and stress vulnerability among Hispanics of differing national origins. The incorporation of biogenetic factors and psychiatric comorbidity into cultural adaptation models requires insight from basic and applied sciences, including neurobiology and psychiatry. (See a review of biological research on drug abuse and addiction in this issue). Finally, each discipline has its own experts on alcohol, tobacco, and psychotropic drugs, as well as illicit substances. In addition to engaging all substance-specific researchers in the design and implementation of studies that advance this research agenda, it would be extremely helpful to have formal arrangements for ongoing cross-substance dissemination of research that speaks to culture change processes. 4.3. Application of multiple research methods Methodological considerations are paramount for three topics in the research agenda: culture change and developmental processes at the individual level, the experiences and meaning of culture shifts among women and families, the measurement of culture change at community levels. Longitudinal studies of Hispanics are necessary to isolate ages at which acculturation processes have an impact, and when the risk for progression from use to abuse may be greatest. Although initiation of substance use in adulthood is rare, other changes in drug use patterns are more likely, and longitudinal designs should capture broad age ranges across multiple cohorts. These design features would help identify conditions and ages when substance use escalates to dependence, or when persons mature out of illegal drug use. For adolescents in particular, who experience tremendous transitions in identity and value formation, narrowly spaced observation points are critical to our understanding of dynamic processes such as adolescent socialization and acculturation. Ethnographic and qualitative studies are needed to understand the substance use implications of changes in cultural norms

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around family functioning and gender roles, and how these might vary with national origin. For example, given evidence that U.S.-born Latino parents have much higher drug use rates than foreign-born Latinos (Vega and Sribney, 2003), it is important to reexamine family dynamics, and reevaluate the acculturation gap hypothesis. Qualitative study might also help identify aspects of culture change and social and economic assimilation that influence drug use because of their main effects on family functioning. For example, some responses to limited economic opportunities could be diminished positive family functioning or decreased ability to nurture prosocial development, which could be probed through interviews and observation. Qualitative studies are also well suited to give voice to Hispanic women and girls about the complicated negotiations around gender roles, expectations, and substance use. In particular, research on the negative consequences of acculturation on familism suggests that maintaining more traditional family roles may be protective, at least with regard to youths’ drug use. It would be important to know the extent to which support for traditional family roles may have unintended consequences for women, possibly by encouraging them to stay in unhealthy relationships with partners who are themselves using substances. Community factors are arguably the least understood influences on individual drug use behavior, and there are many more questions than there are data about interrelationships between shifting neighborhood demographics, cultural norms, and drug use. A set of measures that captures drug activity at the community level, as well as changes in culture, needs to be developed. Surveys of community residents can be used to collect data on such factors as tolerance in the community for drug use, perceived availability of drugs and drug treatment services, and drug use in social networks. Records on arrests, drug mentions in emergency room visits, and actual availability of drugs and drug treatment services can also be used to gauge community level drug use indicators. Changes in culture could be gauged, for example, by monitoring the proportion of the population that is foreign-born, and primarily Spanish speaking. With collaboration across sites, as described above, it would be possible to maximize cost-effectiveness, explanatory value and statistical power. This in turn would facilitate testing differences between unique subgroups and establish opportunities to aggregate data to test hypotheses about culture change and risk and resilience at the individual and community levels. References Alegr´ıa, M., Takeuchi, D., Canino, G., Duan, N., Shrout, P., Meng, X.-L., et al., 2004a. Considering context, place and culture: the National Latino and Asian American study. Int. J. Meth. Psychiatr. Res. 13, 208–220. Alegr´ıa, M., Vila, D., Woo, M., Canino, G., Takeuchi, D., Vera, M., Febo, V., Guarnaccia, P., Aguilar-Gaxiola, S., Shrout, P., 2004b. Cultural relevance and equivalence in the NLAAS instrument: integrating etic and emic in the development of cross-cultural measures for a psychiatric epidemiology and services study of Latinos. Int. J. Meth. Psychiatr. Res. 4, 270–288. Amaro, H., Hardy-Fanta, C., 1995. Gender relations in women’s addiction and recovery. J. Psychoactive Drugs 27, 325–337. Amaro, H., Whitaker, R., Coffman, G., Heeren, T., 1982-84. Acculturation and marijuana and cocaine use: Findings from the HHANES. Am. J. Public Health 80, 54–60.

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