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American Journal of Epidemiology Advance Access originally published online on August 13, 2007
American Journal of Epidemiology 2007 166(9):1068-1079; doi:10.1093/aje/kwm180
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American Journal of Epidemiology © The Author 2007. Published by the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org.

ORIGINAL CONTRIBUTIONS

Self-reported Racial Discrimination and Substance Use in the Coronary Artery Risk Development in Adults Study

Luisa N. Borrell1, David R. Jacobs, Jr2,3, David R. Williams4, Mark J. Pletcher5, Thomas K. Houston6,7 and Catarina I. Kiefe6,8

1 Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
2 Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, MN
3 Department of Nutrition, University of Oslo, Oslo, Norway
4 Departments of African and African American Studies and of Sociology, School of Public Health, Harvard University, Boston, MA
5 Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
6 Deep South Center on Effectiveness, Birmingham Veterans Affairs Medical Center, Birmingham, AL
7 Division of General Internal Medicine, University of Alabama, Birmingham, AL
8 Division of Preventive Medicine, University of Alabama, Birmingham, AL

Correspondence to Dr. Luisa N. Borrell, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY 10032 (e-mail: lnb2{at}columbia.edu).

Received for publication December 22, 2006. Accepted for publication May 18, 2007.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
The authors investigated whether substance use and self-reported racial discrimination were associated in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Smoking status, alcohol consumption, and lifetime use of marijuana, amphetamines, and opiates were ascertained in 2000–2001, 15 years after baseline (1985–1986). Most of the 1,507 African Americans reported having experienced racial discrimination, 79.5% at year 7 and 74.6% at year 15, compared with 29.7% and 23.7% among the 1,813 Whites. Compared with African Americans experiencing no discrimination, African Americans reporting any discrimination had more education and income, while the opposite was true for Whites (all p < 0.001). African Americans experiencing racial discrimination in at least three of seven domains in both years had 1.87 (95% confidence interval (CI): 1.18, 2.96) and 2.12 (95% CI: 1.42, 3.17) higher odds of reporting current tobacco use and having any alcohol in the past year than did their counterparts experiencing no discrimination. With control for income and education, African Americans reporting discrimination in three or more domains in both years had 3.31 (95% CI: 1.90, 5.74) higher odds of using marijuana 100 or more times in their lifetime, relative to African Americans reporting no discrimination. These associations were similarly positive in Whites but not significant. Substance use may be an unhealthy coping response to perceived unfair treatment for some individuals, regardless of their race/ethnicity.

adaptation, psychological; African Americans; alcohol drinking; amphetamines; cannabis; cocaine; prejudice; smoking

Abbreviations: CARDIA, Coronary Artery Risk Development in Young Adults; CI, confidence interval


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Racial discrimination has recently emerged as an important health risk that is differentially distributed across racial/ethnic groups and may contribute to elevated health risks for African Americans (1–6). For example, a substantial proportion of African Americans experience discrimination adversely affecting multiple indicators of health status, including poorer self-rated physical and mental health (1, 4, 5, 7–12), blood pressure, and other cardiovascular outcomes (4–6, 13–17).

Although associations between racial discrimination and health outcomes have been reported consistently, the mechanism underlying these associations remains a challenge. It has been hypothesized that discrimination may lead to negative health outcomes through detrimental health behaviors, such as use of harmful substances. However, few studies have focused on the relation between racial discrimination and health risk behaviors, such as smoking, excessive alcohol consumption, or illicit substance use (18–30). Although these studies suggested that the stress associated with racial discrimination may lead to alcohol use and smoking among African Americans, they were based on small or specialized samples; for example, African-American adolescents and American-Indian children perceiving racism were more likely to report drug use than were those perceiving no racism (27, 28). However, to the best of our knowledge, no studies have investigated these associations in a population-based sample of African-American or White adults.

The Coronary Artery Risk Development in Young Adults (CARDIA) Study, a prospective cohort of Whites and African Americans with 15 years of follow-up, provides a unique opportunity to investigate the association of self-reported racial discrimination with cigarette smoking, alcohol consumption, and use of illicit substances, before and after adjustment for important covariates, including indicators of socioeconomic position and psychosocial measures, among younger adults. Specifically, we investigated whether self-reported discrimination in years 7 and 15 of the CARDIA Study is associated with smoking, alcohol consumption, and use of marijuana, crack, cocaine, speed, and heroin in African Americans at year 15; we further assessed whether parallel associations exist in Whites.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Study design
A total of 5,115 persons aged 18–30 years at baseline (1985–1986) were recruited for the CARDIA Study, primarily by telephone at random in three cities (Birmingham, Alabama; Chicago, Illinois; and Minneapolis, Minnesota) and at random from the membership roster of a large health plan (Oakland, California) (31, 32). The overall response rate for recruitment was about 50 percent. The recruitment targeted obtaining at each center nearly equal numbers of African Americans and Whites, men and women, persons aged less than 25 and 25 or more years, and persons with a high school education or less and those with a post-high school education. Response rates at year 7 (1992–1993) and at year 15 (2000–2001), used in these analyses, were 80 percent and 74 percent, respectively, for a sample of 3,330. This report is limited to African-American (n = 1,507) and White (n = 1,813) participants with nonmissing racial discrimination data at years 7 and 15 and substance use data at year 15. The institutional review board at each center approved the study protocol.

Independent variable
At years 7 and 15, participants were asked about their experiences of discrimination due to race or color, gender, and socioeconomic position or social class (7, 14); we focus on discrimination due to race only. Because self-reported racial discrimination was far less frequent in Whites than in African Americans and may be a qualitatively different phenomenon with different health implications, we analyzed racial discrimination among African Americans and Whites separately.

During the year 7 examination, participants were asked whether they had ever experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior because of their race or color in seven domains (yes/no): at school, getting a job, at work, getting housing, getting medical care, on the street or in a public setting, and from the police or in the courts. At year 15, the phrase "been prevented from doing something" was dropped from the discrimination question, and the domain "from the police or in the courts" was replaced with "at home." We found little difference in African Americans between the prevalence of racial discrimination in one or more domains at year 7 versus at year 15 (79.5 percent and mean 2.8 domains vs. 74.6 percent and mean 2.3 domains). The same was true for Whites. Examination of time changes and repeatability yielded little difference in discrimination experience between years 7 and 15. We therefore studied a four-category variable that captured the extent of discrimination and its persistence: reporting discrimination in three or more domains at both years; reporting any discrimination in three or more domains at 1 year only; reporting any discrimination in at least 1 year but less than three domains at both years; and reporting no discrimination exposure. Findings were similar in both the continuous (sum of the seven domains across both years) and categorical variables, and we reported results only for the categorical variable.

Dependent variables
Smoking status (never, former, and current smoker), alcohol consumption, and lifetime use of illicit substances were ascertained at year 15. Participants were asked, "Did you drink any alcoholic beverages in the past year? Yes/no" and three follow-up questions regarding how many drinks of wine, beer, and liquor were usually consumed per week. Total consumption was categorized as those drinking more than 15.0 ml per week and those who did not. Alcohol consumption was also dichotomized as binge drinking, defined as five or more drinks in any 24 hours for men and four or more drinks in any 24 hours for women. Lifetime use of substances (marijuana, cocaine, crack, speed, and heroin) was recorded as one of the following: never, 1–10 times in lifetime, 11–99 times in lifetime, and 100 or more times in lifetime. The frequency of each substance use in the past 30 days was also queried as yes/no.

Other covariates
Two questions were asked at year 15 regarding coping mechanisms for unfair treatment: "If you feel you have been treated unfairly, 1) do you usually accept it as a fact of life or try to do something about it; and 2) do you usually talk to others about it or keep it to yourself?" These variables were categorized in three levels: those who both talk to others about it and do something; those who either try to do something about it or talk to others about it, but not both; and those who both do nothing about it and keep it to themselves (33).

Psychosocial measures of control/mastery (34), social network (35), anger (36, 37), and social support (38, 39) were calculated at year 15. The measure of control of one's life was calculated by adding responses to seven questions regarding one's control over things that happen in life, ability to solve problems and change important things in one's life, and feelings of helplessness with answers ranging from 1 (strongly agree) to 5 (strongly disagree), for a maximum score 35. Social network was assessed through six questions: "Do you belong to any of these kinds of groups? Social or recreational group; labor union, commercial group, or professional organization; church group; a group concerned with children; a group concerned with community betterment, charity, or service; or any other group?" Answers were added, each "yes" answer receiving a score of 2, with a maximum score of 12.

Anger was assessed in eight domains related to expression and feeling of anger, with answers ranging from 1 (almost never) to 4 (almost always), with a summary score calculated by adding the answers to the eight questions and a maximum score of 32. Social support was classified as emotional and negative support by adding responses to four questions for each domain, ranging from 1 (not at all) to 4 (a lot) for a maximum score of 16 for each domain of social support. Questions considered for emotional support were the following: How much 1) do members of your family or friends really care about you?; 2) do they understand the way you feel about things?; 3) can you rely on them if you need to talk about your worries?; and 4) can you open up to them if you have a serious problem? For negative support, these questions were as follows: How often 1) do members of your family or friends make too many demands on you?; 2) do they criticize you?; 3) do they let you down when you are counting on them?; and 4) do they get on your nerves? High score values indicate high control, high social network, higher anger, and high social emotional or negative support.

Age and sex were ascertained at baseline and updated at year 2. Income and education obtained from the year 15 interviews were used as socioeconomic position indicators, with combined family annual income selected from nine categories (<$5,000; $5,000–$11,999; $12,000–$15,999; $16,000–$24,999; $25,000–$34,999; $35,000–$49,999; $50,000–$74,999; ≥$75,000; and nonresponse). Income was missing for 1.1 percent (28 African Americans, eight Whites). Educational attainment was collected in years from 1 to 20 and as categorical variable as high school diploma or general equivalence diploma (GED); associate degree; bachelor's degree; master's degree; doctorate; and professional (doctor of medicine (MD), doctor of jurisprudence (JD), doctor of dental science (DDS), and so on) and recoded as less than high school, high school, some college, college graduate, and graduate school.

Statistical analysis
Descriptive statistics for selected characteristics were calculated by level of racial discrimination in Blacks and Whites separately, with the statistical significance of differences assessed via chi-squared and analysis-of-variance tests, as appropriate.

Logistic regression estimated the strength of the association between self-reported racial discrimination at years 7 and 15 and any alcohol consumption at year 15, while multinomial logistic regression estimated the association of discrimination with smoking and lifetime use of marijuana, crack, cocaine, speed, and heroin in separate models for each outcome, before and after adjustment for covariates including education and income. To assess whether one substance predominated in a cluster of behaviors, we further adjusted the models for smoking status and alcohol consumption by marijuana use, and vice versa. To determine whether the effect of racial discrimination differs by coping mechanisms to unfair treatment, sex, income, and education, we tested appropriate interaction terms in the final models.

Additional analyses that further exploited the longitudinal nature of the CARDIA Study but yielded no qualitatively different conclusions are included in a supplemental document referred to as the "Web Appendix" and posted to the Journal's website (http://aje.oxfordjournals.org/). Two-sided p values of less than 0.05 were considered statistically significant. Analyses were performed using SAS, version 9.1.3, software (40).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Most African Americans reported experiencing racial discrimination, with 89 percent reporting any discrimination at year 7 or year 15 and 34 percent reporting discrimination in at least three of seven domains in both years. African Americans reporting racial discrimination also reported more education, higher income, less control of their life, more anger, less emotional support, more negative interactions, and having a stronger social network than those reporting no racial discrimination (table 1). Racial discrimination was far less common among Whites, with 1 percent reporting racial discrimination in three or more domains in both years and 38 percent reporting any discrimination in either year (table 2). In contrast to African Americans, Whites reporting racial discrimination reported less education and lower income than did those who reported none. Similar to African Americans, Whites reporting any discrimination were more likely to report less control of their life, more anger, less emotional support, and more negative interactions than did their counterparts reporting none (all p values < 0.001).


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  		TABLE 1. Selected sociodemographic characteristics at year 15, by self-reported racial discrimination in years 7 and 15 among African Americans, the CARDIA* Study, 1992–2001

 

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  		TABLE 2. Selected sociodemographic characteristics at year 15, by self-reported racial discrimination in years 7 and 15 among Whites, the CARDIA* Study, 1992–2001

 
African Americans reporting any discrimination were more likely to report drinking any alcohol in the past year and using marijuana and cocaine 11 or more times in their lifetime (table 3). Distinct monotonic increase patterns with increasing reported racial discrimination were seen for any alcohol consumption in the past year and for marijuana and cocaine lifetime uses of 11–99 and 100 or more times. There was no association between self-reported racial discrimination and moderate to heavy drinking or binge drinking in the past month, nor with current (last 30 days) marijuana use.


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  		TABLE 3. Prevalence of smoking, alcohol consumption, marijuana use, cocaine, crack, speed, and heroin at year 15, according to self-reported racial discrimination in years 7 and 15 among African Americans, the CARDIA* Study, 1992–2001

 
After full adjustment, as shown in model 2 of table 4, African Americans experiencing racial discrimination in at least three domains in both years had 1.87 (95 percent confidence interval (CI): 1.18, 2.96) and 2.28 (95 percent CI: 1.19, 4.36) higher odds of reporting current and former tobacco use than did those experiencing no discrimination. Those reporting discrimination were also more likely to report having any alcohol in the past year as compared with those reporting none, before and after full adjustment.


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  		TABLE 4. Odds ratios and their 95% confidence intervals for smoking status and alcohol consumption at year 15 by self-reported perceived racial discrimination experience in years 7 and 15 among African Americans, the CARDIA* Study, 1992–2001{dagger}

 
African Americans reporting discrimination were more likely to report lifetime marijuana use compared with those reporting no discrimination, before and after full adjustment (table 5). This pattern was observed for those reporting having used marijuana 1–10 times, 11–99 times, and 100 or more times in their lifetime. For African Americans reporting being discriminated in three or more domains in both years, the odds of using cocaine 11–99 times over their lifetime were 7.04 (95 percent CI: 1.65, 29.96) versus no discrimination. The adjusted associations between crack, speed, and heroin and racial discrimination were not significant (data not shown).


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  		TABLE 5. Odds ratios and their 95% confidence intervals for marijuana use and cocaine use at year 15 by self-reported perceived racial discrimination experience in years 7 and 15 among African Americans, the CARDIA* Study, 1992–2001{dagger}

 
There was no evidence that discrimination interacted with sex, income, education, and coping for smoking status, alcohol consumption, or marijuana use. The odds ratios for smoking and alcohol for model 2 in table 4 were further adjusted for marijuana and cocaine (analysis not shown). After this adjustment, the association was attenuated to nonsignificance for smoking, while for alcohol, the odds ratio decreased by 50 percent in the high level of discrimination (odds ratio = 2.12 vs. 1.59). However, when the models for smoking and alcohol consumption were additionally adjusted only for each other, the associations barely changed. When the model for marijuana use was additionally adjusted for smoking, alcohol consumption, and cocaine, the association remained significant, although its magnitude decreased somewhat (range: 17–24 percent).

Whites reporting any discrimination both years were more likely to report using marijuana, cocaine, and speed in their lifetime than were Whites reporting none (all p < 0.001) (table 6). In fact, there was a positive monotonic pattern for those using marijuana, cocaine, and speed 100 or more times in their lifetime. Although discrimination in three or more domains in both years was rare among Whites (1.2 percent), the pattern of association of racial discrimination with marijuana and cocaine was similar to the one for African Americans in the fully adjusted model (data not shown). For example, in Whites reporting being discriminated in three or more domains in both years, the fully adjusted odds of using marijuana and cocaine 100 or more times during their lifetime were 3.00 (95 percent CI: 0.77, 11.71) and 2.24 (95 percent CI: 0.42, 12.05) versus Whites reporting no discrimination.


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  		TABLE 6. Prevalence of smoking status, alcohol consumption, marijuana use, cocaine, crack, speed, and heroin at year 15, according to self-reported racial discrimination in years 7 and 15 among Whites, the CARDIA* Study, 1992–2001

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
We found that self-reported racial discrimination was common in African Americans, with 89 percent reporting any discrimination when queried 8 years apart and 34 percent reporting racial discrimination in at least three of seven domains in both years. Racial discrimination was much less common among Whites, with self-reported rates of 38 percent and 1 percent, respectively. Self-reported racial discrimination in African Americans was associated with smoking, past year alcohol consumption, and lifetime use of marijuana and cocaine (as it was in Whites). However, experiencing racial discrimination was unrelated to marijuana use in the past 30 days, was stronger in former than in current smokers, and was unrelated to amount of alcohol consumed. Although less common in Whites, the pattern of association of drug use and discrimination was clear in both racial/ethnic groups, indicating that unfair treatment may lead to similar coping responses in African Americans and Whites.

Our findings are consistent with those of some studies reporting an association between self-reported discrimination and smoking among African Americans in the United States (20, 22, 23, 25, 27) and in other ethnic groups elsewhere (29). The odds ratios for current smoking in these studies range from 1.37 to 2.10. For example, in the United States, Landrine and Klonoff (20) found that African-American college students reporting high discrimination were 1.87 times more likely to smoke than were those reporting a lower level of discrimination. Guthrie et al. (22) found that African-American adolescents reporting racial discrimination were 1.37 times more likely to smoke than were those who did not, and Bennett et al. (23) found a stronger association (odds ratio = 2.10) among African-American young adults. Similarly, Harris et al. (29) found that those reporting lifetime discrimination in New Zealand (mostly non-European ethnic groups such as Maori, Pacific Islanders, and Asians) were 1.67 times more likely to smoke than were those reporting no discrimination. We found that those reporting discrimination in three or more domains on two occasions had 1.87 times higher odds of reporting current smoking than did those reporting no discrimination. Interestingly, the association for past smoking was stronger than for current smoking (odds ratio = 2.28).

Previous studies examining the association between racial discrimination and alcohol consumption have produced mixed results (18, 19, 21, 25, 27). For example, Yen et al. (18, 19) found no association between racial discrimination and heavy drinking among African Americans after adjusting for age, sex, education, income, marital status, and seniority among transit operators in San Francisco, California. Resnicow et al. (27) reported similar findings in African-American adolescents. However, Martin et al. (21), using data from the National Survey of Black Workers, found that African Americans reporting discrimination were 2.12 times more likely to report problem drinking than were those who did not. Our findings suggest an association between discrimination and alcohol consumption within the past year, although we found neither a dose-response effect nor an association with heavy or binge drinking.

Among the substances that we studied, the relation with marijuana use appeared strongest, with a dose-response effect. There was an association between racial discrimination and lifetime cocaine use among those reporting high discrimination in both years and using cocaine 11–99 times, but not for 0–10 or 100 or more times. Although we did not find any previous study examining the association of racial discrimination with marijuana and cocaine use in adults, studies have found that African-American adolescents and American-Indian children perceiving racism were more likely to report drug use including marijuana than were those perceiving no racism (27, 28). If replicated by future research, our finding of an association of self-reported discrimination with marijuana and cocaine use may be generalizable across multiple health practices behaviors. We found no association between discrimination and crack, speed, and heroin. Possibly, this relates to the lower prevalence of the use of these substances, compared with marijuana and cocaine.

Previous studies have found that racial discrimination is positively associated with socioeconomic position in African Americans (7, 12, 18, 19, 41–43). Specifically, African Americans with higher education were more likely to experience discrimination (7, 12, 18, 19, 42). We found that African Americans reporting discrimination in three or more domains in both years had higher levels of education and income than did those who reported experiencing less or no discrimination. In Whites, the associations were in the opposite direction, with the least educated and lowest income subjects more likely to report discrimination. Possibly, African Americans with a higher socioeconomic position report more discrimination because they are more exposed to situations in which they are discriminated, or they may be more aware of subtle forms of discrimination. In contrast, Whites with a low socioeconomic position may be more likely to be exposed to environments in which they are the minority and, therefore, be more likely to feel discriminated.

The findings of Armstead et al. (43) indicate, albeit without a formal mediation analysis, that anger may be a mediator of the association between racial discrimination and blood pressure. However, Clark (44) shows that seeking social support was associated with higher levels of blood pressure under high perceived racism. Moreover, Steffen et al. (45) found that anger did not explain the association between perceived racism and blood pressure. We found that CARDIA Study participants reporting any discrimination were more likely to report less control of their life, higher anger, lower emotional support, and more negative interactions than those reporting none, regardless of race/ethnicity. Furthermore, our study shows that anger, control, social support, and networks partially mediated the association of racial discrimination with smoking and marijuana in both African Americans and Whites. Assuming that smoking and marijuana help to relieve at least some of the negative feelings generated by racial discrimination, we find it possible that anger, emotional support, negative interactions, and social network may amplify or diminish the need for using smoking and marijuana as a buffer for the negative effect of discrimination.

Among the strengths of our study are its population-based nature, the focus on young to middle-aged adults, the wide ranges of educational attainment and income, the information on illicit substance use, and socioeconomic position indicators. An important limitation is the observational nature of the data. Remarkably, current marijuana use at years 0 and 2 of the CARDIA Study was greater among persons reporting (in years 7 and 15) discrimination ever, compared with never (data not shown). Given that discrimination was queried as "ever," conceivably persons who experienced early life discrimination also engaged in substance misuse in early adulthood and then gave it up; however, the temporal ordering of the questions precludes clear inference. Further, because both exposure and outcome measures were self-reported, same-source bias (i.e., a tendency for individuals who report more risky behaviors to also report more discrimination) could have biased the results away from the null.

We found that, after controlling for education and income, African Americans experiencing discrimination were more likely to have used marijuana relatively often during their lifetimes and to smoke and drink at least casually. Although discrimination was less frequent in Whites, their findings parallel those in African Americans. With due regard for issues of temporal ordering of the associations found here, it is possible that use of a recreational drug helps to cope with life stress resulting from perceived unfair treatment because of one's race/ethnicity. Our findings that current use of marijuana was not related to discrimination and that risk of being a former smoker was increased suggest that, by early middle age (average age, 40 years), people may have found other ways to cope. However, the persistence of excess current smoking, which is associated with adverse effects on long-term health in this sample (46), suggests that this particular addictive habit may be more lasting (47), even as alternative coping behaviors are adopted.


   ACKNOWLEDGMENTS
 
This work was supported by the National Institute of Dental and Craniofacial Research (grant K22DE15317) and by the Robert Wood Johnson Health and Society Scholars Program (to L. N. B.). The CARDIA Study was supported by National Heart, Lung, and Blood Institute contracts N01-HC-48047, N01-HC-48048, N01-HC-48049, N01-HC-48050, and N01-HC-95095.

The authors thank the staff of the CARDIA Study for their important contributions.

Conflict of interest: none declared.


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

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