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Am J Public Health. 2008 June; 98(6): 1107–1114.
PMCID: PMC2377285

Prevalence of Substance Use Disorders Among African Americans and Caribbean Blacks in the National Survey of American Life

Abstract

Objectives. We sought to estimate the prevalence of substance disorders for African Americans and Caribbean Blacks in the United States using data from the National Survey of American Life.

Methods. A national household probability sample of noninstitutionalized African Americans (n=3570) and Caribbean Blacks (n=1621) was obtained between February 2001 and June 2003 using a slightly modified version of the Composite International Diagnostic Interview.

Results. Overall differences in prevalence of substance disorders between the ethnic groups were not significant. Prevalence rates of substance disorders among African Americans exceeded that of Caribbean Blacks among women, those aged 45 to 59 years, and those who were divorced. African Americans in major metropolitan areas had higher prevalence rates, and those in the South had lower ones, compared with those living in other areas. Overall, first-generation Caribbean Blacks were significantly less likely, but second-generation more likely, than were African Americans to meet criteria for overall substance disorders.

Conclusions. Failure to distinguish between African Americans and Caribbean Blacks masks important differences in substance use patterns among the Black population in the United States.

In the United States, about 51% of older adolescents and adults have used illegal drugs or illegally diverted prescription drugs over their lifetimes, and about 15% have used them over the prior 12 months.1 In a recent national study among adults, prevalence rates for any substance disorder were 14.6% for lifetime, and 3.8% for the prior 12 months.2,3 Studies of racial and ethnic differences have found that Whites have higher prevalence rates of substance abuse disorders than do other racial and ethnic groups,2,4,5 but racial and ethnic minorities have been shown to have substance abuse disorders that persist for longer periods of time.5 Findings from the National Survey on Drug Use and Health also showed higher drug abuse rates for Whites than for racial or ethnic minorities, except for abuse of crack cocaine and heroin.6 Despite the lifetime and current prevalence rates of illegal drug use being lower for Blacks, Blacks are overrepresented in the health and criminal justice systems.79

Previous research on substance abuse among Blacks has lumped the Caribbean Black and African American populations together. This is true of almost all studies,26 with few exceptions.10 Previous research, however, is clear in noting that these 2 populations are quite distinct.1115 The differences between the 2 groups exist among most sociodemographic categories. For example, the Caribbean Black population is overwhelmingly northern, whereas the African American population is predominantly Southern.10,14,15 There are also important socioeconomic differences, such as family income and college attendance.1117 Another key difference is that qualitative experiences of racial discrimination are somewhat distinct.12,13,15,18 Finally, the Caribbean Black population is significantly more likely to be comprised of first-generation immigrants and second-generation children of immigrants, whereas this is not true for the African American population.1116

Although the extant literature provides important information about the prevalence of substance use disorders among racial and ethnic minorities, there are several concerns that limit the policy implications of these findings. For example, studies that have nationally representative samples either rely on data collected more than a decade ago or do not permit diagnoses using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV ).1,19 Those that do use DSM–IV diagnostic criteria typically do not present substance use disorders separately by race and ethnicity; instead, they group together all non-Hispanic Black respondents into a catch-all category of “Black” or “African American.”36 In the past, when the Caribbean Black population was small, this was a practical solution. With the growing population of Caribbean Blacks in the United States, however, aggregating all “Black” respondents into a single category may mask important differences in substance use disorders. We address these limitations by providing estimates of substance use disorders separately for African American and Caribbean Black populations. We present data on substance abuse disorders among African Americans and Caribbean Blacks in the United States diagnosed using DSM–IV criteria,19 utilizing data from the National Survey of American Life (NSAL).20

METHODS

Sample

The NSAL is a comprehensive study of the mental health of US Blacks.20 The study, conducted between February 2001 and June 2003, is part of an National Institute of Mental Health Collaborative Psychiatric Epidemiology Surveys initiative.21 The NSAL adult sample, all 18 years and older, is an integrated national household probability sample of 3570 African Americans, 1621 Blacks of Caribbean descent (Caribbean Blacks), and 891 non-Hispanic Whites who live in areas where at least 10% of the population is Black.22 In both the African American and Caribbean Black samples, it was necessary for respondents to self-identify their race as Black. Those self-identifying as Black were included in the Caribbean Black sample if they answered affirmatively when asked if they were of West Indian or Caribbean descent or if they said they were from a country included on a list of Caribbean-area countries provided by the interviewers. Most interviews were conducted face-to-face with a computer-assisted instrument and lasted an average of 2 hours and 20 minutes. The final overall response rate was 72.3%, but 70.7% for the African American sample, 77.7% for the Caribbean Blacks, and 67.7% for the non-Hispanic Whites. Because of time and budget constraints, White respondents were not asked the substance use questions. We focused on the 2 Black ethnic samples.

Measures

The DSM–IV

World Mental Health Composite International Diagnostic Interview (WMH–CIDI), a fully structured diagnostic interview, was used to assess a wide range of mental disorders. The mental disorders sections used for the NSAL, including that for substance use, are slightly modified versions of those developed for the World Mental Health project initiated in 200023 and the instrument used in the National Comorbidity Survey Replication (NCS–R).3,24

Sociodemographic correlates included ethnicity (African American, Caribbean Black), age (18–29 years, 30–44 years, 45–59 years, ≥ 60 years), gender, employment status (employed, unemployed, not in labor force), years of education completed (0–11 years, 12 years, 13–15 years, ≥16 years), household income (divided approximately into quartiles of < $18000, $18000–$31999, $32 000–$54 999, ≥$55 000), marital status (married or cohabiting, previously married, never married), place of birth (in United States or not), region as defined by the Bureau of Census Department of Labor25 (Northeast, Midwest, South, and West), and urbanicity as defined by the US Department of Agriculture’s 2003 Rural–Urban Continuum Codes to include major metropolitan areas, other urban (suburbs with population 2500 or greater), and rural (completely rural or less than 2500 urban).25,26

Immigrant status was assessed by asking respondents how long they had been in the United States. About 98% of the African American population was born in the United States, whereas 65% of the Caribbean Black population was born outside the United States (Table 1 [triangle]). We constructed a 3-category variable for most analyses and for the Caribbean sample only: 1 = first-generation Caribbean Black, where the respondent was born outside the United States; 2 = second-generation Caribbean Black, where the respondent was born in the United States, but at least 1 parent was born outside the United States; and 3= third-generation or more Caribbean Black, where both the respondent and his or her parents were born in the United States. Because of small sample sizes for the diagnostic categorization, it was necessary to collapse respondents who came to the United States at different times into broad time categories. African Americans born in the United States were added as a fourth category for final immigration analyses.

TABLE 1
Weighted Distribution of Sociodemographic Variables, by Ethnicity: National Survey of American Life Sample, 2001–2003

Analysis Procedures

We used cross-tabulations to present ethnic differences in the prevalence of lifetime substance disorders. We used odds ratios and 95% confidence intervals from logistic regression models to assess associations between sociodemographic indicators and the prevalence of a range of substance and alcohol disorders. We weighted data used in these analyses to correct for unequal probabilities of selection, nonresponse, and for population representation across various sociodemographic characteristics. All analyses were conducted with SAS 9.1.2 (SAS Institute Inc, Cary, NC), which uses the Taylor expansion approximation technique for calculating the complex-design–based estimates of variance. Throughout the analyses, the .05-level on a 2-sided design-based test of significance represented the cut-off for assessing statistical significance.27 Because standard errors adjusted for complex designs are usually larger than nonadjusted standard errors, differences that may appear large may not be statistically significant.

RESULTS

Table 1 [triangle] presents the distribution of demographic variables for the NSAL sample by ethnic group. The data indicated that, compared with the African American population, a greater percentage of Caribbean Blacks had higher levels of education and income and they were more likely to be married, to be employed, to reside in the Northeast, to reside in major metropolitan areas, and to be born outside the United States. The weighted sample characteristics approximate those of their corresponding ethnic group populations in the United States.15,16,28

Substance abuse was defined as either alcohol or drug abuse; similarly, substance dependence included alcohol and drug dependence. The results in Table 2 [triangle] show DSM–IV prevalence rate estimates for lifetime substance abuse and lifetime substance dependence by ethnic group. The overall estimate is presented in the first row of the table labeled “Overall.” Tests for ethnic differences on prevalence estimates by demographic measures are in the last column. The last row for each demographic measure includes tests of association between that demographic variable and the specific diagnostic rates, separately for African Americans and Caribbean Blacks.

TABLE 2
Prevalence of Lifetime Substance Abuse and Dependence, by Demographics and Ethnicity: National Survey of American Life Sample, 2001–2003

The overall prevalence rates of substance abuse were slightly higher, yet not statistically different, for African Americans (11.5%) than for Caribbean Blacks (9.6%). The same was true for substance dependence: 4.9% and 4.1%, respectively. There were important significant differences across demographic variables, however. African Americans aged 45 to 59 years had higher prevalence rates of both substance abuse and substance dependence than did Caribbean Blacks of the same age. Prevalence rates of substance abuse among African American women (6.3%) were higher than that among Caribbean Black women (2.8%). Significant ethnic differences in substance dependence prevalence were observed for respondents with 12 years of education and lower- to mid-income level of $18 000 to $31 999; African Americans had much higher rates than did Caribbean Blacks in both categories. African Americans who were divorced, separated, or widowed had much higher prevalence rates for both substance abuse and dependence than did Caribbean Blacks of the same marital status. African Americans in the Northeast had a much higher prevalence of both substance abuse and substance dependence than did Caribbean Blacks. No between-ethnic-group differences in lifetime prevalence rates were found by work status, place of birth, urbanicity, and whether born in or outside the United States.

In both ethnic groups, men had a substantially higher prevalence of substance abuse and substance dependence than did women. Among African Americans, there was a higher prevalence of substance use disorders among those aged 30 to 59 years compared with younger and older cohorts. In terms of education and income, African Americans with the lowest levels of education and lowest income had the highest prevalence rates of both substance abuse and substance dependence, whereas those with the highest level of education and highest income had the lowest rates of substance disorder. There were no significant differences across education and income for Caribbean Blacks, although a similar pattern was found such that those with the lowest education and income had the highest rates of substance dependence. Among both African Americans and Caribbean Blacks, those born in the United States had a much higher prevalence rate of substance abuse than those born outside the United States. Third-generation US-born Caribbean Blacks, however, had higher rates of substance dependence than did the first and second generation Caribbean Blacks.

African Americans living in the South and Caribbean Blacks living in the Northeast had the lowest prevalence rates of substance dependence. Because of small sample sizes, no estimates by urban versus rural status could be calculated for the Caribbean Black population. For African Americans, however, the prevalence rates of substance disorders were largest for those in metropolitan areas.

Because of space limitations, prevalence rates of substance abuse over the prior 12 months are not shown; however, there were some notable patterns. Similar to lifetime prevalence rates, there were no significant ethnic differences in 12-month prevalence rates of overall substance abuse and dependence—3.4% for Caribbean Blacks and 2.8% for African Americans. Twelve-month prevalence rates for substance dependence were 1.5% for African Americans and 1.2% for Caribbean Blacks. Because of smaller prevalence rates, and correspondingly smaller sample sizes, there were fewer significant results for the 12-month diagnoses. There were 2 noteworthy patterns, however. First, among women only, there were significantly higher prevalence rates of both 12-month substance abuse and dependence for African Americans compared with Caribbean Blacks. Second, although the likelihood of 12-month substance abuse decreased with age among both groups, the prevalence decreased most notably for Caribbean Blacks. This pattern was marked in those in the age group of 45 to 59 years, because a significantly greater percentage of African Americans had 12-month diagnoses of substance abuse and substance dependence than did Caribbean Blacks in this age range.

Table 3 [triangle] presents separate estimates of lifetime rates and odds ratios from bivariate logistic regressions across demographic characteristics for alcohol abuse, alcohol dependence, drug abuse, drug dependence, and any substance use disorder diagnoses by each ethnic group. For African American respondents, the corresponding lifetime prevalence rates for alcohol abuse, alcohol dependence, drug abuse, and drug dependence, or any substance use disorders were 9.7%, 3.7%, 6.3%, 2.5%, and 11.5%, respectively (Table 3 [triangle]). Results for sociodemographic differences largely mirror those found in Table 2 [triangle]. As shown in Table 3 [triangle], there were a number of differences in the odds of substance use disorders by age, gender, employment status, education, income, and marital status among African Americans. The lifetime prevalence rates for the Caribbean Black population of alcohol abuse, alcohol dependence, drug abuse, drug dependence, and any substance use disorders were 9.1%, 3.4%, 5.9%, 2.8%, and 9.6%, respectively. These prevalence rates were slightly lower than those for the African American population with the exception of drug dependence, which was slightly higher. As shown in Table 3 [triangle], odds ratios varied by age, gender, education, income, marital status, birthplace, and immigration status for various diagnoses.

TABLE 3
Demographic Correlates of Lifetime Substance Abuse and Substance Dependence, by Ethnicity: National Survey of American Life Sample, 2001–2003

The next set of analyses examined whether immigrant status affects substance abuse (Table 4 [triangle]). For this analysis, we combined African Americans and Caribbean Blacks in 3 sets of multivariate logistic regression analyses, where the dependent variables were DSM–IV lifetime diagnoses for alcohol abuse, drug abuse, and substance disorder, including both abuse and dependence, where 1=met DSM–IV diagnosis criteria and 0=did not meet criteria. We excluded diagnoses of alcohol and drug dependence because of small sample sizes, which resulted in unstable parameter estimates. The immigration variable consisted of Caribbean Blacks categorized as first-generation immigrants, second-generation Caribbeans, third-generation or later Caribbeans, and US-born African Americans. Because the number of foreign-born African Americans was very small, all African Americans were coded as 1 group without distinguishing between immigrant status; the same was the case for Caribbean Blacks. The African American group was the reference category for the analyses. We controlled for age, gender, work status, education, income, and marital status.

TABLE 4
Odds Ratios for Lifetime Substance Disorders (N = 4908), by Immigration and Ancestry Status: National Survey of American Life, 2001–2003

The analyses on immigration and ancestry status revealed that third-generation or later Caribbean Blacks did not significantly differ from African Americans for all 3 diagnoses studied. Second-generation Caribbean Blacks were more than twice as likely as African Americans to meet criteria for alcohol and drug abuse and overall substance disorder. Being a first-generation immigrant made an important difference: they were significantly less likely than were African Americans to meet criteria for alcohol abuse and overall substance disorder.

DISCUSSION

To our knowledge, this is the first study to provide estimates of DSM–IV substance abuse and dependence diagnoses separately and comparatively for nationally representative samples of the African American and Caribbean Black populations. Perhaps the most significant finding was that there were substantial differences in the patterns of substance abuse and substance dependence between and within the African American and Caribbean Black populations. We also found important differences on the basis of immigrant status among the Caribbean Black population. It is particularly important to report these differences, given that these 2 populations have most often not been disaggregated in previous studies. Our analyses demonstrate that aggregating across Black ethnicities obscures important distinctions when substance abuse and substance dependence disorders are being examined.

We found important demographic differences within and across the African American and Caribbean Black samples. For example, substantial ethnic differences in prevalence of substance abuse and substance dependence were observed by geographical regions of the United States. Gender, education, income, and marital status differences in substance use disorders were also found; these patterns are consistent with what we might expect given previous research.16

The finding that lifetime substance abuse and substance dependence were significantly lower for foreign-born Caribbean Blacks (and the relatively small numbers of foreign-born African Americans) is important and largely consistent with previous research on the association between immigration, acculturation, and substance use.2933 Consistent with findings for physical health and mortality,32,33 the results suggest that immigrant status lends protection against substance use disorders. Several reasons have been offered as to why immigrant populations have lower rates of health disorders. Most of these involve selection effects, the importance of strong family and social support systems, and a lack of acculturation to the new society.3133 For example, a study of adolescents in Massachusetts found that although immigrant youths reported lower rates of substance use, recent immigrant youths reported more peer pressure to engage in risk behaviors and less parental support to avoid risk behaviors.31 Other studies strongly suggest that, generally over time, immigrant health and health behavior patterns come to mirror those of the native population for specific ethnic groups, such as Blacks and Hispanics.3133

The fact that the NSAL data suggest lower overall prevalence rates for Caribbean Blacks but differences by immigrant status may provide support for this type of first-generation theorizing; i.e., a breakdown in these protective factors may be more detrimental for second-generation Caribbean Blacks (the pattern found here) than for those either not acculturated (first generation) or more acculturated, subsequent-generation Caribbean Blacks (third generation and later). Further studies will explore both at the population and individual levels how these structures and processes of immigrant protection may operate differentially in affecting rates of substance use disorders in first- and subsequent-generation Caribbean Blacks.

Several limitations should be considered when interpreting the results. The major limitation is associated with a modification in the WMH-CIDI questions used to assess alcohol and drug dependence. An error in the skip pattern was included following substance abuse criteria. Thus, respondents who did not meet abuse criteria were not assessed for dependence. In the DSM–IV, however, dependence can be diagnosed whether or not abuse was present. As a consequence, rates of substance dependence were underreported.

In addition, our sample is based upon community-dwelling individuals in households; homeless and institutionalized individuals were not included. Because the underrepresented groups of homeless and institutionalized Blacks is relatively small, however, the effect of underrepresenting these groups is likely minimal. Also excluded were individuals who did not speak English at all or well enough to be interviewed, which may have resulted in the under-representation of French-, Spanish-, and Creole-speaking Caribbean Blacks. Because both underrepresented groups are relatively small in the United States, however, their effect on the substance use disorder rates is likely to be minimal. Another limitation concerns the relatively small and highly clustered sample of Caribbean Blacks, at least when compared with the larger, more diverse sample of African Americans, that resulted in larger standard errors, likely resulting in fewer significant differences than may actually be present in the population. Finally, because of the high cost associated with interviewing nationally representative samples of African Americans and Caribbean Blacks, it was decided to not administer the substance use questions to the non-Hispanic White sample; therefore, a direct comparison of rates of substance disorders and their demographic correlates with non-Hispanic Whites in the NSAL was not possible.

All of the studies in the National Institute of Mental Health Collaborative Psychiatric Epidemiology Surveys initiative utilized the WMH–NCS–R–modified CIDI, a lay-administered interview. Some research suggests that DSM–IV diagnoses may be overestimated with lay-administered interviewing. The most definitive research suggests that this is particularly true for nonaffective psychoses,3438 which were not assessed in the NSAL. On the other hand, some studies have shown that estimates of prevalence rates for all disorders with the WMH–CIDI are generally conservative.39

We believe that the overall effect of most of these limitations is to make our estimates more conservative than might otherwise have been the case. Therefore, it is unlikely that any positive, significant results found and reported in this study would have been affected by these limitations.

The NSAL included a population group, Caribbean Blacks, for which there is no preexisting data on substance use diagnoses and for whom national data are lacking. Thus, future studies will be necessary to replicate the findings we report. More research is also needed on the African American population for several reasons. First, the use of DSM–IV diagnostic criteria may result in differences in prevalence with other studies that might be partly attributable to differences in the updated criteria used. Second, participants who were defined as Caribbean Blacks for our study were not distinguished from African Americans in previous studies. It is unclear what effect this may have had on the results of previous studies, including the Epidemiological Catchment Area, National Survey on Drug Use and Health, NCS, and NCS–R studies. Prevalence estimates for Blacks obtained in earlier studies may differ from the ones found in this study for these 2 population subgroups. It is plausible that these differences may indicate that previous studies were in error in not considering and comparing Black ethnic groups. Consequently, comparing our estimates with findings from previous studies is complicated. Only future studies that attend to these ethnic differences among the US Black population can fully resolve these issues.

Acknowledgments

The NSAL was supported by the National Institute of Mental Health (U01-MH57716), with supplemental support from the Office of Behavioral and Social Science Research at the National Institutes of Health, and the University of Michigan.

We appreciate the assistance provided in all aspects of the National Survey of American Life study by the Program for Research on Black Americans faculty and research staffs, including Jamie M. Abelson, Jane Rafferty, Phyllis Stillman, and Julie Sweetman. We thank the staff at the Survey Research Center’s Survey Research Operations department for their assistance with instrumentation and fieldwork for the National Survey of American Life study.

Human Participant Protection
Approval was obtained for this study through the University of Michigan institutional review board. The board screened and approved all procedures used that pertained to data collection and human participants contact.

Notes

Peer Reviewed

Contributors
C.L. Broman was the lead author. H.W. Neighbors contributed to writing and was the co–principal investigator for the data collection. J. Delva contributed to the writing. M. Torres performed data analysis and contributed to the writing. J.S. Jackson was principal investigator for the data collection and contributed to the writing. All coauthors were involved in the conceptualization of the paper.

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