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. Author manuscript; available in PMC: 2025 Mar 1.
Published in final edited form as: Alcohol Clin Exp Res (Hoboken). 2024 Jan 21;48(3):545–555. doi: 10.1111/acer.15268

Prevalence and correlates of 12-step and second-wave mutual-help attendance in a nationally representative US sample

Brandon G Bergman 1, M Claire Greene 2, Sarah E Zemore 3, John F Kelly 4
PMCID: PMC10939786  NIHMSID: NIHMS1958787  PMID: 38246752

Abstract

Background:

Mutual-help organizations (MHOs) are effective community-based, recovery support options for individuals with alcohol and other drug use disorders (i.e., substance use disorder; SUD). Greater understanding of second-wave MHOs, such as SMART Recovery, can help build on existing research that has focused primarily on 12-step MHOs, such as Alcoholics Anonymous, to inform scientific, practice, and policy recommendations.

Methods:

We conducted a secondary analysis of the National Recovery Study, a representative sample of US adults who resolved a substance use problem (N = 1984). Using survey-weighted estimates, we examined descriptive statistics for any lifetime, weekly lifetime, and past 90-day MHO attendance; we compared rates of 12-step and second-wave MHO attendance over time by descriptively examining distributions for calendar year of first meeting attended; and we conducted two logistic regression models to examine demographic, substance use, clinical, and recovery-related correlates of weekly lifetime attendance separately for 12-step (n = 692) and second-wave MHOs (n = 32).

Results:

For any attendance, 41.4% attended a 12-step MHO and 2.9% a second-wave MHO; for weekly attendance, 31.9% attended a 12-step MHO, and 1.7% a second-wave MHO. Two-thirds (64%) of initial second-wave attendance occurred between 2006 and 2017 compared to 22% of initial 12-step attendance during this time frame. Significant correlates of weekly 12-step MHO attendance included histories of SUD treatment and arrest. Significant correlates of weekly second-wave MHO attendance included Black identity (vs. White) and history of SUD medication.

Conclusions:

Attendance at second-wave MHOs is far less common than 12-step MHOs, but appears to be on the rise. Observed correlates of second-wave MHO attendance should be replicated in larger second-wave MHO samples before integrating these findings into best practices. Enhanced linkages from clinical and criminal justice settings to both second-wave and 12-step MHOs may help continue to “broaden the base” of MHOs.

Keywords: mutual-help organizations, addiction recovery, SMART Recovery, Alcoholics Anonymous

Introduction

Twelve-step mutual-help organizations (MHOs) like Alcoholics Anonymous (AA), founded in 1935, and Narcotics Anonymous (NA), founded in 1953, are commonly-attended (Grant et al., 2016, 2015), effective (Crits-Christoph et al., 1999; Gossop et al., 2008; Humphreys et al., 2020, 2014; Kelly et al., 2020a; Weiss et al., 2005; Ye and Kaskutas, 2009), and cost-effective (Humphreys and Moos, 2007; Kelly et al., 2020a; Mundt et al., 2012) recovery support options for individuals with current and remitted alcohol and other drug use disorders (e.g., opioids, stimulants, cannabis, etc.), collectively referred to as substance use disorders (SUD). At the same time, the demographic, psychosocial, and clinical heterogeneity of those with, or in recovery from, SUD (Grant et al., 2016, 2015; Kelly et al., 2017) extend well beyond what can be addressed by 12-step MHOs alone.

A second “wave” of MHO options, emerging in the 1970s, 80s, and 90s (Humphreys, 2004; Kelly and White, 2012; Zemore et al., 2018) include those grounded in: a) principles of cognitive-behavioral skill building and personal growth – for example, SMART Recovery (hereafter SMART), LifeRing, and Secular Organization for Sobriety (or SOS), sometimes referred to collectively as secular MHOs; b) Christian scripture (e.g., Celebrate Recovery); c) non-abstinence goals (e.g., Moderation Management); and d) the needs, priorities, and values of specific sub-groups (e.g., Women for Sobriety; WFS). Theory suggests second-wave MHOs may mobilize the same mechanisms that explain 12-step MHO benefit (e.g., abstinence self-efficacy; Kelly, 2017; Kelly et al., 2009) and emerging evidence suggests participation in SMART, LifeRing, and WFS may yield benefits equal to those from 12-step MHOs after adjusting for substance use goal (Zemore et al., 2018).

Kelly and White (2012) suggested these second-wave options are needed to “broaden the base of addiction mutual-help” though very little is known empirically regarding these second-wave options to inform practice and policy recommendations. This study leverages a nationally representative sample to examine the prevalence and correlates of attendance, as well as shifts in attendance across time, for both 12-step and second-wave MHOs.

Prevalence and Growth of MHO Attendance

AA and other 12-step MHOs report substantial increases in the number of community-based groups and weekly meetings throughout the 20th century (Humphreys, 2004; Kelly and White, 2012). Despite smaller absolute numbers of groups, second-wave MHOs like SMART also document recent growth (SMART Recovery, 2020). As would be expected given the greater availability of 12-step MHOs, clinical and community SUD samples both report greater likelihood of attendance at 12-step versus second-wave MHOs (Kaskutas et al., 2014; Kelly et al., 2006; Laudet, 2013; Zemore et al., 2017). In addition, among individuals with lifetime alcohol use disorder and currently attending an MHO, those identifying a second-wave group as their primary MHO (versus a 12-step group) – namely SMART, LifeRing, or WFS – attended fewer past-month meetings, but had similar levels of active involvement (i.e., participation beyond attendance) and greater perceived group cohesion and satisfaction (Zemore et al., 2018, 2017).

Documenting patterns of attendance and growth in second-wave alongside 12-step MHOs would provide useful information regarding their accessibility and the degree to which they warrant more specific focus in future research.

Correlates of MHO Attendance

12-step MHOs

Regarding demographics, studies primarily among individuals with alcohol use disorder show that older individuals are more likely to attend 12-step MHOs than their younger counterparts (Bergman et al., 2017; Bogenschutz, 2008; Hoeppner et al., 2014). Young adults’ lower participation rates may be explained by lower levels of severity and consequences, as these are strong and consistent predictors of MHO participation (Bogenschutz, 2008; Dawson et al., 2006; Hasin and Grant, 1995).

Studies examining gender and race/ethnicity, however, offer a more complicated picture (Zemore et al., 2021). Women generally attend 12-step MHOs as often as men (Kelly et al., 2006; Zemore et al., 2014). While Black individuals had been shown to participate as much or more than their White counterparts (Chartier and Caetano, 2011; Kaskutas et al., 1999; Perron et al., 2009; Wu et al., 2016), more recent data points to lower MHO attendance (Hai et al., 2022). Latinx individuals, overall (Zemore et al., 2021), and individuals of all racial/ethnic groups with lower English proficiency (Hai et al., 2022), may be less likely to attend 12-step MHOs than their White and English proficient counterparts, respectively. Considering the intersection of gender and race/ethnicity among those with lifetime alcohol use disorder, Black and Latinx women may be less likely to attend 12-step MHOs than Black and Latinx males, while rates of 12-step attendance may be similar when comparing White women and men (Zemore et al., 2021, 2014).

Among veterans in residential SUD treatment, greater baseline religiosity predicts more 12-step MHO meetings attended at 1-year follow-up (Winzelberg and Humphreys, 1999) and decreased likelihood of 12-step MHO discontinuation between baseline and 1-year follow-up (Kelly and Moos, 2003). Of note, our group’s prior work has shown that when spirituality and religiosity are measured separately, greater spirituality is associated with weekly 12-step MHO attendance but religiosity and attendance are unrelated (Kelly and Eddie, 2020).

Second-wave MHOs

Existing data on correlates of second-wave MHO attendance is limited, thus Zemore et al.’s (2017) study of individuals with lifetime alcohol use disorder and current MHO attendance offers relevant insight. This study showed that, compared to those whose primary MHO was a 12-step group, individuals whose primary MHO was a second-wave group: a) were more likely to identify as male (excluding WFS which caters to women); b) had similar likelihood of identifying as Black or Latinx; c) had lower levels of spirituality and religiosity; d) had higher levels of education and income; and e) were less severe clinically as indicated by lower likelihood of a lifetime drug use disorder diagnosis and fewer recent mental health challenges.

The Current Study

The current study examined patterns of attendance for both 12-step and second-wave MHOs in a nationally-representative sample of US adults who resolved an alcohol or drug use problem (Kelly et al., 2017).

Aim 1 reports the prevalence of any lifetime, weekly, and past 90-day attendance a) for MHOs overall, b) for an aggregate of 12-step MHOs and an aggregate of second-wave MHOs separately, and c) for each individual MHO. Though analyses were descriptive, we expected participants would be more likely to report attendance in 12-step vs. second-wave MHOs for each temporal horizon - lifetime, weekly, and past 90-day (Kaskutas et al., 2014; Kelly et al., 2006; Laudet, 2013; Zemore et al., 2017).

Aim 2 illustrates the calendar year of one’s first meeting separately for 12-step and second-wave MHO attendance. Though analyses were also descriptive, we expected that among 12-step MHO attendees, greater proportions had attended their first meeting earlier in time (e.g., 1980s and 1990s), and among second-wave MHO attendees, greater proportions had attended their first meeting more recently (e.g., 2000s and 2010s).

Aim 3 presents demographic, substance use, clinical, recovery-related, and criminal justice correlates of weekly attendance separately for 12-step and second-wave MHOs. We hypothesized that any weekly 12-step MHO attendance would be associated with greater likelihood of SUD treatment history. We did not offer hypotheses regarding gender and race/ethnicity for either 12-step or second-wave MHO attendance given complex findings in prior work (Zemore et al., 2021). Similarly we did not offer hypotheses regarding correlates of second-wave MHO attendance, more generally, given how little is known epidemiologically about these promising (Zemore et al., 2018), but understudied, recovery support options.

Methods

Procedure

This study was a secondary analysis of the National Recovery Study (NRS; Kelly et al., 2017), a nationally-representative survey of non-institutionalized individuals in the US aged 18 years and older that answered yes to the screening question: “Did you used to have a problem with drugs or alcohol, but no longer do?”. A brief synopsis of data collection methods is presented here and a more detailed set of methods can be found in Kelly et al. (2017). Data were obtained by the survey company Ipsos (formerly GfK), using a probability sampling approach to screen their KnowledgePanel. A representative subset of 39,809 individuals were sent the screening question via email, to which 25,229 responded (63.4%). This response rate is similar to other nationally representative surveys (Center for Behavioral Health Statistics and Quality, 2016; Centers for Disease Control and Prevention (CDC), 2013; Grant et al., 2014). Consistent with approaches to analyzing other nationally representative surveys, data were weighted using the method of iterative proportional fitting to produce unbiased estimates of the US adult civilian population (Battaglia et al., 2009). Of the 25,229 respondents, the National Recovery Study (NRS) sample includes 2002 participants who responded “yes” to the screening question and were determined to be valid responders based on a systematic evaluation (Kelly et al., 2017). In the NRS, 99.1% (N = 1984) reported on their MHO attendance and were included in analyses for the current study. Demographic, substance use, clinical, recovery-related, and criminal justice characteristics for the sample are presented in Supplemental Table S1 (left column).

Measures

MHO Attendance History

We asked participants “Which of the following self-help groups have you ever attended to help you with your alcohol/drug problem?” (Kelly et al., 2011): 1) Alcoholics Anonymous (AA); 2) Narcotics Anonymous (NA); 3) Marijuana Anonymous; 4) Cocaine Anonymous; 5) Crystal Methamphetamine Anonymous; 6) SMART Recovery (i.e., SMART); 7) LifeRing Secular Recovery (i.e., LifeRing); 8) Moderation Management; 9) Celebrate Recovery; 10) Women for Sobriety (WFS); 11) Secular Organizations for Sobriety (SOS); or 12) Other. Of note, “other” groups included those for family members of individuals with an SUD (e.g., “adult children of alcoholics”, Al-anon, etc.) as we could not rule out that participant attendance was unrelated to substance use problem resolution, “church” programs or groups, and meetings mandated via criminal justice system. Overall MHO attendance variables collapsed attendance across all MHO types, including Other. Twelve-step MHO attendance variables collapsed attendance across AA, NA, Marijuana Anonymous, Cocaine Anonymous, and Crystal Meth Anonymous. Second-wave MHO attendance variables collapsed attendance across the non-religious MHO options including SMART, LifeRing, Moderation Management, Women for Sobriety, and Secular Organization for Sobriety. For interpretive purposes, we excluded the religious MHO Celebrate Recovery from 12-step MHO aggregates because the “Christ-centered”, religious recovery pathway for “hurt, hang-ups, and habits of any kind” in Celebrate Recovery (“About - Celebrate Recovery®,” n.d.) does not align with spiritual, “not religious” (e.g., Galanter et al., 2013; Narcotics Anonymous, 2008), recovery pathways for substance use in 12-step MHOs. We also excluded Celebrate Recovery from second-wave MHO aggregates because it does not align with newer groups that cater primarily to individuals interested in secular recovery pathways (Zemore et al., 2017).

For each MHO, those with lifetime attendance also reported lifetime history of weekly attendance, number of meetings attended in the past 90 days, and age of first attendance. Final MHO variables in analyses were as follows: any lifetime attendance (yes/no), any weekly attendance (yes/no), any past 90-day attendance (yes/no), and year of first attendance (derived from participant’s current age and age of first attendance).

Demographic Characteristics

We used several demographic variables that participants provided for their initial KnowledgePanel recruitment including age (modeled continuously); level of education (highest degree completed modeled as bachelor’s degree vs. less than bachelor’s degree); race/ethnicity (White, Non-Hispanic/Black, Non-Hispanic/Other-Race, Hispanic, 2+ Races); gender (Male or Female); employment status (modeled as employed vs. unemployed); and marital status (modeled as married or living with partner vs. not married or living with partner). The survey assessed the extent to which individuals considered themselves religious or spiritual (in separate items) on a Likert scale from 1 = not religious/spiritual at all to 4 = very religious/spiritual (Idler et al., 2003).

Substance Use History

Participants reported whether they used each of 15 substances/classes of substances (hereafter simply referred to as substances) on 10 or more occasions (Dennis et al., 2002). For each substance endorsed, participants also reported age of substance use onset and whether the substance was a problem for them – from which we determined overall age of onset (i.e., earliest onset across all substance use classes) and computed total number of lifetime problem substances (with a maximum of 16, including the 15 substances and an “other” option). They also indicated which of these problem substances they considered primary. Consistent with prior NRS studies (e.g., Kelly et al., 2018, 2017), we categorized primary substance groups into alcohol, cannabis, opioids, other (e.g., cocaine, benzodiazepines, etc.), and none (i.e., did not endorse any substance use as a problem or did not indicate a primary substance among those that were a problem).

Clinical History

Participants indicated any lifetime history of outpatient SUD treatment, inpatient or residential SUD treatment, and medication use (Institute of Behavioral Research, 2002), including psychiatric and SUD-specific medications. For SUD medications, participants who indicated having been prescribed a medication to “prevent you from drinking alcohol” or “prevent you from using opioids” were categorized as having an SUD medication history. Co-occurring psychiatric disorder history was determined by self-report of having been diagnosed with one or more of 16 non-SUD psychiatric disorders (Dennis et al., 2002) including anxiety disorders, mood disorders, eating disorders, psychotic disorders, and personality disorders.

Recovery-Related History

Years since problem resolution was measured by asking participants “How long has it been since you resolved your problem with alcohol/drugs?”. Helpfulness of spirituality to recovery and helpfulness of religiosity to recovery were assessed with the following ordinal scale for each item: not at all; a little bit; moderately; a lot; made all of the difference.

Criminal Justice History

Participants indicated whether they had ever been arrested (yes/no) in their lifetime and, if yes, whether they participated in a drug court (yes/no) yielding a 3-level categorical variable: a) never arrested; b) arrested with drug court; c) arrested without drug court.

Statistical Analyses

Aim 1 estimates the prevalence of any (vs. no) lifetime attendance, any lifetime weekly attendance, and any past 90-day attendance: a) across all MHOs; b) separately for 12-step and second-wave MHO aggregates; and c) for each individual MHO. Among past-90-day attendees only, we report the mean number of meetings attended in the past 90 days. Among lifetime attendees, we report proportions with 12-step MHO attendance who also attended a second-wave MHO, and vice versa, both for lifetime and past 90-day attendance. As individuals might attend both 12-step and second-wave MHOs, including different patterns of attendance among each MHO type, measures of MHO participation were not mutually-exclusive for Aim 1 or any of the other study aims.

Aim 2 describes the calendar year of first meeting attended separately for any lifetime 12-step and any lifetime second-wave MHO attendance. For this aim, we examined the distributions of year of first attendance for both 12-step and second-wave MHOs, comparing 25th, 50th, and 75th percentiles for each MHO type. Individuals who reported lifetime attendance in both 12-step and second-wave MHOs were included in both distributions. We illustrated growth over time using a histogram of year of first meeting attended separately for 12-step and second-wave MHOs in 5-year periods. Given that survey weights were derived from population data corresponding with year of survey administration, and we cannot assume these weights would be consistent across calendar years, we report raw, unweighted data for these distributions to illustrate attendance by calendar year.

Aim 3 presents results from two multivariate logistic regression models testing demographic, clinical, substance use, recovery-related, and criminal justice correlates of weekly attendance separately for 12-step and second-wave MHOs aggregates. Models focused on weekly attendance (e.g., rather than lifetime attendance) to approximate more active involvement given its stronger prediction of substance use outcomes in longitudinal studies (Kelly et al., 2013; Weiss et al., 2005). For each model predicting weekly MHO attendance, we first examined unadjusted (i.e., bivariate) associations with the following variables (see Supplemental Material, Table S1): demographic and other current individual characteristics (age, sex, education, race/ethnicity, marital status, employment status, religiosity, and spirituality), substance use history (number of substances used, primary substance, age of substance use onset), clinical history (i.e., co-occurring psychiatric disorder, outpatient treatment, inpatient treatment, psychiatric medication, and SUD medication), recovery-related history (i.e., years since problem resolution, helpfulness of spirituality/religiosity to problem resolution), and criminal justice history. We then included all variables that were statistically significant in unadjusted models (p < .05) in a multivariate logistic regression model to examine unique associations between these variables (predictors) and each MHO attendance variable (outcome).

All analyses were survey-weighted unless otherwise specified and conducted using the svy package in Stata Version 14 and the complex samples module in SPSS 28. All study procedures were approved by the Mass General Brigham (formerly Partners HealthCare) Institutional Review Board.

Results

Prevalence of MHO Attendance

Lifetime, Weekly, and Past 90-Day Attendance

For MHOs overall, 44.3% reported any lifetime MHO attendance, 34.8% weekly attendance, and 12.6% past 90-day attendance (Table 1). Comparing across MHO aggregates, 12-step attendance was by far the most common, followed by second-wave MHOs, and the religious MHO Celebrate Recovery. Among individual MHOs, AA was the most commonly attended, followed by NA, Other fellowships, CA, and Celebrate Recovery.

Table 1.

Unweighted frequencies and weighted prevalence estimates for any lifetime, weekly, and past 90-day mutual-help attendance (N = 1984)

MHO Lifetime
Unweighted n
(Weighted %)		 Weekly
Unweighted n
(Weighted %)		 Past 3-Month
Unweighted n
(Weighted %)
Any MHO 910 (44.3%) 753 (34.8%) 244 (12.6%)
Any 12-step MHO 842 (41.4%) 692 (31.9%) 215 (10.8%)
 Alcoholics Anonymous 765 (35.1%) 614 (26.4%) 184 (8.6%)
 Narcotics Anonymous 319 (17.7%) 212 (12.3%) 55 (2.9%)
 Marijuana Anonymous 9 (0.9%) 5 (0.8%) 3 (0.8%)
 Cocaine Anonymous 47 (2.3%) 23 (0.8%) 6 (0.3%)
 Crystal Meth Anonymous 8 (0.8%) 5 (0.6%) 2 (0.3%)
Any Second-wave MHOa 50 (2.9%) 32 (1.7%) 15 (0.9%)
 SMART 22 (1.3%) 14 (0.8%) 7 (0.4%)
 LifeRing 4 (0.4%) 2 (0.3%) 1 (0.3%)
 Moderation Management 5 (0.2%) 2 (0.1%) 0 (0.0%)
 Women for Sobriety 22 (1.2%) 14 (0.6%) 7 (0.3%)
 Secular Organization for Sobriety 6 (0.2%) 2 (0.1%) 3 (0.2%)
Celebrate Recovery 47 (2.2%) 28 (1.3%) 17 (0.8%)
Other 81 (3.1%) 61 (2.3%) 15 (0.7%)
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a

Given the conceptual difference between the religious MHO, Celebrate Recovery, and other MHOs in the second-wave MHO set, this grouping does not include Celebrate Recovery.

Number of Meetings Attended

Among individuals with at least one past 90-day meeting, for MHOs overall, participants attended 6.87 (95% CI = 4.58 – 9.16) meetings, on average. Meeting count was highest for 12-step MHOs (M = 6.53; 95% CI = 4.22 – 8.84), followed by the religious MHO Celebrate Recovery (M = 3.23; 95% CI = 0 – 7.11), and second-wave MHOs (M = 1.38; 95% CI = .44 – 2.33). In the 12-step set, AA attendance had the highest meeting count (M = 5.21; 95% CI = 3.73 = 6.69), and in the second-wave set, Secular Organization for Sobriety (SOS) had the highest meeting count (M = 1.77; 95% CI = 0 – 4.75).

Dual Attendance in 12-Step and Second-wave MHOs

Among those with any lifetime attendance, 7.7% (95% CI = 5.46 – 10.68) attended both 12-step and second-wave MHOs. Of those with past 90-day second-wave MHO attendance, 25.9% (95% CI = 8.9 – 55.6) also had past 90-day 12-step attendance, while only 2.2% (95% CI = 0.94 – 5.04) of those with past 90-day 12-step MHO attendance also had past 90-day second-wave attendance.

Changes in First MHO Meeting Attended Over Time

For individuals with lifetime 12-step MHO attendance, 25% attended their first meeting by 1987, 50% (median) by 1994, and 75% by 2004. For individuals with lifetime second-wave attendance, 25% attended their first meeting by 1997, 50% (median) by 2009, and 75% by 2015.

Figure 1 illustrates the number of participants in each 5-year time period who attended their first MHO meeting separately by 12-step and second-wave MHOs. For all 5-year periods, the absolute, unweighted frequency of participants attending their first 12-step MHO meeting is greater than those attending their initial second-wave meeting. Of note, however, 64% of initial second-wave attendance has occurred since 2006. Across all 5-year time periods, the greatest percentage of initial second-wave attendance (24%) occurred in 2011–2015, while 20% of initial second-wave attendance occurred in just the 2 years prior to survey completion.

Figure 1.

Figure 1.

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The percentage that attended their first meeting in a given 5-year period by 12-step versus second-wave MHOs. The absolute number of participants attending their first 12-step MHO meeting is greater than those attending their initial second-wave MHO meeting during all 5-year periods. Of note, however, 64% of first meetings attended in second-wave MHOs has occurred since 2006. The greatest percentage (24%) occurred in 2011–2015, the 5-year-period most recent to 2017, while 20% of initial attendance has occurred in just the 2 years prior to survey completion.

Correlates of Weekly MHO Attendance

12-Step MHOs

As shown in Table 2, among demographic characteristics, significant correlates of weekly 12-step MHO attendance included older age and marital status (married/living with partner associated with lower odds of attendance). Male identity (vs. female) was associated with greater odds of attendance but just missed statistical significance (p = .06). Regarding substance use history, younger age of onset was significantly associated with greater odds of attendance while the absence of a primary substance (vs. alcohol primary) was significantly associated with lower odds of attendance. Regarding clinical history, outpatient addiction treatment and inpatient addiction treatment were each associated with 4 to 5 times greater odds of weekly 12-step MHO attendance. Compared to no arrest history, having been arrested both with and without drug court participation were significantly associated with 12-step MHO attendance.

Table 2.

Weighted descriptive statistics and adjusted odds ratios for multivariate logistic regression models predicting any weekly lifetime attendance for 12-step and second-wave MHO groups.

Full Sample
Weighted M (SE) or % 		12-step MHO Second-wave MHO
aOR p aOR p
Age (in years) 46.8 (0.5) 1.03 <.01 0.98 .11
Gender (0 = female; 1 = male)a 39.9% 1.41 .06 0.39 .06
Race/Ethnicity
 White, Non-Hispanic (ref) 61.2% -- -- (ref) (ref)
 Black, Non-Hispanic 13.8% -- -- 5.12 < .01
 Other, Non-Hispanic 5.9% -- -- 4.72 .07
 Hispanic 17.4% -- -- 1.84 .39
 2+ Races, Non-Hispanic 1.7% -- -- b b
Marital status (0 = not married; 1 = married or living with partner) 47.7% 0.70 .03 -- --
Spirituality (0 – 4) 2.7 (0.03) 1.11 .36 -- --
Number of substances used 3.4 (0.9) 1.00 .98 -- --
Primary substance
 Alcohol (ref) 58.6% (ref) (ref) -- --
 Cannabis 12.4% 0.54 .09 -- --
 Opioids 6.1% 0.80 .58 -- --
 Other 22.9% 0.84 .42 -- --
 None 12.5% 0.33 <.01 -- --
Age of substance use onset (yrs) 14.6 (0.1) .93 <.01 -- --
Psychiatric Disorder (0 = no) 66.8% 1.14 .60 -- --
Outpatient addiction treatment (0 = no) 83.0% 5.92 < .01 -- --
Inpatient or residential addiction treatment (0 = no) 84.9% 5.60 < .01 -- --
Psychiatric medication (0 = no) 69.4% 0.80 .40 1.93 .14
SUD medication (0 = no) 91.4% 1.35 .36 5.41 < .01
Years since substance use problem resolution 11.8 (0.3) -- -- .98 .41
Helpfulness of spirituality to recovery (0 – 4) 2.96 (0.05) 1.21 .07 -- --
Helpfulness of religion to recovery (0 – 4) 2.76 (0.05) 1.03 .75 -- --
Criminal Justice Involvement
 None (ref) 49.3% (ref) (ref) -- --
 Arrested with drug court 7.9% 6.38 < .01 -- --
 Arrested without drug court 42.8% 2.07 < .01 -- --
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Note: Regular attendance is defined as weekly or more frequently.

Note: 12-step MHO group comprised Alcoholics Anonymous, Narcotics Anonymous, Marijuana Anonymous, Cocaine Anonymous, and Crystal Meth Anonymous; Second-wave MHO group comprised SMART, LifeRing, Moderation Management, Women for Sobriety, and Secular Organization for Sobriety

Note: For dichotomous variables all sample sizes correspond to the reference group.

Note: Variables with no reference group specified (i.e., “ref” or 0 = XX) were modeled as continuous.

Note: Cells with two dashes (--) correspond with variables not significant in a respective univariate model (see Supplemental Material, Table S1), i.e., not significantly associated with either 12-step or second-wave lifetime weekly attendance and therefore not included in the multivariate logistic regression model.

a

Sample sizes for genders apart from male and female (i.e., non-binary) were too small to provide reliable estimates.

b

No estimate could be provided as 0 participants identifying as 2+ races had weekly second-wave MHO attendance.

Second-wave MHOs

As shown in Table 2, among demographic characteristics, Black race/ethnicity (vs. White) was associated with 5 times greater odds of second-wave attendance. Female identity (vs. male) was associated with greater likelihood of second-wave attendance but just missed statistical significance (p = .06). Among substance use, clinical, and recovery related variables, only SUD medication was a significant correlate of second-wave attendance.

Discussion

In a nationally-representative sample of US adults who resolved an alcohol or other drug use problem, lifetime MHO attendance was common particularly for 12-step MHOs. As expected, the prevalence of lifetime, weekly, and past 90-day attendance was descriptively greater for 12-step than for second-wave MHOs (e.g., SMART, LifeRing, WFS, etc.). Also as expected, however, the majority of initial second-wave attendance has occurred since the year 2000 whereas the majority of initial 12-step attendance occurred in the 1980s and 1990s. Consistent with our hypothesis, a history of SUD treatment was uniquely associated with weekly 12-step MHO attendance. Study findings showed some important differences between correlates of weekly 12-step and weekly second-wave attendance with potential implications for clinical and public health recommendations.

Attendance at Second-wave MHOs May Be on the Rise

Twelve-step attendance was substantially more prevalent than second-wave attendance, similar to findings from prior research (Kaskutas et al., 2014; Kelly et al., 2006) and following from their greater longevity. The low prevalence of second-wave attendance may indeed be explained by their more recent emergence, making them less available, and potentially less well-known to clinicians and recovery support service staff. As noted in Kelly and White (2012), second-wave MHOs may suffer from a “Catch-22” scenario whereby limited availability leads to low awareness of these options on the part of referral sources, which in turn inhibits referral and thus growth.

In line with this “Catch-22” explanation, we found histories of formal treatment, both inpatient and outpatient, as well as histories of arrest and drug court participation, were significant correlates of 12-step, but not second-wave MHO attendance. Furthermore, our data show initial 12-step MHO attendance peaked during the late 1980s and early 1990s. The timing of this 12-step peak may reflect large-scale coverage by third-party payors for inpatient/residential SUD treatment programs during this time, which are likely to refer patients to 12-step MHO meetings (Roman and Blum, 2004). Similarly, therapeutic jurisprudence for cases involving SUD included requirements to attend 12-step MHOs for many years. Of note however, best practices for drug court professionals now strongly recommend allowing for both 12-step and secular MHO alternatives, such as SMART (Center for Justice Innovation & All Rise [formerly National Association of Drug Court Professionals], 2023).

Importantly, study findings suggest accessibility to groups such as SMART, LifeRing, and WFS may be increasing, with 75% of initial second-wave attendance occurring since the year 2000. Also noteworthy was that attendance in the Christianity-based Celebrate Recovery was more prevalent than for any of the other, primarily secular, second-wave groups. This explicitly religious MHO may be an attractive option for individuals who identify as Christian and prefer a religious recovery pathway.

Overall, research characterizing participation and outcomes (e.g., Hester et al., 2013; Zemore et al., 2018) combined with apparent growth in access to second-wave MHOs may result in enhanced rates of clinical referral. Increases in clinical referral may, in turn, help catalyze more growth, thereby “broadening the base” of addiction mutual-help (Kelly and White, 2012).

Demographic Correlates of MHO Attendance

Several demographic, substance use, clinical, and recovery-related variables were differentially related to 12-step and second-wave MHO attendance. Older age was uniquely associated with weekly 12-step MHO attendance and younger age was correlated in the unadjusted univariate model with weekly attendance at second-wave MHOs (Supplemental Table S1). Given that models accounted for time since problem resolution and indicators of substance use severity such as age of onset, other factors seem to explain why younger adults are less likely to attend 12-step MHOs and may be more likely to attend a second-wave group. Future qualitative research examining reasons why emerging adults engage with MHOs (e.g., Labbe et al., 2014) may help tailor MHO recommendations for this developmentally unique group.

We found Black individuals were more likely than White individuals to attend a second-wave MHO. This finding should be interpreted with caution, however, as only six Black individuals (unweighted) out of 1984 participants were weekly second-wave attendees. Indeed, all analyses examining second-wave correlates were based on small cell sizes given low numbers of weekly attendance in groups like SMART, WFS, and LifeRing in the NRS. Subsidiary, post-hoc analyses showed that 2.87 was the minimum odds ratio needed to detect a significant effect (p < .05) 80% of the time in the second-wave MHO multivariate logistic regression model. Adequately powered research on second-wave MHO attendance among Black individuals is needed before concrete conclusions can be drawn regarding a potential disparity. Such research might also build on the current study by examining active MHO involvement in addition to attendance. Kaskutas (1999), for example, showed that Black individuals were less likely than their white counterparts to have a 12-step sponsor, a consistent predictor of better substance use outcomes (Kelly et al., 2016; Zemore et al., 2013).

While just missing statistical significance in multivariate models, we found female identification was associated with lower likelihood of 12-step attendance unlike prior epidemiological (Hai et al., 2022; Zemore et al., 2014) and clinical (Kelly et al., 2006) research that found similar attendance compared to males. On the other hand, women had greater likelihood of second-wave MHO attendance (also just missing significance in the multivariate model), likely explained by WFS, a female-centric MHO, in the second-wave aggregate. This recovery-focused, nationally-representative study – allowing for heterogeneous diagnostic and treatment histories -- adds to a growing, nuanced literature examining gender and MHO participation (Zemore et al., 2021, 2014).

SUD Medication and MHO Attendance

Having been prescribed SUD medication for alcohol or opioid use disorder was a correlate of second-wave attendance. However, just as for the association between Black identity and second-wave MHO attendance, the unweighted cross-section with both SUD medication and weekly second-wave attendance (10 participants) resulted in a great deal of statistical uncertainty around the estimate. Other studies show 25% of those who are prescribed OUD medication also attend MHOs (Wen et al., 2020), while those taking agonist medications like buprenorphine may both derive benefit from 12-step MHO participation (Harvey et al., 2020; Monico et al., 2015) and also encounter negative messaging about opioid agonist medications there (Monico et al., 2015). As such, the intersection between SUD medication and MHOs – both 12-step and second-wave – remains a critical area for future research.

Limitations

These study findings should be contextualized within the following limitations. First, the NRS assessed only for a subset of second-wave MHOs, though participants could select and specify “other” MHO attendance. It is possible providing specific options for second-wave groups such as Refuge Recovery and Recovery Dharma, Buddhism-based MHOs (e.g., LaBelle et al., 2021), or All Recovery, meetings commonly offered at recovery community centers that accommodate multiple pathway to recovery (Kelly et al., 2020b), may have yielded different results. Second, the cross-sectional nature of the study means we cannot determine temporal ordering of the variables; that is, our models did not test the theoretical presumption that substance use, clinical, recovery-related, and criminal justice experiences occurred before MHO attendance. Third, only 3% of our nationally representative sample attended a second-wave MHO. Analyses examining associations between second-wave attendance and other variables that were less commonly endorsed (e.g., history of SUD medication) were based on small cell sizes and potentially underpowered tests of significance. Fourth, we did not use statistical tests of interaction to compare patterns of attendance between 12-step and second-wave groups; it is uncertain whether observed differences (e.g., variables significantly correlated with one type of MHO but not the other) correspond with true population differences. Finally, the NRS specifically targeted individuals who identified as having resolved a substance use problem. These data may not generalize to all individuals seeking help for a substance use problem. Relatedly, self-reported problem resolution constitutes only one pathway across the spectra of changes in substance use health behaviors (e.g., Cunningham and Godinho, 2021).

Summary and Conclusion

This analysis of a nationally representative sample of US adults who resolved a substance use problem showed that while the prevalence of second-wave attendance at MHOs like SMART, LifeRing, and WFS is far lower than for 12-step MHOs, data also showed second-wave attendance may be on the rise. Thus, while the MHO base is indeed broader now than during prior inflection points in the history of US addiction treatment and recovery, substantial opportunities for growth in second-wave MHOs lie ahead. Future research might examine whether second-wave MHOs benefit subgroups of individuals with SUD that are especially attracted to the recovery support offered in each of these groups. These candidate subgroups may include women, Black individuals, and those taking SUD medications like opioid agonists. Overall, by responding to the heterogeneity of recovery preferences and pathways, the potential expansion in the menu of MHO options documented here may extend the support offered in 12-step MHOs to engage and assist a wider array of individuals with SUD.

Supplementary Material

Supinfo

Contributor Information

Brandon G. Bergman, Recovery Research Institute, Massachusetts General Hospital & Harvard Medical School, Boston, MA.

M. Claire Greene, Program on Forced Migration and Health, Columbia University Mailman School of Public Health, New York, NY.

Sarah E. Zemore, Alcohol Research Group, Emeryville, CA.

John F. Kelly, Recovery Research Institute, Massachusetts General Hospital & Harvard Medical School, Boston, MA.

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