Abstract
Background
Substance use stigma presents a significant barrier to treatment and recovery, particularly in societies where cultural and religious values frame substance use as a moral failing. Although heroin-related stigma has been studied globally, there is limited research exploring how demographic factors influence stigma toward people who use heroin in Jordan. This study aimed to assess the impact of smoking, marital, and employment status influence public stigma toward people who use heroin among Jordanian adults.
Methods
A nationwide, cross-sectional online survey was conducted in April 2024 among Jordanian adults aged 18–65. Participants were recruited via Facebook and completed a questionnaire assessing stigma using five items adapted from validated scales. Demographic variables included smoking status, marital status, employment status, age, and region. Associations between demographics and stigma were examined using chi-square tests and multivariable logistic regression models.
Results
A total of 908 participants completed the survey. Overall, respondents expressed strong stigma toward people who use heroin, with high perceived risks of career damage, social rejection, and legal trouble. Non-smokers, married individuals, and retired participants reported significantly stronger negative views compared to smokers, unmarried individuals, and students, respectively. No significant differences were observed based on sex.
Conclusions
Smoking, marital, and employment status are associated with public stigma toward people who user drugs in Jordan. These findings highlight the influence of traditional social norms on stigmatizing attitudes and emphasize the need for culturally sensitive public health interventions in order to reduce stigma and improving treatment access for individuals with substance use disorders in Jordan.
Clinical trial number
Not applicable.
Supplementary Information
The online version contains supplementary material available at 10.1186/s13011-025-00696-0.
Keywords: Substance use stigma, Heroin, Public health, Jordan, Demographic factors
Introduction
Substance use stigma refers to the lack of social acceptance and the marginalization of people who use drugs due to negative attitudes, perceptions, and discrimination [1]. A narrative review on substance use stigma in non-clinical settings in multiple countries found that many respondents perceived people with substance use disorders (SUDs) as more likely to be dangerous, and less capable of adequate decision-making, and blameworthy for their condition. Respondents also commonly endorsed social distancing, and expressed significantly less willingness to help individuals with SUDs compared to other mental illnesses, such as schizophrenia [2]. In a study at the University of Northern Iowa, it was found that participants (students) stigmatized heroin use significantly more than marijuana use, based on the Social Distance Scale for People Substance use disorders, which measures willingness to interact with person experiencing substance use challenges [3]. This could have long-term negative consequences for access to treatment, careers, social relationships, and legal outcomes.
Recent research continues to highlight the global persistence of stigma toward people with SUD. Studies from diverse settings, including Korea, Europe and United States, have reported that despite greater awareness of addiction as a health condition, public stigma remains high, particularly toward people who use heroin and opioid [4]. Furthermore, pandemic-related stressors and increased media exposure to opioid crises have influenced societal attitudes, reinforcing negative stereotypes in some contexts while promoting empathy in others [5, 6].
Recent global studies [7, 8] indicate that in spite of increased awareness of addiction as a medical condition, stigma toward people who use heroin and opioid remain high across varied cultural settings. These studies highlight the persistence of negative societal attitude, the influence of demographic factors, in addition to the role of moral judgments on stigmatizing views.
People who use heroin experience poor job stability, partially due to stigma. Most employers in a web-based survey in the UK would not hire a person with a history of heroin use [9]. It was also observed that employers treat people who previously used drugs differently due to fear of relapses and a 23% higher job loss rate than in the absence of a drug use history was recorded [10]. Assumed dangerousness was observed as the major contributor of stigma towards heroin use [11]. Such negative attitudes could lead to social exclusion and strained social relationships. Structural or institutional stigma is systemic, existing through policies and practices that undermine and restrict opportunities for the stigmatized group, such as underfunding SUDs treatment and inequitable allocation of resources. This stigma is negatively associated with health outcomes for people who use heroin. Stereotypes extend into the healthcare space, characterizing these patients as unmotivated, manipulative, unlikely to recover, and undeserving of treatment [12]. Research shows that healthcare providers are frequently reluctant to prescribe opioid agonist therapy due to stigma associated with substance use [8].
Societal attitudes towards heroin use vary across different demographic characteristics, including smoking, marital, and employment status. Research suggests that those adhering to conventional social arrangements, such as marriage and employment hold more negative views towards people who use heroin. A study using survey-based stigma assessments comparing attitudes across marital statuses, found that married individuals reported the highest level of stigma toward people with SUDs [13]. Smokers have been found to show lower odds of expressing stigma towards heroin use and substance use, possibly due to a shared experience of dealing with societal stigma towards personal habits and choices [14]. Employment status may also have an impact, as employed individuals may value both personal and collective contributions to society through labor and could perceive heroin use as a deviation away from a social collective responsibility and putting strain on the system.
Jordan’s cultural and social framework greatly influence perceptions of substance use. Factors such as social standing and reputation discourage conversations about substance use, contributing to the stigma. Jordan is both a traditional and collectivist society, wherein drug use is often perceived as a moral weakness. But homelessness, often associated with heroin use, receives sympathy and the unhoused are not blamed for their status [15]. Reputation and honor are also highly valued, thus, families often hide a person who uses drugs out of fear of social ostracization instead of seeking help, contributing to the stigma and creating larger barriers to treatment [16]. Jordanian society has strong family values, playing a role in shaping personal identity and social expectations. Drug use is seen as a direct threat to honor and familial stability. Hence, people who use drugs may be disowned or shamed, and therefore avoid seeking help, in fear of damaging their family’s reputation [17]. People often equate the use of drugs to moral corruption, believing addiction stems from weak faith or lack of religious discipline, rather than a medical condition. Individuals suffering with substance use challenges often internalize feelings of shame and guilt, believing they have committed a grave sin, which further amplifies stigma [18].
This study aims to examine how smoking, marital, and employment status are associated with public stigma toward people who use heroin among in the Jordanian population. Given the cultural sensitivity surrounding drug use in Jordanian society and the deep-rooted social and religious norms that shape public opinion, understanding the demographic factors that contribute to stigma is crucial. By identifying which groups harbor more stigmatizing attitudes, the findings of this study can inform targeted public health interventions, improve access to treatment for SUDs, and support efforts to dismantle stigma while promoting compassionate, evidence-based care for people with SUDs in Jordan.
Methods
Study design, participants and completion rates
This study analyzed data from a nationwide survey conducted in April 2024 to assess public perceptions of disability and its association with employment among Jordanian adults. The target population consisted of individuals aged 18 to 65 years who were residing in Jordan at the time of data collection. Participants were recruited through Facebook, a widely used platform accessed by approximately 65.94% of the Jordanian population during the survey period. The survey was distributed via a targeted advertisement directed at the eligible demographic, and participants were encouraged to share the survey link to facilitate snowball sampling. The survey was administered using Qualtrics, a secure online platform widely used in health research [19]. To ensure data integrity, measures were implemented to prevent duplicate responses, including activating the platform’s “prevent ballot box stuffing” feature and manually reviewing IP addresses for potential duplicates. The survey was available in both Arabic and English to accommodate linguistic diversity.
A total of 4,257 individuals accessed the survey link. Of these, 2,434 (57.2%) met the eligibility criteria, which excluded individuals under 18 years of age or those not residing in Jordan during survey administration. Among the eligible participants, 908 completed the survey, resulting in a completion rate of 37.3% among eligible respondents and 21.3% of all individuals who accessed the survey link.
While snowball and Facebook sampling enabled access to a broad audience effectively, this approach may have introduced sampling bias. Participants are likely to be more technologically connected, younger and socially networked, which could dominate certain demographic groups. Furthermore, geographic imbalances were observed, with greater participation from Al Balqa and Irbid, and a dominance of unmarried individuals, possibly limiting the generalizability of findings to the broader Jordanian population.
Measures
Stigma toward people who use heroin was assessed using a set of five items adapted from Cunningham et al.‘s validated survey measuring public stigma toward people with SUDs [20]. The original items were adapted for linguistic and cultural appropriateness to the Jordanian context through a forward–backward translation process and expert review by bilingual public health researchers. Although the original scale by Cunningham et al. (1993) is validated, the adapted version used in this study has not been formally validated in the Jordanian population. However, expert reviewers ensured that the examples, language, and sociocultural nuances were suitable for local interpretation, thereby improving content validity in the Jordanian context. Participants were asked to respond to a hypothetical scenario involving “Joseph,” a man who injects heroin daily for one year. Items assessed perceived career damage (STIGM1), willingness to work with the individual (STIGM2), comfort inviting the individual to a social event (STIGM3), perceived likelihood of marital dissolution (STIGM4), and perceived likelihood of legal trouble (STIGM5). Responses for each item were measured on a 5-point Likert scale (Very likely, Quite likely, Neutral, Unlikely, Very unlikely) with an additional “Don’t know” option.
Demographic characteristics collected included age, marital status (married, divorced, widowed, separated, never married), employment status (employed, unemployed, student, retired), and region of residence (categorized across Jordan’s twelve governorates). Marital status, employment status, and smoking status were primary independent variables of interest. Smoking status was assessed using a single-item question asking participants whether they currently smoked tobacco on a daily basis, less than daily, or not at all. Marital status, employment status, and smoking status were the primary independent variables of interest [21].
The survey items, with their coding variables and references, are presented in Appendix A.
Ethical considerations
This study was approved by the University of Jordan Ethical Committee on March 18th 2024, Decision No. 181/2024. Participants were recruited via Facebook, and an online information sheet of the survey was provided at the start of the study’s purpose, voluntary nature, procedures and the measures. Informed consent was procured electronically before participants could access the survey. The participation was completely voluntary, and participants withdraw at any time without any penalty. All responses were de-identified and stored securely on Qualtrics, and reported only in compiled form to ensure the confidentiality.
Statistical analysis
Descriptive statistics were calculated for demographic variables and stigma items. Associations between smoking status, marital status, employment status, and stigma responses were examined using chi-square tests for categorical variables and independent samples t-tests where applicable. Multivariable logistic regression models were constructed to assess the independent association of smoking, marital, and employment status with stigma outcomes, adjusting for age and region of residence. Statistical significance was defined as a two-sided p-value < 0.05. Analyses were conducted using PQStat Software v.1.8.2.238.
To evaluate reliability Cronbach’s alpha was used to assess the internal consistency of the five-item stigma scale.
Results
Demographic characteristics
We included 908 participants with a mean age of 31.43 (± 13.79), with a median of 24. More than half of the participants (55.6%) are female, 73% are non-smokers, and nearly half (49.8%) are students; the remaining are employed (31.6%), unemployed (11.2%), or retired (7.4%). Most respondents (62%) have never married, while one-third (32.6%) are married. Geographically, the largest proportion of participants live in Irbid (45.4%) and Balqa (38%), with smaller numbers from other Jordanian cities (Table 1). Standardized Cronbach alpha was 0.791.
Table 1.
Demographic characters of the 908 participants, frequencies reported as N (%)
| Age | 31.43 ± 13.79; [24 (22 - 41)]* |
|---|---|
| Sex | |
|
Female Male |
505 (55.6) 403 (44.4) |
| Smoker | |
|
Yes No |
245 (27) 663 (73) |
| Employment | |
|
Retired Student Unemployed Employed |
67 (7.4) 452 (49.8) 102 (11.2) 287 (31.6) |
| Marital Status | |
|
Never married Separated Widowed Divorced Married |
563 (62) 13 (1.4) 21 (2.3) 15 (1.7) 296 (32.6) |
| City | |
|
Karak Madaba Zarqa Amman Balqa Mafraq Jerash Ajloun Aqaba Ma’an Tafila Irbid |
3 (0.3) 12 (1.3) 5 (0.6) 26 (2.9) 345 (38) 22 (2.4) 6 (0.6) 21 (2.3) 15 (1.6) 39 (4.3) 2 (0.2) 412 (45.4) |
* reported as mean ± SD; [median (IQR)]
Overall stigma perceptions
Across all items, respondents demonstrated strong stigma toward people who use heroin, perceiving higher risks to social relationships, career and legal outcomes. Working or socializing with comfort with a person who uses heroin was generally low. (Fig. 1).
Fig. 1.
Overall stigma perceptions reported as numbers (n) and percentages for the following questions: (a) “Do you think that this would damage Joseph’s career?“; (b) “Would you be comfortable if Joseph were your colleague at work?“; (c) “Would you be comfortable inviting Joseph to a dinner party?“; (d) “How likely do you think it is that Joseph’s wife would leave him?“; and (e) “How likely do you think it is that Joseph would get in trouble with the law?”
Sex differences
No significant differences were observed between males and females regarding any stigma-determinant questions (Table 2).
Table 2.
Differences in stigma perceptions between females and males
| Answers | Female | Male | Chi-squared test | |
|---|---|---|---|---|
| χ2 (df) | Sig. | |||
| Do you think that this would damage Joseph’s career? | ||||
| Very likely | 323 (80.1) | 395 (78.2) | 6.0 (4) | 0.199 |
| Likely | 51 (12.7) | 77 (15.2) | ||
| Neutral | 19 (4.7) | 29 (5.7) | ||
| Unlikely | 6 (1.5) | 3 (0.6) | ||
| Very unlikely | 4 (1) | 1 (0.2) | ||
| Would you be comfortable if Joseph was your colleague at work? | ||||
| Extremely uncomfortable | 194 (48.1) | 251 (49.7) | 1.1 (4) | 0.901 |
| Somewhat uncomfortable | 132 (32.8) | 161 (31.9) | ||
| Neither comfortable nor uncomfortable | 66 (16.4) | 77 (15.2) | ||
| Somewhat comfortable | 9 (2.2) | 11 (2.2) | ||
| Extremely comfortable | 2 (0.5) | 5 (1) | ||
| Would you be comfortable inviting Joseph to a dinner party? | ||||
| Extremely uncomfortable | 223 (55.3) | 283 (56) | 1.9 (4) | 0.749 |
| Somewhat uncomfortable | 98 (24.3) | 125 (24.8) | ||
| Neither comfortable nor uncomfortable | 63 (15.6) | 67 (13.3) | ||
| Somewhat comfortable | 16 (4) | 23 (4.6) | ||
| Extremely comfortable | 3 (0.7) | 7 (1.4) | ||
| How likely do you think it would be for Joseph’s wife to leave him? | ||||
| Very likely | 215 (53.3) | 289 (57.2) | 6.1 (4) | 0.194 |
| Likely | 131 (32.5) | 135 (26.7) | ||
| Neutral | 40 (9.9) | 66 (13.1) | ||
| Unlikely | 15 (3.7) | 13 (2.6) | ||
| Very unlikely | 2 (0.5) | 2 (0.4) | ||
| How likely do you think it would be for Joseph to get in trouble with the law? | ||||
| Very likely | 267 (66.3) | 331 (65.5) | 2.7 (4) | 0.606 |
| Likely | 82 (20.3) | 109 (21.6) | ||
| Neutral | 36 (8.9) | 40 (7.9) | ||
| Unlikely | 14 (3.5) | 14 (2.8) | ||
| Very unlikely | 4 (1) | 11 (2.2) | ||
Smoking status
Smoking status was significantly associated with levels of stigma. Non-smokers consistently expressed stronger negative perceptions than smokers across all items, indicating higher overall stigma among non-smokers. Smoker’s lower stigma may consider empathy arising from their own experiences with social exclusion or stigma associated with tobacco use, whereas non-smokers may follow more strictly social and moral norms. (Table 3)
Table 3.
Differences in stigma perceptions between smokers and non-smokers
| Answers | Non-smoker | Smoker | Chi-squared test | |
|---|---|---|---|---|
| χ2 (df) | Sig. | |||
| Do you think that this would damage Joseph’s career? | ||||
| Very likely | 541 (81.6) | 177 (72.2) | 24.7 (4) | < 0.001 |
| Likely | 92 (13.9) | 36 (14.7) | ||
| Neutral | 23 (3.5) | 25 (10.2) | ||
| Unlikely | 3 (0.5) | 6 (2.4) | ||
| Very unlikely | 4 (0.6) | 1 (0.4) | ||
| Would you be comfortable if Joseph was your colleague at work? | ||||
| Extremely uncomfortable | 350 (52.8) | 95 (38.8) | 34.5 (4) | < 0.001 |
| Somewhat uncomfortable | 215 (32.4) | 78 (31.8) | ||
| Neither comfortable nor uncomfortable | 85 (12.8) | 58 (23.7) | ||
| Somewhat comfortable | 12 (1.8) | 8 (3.3) | ||
| Extremely comfortable | 1 (0.2) | 6 (2.4) | ||
| Would you be comfortable inviting Joseph to a dinner party? | ||||
| Extremely uncomfortable | 389 (58.7) | 117 (47.8) | 18.7 (4) | 0.001 |
| Somewhat uncomfortable | 161 (24.3) | 62 (25.3) | ||
| Neither comfortable nor uncomfortable | 85 (12.8) | 45 (18.4) | ||
| Somewhat comfortable | 25 (3.8) | 14 (5.7) | ||
| Extremely comfortable | 3 (0.5) | 7 (2.9) | ||
| How likely do you think it would be for Joseph’s wife to leave him? | ||||
| Very likely | 378 (57) | 126 (51.4) | 12.6 (4) | 0.013 |
| Likely | 197 (29.7) | 69 (28.2) | ||
| Neutral | 72 (10.9) | 34 (13.9) | ||
| Unlikely | 15 (2.3) | 13 (5.3) | ||
| Very unlikely | 1 (0.2) | 3 (1.2) | ||
| How likely do you think it would be for Joseph to get in trouble with the law? | ||||
| Very likely | 449 (67.7) | 149 (60.8) | 11.7 (4) | 0.02 |
| Likely | 141 (21.3) | 50 (20.4) | ||
| Neutral | 50 (7.5) | 26 (10.6) | ||
| Unlikely | 15 (2.3) | 13 (5.3) | ||
| Very unlikely | 8 (1.2) | 7 (2.9) | ||
Marital status
Marital status also influenced stigma levels. Married participants generally held more negative attitudes toward people who use heroin than unmarried, separated, or divorced individuals. They were more likely to perceive heroin use as leading to marital dissolution, social rejection, and legal trouble. Differences across marital groups were statistically significant for most stigma indicators (Table 4). Married participants with stronger stigma are likely to reflect the collectivist cultural significance on social responsibility and family honor. Never-married, divorced participants may detect heroin use differently due to varied social experiences or decreased compliance with these traditional norms.
Table 4.
Differences in stigma responses by marital status
| Answers | Never married | Separated | Widowed | Divorced | Married | Chi-squared test | |
|---|---|---|---|---|---|---|---|
| χ2 (df) | Sig. | ||||||
| Do you think that this would damage Joseph’s career? | |||||||
| Very likely | 450 (79.9) | 7 (53.8) | 14 (66.7) | 7 (46.7) | 240 (81.1) | 46.1 (16) | < 0.001† |
| Likely | 77 (13.7) | 4 (30.8) | 1 (4.8) | 7 (46.7) | 39 (13.2) | ||
| Neutral | 28 (5) | 2 (15.4) | 4 (19) | 1 (6.7) | 13 (4.4) | ||
| Unlikely | 5 (0.9) | 2 (15.4) | 2 (9.5) | 0 (0) | 2 (0.7) | ||
| Very unlikely | 3 (0.5) | 0 (0) | 0 (0) | 0 (0) | 2 (0.7) | ||
| Would you be comfortable if Joseph was your colleague at work? | |||||||
| Extremely uncomfortable | 247 (43.9) | 3 (23.1) | 11 (52.4) | 6 (40) | 178 (60.1) | 50.2 (16) | < 0.001†† |
| Somewhat uncomfortable | 197 (35) | 4 (30.8) | 3 (14.3) | 8 (53.3) | 81 (27.4) | ||
| Neither comfortable nor uncomfortable | 100 (17.8) | 4 (30.8) | 5 (23.8) | 1 (6.7) | 33 (11.1) | ||
| Somewhat comfortable | 12 (2.1) | 4 (30.8) | 2 (9.5) | 0 (0) | 4 (1.4) | ||
| Extremely comfortable | 7 (1.2) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | ||
| Would you be comfortable inviting Joseph to a dinner party? | |||||||
| Extremely uncomfortable | 299 (53.1) | 6 (46.2) | 9 (42.9) | 8 (53.3) | 184 (62.2) | 38.5 (16) | 0.001††† |
| Somewhat uncomfortable | 153 (27.2) | 1 (7.7) | 4 (19) | 4 (26.7) | 61 (20.6) | ||
| Neither comfortable nor uncomfortable | 81 (14.4) | 2 (15.4) | 6 (28.6) | 2 (13.3) | 39 (13.2) | ||
| Somewhat comfortable | 22 (3.9) | 2 (15.4) | 2 (9.5) | 0 (0) | 12 (4.1) | ||
| Extremely comfortable | 8 (1.4) | 1 (7.7) | 0 (0) | 1 (6.7) | 0 (0) | ||
| How likely do you think it would be for Joseph’s wife to leave him? | |||||||
| Very likely | 301 (53.5) | 3 (23.1) | 10 (47.6) | 5 (33.3) | 185 (62.5) | 67.8 (16) | < 0.001†††† |
| Likely | 191 (33.9) | 4 (30.8) | 5 (23.8) | 2 (13.3) | 64 (21.6) | ||
| Neutral | 60 (10.7) | 3 (23.1) | 4 (19) | 6 (40) | 33 (11.1) | ||
| Unlikely | 9 (1.6) | 3 (23.1) | 2 (9.5) | 2 (13.3) | 13 (4.4) | ||
| Very unlikely | 2 (0.4) | 1 (7.7) | 0 (0) | 0 (0) | 1 (0.3) | ||
| How likely do you think it would be for Joseph to get in trouble with the law? | |||||||
| Very likely | 374 (66.4) | 3 (23.1) | 10 (47.6) | 6 (40) | 205 (69.3) | 53.6 (16) | < 0.001††††† |
| Likely | 128 (22.7) | 3 (23.1) | 6 (28.6) | 4 (26.7) | 50 (16.9) | ||
| Neutral | 42 (7.5) | 3 (23.1) | 3 (14.3) | 5 (33.3) | 23 (7.8) | ||
| Unlikely | 13 (2.3) | 3 (23.1) | 1 (4.8) | 0 (0) | 12 (4.1) | ||
| Very unlikely | 6 (1.1) | 2 (15.4) | 1 (4.8) | 0 (0) | 6 (2) | ||
† Significant differences between widowed and never married (p = 0.002), and between never married and married (p = 0.002), post-hoc (Multiple comp. Bonferroni)
†† Significant differences between married and never married (p = 0.001), and between separated and married (p = 0.006), post-hoc (Multiple comp. Bonferroni)
††† Significant differences seprated and never married (p = 0.032), between separated and married (p < 0.001), and between divorced and married (p = 0.004), post-hoc (Multiple comp. Bonferroni)]
†††† Significant differences between never married and separated (p = < 0.001), never married and divorced (p = 0.001), never married and married (p = 0.009), and betwwen separated and married (p = 0.009), post-hoc (Multiple comp. Bonferroni)
††††† Significant differences seprated and never married (p < 0.001), between separated and married (p = 0.005), post-hoc (Multiple comp. Bonferroni)
Employment status
Employment status showed a mixed pattern. While perceptions of career damage did not differ significantly across employment groups, retired participants exhibited the strongest overall stigma, particularly regarding comfort with people who use heroin in workplace and social settings. Students tended to hold fewer stigmatizing attitudes than other groups. These differences were significant for several items (Table 5).
Table 5.
Differences in stigma responses by employment status
| Answers | Retired | Student | Unemployed | Employed | Chi-squared test | |
|---|---|---|---|---|---|---|
| χ2 (df) | Sig. | |||||
| Do you think that this would damage Joseph’s career? | ||||||
| Very likely | 58 (86.6) | 355 (78.5) | 78 (76.5) | 227 (79.1) | 10.4 (12) | 0.584 |
| Likely | 4 (6) | 67 (14.8) | 16 (15.7) | 41 (14.3) | ||
| Neutral | 3 (4.5) | 23 (5.1) | 7 (6.9) | 15 (5.2) | ||
| Unlikely | 1 (1.5) | 23 (5.1) | 1 (1) | 1 (0.3) | ||
| Very unlikely | 1 (1.5) | 1 (0.2) | 0 (0) | 3 (1) | ||
| Would you be comfortable if Joseph was your colleague at work? | ||||||
| Extremely uncomfortable | 45 (67.2) | 193 (42.7) | 53 (52) | 154 (53.7) | 28.5 (12) | 0.005† |
| Somewhat uncomfortable | 17 (25.4) | 162 (35.8) | 28 (27.5) | 86 (30) | ||
| Neither comfortable nor uncomfortable | 5 (7.5) | 78 (17.3) | 17 (16.7) | 43 (15) | ||
| Somewhat comfortable | 0 (0) | 78 (17.3) | 4 (3.9) | 4 (1.4) | ||
| Extremely comfortable | 0 (0) | 7 (1.5) | 0 (0) | 0 (0) | ||
| Would you be comfortable inviting Joseph to a dinner party? | ||||||
| Extremely uncomfortable | 48 (71.6) | 239 (52.9) | 50 (49) | 169 (58.9) | 21.6 (12) | 0.043†† |
| Somewhat uncomfortable | 8 (11.9) | 119 (26.3) | 24 (23.5) | 72 (25.1) | ||
| Neither comfortable nor uncomfortable | 10 (14.9) | 70 (15.5) | 18 (17.6) | 32 (11.1) | ||
| Somewhat comfortable | 1 (1.5) | 70 (15.5) | 8 (7.8) | 13 (4.5) | ||
| Extremely comfortable | 0 (0) | 7 (1.5) | 2 (2) | 1 (0.3) | ||
| How likely do you think it would be for Joseph’s wife to leave him? | ||||||
| Very likely | 41 (61.2) | 233 (51.5) | 53 (52) | 177 (61.7) | 38.1 (12) | < 0.001††† |
| Likely | 12 (17.9) | 161 (35.6) | 23 (22.5) | 70 (24.4) | ||
| Neutral | 8 (11.9) | 47 (10.4) | 19 (18.6) | 32 (11.1) | ||
| Unlikely | 6 (9) | 47 (10.4) | 5 (4.9) | 7 (2.4) | ||
| Very unlikely | 0 (0) | 1 (0.2) | 2 (2) | 1 (0.3) | ||
| How likely do you think it would be for Joseph to get in trouble with the law? | ||||||
| Very likely | 45 (67.2) | 297 (65.7) | 60 (58.8) | 196 (68.3) | 53.6 (12) | 0.828 |
| Likely | 14 (20.9) | 101 (22.3) | 25 (24.5) | 51 (17.8) | ||
| Neutral | 5 (7.5) | 36 (8) | 9 (8.8) | 26 (9.1) | ||
| Unlikely | 2 (3) | 36 (8) | 6 (5.9) | 8 (2.8) | ||
| Very unlikely | 1 (1.5) | 6 (1.3) | 2 (2) | 6 (2.1) | ||
† Significant differences between student and retired [p = 0.02, post-hoc (Multiple comp. Bonferroni)]
†† No significant differences were observed after post-hoc (Multiple comp. Bonferroni)]
††† Significant differences between student and retired (p = 0.024) and between student and unemployed (p = 0.019), post-hoc (Multiple comp. Bonferroni)
Retired participant’s stronger stigma may stem from long-term adherence to societal norms emphasizing responsibility, whereas students’ lower stigma may reflect generational exposure to globalized perspectives and evolving social narratives.
These patterns can be understood through Stigma theory, which proposes that negative social beliefs about atypical behavior are integrated and maintained by social norms. Attribution theory recommends that individuals may assign moral blame to people who use heroin, particularly if they perceive substance use a controllable choice, which may clarify stronger stigma among retirees or married participants adhering to conventional social roles. Social Identity theory recommends that participants who strongly adhere to traditional social norms may show greater stigma toward behaviors viewed as atypical, such as heroin use.
Summary of Patterns:
Overall, stigma was higher among participants adhering more closely to traditional social norms (married, non-smokers, retired), while the groups were potentially experiencing themselves stigma (unmarried, smokers, ad students) shows relatively lower stigma. The detailed numbers and comparisons are provided in Tables 1, 2, 3, 4 and 5.
Discussion
Overview and theoretical context
This study examines how demographic factors influence stigma toward people who use heroin among a sample of Jordanian adults, contributing to the limited research on substance use stigma in Jordan. These findings can be analyzed using well-established theoretical frameworks. According to Goffman’s Stigma Theory, participants who depart from societal norms, such as people who use heroin which are labeled as ‘spoiled identities’ and socially marginalized. Attribution Theory indicates that people assign responsibility to those perceived as causing their condition, which may explain why married and non-smokers participants expressed higher stigma. Social Identity Theory also helps explain how group membership, such as employment or marital status, impacted adherence to stigmatizing attitudes and social norms. To our knowledge, this is the first study, to explore the impact of smoking, marital, and employment status on stigma toward people who use heroin in a Jordanian population — a group that remains highly understudied in both public health and substance use research. By focusing on an often-overlooked societal issue, this study seeks to fill a critical gap in the literature and initiate important conversations about stigma in a region where substance use is rarely openly addressed.
Cultural and social context in Jordan
The findings show that among a sample of Jordanians, heroin use is perceived as having a strong association with career prospects, social relationships, and legal outcomes. Demographic factors, including smoking status marital and employment status, were associated with higher levels of stigma toward people who use heroin. Non-smokers, married individuals, and retired participants exhibited higher levels of stigma compared to smokers, unmarried individuals, and students, respectively.
These findings align with existing research on substance use stigma, particularly in Jordan [22–25]. Stigma surrounding substance use is deeply influenced by social context, reinforcing marginalization through negative stereotypes and discrimination at the personal, societal, and policy levels. It is associated with public attitudes, health outcomes, and policy responses, ultimately exacerbating the harms associated with substance use and limiting individuals’ access to treatment and support services [1]. In Jordan specifically, substance use stigma is embedded within sociocultural structures, where religious norms and traditional customs strongly define acceptable behavior [25, 26].
Within Jordan’s collectivistic cultural framework, substance use is often perceived as a violation of societal and religious expectations, resulting in social exclusion and a lack of support for affected individuals [25]. Fear of judgment, self-disclosure, and potential damage to family honor may discourage individuals struggling with substance use from seeking help, further hindering recovery [22]. Together, these cultural and social dynamics create an environment where stigma is reinforced, posing significant barriers to addressing substance use and addiction effectively.
Smoking and stigma
Our findings also highlight how personal behaviors, such as smoking status, are linked with attitudes toward heroin use. While both smokers and non-smokers generally expressed negative views about the consequences of heroin use, non-smokers held significantly stronger negative perceptions. This distinction may stem from the broader societal context in Jordan, where any form of substance use is viewed as a breach of religious and cultural norms, even as smoking tobacco becomes increasingly common worldwide [27]. Despite its prevalence, tobacco smoking remains legally permitted and is often seen as less morally egregious than heroin use, which is closely tied to severe addiction, criminality, and perceived moral failure [1]. Although smoking tobacco is somewhat normalized compared to illicit drug use [28], smokers themselves are increasingly subject to social stigma [29]. It is possible that smokers, by virtue of facing stigma for their own behaviors, may be more empathetic toward people who use heroin, whereas non-smokers, who do not experience similar stigmatization, may judge people who use heroin more harshly based on moral and social norms.
Marital status and stigma
Marital status also emerged as an important factor was related to attitudes toward people who use heroin. Those who were married held the strongest negative views toward heroin use, followed by never married individuals, and then widowed, separated, and divorced individuals. The collectivistic nature of Jordanian society likely contributes to the emphasis on family honor and adherence to religious and traditional values observed among respondents, and marriage is seen as a fundamental institution ingrained in cultural, religious, and familial expectations. Non-marriage carries social stigma in Jordanian society; remaining single beyond a certain age may be perceived as a failure, while divorce may be viewed as a moral shortcoming [30]. In our sample, married individuals may hold more family-oriented, conservative views and may perceive heroin use as a threat to family reputation, stability, and social standing. Non-married individuals, while possibly aspiring to marry, may share similar views based on their expectations for a suitable marriage partner and desire for social and family stability, both of which are viewed as incompatible with drug use. Those who are widowed, separated, or divorced often differ in social standing and may themselves face stigmatization, particularly divorced individuals [31]. Having experienced social judgment regarding their marital status, they may be less rigid and less likely to view people who use heroin as morally deviant, as they may be more attuned to the complexities of non-conformance to social norms. These findings are specific to the participants in our study and may not be generalizable to all individuals in comparable marital statuses.
Employment status and stigma
Employment status additionally showed an association with public perceptions toward people who use heroin. Retired participants held the strongest negative views, particularly regarding comfort working with a person who uses heroin and perceptions of the broader social consequences of heroin use. This finding is consistent with research showing that attitudes toward SUDs vary based on age, gender, and prior experiences, with younger and female students generally demonstrating more positive attitudes toward SUDs compared to older or male students [23]. Retired participants, who may have spent decades adhering to occupational and societal norms emphasizing responsibility, discipline, and self-sufficiency, may be more likely to express strong opposition to behaviors perceived as irresponsible or destabilizing, such as substance use. In contrast, students represent a younger generation exposed to globalization, political and social changes, and shifting cultural narratives, leading to relatively more open or nuanced views. Relatedly, it is also estimated that over 16% of undergraduate students in Jordanian universities are users of illicit substances [32]. However, despite these evolving generational perspectives, stigma surrounding substance use remains deeply entrenched in Jordanian society [24].
Global comparison and broader implications
Globally recent studies (2020–2025) shows that stigma toward participants with SUDs remains a pervasive challenge despite increased policy awareness and efforts campaigns [4, 7]. Cross-cultural analyses reveal that stigma is often higher in religiously and collectivist conservative societies, aligning with our findings in Jordan [14]. Efforts to humanize addiction and frame it as a treatable condition. Rather than a moral failing that have shown promise in alleviating stigma and encouraging treatment seeking behaviors [6].
Summary
The cumulative findings of this study suggest that Jordan’s broader cultural context, particularly demographic and social factors, may influence how stigma toward substance use manifests among respondents. While all groups in our sample viewed heroin use unfavorably, those more closely adhering with traditional social norms, such as being married, employed, or non-smoking, tended to express more rigid and negative views. Conversely, individuals who may experience stigma in other domains, such as smokers, divorced, or unemployed participants, exhibited slightly greater empathy toward people who use heroin. These patterns may reflect how deeply rooted social and religious values shape public attitudes toward substance use in Jordan, where addiction is often perceived not only as a health concern but also as a moral or social failing. Traditions emphasizing personal responsibility and adherence to social codes may contribute to viewing substance use as a violation that affects not just the individual but their family and community as well [30].
Clinical and policy implications
These patterns have important public health implications, particularly for addiction treatment, prevention efforts, and policy. This is especially so given the concerning estimate by the Anti-Narcotics Department, which suggests that more than 85% of illicit substance users in Jordan do not receive appropriate treatment [33]. The strong societal condemnation of substance use, as reflected in our sample, may contribute to barriers to care, as individuals may avoid seeking help, out of fear of judgment and societal repercussions that extend beyond personal consequences to affect familial and social standing. Stigma may also reduce policymakers’ willingness to allocate adequate resources for addiction services and can shape healthcare providers’ attitudes toward treating individuals with SUDs [2, 23]. Without targeted efforts to address and dismantle stigma, broader public health initiatives aimed at reducing substance use and promoting recovery will remain limited in their effectiveness.
Jordan’s National Mental Health and Substance Use Action Plan (2022–2026) reflects a growing recognition of these challenges by aiming to integrate mental health and substance use services into primary healthcare settings, strengthen the National Center for Mental Health, and reduce stigma [34]. However, despite these efforts, stigma remains a significant and persistent barrier. Although the Action Plan outlines intentions to promote advocacy and reduce stigma, it does not comprehensively specify how advocacy strategies will be operationalized. Cultural perceptions of substance use as a moral failing may continue to deter individuals from seeking treatment, driven by fears of judgment, family dishonor, and social exclusion.
To overcome these barriers, culturally sensitive interventions and advocacy efforts are urgently needed to educate the public, challenge negative stereotypes, and foster a more supportive environment. At a national level, clinical interventions must address the growing need for education and care for individuals who use illicit substances in Jordan. Findings from the Anti-Narcotics Department align with our study, which shows that stigma remains high, and treatment rates remain low. Changes must begin from the ground up, starting with the training of undergraduate students in health-related fields. These students should be trained to provide appropriate patient care that is both empathetic and professional, supported by well-developed and culturally relevant educational programs [32].Training should also extend to practicing healthcare providers, especially nurses and physicians, to ensure they understand how to care for individuals with SUDs. A study by Gilchrist et al. (2011) found that many healthcare students held negative attitudes toward individuals who use substances. Other research has shown that stigma can significantly impact a patient’s decision to seek proper treatment [35, 36]. Therefore, to promote long-term change, it is essential to assessing and addressing the attitudes and potential discriminatory behaviors of undergraduate students before they enter the healthcare workforce as licensed professionals [32].
Significantly, however, our study found that students (both male and female) held more positive attitudes toward substance use, particularly of heroin. This suggests that developing educational and support programs targeting university students may be particularly effective in equipping both undergraduate health students and practicing professionals, such as nurses and physicians, with a deeper psychological and physiological understanding of how to care effectively for individuals with SUDs. Our findings are supported by prior research in the literature, who reported that health professionals with lower levels of discrimination toward drug users demonstrated greater acceptance and empathy [37]. Similarly, Abbasi-Ghahramanloo et al. found that health professional students in their study believed it was unethical to deny services to individuals who use illicit substances and emphasized the importance of providing necessary care [38]. Moreover, a 2021 study on “Undergraduate health profession students’ attitudes toward illicit substance users in Jordan” found that many participants reported had not received any training or education regarding, the physical, psychological, and social problems encountered by individuals who use illicit substances [32].
Consequently, such targeted policy and clinical efforts are critical to enhancing the effectiveness of existing national strategies and promoting better health outcomes for individuals affected by SUDs in Jordan.
Limitations
This study has several limitations that should be acknowledged. First, the use of an online survey platform and recruitment through Facebook may have introduced selection bias, potentially favoring individuals who are younger, more technologically literate, and more socially connected, thereby limiting generalizability to the broader Jordanian population. Additionally, the use of snowball sampling through Facebook may have presented geographic and social sampling bias in participants demographics, resulting in dominance of certain regions (Al Balqa and Irbid) and social groups (predominant unmarried respondents). These disparities should be considered when interpreting the findings and may have affected the representative of the samples. Therefore, the findings may not fully generalize to older, less or rustic digitally connected populations in Jordan. Second, the cross-sectional design of the study captures associations at a single point in time and precludes any conclusions about causality between demographic characteristics and stigma toward heroin users. Third, the use of self-reported measures may introduce response biases, such as social desirability bias, wherein participants may underreport or overreport stigmatizing attitudes. Fourth, the survey relied on hypothetical scenarios rather than real-life interactions, which may not fully capture participants’ behaviors toward individuals with SUDs in real-world settings. Additionally, while the survey items were adapted from a validated scale [20], the adapted version was not formally validated within the Jordanian population. Future study researchers should include a psychometric formal validation of the adapted stigma scale within the Jordanian population to confirm its cross-cultural applicability and reliability. Finally, although this study focused on smoking, marital, and employment status, it did not account for other potentially influential factors such as religious intensity, education level, prior personal experiences with substance use, or mental health status, which may further shape stigma and should be considered in future research.
Future research
Future research should aim to build upon these findings by utilizing more diverse recruitment strategies to ensure broader representation across age groups, socioeconomic statuses, and rural versus urban populations in Jordan. Longitudinal studies are needed to better understand how stigma toward heroin users evolves over time and in response to societal changes or public health interventions. Additionally, future work should explore the impact of other demographic, psychological, and cultural factors—such as religious beliefs, education, prior exposure to substance use, and mental health status—on public attitudes toward substance users. Intervention-based studies evaluating the effectiveness of stigma-reduction programs and culturally sensitive public health campaigns would be particularly valuable in developing strategies to dismantle barriers to treatment. Comparative research across Middle Eastern countries could also offer insights into how different sociocultural environments influence stigma and inform the design of regionally tailored interventions.
Conclusion(s)
In conclusion, this study highlights how smoking, marital, and employment status are associated with public stigma toward heroin users in Jordan, a topic that remains significantly understudied in public health and substance use research. Our findings reveal that individuals more closely aligned with traditional societal norms tend to hold stronger negative views toward heroin users, while those who may experience stigma themselves exhibit slightly greater empathy. By incorporating recent global studies (2020–2025) and implementing theoretical frameworks, this study contextualizes how demographic factors interact with the cultural and social norms to shape stigmatizing attitudes. The findings highlight the need for culturally sensitive interventions to decrease stigma and improve access to treatment. These results highlight the deep entrenchment of stigma within Jordanian cultural and social frameworks and its critical impact on individuals’ willingness to seek help and access treatment. Addressing substance use stigma through culturally sensitive public health initiatives, education, and advocacy may be essential for improving treatment engagement and advancing the effectiveness of national strategies aimed at supporting individuals struggling with SUDs.
Supplementary Information
Below is the link to the electronic supplementary material.
Author contributions
Y.A.A. led the study conceptualization, planning, data interpretation, and manuscript writing. M.T. and M.A. contributed to data collection, cleaning, and statistical analysis. D.A.O., S.S., R.B., J.C., and Y.N. assisted in writing, editing, and literature review. All authors reviewed and approved the final manuscript.
Funding
We received no funding for this study.
Data availability
The data is available upon reasonable request from the corresponding author.
Declarations
Ethics approval and consent to participate
This study was approved by the University of Jordan Ethical Committee on March 18th 2024, Decision No. 181/2024. Participants were recruited via Facebook, and an online information sheet of the survey was provided at the start of the study’s purpose, voluntary nature, procedures and the measures. Informed consent was procured electronically before participants could access the survey. The participation was completely voluntary, and participants could take out at any time without any penalty. All responses were de-identified and stored securely on Qualtrics, and reported only in compiled form to ensure the confidentiality.
Consent to publish
All participants provided informed consent for participation in the survey. Responses were collected anonymously, and participants were informed that aggregated, de-identified results would be published in academic outlets.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Supplementary Materials
Data Availability Statement
The data is available upon reasonable request from the corresponding author.