Differences in adolescent substance use by Hispanic subgroup: What we know and what we need to find out

Abstract

Differences in health outcomes on the basis of racial and/or ethnic group membership have been documented among Hispanics in the U.S. As this heterogeneous population continues to grow, so does the importance of understanding the subgroups within it and the possible effect that between-group variations may have on health outcomes. This paper highlights a major limitation of the existing research - that the Hispanic population is almost exclusively lumped into one pan-ethnic category when examining substance use behaviors. However, there is evidence to suggest that differences in substance use behaviors exist between Hispanic subgroups, which may be important when designing prevention and intervention programs. While the majority of research in this arena has focused on adults, more research is required to understand subgroup differences in substance use behaviors among Hispanic youth.

This paper provides a synopsis of the research on U.S. Hispanic substance use behaviors, including how factors such as acculturation, nativity, and culture of origin can act as risk and protective factors. However, there is an insufficient amount of research looking at how the differences between Hispanic subgroups may interact with acculturation levels to increase or decrease risk factors associated with substance use. Therefore, the authors suggest that substance use researchers attempt to improve future study designs by asking standardized demographic questions of national origin and/or ethnic/subgroup identity and take this into account in their analyses. The collection of such specific data could then be used to develop more targeted prevention and intervention programs.

INTRODUCTION

Differences in health outcomes on the basis of racial and/or ethnic group membership have been documented among Hispanics residing in the U.S. (Hernandez & Blazer, 2006; Kagawa-Singer, Dadia, Yu, & Surbone, 2010). Counted together as a broad category, Hispanics currently make up 16% of the population and are estimated to reach 30% of the population by mid-2050 (Ennis, Ríos-Vargas, & Albert, 2011; United States Census Bureau, 2011). Hispanics also accounted for more than half of the growth of the total U.S. population between 2000 and 2010 (United States Census Bureau, 2011). As this heterogeneous population continues to grow, so does the importance of understanding the subgroups that comprise it and the effect that between-group variations may have on health behaviors and outcomes.

According to the U.S. Census Bureau, Hispanics/Latinos include anyone who classified themselves on the 2010 census as a Hispanic, Spanish, or Latino category such as Mexican, Puerto Rican, or Cuban, as well as anyone who classified themselves as “another Hispanic, Latino, or Spanish origin” (United States Census Bureau, n.d.). The term Hispanic or Latino (often used interchangeably) therefore includes people whose ethnic origin may be Mexican, Cuban, Puerto Rican, Dominican, Spanish (from Spain), as well as any other Central or South American country or any combination of these and other nations (United States Census Bureau, n.d.). Hispanic is not considered a race, and for this reason, Hispanics are often categorized by both race and ethnicity as in “black Hispanic,” “white Hispanic,” or “other Hispanic.”

Disaggregating Hispanic health data on the basis of national ethnicities and culture can be important. An analysis of data from the 1997–2001 National Health Interview surveys demonstrated that there are significant differences in health outcomes between Mexicans, Puerto Ricans, Cubans, and Dominicans in the U.S. (Zsembik & Fennell, 2005). For example, Zsembik and Fennell demonstrated that more acculturated Mexican Americans with higher levels of socioeconomic status (SES) had worse general health outcomes (e.g., medical conditions and functional impairments) than their less acculturated peers with lower levels of SES, while the opposite was true among Puerto Ricans (Zsembik & Fennell, 2005). Likewise, Mainous and colleagues found that management of diabetes varied based on ethnic subgroup (Mexican, Puerto Rican, other Latino) (Mainous, Diaz, Saxena, & Geesey, 2007). A report from the National Survey on Drug Use and Health (NSDUH) (2013) also demonstrated that subgroups of Hispanics differed in their need and receipt of treatment for substance use disorders (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). The report found that Mexicans and Puerto Ricans were most likely to need treatment, but that Puerto Ricans were the most likely to receive it, while Central and South Americans were least likely to require or receive treatment (SAMHSA, 2013).

Substance use among Hispanics living in the U.S. is a significant public health issue. While the NSDUH showed that rates of illicit drug use (6.6%) and past month alcohol use (46.1%) were lower among Hispanics (considered together as a single ethnic category) than the overall population, (7.9% and 55.2% respectively) (SAMHSA, 2013), the rates of past month binge drinking were higher for Hispanics (26.3%) than the national average (24.5%) (SAMHSA, 2008). Furthermore, there is evidence to suggest that differences in substance use behaviors exist between Hispanic subgroups on the basis of acculturation, nativity, and national subgroup. (Caetano, Ramisetty-Mikler, & Rodriguez, 2008; Delva et al., 2005).

While research demonstrates variations in substance use behaviors between subgroups of Hispanic adults, less is known about subgroup differences in substance use behaviors among Hispanic youth. Currently, the majority of existing epidemiological data on substance use variations between Hispanic subgroups has focused only on adults (Delva et al., 2005). The few studies that do include Hispanic adolescents have often combined the various subgroups into one category and have failed to elucidate the potential variations between subgroups (Delva et al., 2005). Further research on the substance use behaviors of Hispanic adolescent subgroups is warranted; in particular because research on adolescent substance use has shown that early onset of alcohol and drug use is associated with an increased risk of alcohol and drug dependence later in life (Grant & Dawson, 1997; SAMHSA, 2008). In addition, the wide variations in acculturation levels, cultural practices, and immigration history between and within Hispanic subgroups represent inherent differences that may positively or negatively affect substance use and should be further studied.

METHODS

For this commentary paper, a literature review was conducted to determine the status of current research regarding the differences in substance use behaviors between and among Hispanic adolescent subgroups. To locate peer-reviewed articles on this topic, PubMed and Google scholar were searched using various combinations of the terms “Hispanic,” “Latino,” “adolescent,” “substance use,” “alcohol,” “drugs,” “differences,” and “subgroup.” Due to the small number of articles found on Hispanic adolescent subgroup substance use, we did not limit our search by date, and we expanded our search to include studies conducted with adults. Because we were looking for original research studies, we did not identify review articles or meta-analyses specific to our search criteria. We found additional studies through examining the reference lists of the original articles. We ultimately identified approximately 30 articles, from which we excluded those that were not specific to substance use, and those that did not look at more than one Hispanic subgroup. Because acculturation is such a renowned and highly covered topic in Hispanic substance use research and we felt that it warranted discussion, we also searched PubMed for articles on the influence of acculturation, nativity, and country/culture of origin on substance use and other health outcomes. Since there is already such a surplus of literature reviews on the topic of acculturation and Hispanic substance use, we chose to only include some of the more widely cited original research articles. For data on substance use rates among Hispanic adolescents as a whole as compared to other racial/ethnic groups, we used data from the 2013 Youth Risk Behavior Surveillance survey, which is a nationally representative survey conducted annually.

HISPANIC ADOLESCENTS AND SUBSTANCE USE

Substance use is a significant problem for all U.S. youth, and in broad racial/ethnic comparisons, Hispanic youth appear to use some substances at higher rates than other groups (Table 1). According to the 2011 Youth Risk Behavior Surveillance System (YRBSS), 70.8% of high school students in the U.S. have had at least one drink of alcohol in their lifetime (Eaton et al., 2012). However, the prevalence of having ever had alcohol is higher among Hispanic students (73.2%) than either white (71.7%) or black students (63.5%), and slightly higher among Hispanic females (74.1%) than males (72.4%) (Eaton et al., 2012). In addition, 27.2% of Hispanic males and 23.0% of Hispanic females have tried alcohol before age 13, whereas the national average is 20.5% (Eaton et al., 2012). While 39.1% of Hispanic female students have tried marijuana, mirroring the national rate, the prevalence among Hispanic male high school students is higher (45.0%) (Eaton et al., 2012). With respect to underage cigarette use, 48.6% of Hispanic students, 44.2% of white students, and 39.1% of black students have ever tried a cigarette in their lifetime (Eaton et al., 2012). These nationwide statistics demonstrate that Hispanic youth may try substances earlier and at slightly higher rates compared to black and white youth.

Table 1.

Prevalence of Adolescent Alcohol Use by Racial/Ethnic Group - 2011 Youth Risk Behavior Survey (YRBS) Data¹

YRBS Question	Total (U.S. High school students) %	Hispanic %	Non- Hispanic white %	Non-Hispanic black %
Had at least one drink of alcohol in their lifetime	70.8	73.2	71.7	63.5
		Male: 69.0
		Female: 75.6
Tried alcohol before age 13	20.2	25.2	18.1	21.8
		Male: 23.4
		Female: 20.2
Ever tried marijuana	39.9	42.1	37.9	43.0
		Male: 50.0
		Female: 47.6
Ever tried a cigarette	44.7	48.6	44.2	39.1
		Male: 45.1
		Female: 41.4

¹Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S., Flint, K. H., Hawkins, J., … Centers for Disease Control and Prevention (CDC). (2012). Youth risk behavior surveillance - United States, 2011. Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, D.C.: 2002), 61(4), 1–162.

SUBGROUP DIFFERENCES – HIGHLIGHTS OF THE EXISTING RESEARCH

Data on substance use among Hispanic adults indicate distinct subgroup differences. (Caetano et al., 2008; Delva et al., 2005). The lack of epidemiological data among adolescents suggests that the potential variation in substance use between Hispanic adolescent subgroups is not being captured. Among adults, one of the larger epidemiological studies (5,224 participants) to examine the variations in alcohol abuse and dependence between Hispanic subgroups living in the U.S. is the 2006 Hispanic American Baseline Alcohol Survey (HABLAS) (Table 2). Subgroup analyses showed that rates of past year alcohol abuse in male participants were 1.8% for Cuban Americans, 4.2% for Central/South Americans, 5.2% for Puerto Ricans, and 5.6% for Mexican Americans (Caetano et al., 2008). The rates for females were lower, ranging from 0.2% for Central/South Americans to 1.1% for Cuban Americans (Caetano et al., 2008). According to data from the 2001–2002 National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), alcohol abuse rates in the overall adult U.S. population were 6.9% for males and 2.6% for females (Grant et al., 2006). Based on these data, prevalence of alcohol abuse is lower among both male and female Hispanics than the U.S. national averages for adults (Caetano et al., 2008). However, among Puerto Rican and Mexican American men, rates of alcohol dependence were higher, at 15.3% and 15.1% respectively, than the overall U.S. rate among men (5.4%) (Caetano et al., 2008; Grant et al., 2006). The rates among Central/South American and Cuban American men were 9.0% and 5.3% respectively (Caetano et al., 2008). Among women, Puerto Ricans still had the highest rates of alcohol dependence at 6.4%, followed by Mexican American (2.1%), Cuban American (1.6%), and South/Central American (0.8%) compared to 2.3% in the overall U.S. population (Caetano et al., 2008).

Table 2.

Prevalence of Alcohol Use Disorders by Gender Among Adult Hispanic National Groups Compared to U.S. Population Averages¹, ²

	Total U.S. population1	Total Hispanic Population1	Hispanic Subgroup
Alcohol Use Disorder			Puerto Rican2	Cuban American2	Mexican American2	South/Central American2
Alcohol abuse
Males	6.9	6.2	5.2	1.8	5.6	4.2
Females	2.6	1.7	0.7	1.1	0.8	0.2
Alcohol dependence
Males	5.4	5.9	15.3	5.3	15.1	9.0
Females	2.3	1.9	6.4	1.6	2.1	0.8

¹Grant, B. F., Dawson, D. A., Stinson, F. S., Chou, S. P., Dufour, M. C., & Pickering, R. P. (2006). The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence. Alcohol Research and Health, 29(2), 79–91.

²Caetano, R., Ramisetty-Mikler, S., & Rodriguez, L. A. (2008). The Hispanic Americans baseline alcohol survey (HABLAS): Rates and predictors of alcohol abuse and dependence across Hispanic national groups. Journal of Studies on Alcohol & Drugs, 69(3), 441–448.

In one of the few studies that examined rates among subgroups of Hispanic adolescents, Khoury and colleagues found that both Cuban and Central/South American groups had significant increases in substance use over time (from 7th to 9th grade), but use of certain illicit drugs (i.e. cocaine, crack, PCP, barbiturates/amphetamines, tranquilizers, and LSD) only significantly increased in the Central/South American group (Khoury, Warheit, Zimmerman, Vega, & Gil, 1996). Further analyses found that regardless of Hispanic subgroup, those born outside the U.S. had lower substance use rates than those born in the U.S. and that Hispanic girls who had lived in the U.S. less than two years had significantly lower substance use rates than those who had lived in the U.S. for longer (Khoury et al., 1996).

Additional research dedicated to evaluating substance use rates among any Hispanic subgroup has focused mainly on one group, such as Mexican Americans, as they are the largest Hispanic subgroup in the U.S. (Ennis et al., 2011). Epidemiological surveys (Grant et al., 2004; Kessler & Walters, 2002; Robins & Regier, 1991; Vega & Gil, 1998) comparing substance use rates among foreign-born vs. U.S. born Mexican Americans found that substance use rates were significantly lower among those who were foreign-born (Grant et al., 2004). Vega and colleagues found similar results when they compared substance use rates between persons of Mexican heritage living in Fresno, California with persons of Mexican heritage who remained living in Mexico (Vega & Gil, 1998; Vega et al., 2002). The drug use rate among participants in Fresno was 24.6%, compared to the drug use rate among the sample in Mexico City, which was only 2.9% (Vega et al., 2002). These results demonstrate the stark difference in substance use behaviors between Mexican Americans and Mexicans, indicating that Hispanic substance use behaviors are likely affected by factors related to acculturation to U.S. cultural norms and values, and potentially other influences, such as location and access. Further, variations in substance use rates between the different Hispanic national origin groups indicate that Hispanic subgroup culture may also play a role.

ACCULTURATION AND SUBSTANCE USE

Much of the literature has attributed the differences in substance use among Hispanic subgroups to varying acculturation levels, acculturation stress, U.S. vs. foreign nativity, and country of origin (Caetano et al., 2008; Delva et al., 2005; Khoury et al., 1996; Vega & Gil, 1998). Acculturation is the process by which an individual adopts the practices and values of the dominant culture where he or she lives (Warner et al., 2006). Acculturation is frequently measured by language use (e.g. Spanish vs. English), length of time living in the U.S., cultural preferences, and cultural identity (Gil, Wagner, & Vega, 2000). When we widen our lens to look at Hispanics as a single group, it appears that while definitions of acculturation vary and measurement processes for use within health research have been critiqued, (Hunt, Schneider, & Comer, 2004), the majority of studies have shown that Hispanic individuals who are considered more acculturated to U.S. culture have higher rates of substance use than those who are less acculturated. A review of the literature conducted by Warner and colleagues (2006) also demonstrated that U.S.-born Hispanics have been consistently shown to have higher rates of drug use, abuse, and dependence than their foreign-born counterparts (Warner et al., 2006). As the majority of acculturation research focuses on Hispanics as a whole or on a select few subgroups, more research will be needed to determine how acculturation may affect each subgroup differently, particularly among adolescents, as their subcultures may be different than those of their parents. In addition, factors such as immigration and acculturation stress, which often vary between subgroups, may result in higher rates of alcohol abuse and substance use disorders (Caetano, Ramisetty-Mikler, & Rodriguez, 2009).

Although the precise factors contributing to higher substance use rates among U.S. acculturated and U.S.-born Hispanics are unknown, researchers have argued that Latin American values and cultural norms can be protective against substance use, while U.S. cultural norms and values may contribute to substance use (Castro & Nieri, 2010; Gil et al., 2000). Hispanic American youth, as a broad group, may be influenced by exposure to American norms of alcohol and drug experimentation, which are not as common in their ancestral or native cultures (Castro & Nieri, 2010). Familism is another aspect of Hispanic culture that has been noted in the literature as a potential protective factor for substance use. Familism consists of the level to which Hispanic individuals value their family members, tend to live in close proximity to them, and tend to depend on them for emotional and social support (Gil et al., 2000). The protective nature of famalism lies in its tendency to safeguard against negative environmental influences which could otherwise be contributing factors for substance use. Ultimately, understanding acculturation and familism in the context of different Hispanic subgroups is important in order to more fully understand how these constructs contribute to between-group differences in substance use behaviors.

DISCUSSION

Epidemiological data has shown that when comparing Hispanic adolescents (considered together as a broad group) to black and white adolescents, Hispanics may experiment with alcohol at an earlier age. In addition, underage cigarette use is higher among Hispanic adolescents than other groups, and marijuana use is higher among Hispanic adolescent males when compared to the national average. These relatively high substance use rates indicate that it is important to understand the risk and protective factors related to substance use in this population, particularly so that targeted interventions can be developed to address substance use early on, before it becomes a more serious problem.

A major limitation of the existing research is that the Hispanic population is almost exclusively lumped into one pan-ethnic category when examining substance use behaviors. This makes it exceedingly difficult to identify whether certain substance use risk and protective factors may be associated with particular subgroups. Because research on adults indicates that factors such as acculturation, nativity, country or culture of origin, etc., which vary between and within subgroups, can influence substance use behaviors, it is imperative that we also examine these relationships among adolescents.

RECOMMENDATIONS

While a plethora of studies have found that acculturation to U.S. culture may increase Hispanic individuals’ propensity to use substances, there is still an insufficient amount of research looking at how the differences between Hispanic subgroups may interact with acculturation levels to increase or decrease risk factors associated with substance use, particularly among adolescents. Although evaluating differences in substance use rates between Hispanic subgroups proves challenging, especially as the ethnic and racial backgrounds of individuals in the U.S. become increasingly intermixed, it is recommended that substance use researchers attempt to improve study designs by asking standardized demographic questions of national origin and/or ethnic/subgroup identity and take this into account in their analyses. This may prove to be less complicated in geographic locations with large Hispanic populations where sample sizes of non-majority Hispanic subgroups are larger. In addition, more researchers should consider focusing their attention on one particular subgroup to determine what the specific risk and protective factors are for that group, and then elucidate whether these factors are linked to subgroup culture and/or acculturation. While some work is being done in this arena, further research with this focus would provide additional insight into risk and protective factors specific to different Hispanic subgroups, which could inform the development of culturally competent interventions.

Substance use researchers may also want to consider incorporating empirically defined data such as ecodevelopmental and intrapersonal risk factors into epidemiologic research, as suggested by Prado and colleagues (Prado et al., 2009). Intrapersonal risk factors include adolescents’ attitudes about drug and alcohol use and ecodevelopmental factors refer to the microsystems that an adolescent participates in, such as the family, school, and peer environment (Prado et al., 2009). While some have argued that these empirically defined risk factors should be used in place of ethnic/cultural data, we believe that ecodevelopmental and intrapersonal risk factors can be combined with culturally-specific data to paint a more complete picture of the internal and external factors contributing to substance use.

CONCLUSION

Hispanics living in the U.S. have a unique culture or, more appropriately, set of cultures, which are influenced both by the countries from which they or their ancestors emigrated and by engagement in the dominant U.S. culture. The numerous nations from which Hispanics originate each contain their own cultures and subcultures, which make up the ethnic/cultural subgroups of the Hispanic population in the U.S. and can represent myriad possibilities in cultural identity. The categorization of Hispanics into subgroups for the purposes of research is complex, but however challenging it may be, it is necessary to attempt to study the effect that cultural identity and national origin may have on health outcomes such as substance use. As the U.S. Hispanic population continues to grow, it is our hope that public health researchers will continue to refine the measurement tools used to evaluate the substance use behaviors of Hispanic adolescents so that more nuanced data can be used for the development of appropriate prevention and intervention programs targeted toward this diverse population.