J Blomqvist 3


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J Blomqvist 3

  1. 1. Jan Blomqvist Research report What is the worst ABSTRACT thing you could get J. Blomqvist: What is the worst thing you could get hooked on? Popular images hooked on? of addiction problems in contemporary Sweden AImS Popular images of To investigate potentially crucial aspects addiction problems in of Swedes’ perceptions of nine different contemporary Sweden addictions. DATA AND mETHODS Population survey, sent out to 2,000 adult Swedes (18–74 years), focusing on the perceived severity of, responsibility Introduction for, options to recover from, and Although simplistic and one-sided explana- character of addiction to cigarettes, tions have been legion over the years, most snuff, alcohol, cannabis, amphetamine, theorists tend today to see addiction as a cocaine, heroin, medical drugs, and multi-factorial (bio-psycho-social) phenom- gambling. enon. Moreover, although few endorse the RESULTS type of “vulgar constructionism” criticized There are large differences in the ways e.g. by Best (1995), many agree that addiction in which various addiction problems is to some extent and in some sense a socially are perceived. Whereas tobacco use, constructed problem. Thus West (2007), for and to some extent gambling, are example, contends that addiction is a social seen as relatively harmless “habits”, construct with fuzzy borders, yet a condi- not particularly easy to get hooked on tion in which many underlying pathologies but easy to quit, the use of drugs such and abnormalities become manifest. Put in a as heroin, amphetamine, and cocaine different way, even if addiction is not “just” is seen as a major societal problem, an invention by powerful claims makers, the and users are seen both as “sinners” ways in which a “deviant” substance use or who need to mend their ways and as behaviour is defined, how such deviances powerless “victims”. In between comes are reacted to by society, and – thereby – the the use and misuse of alcohol, cannabis consequences to the individual of her/his and medical drugs, about which deviance, as well as the long-term trajectory perceptions are more divided. of her/his condition, are strongly influenced CONCLUSIONS by norms and traditions that vary with time Respondents tend to downplay the and place (Blomqvist 1998a). This means that risks and dangers with addictive addiction can be seen as an example of what habits that are common and familiar in Hacking (1999) has named “interactive kinds”, mainstream culture, and to dramatise NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 26. 2009 . 4 373
  2. 2. the risks and dangers i.e. phenomena, the official and/or predominant definitions with such habits that are of which influence the self-definition and behaviour of those uncommon or “strange”. defined, thereby in turn at least partly confirming the official This may have unfortunate or institutionalised views. consequences for addicts’ Occasionally, the significance of others’ attributions and options to find a path out of labelling for the origin and developmental course of various their predicaments. addictions, as well as for the options of finding a path out KEy WORDS has attracted the attention of researchers, not seldom from a Addiction, images, social historical perspective (e.g. Roman & Trice 1977; Gus- consequences, population field 1981; Room 1985; Goldberg 2000). Others have found data, Sweden. that dominating views that stigmatise the addict may pre- vent him/her from seeking help or lead to discrimination of ex-problem users in work life (Kilty & Meenaghan 1977; Dean & Rud 1984; Blomqvist 2002). There is also reason to contend that the long-term outcome of treatment is to a large part dependent on what happens outside the clinic door (e.g. Moos 1994; Blomqvist & Cameron 2002). In Sweden, the clearly varying official discourses and policies on alcohol and narcotics are well known and well documented (e.g. Christie & Bruun 1985; Hübner 2001), and there are also indications that the Swedish “doxa”1 on nar- cotic drugs, picturing these as almost inevitably dependence generating (Bergmark & Oscarsson 1988) may decrease other people’s inclination to offer help and support (Blomqvist 2004). People who recover from a heroin addiction seem also to be met with greater distrust than people who recover from an addiction to alcohol (Klingemann 1992; Blomqvist 2002). Moreover, the historical dominance, not least in the USA, of the “popular disease theory”, describing alcoholism as an inexorably progressive deteriorating process (cf. Pattison 1976), has been criticised by some as being directly counter- productive to the options of resolving an alcohol problem (e.g. Peele 1989). Finally, increasing research has shown in recent decades that “self-change” is by far the most common path to recovery from most addictions (e.g. Blomqvist 1996; Cunningham 2000; Klingemann & Sobell 2007; Blomqvist et al. 2007). Research on the processes and influences behind such solutions has clearly demonstrated the important role of other peoples’ support, demands, and general attitudes in motivating attempts to overcome an addiction, as well as in maintaining the resolution (e.g. Blomqvist 1999; 2002; Gran- field & Cloud 1999; Bischof et al. 2004). 374 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 26. 2009 . 4
  3. 3. Although there are thus clear indications a grant from the Swedish Research Coun- that the “governing images” (Room 1978) cil (VR 2004–1831). The main objective of or dominant “social representations” this project has been to get a better under- (Moscovici 1981; 1989) of, various addic- standing of the beliefs and assumptions tions may play a not insignificant role to underlying how people who are trying to the prevalence and long-term course of overcome their addiction problems are met these problems, as well as to the options by treatment professionals and significant of finding working strategies to counteract others. More concretely, the study endeav- them, there is no conclusive and empiri- oured to ascertain what people believe cally founded knowledge of how these at- about nine different addictions or misuse titudes and images differ between e.g., problems occurring in Sweden (addictions various addictions, various cultures, vari- to alcohol, cannabis, heroin, ampheta- ous demographic subgroups, and various mine, cocaine, medical drugs, cigarettes, professions. Rather, the current focus on snuff, and gambling). The main part of the the perceived need to develop “evidence project has been a fairly extensive survey, based practices” tends to distract attention mailed out to a representative population from what might be called “the social con- sample. In a complementary part, three text of recovery”. Even if there is certainly smaller surveys have been directed at three good reason to improve the effectiveness samples of about 200 professionals each, and responsiveness of prevailing treat- mainly working with addiction problems ment systems (e.g., Humphreys & Tucker in each of the social services, health care, 2002; Blomqvist et al. 2007), this is un- and criminal justice systems (cf. Samuels- fortunate, given that only a small propor- son et al. 2009; Christophs 2009). tion of all people with addiction problems The study has partly built on the in- ever come into contact with these systems ternational so-called SINR study (Klin- (ibid.). The study reported in this paper gemann 2003)2, and the Swiss study on has been part of an effort to improve our popular attitudes toward “natural recov- knowledge about the “images of addic- ery” and about the key elements of a “self- tion” underlying how people with such change friendly society” that has been problems are met by their environment, reported by Klingemann (2005; Klinge- including professionals in the addiction mann & Klingemann 2007). Although the treatment field, and so to lay a foundation present study has broadened the scope of for the development of more realistic strat- these studies, the latter study in particular egies to counteract such problems. provides valuable options for comparison regrading perceptions of self-change. Later “The social context of studies conducted in Finland (e.g. Koski- recovery” – aims and research Jännes et al. 2009), Canada (Cunningham questions 2009) and Russia, using basically the same The research project “The social context questionnaire as the Swedish study pro- of recovery – views of addiction and re- vide further possibilities for comparisons. covery in the population and in various Another source of inspiration has been a professional groups” has been financed by Nordic study on substance use and control NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 26. 2009 . 4 375
  4. 4. policies carried out in 1995 and reported of social problems, and their cognitive sig- e.g. by Hübner (2001), a study that also nificance, and still another Brickman and provides some data for comparison. colleagues’ (1982) assertion that the issue This article presents the results from the of moral responsibility for human prob- Swedish population survey, focusing on lems actually involves two questions: the differences between the nine different ad- question of blame (or responsibility for dictions with regard to how serious they causing a problem), and the question of are judged to be as societal problems, their control (or capability and responsibility perceived “addictiveness“, how easy they for solving a problem). Based on these and are believed to be to recover from (with other considerations, the survey has tried and without professional or formally or- to capture some dimensions and aspects of ganised help), to what extent moral re- prevailing “images of addiction” that can sponsibility for developing and solving be assumed to be crucial to how people the undesired condition is attributed to with various addiction problems are met the afflicted individual, and the perceived and treated by others in practice. basic character of the problem in question. Data collection Q Method The survey was mailed out by Statistics the survey Sweden in 2005 to a representative popu- “Addiction”, “dependence”, and “misuse” lation sample of 2,000 adult Swedes (18– are examples of the kind of “fat words”, 74 years) drawn from the official Swedish the use of which Christie & Bruun (1969) population data base (RTB). More con- lamented already four decades ago. It is cretely the questionnaire contained, be- obvious that much of the conceptual con- sides questions about demographic and fusion from those days persists today, and socio-economic circumstances, questions that there are a number of dimensions asking respondents to rank the “serious- and aspects that could be relevant when ness” of various addictions compared to it comes to the exploration of prevailing other social problems, questions about the images of various addictions. The delib- perceived risk of developing an addiction erations that underlie the choice of study to or dependence on the substances or variables for this investigation, has built activities chosen for the study, about the on a number of previous efforts to improve perceived responsibility for developing our understanding of these issues. One ex- and resolving an addiction to these sub- ample is Mäkelä’s (1980) remark that so- stances or activities, and questions about ciety’s response to any type of deviance the perceived chances of recovery – with will be affected by the extent to which the and without treatment or other formal help deviant individual is seen as doing harm – from the same addictions. In addition, to her/himself and/or to her/his environ- information was gathered on respondents’ ment, and by whether effective means to own experiences – by themselves or some- alter the deviance are believed to be avail- one close – of the use of or addiction to the able. Another has been Gusfield’s (1981) substances/activities in question, of treat- distinction between the moral connotation ment and/or “self-change”, and of having 376 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 6. 2 0 0 9 . 4
  5. 5. tried to help others with addiction prob- to a certain extent have been jeopardized lems. Finally, a number of questions were by the low response rate. This means that included aimed at capturing respondents’ caution is needed in generalizing results political – ideological orientation, trust to the population level. Since problem in various authorities, “social distance” drinkers and users of illegal drugs can be to people with addiction and other social expected to be overrepresented among problems, personal “locus of control”, and non-respondents, and socially “undesir- perceptions of major obstacles to recovery able” behaviour can generally be expected from and desirable societal strategies to to be underreported (e.g. Kühlhorn et al. counteract various addictions. 2000), this caveat will be particularly rel- evant with regard to future analyses of the Response rate and potential attrition bias connections between respondents’ images Valid responses were provided by 1,098 of various addictions and their own expe- respondents, giving a response rate of riences with potentially dependence gen- 54.6%. Although this is a low figure, it is erating substances or activities. However, not uncommon for surveys like the present as concerns the differences between their one covering issues such as problem con- images of various addictions, which is the sumption of alcohol and use of illegal focus of the present paper, the results are drugs (cf. Hague & Irgens-Jensen 1987; likely to be more reliable. Kühlhorn et al. 2000; Hübner 2001). Attri- tion was somewhat lower among women the respondent group than men, in the oldest age group (60–74) Table 1 describes the respondent group in than among younger respondents, among terms of some basic demographic charac- respondents who were married or cohabi- teristics, showing e.g., an even distribution tating than among singles, in the high- of women and men, that just under one est income groups than in lower groups, third were university educated whereas among native-born Swedes than among a quarter had only completed elementary people born in other countries, and among school, that one third lived in the metro- respondents with university education politan area and one tenth in rural areas, than among respondents with lower edu- and that the great majority of the respond- cation. In an effort to account for sampling ents were native-born Swedes. and attrition bias, data were weighted, Table 2 describes respondents’ lifetime using the mentioned variables and place experiences with potentially addictive of residence (rural, urban, or metropoli- substances, which by and large seem to tan) as calibration variables. All reported mirror the Swedish “addiction scene”3 analyses except sample sizes are based fairly well, the most common experiences on weighted data, although a number of being, in order of magnitude, with drink- test analyses showed few and insignifi- ing, smoking, snuff use, and – although to cant differences between results based on a much lesser degree – cannabis use, and weighted and unweighted data. In spite of where experiences with amphetamine, co- the weighting process, it must be born in caine, (illegal use of) medical drugs, and, mind that the validity of the results may in particular, heroin, are very limited. The NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 26. 2009 . 4 377
  6. 6. Table 1. Respondent characteristics Women (N = 545) Men (N = 553) All (N = 1.098) Characteristics n % n % n % age 44.2 (s =15.5) 44.1 (s=14.8) 44.2 (s=15.7) married /cohabiting 243 44 7 237 42.9 481 43.8 University education 175 32.2 147 26.5 322 29.3 only elementary education 126 23.2 148 26.7 274 25.0 living in a metropolitan area 197 36.2 163 29.5 360 32.8 living in a rural area 52 9.6 60 10.8 112 10.2 Born in sweden 467 85.7 466 84.3 933 85.0 most obvious difference between respond- enced such problems personally. For ex- ents’ reports and what is known about the ample, although more than nine out of overall prevalence of the habits in ques- ten are previous or present drinkers, only tion in Sweden, is that the proportion of about six per cent, the same proportion as present smokers and snuff users seems to those who never drank, report having been have been higher in the respondent group addicted to or dependent on alcohol. The than what was the case in the population fact that more than four out of ten admit at the time when the survey was conduct- to being or having been dependent on to- ed, although this difference may partly be bacco suggests that this is seen much less due to differing definitions. stigmatising than other addictions. At the Table 3, finally, shows respondents’ re- same time, almost two thirds of all re- ported experiences with addiction prob- spondents report being aware of a present lems, their own or those of somebody or former dependence or misuse problem close (family or close friend). As can be in someone close. However, less than half seen, with the exception of dependence of these respondents report that they per- on tobacco, few admit to having experi- sonally tried to help some of these people. Table 2. Personal substance use experiences (N = 1.098)a Never used Previous use Present use Substance n % n % n % alcohol 65 6.0 68 6.3 948 87.7 Cigarettes 320 29.5 429 39.7 333 30.8 snuff 669 61.6 213 19.6 205 18.9 Cannabis 918 84.5 150 13.8 18 1.7 medical drugs 1029 95.1 34 3.2 19 1.8 amphetamine 1032 95.4 43 4.0 6 0.6 Cocaine 1057 97.5 18 1.7 9 0.9 Heroine 1076 99.3 5 0.5 2 0.2 a) the table shows valid answers and valid percentages 378 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 6. 2 0 0 9 . 4
  7. 7. Table 3. Experiences of dependence/misuse problems in oneself and/or somebody close (N = 1.098) Respondent her/himself Somebody close Tried to help somebody a Dependence to n % n % % alcohol 72 6.8 519 48.6 49.4 tobacco 448 42.3 575 55.1 42.7 Cannabis 23 2.1 149 14.2 56.7 Gambling 27 2.6 128 12.3 59.2 medical drugs 31 2,9 122 11.2 57.2 narcotic drugsb 12 1.2 135 13.0 59.9 any addiction 471 42.9 723 65.9 42.2 a) Percentage of all respondents who were aware of a problem by somebody close; b) Except cannabis Finally, it should be mentioned that of, rather complex matters by answering less than five per cent of all respondents survey questions with pre-coded response reported personal experiences of addic- alternatives. Thus, as pointed out by Hüb- tion treatment, whereas one quarter was ner (2001), the basic idea that there exists a aware of a treatment episode experienced “public opinion” that can be measured by by someone close. About four out of ten traditional polls to representative samples judged these treatment experiences to is certainly open to debate (cf. Bourdieu have been helpful. At the same time, 1972; Österman 1998). For example, there further analyses revealed that about one is no reason to believe that all respond- fifth of the respondents claimed to have ents have the same competence in, or the quit what they saw as an addictive habit, same knowledge of, the issues covered by predominantly smoking or using snuff, the survey (ibid., Hübner 2001). Further, without treatment, and just over one third it is important to consider that opinions reported similar experiences in someone in real life are created in interactions be- close. Data on respondents’ political-ide- tween individuals and groups, and are ological orientation, “social distance” to formed in situations where taking a posi- people with addiction problems, personal tion means choosing between real groups “locus of control”, trust in various authori- that are in conflict (ibid.). This means that ties etc. will be the object of future analy- an opinion poll carried out at one certain ses, and are not presented here. point in time can only “scan the surface”, but not give an in-depth understanding of Q Some theoretical caveats how opinions are mobilised, and what a Besides the uncertainties caused by the certain standpoint means to various re- low response rate, a few words are war- spondents (Österman 1998). In addition, ranted about what can and what cannot the problem posed by a poll will always be captured by asking respondents to re- correspond to specific interests that gov- port their attitudes to, and perceptions ern the meaning of the responses (ibid.). NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 26. 2009 . 4 379
  8. 8. These interests are not likely to be shared of or attitudes towards various addictions by all respondents, which means that it in contemporary Sweden. A fuller under- is not unproblematic to assign the same standing of the meaning of this “aerial value and the same “meaning” to the same photo”, warrants further analyses, explor- response by various respondents. Finally, ing the connections between respondents’ attitudes and perceptions are not individ- images of various addictions, and e.g., ual characteristics but processes, governed their living situation, their own experi- by changing circumstances, actual events ences in the field, their appreciation of the and various kind of information, which in stigma attached to various addictions, and turn means that connections captured by their political-ideological orientation. In opinion polls may be rather casual (Öster- addition, further inquiry will be needed man 1998; Hübner 2001). Another general into the processes by which respondents’ caveat is that the wording of questions and images of various addictions are formed. response alternatives may influence sur- vey results in a significant way, especially Results when the issues concerned are emotion- Based on the considerations discussed in ally or ideologically “loaded”, something the Methods section, the present analysis that can be said to be true at least about focuses on three basic dimensions of pre- the drug issue in Sweden (Hübner 2001). vailing “images of addiction”: (a) the per- Of special interest here may be that there is ceived severity of various addictions, (b) no obvious equivalent to the concept “ad- the attribution of moral responsibility for diction” in modern Swedish, and that the various addictions, and (c) the perceived survey therefore consistently asked about “character” of various addictions. These “misuse of or dependence on” various sub- three basic dimensions have, as will be stances and behaviours. At the same time, seen, in turn be operationalised into more “addiction”, “misuse”, and “dependence” specific aspects. Even if the choice of as- are all “fat words” (cf. above), and in Swe- pects has by necessity been somewhat ar- den the two latter could be expected to be bitrary, the ambition has been to focus on used more or less interchangeably, by lay what might be crucial to how people with people and various “experts” alike, to sig- various addiction problems are met and nify the same broad class of phenomena treated by others in practice. as the English term “addiction”. All in all this means that the results presented in Q Which is the “worst” addiction? this paper need to be interpreted and dis- There are many ways in which the sever- cussed with regard to the currents of the ity of an addiction problem could be de- “addiction scene” (see Note 3), and the dif- fined. On a societal level, severity could fering “instutionalised responses” to and refer e.g. to the prevalence of the problem, media representations of matters like alco- the aggregate costs for the harm caused by hol, narcotic drugs, tobacco and gambling addicts, or society’s efforts to prevent the in Sweden (Hübner 2001) . It also means 4 problem and/or treat addicts. On an indi- that the survey results should only be seen vidual level, severity could refer e.g. to the as an “aerial photo” of prevailing images stigma surrounding various addictions, 380 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 6. 2 0 0 9 . 4
  9. 9. the “addictiveness” of (or the risk of get- Table 4. Rated severity of various societal ting “hooked” on) a certain substance or problems (scale 1 – 10; N = 1.098) a certain habit, to what extent and how an Rank Problem M (s) addictive habit impairs the user’s mental 1 violent crime 9.26 1.42 and physical health and/or causes harm to the environment, as well as to how 2 Drug problems (except 8.66 1.93 cannabis) easy the addiction is to “cure”, and what 3 Environmental problems 8.63 1.78 it takes to do so. The survey has tried to 4 Property crimes (theft, 8.46 1.84 capture at least some of these aspects, and burglary etc.) in the analysis the relations between dif- 5 Cannabis problems 8.15 2.32 ferent aspects have been explored in an 6 Financial crimes (fraud, 8.13 2.18 taxation crimes) effort to further clarify the significance of 7 Poverty 7.99 2.27 respondent’s judgements. 8 Ethnic discrimination 7.89 2.35 How dangerous are different addictions to 9 Prostitution 7.61 2.60 society? 9 alcohol problems 7.61 2.17 As mentioned in the discussion on opin- 11 misuse of medical drugs 7.33 2.44 ion polls in the introduction, the fact that 12 Gender inequality/gender 7.01 2.40 there may be wide differences in the ex- discrimination tent to which an issue concerns various re- 13 Wage differences 6.94 2.44 spondents is crucial to the interpretation of 14 Gambling problems 6.44 2.54 their images of various drugs or activities. 15 tobacco use 5.75 2.49 To gain some estimation of this, respond- note: Differences between groups of items are statisti- ents were asked to rank fifteen such issues cally significant (paired samples t-tests of all subse- quent pairs of items; p < .05) on a ten-point scale with the anchor-points “not severe at all” and “very severe”. The general outline of this question was bor- erty. Cannabis is ranked clearly below rowed from the Nordic survey reported other narcotic dugs, together with finan- by Hübner (2001), although some issues cial crimes and poverty, whereas all other were added, and the wordings of some is- addiction problems appear at the lower sues were changed. The exact wording of end of the ranking list. Alcohol problems, the question was (in translation): “How together with prostitution, are ranked be- serious do you think that the following low ethnic discrimination, but above the societal problems are on a scale from 1 to misuse of medical drugs, and gambling 10?” Table 4 shows respondents’ average problems and tobacco use are ranked as ratings of the fifteen issues mentioned in the two least severe concerns among the the question.5 available options, below gender discrimi- As can be seen, violent crimes end up nation and wage differences. As indicated in a class of their own as the most severe by the standard deviations, it also fol- societal problem, followed by “hard” lows from the fact that “hard” drugs are drugs and environmental problems, and, 6 ranked close to the upper end of the scale, in a separate class, crimes against prop- that there is fairly widespread consensus NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 26. 2009 . 4 381
  10. 10. among respondents about the severity of 1995, when the study reported by Hübner these drugs, whereas the opinions on the (2001) was carried out. Thus, drug prob- severity of, e.g. tobacco and gambling as lems ranked next to violent crimes in the societal problems are more divided. It is previous study, too7, whereas both alcohol possible that the “high profile” of narcotic problems and smoking ranked relatively drugs as a societal problem should partly low8. The most obvious difference seems be seen as an effect of the fact that the sur- to be that prostitution, which ranked low- vey was mainly about addiction problems. est among men and third lowest among However, this interpretation is contradict- women in 1995, has “moved up the scale”, ed by the fact that alcohol problems, the which may be due to the relatively large misuse medical drugs, gambling problems media attention during the past decade to and tobacco all turn up at the end of the the issue of “trafficking” and to the change list. As claimed above, another dimension in the legislation in this area in 1998, that that may be important for the interpreta- made buying sex a crime. In addition, tion of respondents’ images of different cannnabis, which was not distinguished addictions is their personal acquaintance from other narcotic drugs in the previous with various substances and activities. survey, may in reality have moved down- Albeit these relations will be the object ward on the severity scale. One might per- of future, separate analyses, this suggests haps also have expected that the changes that the low ranking of tobacco use as a so- in alcohol policy that followed Sweden’s cietal problem should be seen in the light accession to the EU in 1995, and the sub- of the fact that tobacco dependence seems sequent, rapid and large increase in con- to be surrounded by less stigma than other sumption (e.g. Leifman 2004; Boman et addictions (cf. above). In addition, since al. 2007) should have reflected in alcohol respondents were explicitly asked to rank problems moving “up the scale”. That this the severity of the fifteen issues as societal is not the case may partly be explained by problems, it is also important to consider most respondents making a clear distinc- the way in which such problems are of- tion between “normal drinking” and “al- ficially defined and handled, which may cohol problems”, partly by the fact that influence people’s attitudes towards espe- the recent increase in drinking seems, un- cially such issues with which they have like the simultaneous increase in Finland, little personal experience. Thus, respond- so far to have had fewer negative conse- ents’ ratings of the severity of narcotic quences than might have been expected drugs should most likely to a large extent (e.g. Norström & Ramstedt 2006). be seen as reflections of the strong official stance in Sweden against any use of these Perceived severity of various addictions at drugs, and the fact that objections to this the individual level policy have been more or less banned in Another crucial aspect of the “dangerous- the media (cf. Note 1). ness” of various substances or activities Although the two studies are not totally concerns the risk for individual users of comparable, it is also fairly obvious that “getting hooked”. To get a grasp of this opinions have not changed much since aspect respondents were asked, using a 382 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 6. 2 0 0 9 . 4
  11. 11. four-point scale9 to rate the perceived risk ranging from “no or very little probability” of developing a dependence or misuse if to “very high probability”. Table 5 shows experimenting with each of the nine sub- the ranks and mean ratings for the risk of stances or activities included in the study. getting hooked on, and the overall options As touched upon in the introduction, one of recovery from, the nine addictions in of the reasons for setting the study up was questions. For all addictions, except snuff, the experience that people’s success in try- the overall options of recovery meant the ing to recover from various addictions is rated probability of finding a path out with influenced not least by whether they are treatment (see further below). met with trust and support or with dis- As can be seen, there is, by and large, trust and repudiation by others – family an inverse relation between respondents’ and friends as well as professionals. Thus, views on which addictions it is easiest respondents’ “change optimism” in this to “get into” and “get out of”. Thus, the sense can be claimed to constitute another “hard” drugs (heroin, amphetamine, and crucial aspect of the perceived severity at cocaine) are not only seen as a large so- the individual level of a certain addiction. cietal problem, but also as highly addic- To asses this, respondents were asked to tive and very difficult to quit. At the other rate the perceived probability for recovery end of the scale, drinking, gambling, and from various addictions – with and with- snuff are seen as much less dependence out the help of professional or formally or- generating, and as relatively easy to quit, ganised treatment – including mutual help should an addiction develop. Cannabis groups such as AA, NA etc. These prob- and medical drugs are allotted middle abilities were rated on a five-point scale, ranks in all these respects, whereas ciga- Table 5. Overall perceived risk of becoming addicted and overall “change optimism” (scales 1–5; N = 1.098) Perceived risk Change optimism Problem with Rank m (s) Problem Rank m (s) Heroin 1 4,26 (0,97) Heroin 9 3,52 (1,16) Cocaine 2 4,17 (0,97) Cocaine 8 3,57 (1,13) amphetamine 3 3,99 (1,00) amphetamine 7 3,67 (1,04) Cannabis 4 3,64 (1,09) Cannabis 6 3,83 (0,98) Cigarettes 5 3,18 (1,14) medical drugs 5 3,84 (0,96) medical drugs 6 2,96 (1,07) Gambling 4 3,90 (0,92) snuff 7 2,78 (1,06) Cigarettes 3 3,98 (1,01) Gambling 8 2,65 (1,02) alcohol 2 3,98 (0,88) alcohol 9 2,59 (0,98) snuff 1 4,02 (1,00) mean 3,36 (0,72) mean 3,82 (0,70) note: Regarding responsibility for causing the problem, differences between subsequent pairs of problems are significant except for cigarettes – gambling, cannabis – amphetamine, and cocaine – heroin – alcohol (paired samples t-tests, p < .05); regarding responsibility for solving the problem, all differences between all subsequent pairs of problems are significant. NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 26. 2009 . 4 383
  12. 12. rettes are rated as moderately addictive, As shown in the figure, the perceived although smoking is judged as fairly easy “dangerousness” at the societal and indi- to quit. The small standard deviations also vidual levels seem to converge regarding indicate that there is relatively good agree- “hard” narcotic drugs and to some ex- ment between respondents both concern- tent cannabis, in the sense that these ad- ing the high risk of getting “hooked” on dictions are judged to be the most severe the “hard” drugs and the fairly low risk ones on both levels. However, gambling, of getting “hooked” on alcohol and gam- and the misuse of medical drugs and al- bling. Concerning rated options on finding cohol are all seen as more severe societal a path out of the addiction, standard devi- problems than tobacco use, although the ations indicate fairly good agreement that latter is judged to be stronger dependence it is relatively easy to successfully treat generating. Whereas respondents’ ratings drinking and to some extent gambling of the “addictive potential” of various sub- problems, whereas opinions seem to be stances and activities seems to fit fairly more divided regarding the same options well with what at least some researchers when it comes to “hard” narcotic drugs. have claimed (cf. West 2007), the ratings of their severity to society fit rather poorly Harm to whom? Perceived severity at the with what is known about e.g. the preva- societal and individual levels compared. lence and aggregate costs to society of vari- How is the perceived dependence-gener- ous such problems in Sweden (cf. Note ating capacity of various substances/be- 3). This strengthens the assumption that haviours related to how serious they are these ratings to a large part represent the judged to be as societal problems? To shed official stance on and the prevailing media light on this relation, the two ratings have 10 image of these problems, and that there is been brought together in Figure 1. a strong relation between the perceived „ Severity to society Individual risk to get hooked „ 10 9 8 7 6 5 4 3 2 1 Tobacco Gambling Medical Alcohol Cannabis Other narc. drugs drugs Figure 1. Severity at the societal and individual level (standardized ratings, 1–10) 384 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 6. 2 0 0 9 . 4
  13. 13. “strangeness” of various problems and the of tobacco use, the figure also indicates extent to which they are seen as dangers to that Sweden is rather far from being the society (cf. above; Christie & Bruun 1985). type of “self-change friendly society” that for example Klingemann (2005; Klinge- Change optimism and confidence in mann & Klingemann 2007) has argued for. treatment Rather, respondents’ views of the options As already noted, respondents were asked for self-change seem far more pessimistic to rate the probability for recovery from the than topical research about the prevalence nine addictions both without professional or for such solutions can be claimed to give formally organised help (“self-change”) and grounds for (Klingemann & Sobell 2007; with such help. Based on these rankings, Blomqvist et al. 2007). In fact, if the scale Figure 2 shows the perceived probability used in the figure should be transformed for “self-change”, and what treatment is as- to a percentage scale, it would mean that, sumed to be able to add in finding a solution. besides tobacco dependence, the rated As can be seen, the perceived options probability for self-change would vary be- to quit without professional or formally tween about twenty (heroin addiction) and organised help are high concerning tobac- slightly below fifty per cent (gambling). co use and to some extent gambling, and This should be put in the perspective of lowest concerning “hard” narcotic drugs topical research, indicating that the large of which few Swedes have personal expe- majority of recoveries from dependence rience (cf. Note 3 and Table 3). A closer not only on alcohol, but also on most nar- analysis reveals that only eleven percent cotic drugs, take place outside the treat- of the respondents believe that a heroin ment system (e.g. Blomqvist 2009). addict has any chance at all of finding a On the other hand, the figure also indi- resolution on her/his own, whereas the cates that this pessimism is to a large ex- same proportion for snuff use is close to tent compensated for by a strong general seventy-five per cent. With the exception confidence in the effectiveness of addic- 5 Self-change With treatment 4 3 2 1 Snuff Cigarettes Gambling Alcohol Cannabis Medical Amphe- Cocaine Heroin drugs tamine Figure 2. Change optimism with and without treatment (scales 1–5) NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 26. 2009 . 4 385
  14. 14. tion treatment, where type of addiction tion treatment, further comparisons with does not seem to matter much. Thus, studies in countries with less developed whereas the probability for a successful welfare ambitions may resolve this issue outcome of treatment of alcohol prob- with time. The fact that both Canadian and lems, using the transformed scale, would Swiss respondents (Cunningham 2009; be set at about seventy-five per cent, the Klingemann & Klingemann 2007) are corresponding probability for treatment clearly more optimistic about the options for amphetamine misuse would be set at for self-change from problematic cannabis almost seventy per cent. The figure also use than Finns (Koski-Jännes et al. 2009) shows that the relative importance of ex- and Swedes, and the fact that Finns rate pert help, i.e. the difference between the alcohol as a much larger societal problem rated probabilities for recovery with and than Swedes13, certainly shows that views without treatment, is consequently judged and attitudes differ between countries and to be larger for the “hard” drugs (heroin, contexts. In sum, however, respondents’ amphetamine, and cocaine) than for e.g., ratings on the severity, “addictiveness”, addiction to alcohol and cannabis , and to 11 and options to “get out of” various addic- be more ore less non-existent for depend- tions, rather clearly suggest that the less ence on tobacco (and even negative for common and familiar – to the common snuff). By and large, this may be said to citizen or in mainstream culture – a habit reflect the current situation in the addic- or a substance is, the “worse” – in most tion field in Sweden, where more energy aspects – it is judged to be. and, in relative terms, more resources are spent on treating a rather limited number Q Who is responsible? The moral aspect of drug addicts, than on treating a much As mentioned, drawing on the work of larger number of problem drinkers and al- Brickman et al. (1982) respondents were cohol misusers (cf. Blomqvist 2002; Mel- also asked to what extent they ascribed berg 2006), and where treatment of smok- the responsibility for causing, as well as ers and snuff users is rare12. for solving the nine addiction problems to It is not self-evident how to interpret re- the single individual. The answers to these spondents’ high confidence in addiction two questions are displayed in Table 6. treatment. Potentially, it could be seen As shown by the high means in the first as an indication of a generalised strong column of the table, addiction problems trust in (or at least nostalgia concerning) seem largely to be seen as the individual’s the benevolent welfare state (cf. Rothstein own fault. At the same time, there is a 1994) and/or as mirroring the promises of tendency that the more severe an issue is increasingly “effective cures” (mainly of a rated to be as a societal problem (cf. Ta- medical kind) that are recurrently report- ble 4), the less likely the individual suf- ed by the media (cf. Note 4). Whereas no ferer is to be blamed for having caused the final conclusions can be drawn from the problem. However, there seems to be two fact that studies in Finland (Koski-Jännes exceptions to this. Thus, the group of ad- et al. 2009) and Canada (Cunningham dicts who are to the greatest extent seen 2009) show a similar strong trust in addic- as “victims” are those addicted to medical 386 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 6. 2 0 0 9 . 4
  15. 15. Table 6. Degree to which the individual is deemed responsible for causing and solving the problem (scale 1– 4; N = 1.098) Causing Solving Problem with Rank M (s) Problem with Rank M (s) snuff 1 3,33 (0,76) snuff 1 3,64 (0,58) Cigarettes 2 3.27 (0,76) Cigarettes 2 3,60 (0,62) Gambling 3 3,25 (0,77) Gambling 3 3,22 (0,74) Cannabis 4 2,91 (0,84) alcohol 4 3,09 (0,63) amphetamine 5 2,90 (0,88) Cannabis 5 3,01 (0,72) Cocaine 6 2,89 (0,89) amphetamine 6 2,91 (0,77) Heroin 7 2,87 (0,90) Cocaine 7 2,86 (0,81) alcohol 8 2,87 (0,75) Heroin 8 2,84 (0,82) medical drugs 9 2,54 (0,87) medical drugs 9 2,77 (0,83) mean 2,97 (0,61) mean 3,11 (0,56) note: Regarding responsibility for causing the problem, differences between subsequent pairs of problems are significant except for cigarettes – gambling, cannabis – amphetamine, and cocaine – heroin – alcohol (paired samples t-tests, p < .05); regarding responsibility for solving the problem, all differences between all subsequent pairs of problems are significant. drugs. In addition, problem drinkers are necessarily imply that the majority view is on the average blamed less for their condi- that society is not obliged to offer help, but tion than are users of at least cannabis and rather that the main responsibility for solv- amphetamine. A possible explanation is, ing the problem lies with the individual in the first case, that the misuse of medi- client or patient, whether she or he is in cal drugs is seen to have been “created” by treatment or not. Thus the majority stance doctors or by the health care system who should probably be interpreted according should therefore also take responsibility, to the common view that you cannot help whereas in the other case the results might someone to quit an addiction, unless she be a reflection of repeated claims – from or he really wants to do so. The rankings different parties with differing agendas14 – of various addictions are again, with the that alcoholism is a “disease”. partial exception of the misuse of medical As regards the responsibility for solving drugs, clearly related to their perceived an addiction problem, respondents seem “dangerousness” as social problems, mak- to put even greater pressure on the single ing the individual the more responsible individual, a fact that could at the same for the solution the less severe and/or the time and in some sense be said to refute less risky a certain substance use or activ- the assumption of a widespread disease ity is considered to be. However, the main notion of addiction. Since this question impression from the data shown in Table 6 asked whether the responsibility for solv- is that the blame for developing an addic- ing a problem should rest primarily with tion, as well as the responsibility for find- the individual or society, it should be ing a path out is to a large extent attributed pointed out that the high means do not to the single individual. NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 26. 2009 . 4 387
  16. 16. Q What kind of problems? in Table 4. As can be seen in Table 7, a Although the choice of dimensions and four-factor solution in this analysis result- aspects in trying to capture the prevail- ed in a set of quite distinctive dimensions, ing popular images of various addictions, explaining a fairly large proportion of the has – as already mentioned – by neces- total variance. sity been somewhat arbitrary, the analyses The first factor can clearly be interpret- presented so far could be claimed to have ed to represent an addiction or misuse given a reasonably coherent and meaning- problems factor with high loadings for ful result. There are, however, still some the “traditional” addictions, as well as for aspects that might be added to provide a gambling and to some extent prostitution. more comprehensive understanding of the The second factor can be interpreted as a ways in which the percieved characters “social/political” factor, with high load- of various addictions diverge. One means ings for issues that concern social and eco- for such an understanding would be to ex- nomic justice, gender and ethnic discrimi- plore how respondents’ perceptions of the nation, and environmental protection. severity of various addictions are connect- The third factor stands out as a relatively ed to each other, and to their perceptions distinctive “crime factor” with high load- of the severity of other social problems (cf. ings for all of the, rather different types of, Hübner 2001). To this end, a factor analy- crimes that were included in the question. sis was conducted, using the data shown Finally, the analysis discerns “tobacco Table 7. Factor analysis of ratings of various societal problems. Principal componentsa Variables: Rotated factor matrix Cannabis problems . 812 .059 .382 .065 other drug problems . 786 .124 .398 .032 misuse of medical drugs . 686 .415 .203 .203 Gambling problems . 639 .414 .015 .367 alcohol problems . 605 .151 .240 .417 Ethnic discrimination . 195 .762 .155 .123 Poverty . 280 .762 .243 .031 Environmental damage .098 .580 .354 .257 Gender inequality/discrimination -.037 .575 .144 .065 Prostitution .524 .572 .144 .065 large wage differences .009 .562 ..206 .539 violence crimes .303 .268 .741 -.018 Property crimes .395 .011 .739 .201 Financial crimes .250 .353 .502 .086 tobacco use .337 .068 .086 .824 Eigenvalue 6.90 1.48 1.01 .86 Explained variance b 46.01 % 9.89 % 6. 75 % 5.71 % a) varimax rotation; b) total explained variance: 68. 4 % 388 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 6. 2 0 0 9 . 4
  17. 17. use”, as an own – but as also indicated in should be handled. According to the Table 4, not particularly important – di- “moral model” people are held responsi- mension in Swedes’ apprehension of so- ble for creating a problem as well as capa- cial problems. ble of and responsible for solving it, which It can be noted that a similar analy- means that help essentially takes the form sis conducted on data from the above- of punishments and rewards. According to mentioned Nordic survey (Hübner 2001), the “treatment model” (or perhaps rather yielded three dimensions, represent- the “expert model”) on the other hand, ing a “moral”, a “social/political”, and a problems are seen as caused by forces “crime” factor, where smoking problems beyond the subject’s own control, and as were grouped together with alcoholism, curable only by professional experts. By drug abuse, and prostitution in the first and large these two models correspond factor. The main difference is thus that to- to the “badness-illness” dichotomy that bacco use here appears as a separate fac- has often been used to illustrate different tor, something that may to some extent be ways of looking at addiction problems (cf. due to the fact that the two studies used Mäkelä 1980). To this common figure of partly different items and different word- thought, the authors add the “enlighten- ings (cf. above)15. In sum, this analysis can ment model”, according to which people be claimed to suggest that the public dis- are blamed for having caused their prob- course on addiction problems in Sweden lems, but are at the same time seen as inca- is largely separated from the political dis- pable of solving them. As a consequence, course, and that a distinction is also made, the subject’s best hope for a solution lies even if the border is somewhat blurred, in submitting to a higher moral authority between “addictions proper” (most clearly that can help her or him to overcome their represented by heroin and other “hard” destructive impulses. Since this author- drugs) and “bad habits” (most clearly rep- ity could obviously be both of a spiritual resented by snuff use and smoking). and a profane character, “fostering” might Another way of trying to summarise the in fact be a better name for this model (cf. perceived “character” of various addic- Blomqvist 1998b16). Finally, in the “com- tions would be to apply to them the four pensatory model”, people are seen as “models of helping and coping”, deline- subjected to certain handicaps or obsta- ated by Brickman’s and colleagues (1982). cles imposed on them by the situation or As already mentioned, these authors claim by nature but as basically capable of and that the attribution of moral responsibility responsible for managing their own lives. for human and/or social problems involves Accordingly, they may be entitled to cer- not one but two basic dimensions, namely tain help, given on their own terms, and the question of blame (“who caused he aimed at empowering them to solve their problem”) and control (“who is capable of own problems and manage their own lives and responsible for solving the problem”). on the same terms as other citizens. By combining these two dimensions, they Previous research suggests that the dis- arrive at what they refer to as four “mod- tinctions suggested by Brickman et al. els” of how a certain problem could and (1982) may be more fruitful when applied NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 26. 2009 . 4 389
  18. 18. in e.g., overarching socio-historical analy- responsibility for doing so. Therefore, the ses (cf. Blomqvist 1998b), than in clinical rated responsibility for developing various contexts (e.g. West & Power 1995), and it is addictions has here been combined with not self-evident how the four models could the rated options for “self-change” from and should be operationalised, using the the same problems17. The resulting distri- survey questions. One option would be to bution of preferred “models for helping dichotomize the two questions on respon- and coping” over the nine addictions is sibility for causing and solving various shown in Figure 3. problems, the answers to which are shown When interpreting this figure, it should in Table 3. However, as indicated by the first be noted that with the operationali- same table, that would obviously mean sation used, it follows from respondents’ that a large majority of the respondents ratings of the individual as largely respon- would be claimed to apply the “moral” sible for acquiring an addiction (Table model to all addictions, a result that does 6), that the “moral” and “enlightenment/ neither stand out as particularly meaning- fostering” models are overall more com- ful nor as particularly informative in the monly endorsed than the “compensatory” present context. Further, as already indi- and “treatment/expert” models. This said, cated, the wording of the question on re- it should be noted that respondents seem sponsibility for solving various problems to apply different models for different ad- was not ideal, asking respondents to rate dictive substances or activities. At one end to what extent this responsibility should of the scale, tobacco use (snuff and ciga- be put on the individual or on society. Fi- rettes), and to some extent gambling, are nally, the “control” dimension in the work predominantly seen as “moral concerns” of Brickman et al. (1982) seems on closer or “bad habits”, in the sense that both scrutiny to be at least as much about the starting and terminating these activities capacity to solve a problem as about the is predominantly seen as the individual’s % Moral Enligtenment Treatment Compensatory 80 70 60 50 40 30 20 10 0 Snuff Cigarettes Gambling Alcohol Cannabis Medical Amphe- Cocaine Heroin drugs tamine Figure 3. Preferred model of “helping and coping” with various problems (%) 390 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 6. 2 0 0 9 . 4
  19. 19. own business. At the other end of the scale tion here. The fact that the enlightenment is the use of “hard” drugs (heroin, cocaine, or “fostering” model is the one most en- and amphetamine), where opinions are dorsed by respondents concerning both al- more divided, but where the “enlighten- cohol and narcotic drugs may partly have ment” and “treatment” models, both im- to do with the growing popularity of, and plying that the individual needs external media attention to, AA, NA and other mu- help to overcome her/his predicament, tual help groups (cf. Note 4), partly with and that the addict should be seen either the fact that coercion has always been – as a “sinner” or a “crook” who needs help and is probably been seen by most – as an to mend his/her ways, or a powerless “vic- integral part of society’s efforts to counter tim” who needs expert treatment, clearly addiction problems. The relative unpopu- predominate. In a “middle group” are ad- larity of the “treatment (or expert) model”, dictions to alcohol, cannabis and medi- in spite of respondents’ strong confidence cal drugs, where opinions are even more in the treatment system (see Figure 2), can spread, but where the “compensatory” perhaps be seen in the same light. model gets more “votes” than it gets with In sum, the results presented above may regard to the “hard” narcotic drugs. be claimed to hint that respondents down- The fact that tobacco dependence stands play the severity of and risks with hab- out from the other addictions as being al- its and conditions with which they have most exclusively seen through the eyes of some – direct or indirect – personal experi- the “moral model”, is in line both with the ence and/or which are seen as part of main- fact that this seems to be a fairly common stream culture, whereas problems that are and mundane experience (Table 3), as well more uncommon or “alien” are perceived as with the fact that tobacco use is ranked as more severe or dangerous. In addition, low as a societal problem (Table 4), and the former problems seem to be regarded as is singled out as an “own” dimension in more “private” and to a larger extent as the the factor analysis (Table 7). In addition, individual’s own business, whereas users it suggests that respondents’ assessments of “hard” drugs in particular are seen as be- of the severity and character of tobacco ing both a threat to society and as victims of use pay little attention to matters such as powers stronger than themselves. mortality, morbidity, and harm to others. Together, these data rather suggest that Discussion smoking and snuff use, in spite of recur- This article presented analyses of data rent campaigns pointing to tobacco as a from a survey aimed at capturing prevail- large public health problem, are predomi- ing popular images of nine different ad- nantly seen as “private” as opposed to dictions in contemporary Sweden. The either moral or political concerns in con- results show that these images vary greatly temporary Sweden. between different addictions, and in a fair- The figure also indicates that legal sub- ly consistent way. These differences seem stances or activities are to a greater extent to have little to do with known facts about seen as moral matters than are illegal sub- either the prevalence of different addic- stances – cannabis being a partial excep- tion problems, their harmful and hazard- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 26. 2009 . 4 391
  20. 20. ous effects on user’s health and wellbeing, the addiction treatment system and its po- or their “costs” to society in the form of tential benefits. One possible explanation premature deaths, health care expendi- may be that “treatment” of these problems ture, lost years in work life, or potential is not mainly thought about in terms of, harm to others. Rather, the popular images “expert” or “professional”, specific inter- of various addictions seem to a large extent ventions, but as much – in line with what to reflect beliefs of a rather “ingrown” and the media tend to pay attention to in this stereotypical character. This is true above area – in terms of AA, NA or other mutual all as concerns respondents’ images of help groups, backing up people who have the “hard” narcotic drugs (amphetamine, made a decision to quit, and/or in terms of cocaine, and heroin), which are clearly coercive care, exerting external control to in line with the basic conceptions which make them do so. have been used to justify Sweden’s tradi- Since “self-change” is today known to tionally very restrictive drug policy, de- be the most common path out of many ad- picting narcotic drugs as extremely dan- dictions (e.g., Klingemann & Sobell 2007), gerous and poisonous, with the capacity and since supportive and encouraging, al- to quickly enslave every user, and almost though not undemanding, social networks impossible to quit (cf. Bergmark & Oscars- have been found to be crucial in such proc- son 1988), a picture that has also recur- esses (e.g., Blomqvist 1999; 2002), it can rently been reproduced by the media (cf. be deemed unfortunate that so few of the Hübner 2001). At the other end of the con- respondents endorse what Brickman et al. tinuum are the images of some relatively (1982) term the “compensatory model”, mundane and familiar “habits” – smoking, which guarantees the individual the nec- using snuff, and to some extent gambling essary support, but without putting blame – the dangers and addictive character of on her/him for their distressing condition, which seem rather to be played down by and without expressing scepticism or dis- the respondents. In between come addic- trust. This is the more regrettable given tions to alcohol, cannabis, and medical that only a minority of the respondents drugs, about the severity and character of who had reportedly experienced an addic- which there seems to be less consensus in tion problem in someone close, actually popular thinking, perhaps due to the fact had offered any personal help. that rather divergent views on these issues It is also tempting to dwell on the fact have come to light repeatedly over the that dependence on smoking and snuff in years, also in the media (cf. Hübner 2001; particular are more often seen as “bad hab- Blomqvist 2004). its” than as “real addictions” or “diseas- The fact that respondents largely at- es”, and to relate this to the fact that smok- tribute the responsibility for the devel- ing has decreased substantially in Swe- opment of addictive problems, as well as den during the past two decades, largely the responsibility for solving them to the due to “rational” reactions to measures individual, may seem surprising, not least such as information on health risks, price considering the fact that survey answers policy and, in particular, rendering smok- reflect a generally strong confidence in ing more difficult and more expensive. 392 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 6. 2 0 0 9 . 4
  21. 21. Since earlier studies have shown that the with type of addiction, but also with vari- adoption of a “disease notion” of alcohol ables such as age, gender, socio-economic problems may in certain respects function status, and social context. as a self-fulfilling prophecy, one might To overcome these limitations, more wonder whether a de-stigmatisation and research will be needed. Further analysis wider acceptance of a view of substance of the data from the study presented here use problems as a “central activity” in the will focus on how respondents’ percep- subject’s way of life (Fingarette 1988) or as tions of various addictions relate to their “lifestyles leading to predicaments” (Drew personal addiction experiences, to socio- 1989), might not increase addicts’ options demographic factors such as age, gender, of cutting loose from their addiction (cf. ethnic background, educational level, and Blomqvist 1998a; Blomqvist & Cameron family situation, and to wider political- 2002). This may also have a bearing on the ideological inclinations and attitudes, as present new wave of “bio-medicalisation” well as to the stigma surrounding various of addiction problems, proclaiming these addictions. In addition, the issues under problems to be “diseases of the brain” (see, study in the present survey will be ex- e.g. www.hjarnfonden.se), a tendency that plored in further investigations, using may thus in a longer run not necessarily qualitative methods, in an attempt to cap- prove to be particularly productive to ad- ture more subtle aspects of prevailing con- dicts’ options for finding a path out. ceptions of addiction and how these con- However, it needs to be pointed out that ceptions have been formed. To get a better there are a number of study limitations grasp of how the “images of addiction” that imply that these conclusions should are influenced by various kinds of per- be regarded as tentative. First, the relative- sonal addiction experiences, such studies ly low response rate means that generalisa- should include not only lay people and tions need to be made with caution, even professionals, but also persons with past if attrition bias does not seem to be a major and present addiction problems (cf. Koski- problem. Secondly, as has already been Jännes et al. 2009). Finally, and consider- pointed out, a survey of this kind can only ing that similar research is ongoing in sev- “scan the surface” when it comes to peo- eral countries, cross-cultural comparisons ples’ conceptions and beliefs about vari- in this area offer, as already disussed, an ous addictions. For example, the way in interesting option. which this study was been conducted has Jan Blomqvist, Professor not left room for more nuanced statements Centre for social Research on alcohol and from the respondents, e.g. to the effect that Drugs, soRaD stockholm University the perceived risk of becoming addicted or sE-106 91 stockholm, sweden options for self-change may vary not only E-mail: jan.blomqvist@sorad.su.se NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 26. 2009 . 4 393
  22. 22. NOTES ween six and ten per cent (Leifman 2008). 1) Bergmark & Oscarsson (1988) use this term However, seen in a European perspective, to refer to a set of undisputed, and alleged- Swedish drug policy seems to have been ly undisputable, themes that they claim to less successful in keeping down “heavy” provide the unreflected basis for any debate drug abuse and drug-related mortality in on and public action targeting the drug particular (ibid.). Still, the use and misuse problem in Sweden. According to Hübner of narcotic drugs is uncommon in Sweden, (2001) this “doxa” has, by and large, also as shown by the fact that, since the turn been adopted by the media, thereby leaving of the millennium, past year prevalence little room in the public debate for oppo- of cannabis use has been estimated to less nents to the official Swedish drug policy, than 2.5 per cent, and the use of other based on zero tolerance. narcotic drugs to less than 1.5 per cent 2) Societal Images of Natural Recovery. This (ibid.) As for the misuse of medical drugs, study explored the confidence in “self- there are no reliable reports on illegal use change” from different addictions, based of drugs sold on prescription (which is on 30 “key informants” (representing probably not very common), albeit that the addiction professionals as well as “lay Swedish National Association for Helping therapists” and “common people”) in nine Misusers of Pharmaceutics (RFHL), claim large cities in seven different countries. that a quarter of a million Swedes are The Swedish part of this study, reported dependent on (illegal or legally prescribed) by Andersson et al. (2004), was led by such drugs. Finally, Jonsson et al. (2000) the present author. The results pointed to found that one and a half per cent of the considerable differences between various population over 15 years were present addictions, but also between settings, and problem gamblers, and that as many were between professionals and lay people. former problem gamblers. The highest 3) Regarding alcohol, less than 5 per cent of prevalence was found among the youngest the adult Swedish population are today men (ibid.). lifetime abstainers (Blomqvist et al. 2007), 4) By and large, Sweden has long spent more whereas slightly more than 10 per cent per-capita resources in care and treatment could at the time of the survey be charac- of alcohol and drug problems than most terised as “frequent binge drinkers” (Selin comparable countries. The main responsi- 2004). With regard to tobacco use, the bility for this care lies with the municipal proportion of daily smokers in Sweden Social Services, and has to a large extent decreased from 36 per cent of the men been focussed on social and psychosocial and 29 per cent of the women in 1980, to rehabilitation, although treatment for alco- 14 per cent of the men and 19 per cent of hol problems has largely been more “thera- the women in 2004, and has decreased peutic” in character, and treatment for drug further since (Lundquist 2007). At the same problems more aimed at re-socialisation time snuff use has increased, partly as a (Blomqvist 2004). However, in recent years, substitute for smoking, and 23 per cent of the quest for “evidence-based practice” the men and 4 per cent of the women were that has accompanied various attempts to daily users during 2004 (ibid.). As concerns make the public sector more rational and narcotic drugs, Sweden’s extremely restric- more cost-effective, has also given way tive policy in this area, making any use of for an increasing “bio-medicalisation” (cf. narcotics classified substances a punishable Blomqvist et al. 2009). This has become crime, has been fairly successful in keeping evident not least in the official rhetoric and youthful, recreational use on a low scale in the media, where more attention seems (Olsson 2009). For example, lifetime use of at present to be paid to “promising” phar- any narcotic substance among nine-graders macological treatments and to “disease- has during the past decades fluctuated bet- based” mutual help groups such as AA and 394 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 6. 2 0 0 9 . 4
  23. 23. NA, than to traditional psychosocial care. tic drugs” (than cannabis). Therefore, the In recent decades, with increased interna- individual risk to develop tobacco depen- tionalisation and increased Internet access, dence has been calculated as the mean risk new forms of gambling have appeared for cigarettes and snuff, and the risk to get and have become an integral part of the “hooked” on other narcotic drugs (“hard entertainment industry, including TV. At drugs”) as the mean risk for amphetamine, the same time, gambling problems have re- cocaine, and heroin. ceived increasing attention, and a number 11) Although paired t-tests showed these dif- of separate treatment facilities for such pro- ferences to be statistically significant for all blems have been established. There are also these addcitions (p < .05). a few specialised facilities for persons who 12) Except for the use of substitutes such as misuse medical drugs, although those enga- nicotine pills, chewing gums or plasters ged in these matters often claim this to be a (or, for that part, substituting cigarettes for “hidden” problem, more or less neglected snuff ). It should also be noted there is an by both the prescribing doctors and the increasing commercial launching of such media. Finally, smoking has been officially means. discussed largely as a health issue, and as 13) This may at least partly be explained by an economic burden to society, but seldom the Finnish “experiment” with lower taxes in terms of an individual “disease”. Ac- on liquor to counter increased private im- cordingly, the official strategy in this area – port, that lead to a rapid increase in alcohol which has been fairly successful (see Note mortality and alcohol related harm during 3) – has largely consisted in a combination the years before the Finnish survey was of health information (pamphlets, warning conducted in 2007. labels etc.), and campaigns and measures 14) Whether the assumptions about metabolic aimed at rendering smoking more difficult. or other physiological aetiological factors of Regarding snuff use, there has been some the popular disease model of the 1940s (cf. debate concerning potential health risks, Pattison 1976), AA: s concept of “spiritual but by and large, snuff has not been a big disease”, or topical claims of all kinds of issue neither to the authorities nor in the addictions as “brain diseases”. media. 15) In addition it can be noted that in a three- 5) Although not necessarily statistically cor- factor solution using the present data, rect in all aspects, paired t-test was consis- “hard” drugs and cannabis got grouped tently applied to all ratings to test whether together with all types of crime in a “moral- the mean rating of a certain problem was legal” factor, the “social/political” factor statistically different from its next lower or looked much the same as in the four-factor higher counterpart. solution, and tobacco got grouped together 6) It should be noted thought that the official with alcohol and gambling in what could drug discourse in Sweden does not make be seen as a “bad habits” factor. this distinction between e.g. cannabis and 16) In this article, ”guilty” vs. “victim”, and “harder” drugs “capable” vs. “incapable” are distinguis- 7) In this study, “crimes against the person” hed as the two basic dimensions of the (murder, rape a.s.o.) ranked highest before Brickman et al. model, and “discipline” or “family violence” and “drug abuse”. “fosterage” and “conversion” are discus- 8) In places seven and nine out of ten respec- sed as the implications in practice of the tively. “enlightenment” model. 9) Transformed in the analysis, for the sake of 17) Responsibility entirely or mostly on comparability, to a five-pont scale. the individual vs. entirely or mostly on 10) It should be observed that severity on circumstances; and no or relatively low vs. the societal level was, except for alcohol, moderate to very high probability for “self- gambling, medical drugs, and cannabis, change”. only rated for “tobacco” and “other narco- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 26. 2009 . 4 395