Objective. The purposes of this article are to inform pediatricians and other health professionals of key contextual risk factors that elevate black and Hispanic Americans' likelihood to use substances and to discuss selected protective mechanisms that may shield members of these populations against substance use.
Method. The article selectively reviews the literature on the epidemiology, etiology, and consequences of alcohol and other drug use among white, black, and Hispanic adults and youth.
Results. The extant research suggests that historical and contemporary racialized practices and ideologies influence racial/ethnic differences in substance use outcomes, both directly and indirectly, through their influence on the communities in which people of different racial/ethnic groups are placed, through their influence on the structure and process of people's interpersonal relationships, and through the impact that they have on individuals' psychology and behavior.
Conclusions. Although the emphasis of pediatricians' and many other helping professionals' work focuses on individuals and individual-level behaviors, these behaviors can only be properly examined, diagnosed, and treated when they are understood in light of the community and societal contexts in which they occur.
As a result of America's rapidly changing demographic profile, the populations that pediatricians and other helping professionals serve are becoming increasingly diverse in their racial and ethnic composition. Today, there are 264 million Americans; 82% of them are white, 12% are black, and 10% are Hispanic. By the year 2050, it is projected that 75% of America's 393 million citizens will be white, 15% will be black, and 25% will be Hispanic.1The expected rapid growth of America's black and Hispanic populations is linked to the fact that they are significantly younger than their white counterparts (median age, 29 and 26 years, respectively, vs 35 years for whites). Nationally, more than one third of the black (34%) and Hispanic (36%) populations are younger than 18 years of age, compared with only one quarter (24%) of the white population. Given the expected future growth of the black and Hispanic populations and the fact that black and Hispanic young people already make up the majority of the youth population in many urban centers, the health of America's nonwhite youth is of increasing importance to pediatricians and to the nation as a whole.
In addition to their relative youthfulness, America's black and Hispanic populations share a number of other demographic commonalities that have important implications for helping professionals. For example, relative to their white counterparts, black and Hispanic children, youth, and families are more likely to be poor, headed by a single parent, unemployed, to lack health care and to be concentrated in crowded urban environments that are detrimental to their mental and physical health. Racial and ethnic differences in poverty, and its associated personal and community conditions, often result in racial and ethnic differences in exposure and vulnerability to risk for a host of social problems, one of the most pressing being substance abuse and its sequelae.
The abuse of alcohol, tobacco, and other drugs has been identified as a cause of nearly 500 000 premature deaths in America annually.2 In addition to its cost in human life, alcohol and other substance abuse has been found to relate to motor vehicle crashes, violent crimes, a variety of physical maladies, domestic violence, child abuse, and numerous other social problems.3 In view of the widespread use of licit and illicit drugs, alcohol, tobacco, and other drugs affect virtually every person in America in some way. Nevertheless, the cost that substance abuse exacts from Americans is not distributed equally across the population; rather, its impact is experienced disproportionately by black and Hispanic adults, families, and children.
Research that identifies empirically the risk factors for racial/ethnic differences in alcohol and other substance use and related problems is sorely lacking. Although there is a large and growing body of research on intrapersonal and interpersonal risk factors for substance use, recent reviews of the literature4,,5 have generally ignored racial/ethnic differences in substance use and racial/ethnic differences in the macrolevel risk factors to which nonwhite populations are disproportionately exposed. Accordingly, the purposes of this article are to inform pediatricians of some of the key contextual risk factors that might elevate black and Hispanic Americans' likelihood to use substances and to discuss selected protective mechanisms that may shield many members of these populations against substance use. Before addressing these broader issues, however, the article reviews briefly the epidemiology of alcohol and other drug use and related consequences among white, black, and Hispanic adults and youth.
RACIAL/ETHNIC DIFFERENCES IN THE EPIDEMIOLOGY OF ALCOHOL USE AND ABUSE
Data from recent national surveys of secondary students indicate that lifetime, annual, 30-day, and heavier prevalence of alcohol and other drug use is generally higher among Hispanic 8th graders than among black and white 8th graders; by 10th grade, white and Hispanic students' alcohol and other drug prevalences are more comparable. By 12th grade (when there has been significant dropping out among Hispanic students) white students' prevalences typically match or exceed those of Hispanic students, whereas black students' use remains lower than that of the other two groups.6–9 For example, 30-day alcohol prevalences are 32%, 25%, and 19% among Hispanic, white, and black 8th graders, respectively.10 By 10th grade, white and Hispanic students' alcohol prevalences are identical (41%), whereas black students' prevalence (28%) is lower than that of the other groups. Among 12th graders, 55% of white students, 49% of Hispanic students, and 35% of black students report using alcohol in the last 30 days. The same general pattern of racial/ethnic differences by grade level differences exist in binge drinking (ie, having 5 or more drinks in a row in a single sitting in the last 2 weeks) and in the prevalence of drunkenness.
Among adults, recent national data indicate that annual and current alcohol prevalences generally are highest among whites, at an intermediate level among Hispanics, and lowest among blacks.11,,12 For example, among adults 18 to 25 years of age, the white, Hispanic, and black 30-day prevalences are 65%, 50%, and 45%, respectively. Among 26- to 34-year-olds, 66% of whites, 56% of Hispanics, and 55% of blacks reported any alcohol use in the last 30 days. For Americans 35 years of age and older, the 30-day alcohol prevalences were 52% for whites, 47% for Hispanics, and 36% for blacks. In general, the prevalence of heavy drinking among white, black, and Hispanic adults is comparable with their patterns of 30-day use. It should be noted, however, that there are substantial gender differences in alcohol use patterns, with the within-racial/ethnic group differences being particularly large for black and Hispanic men and women. For example, data from the 1992 National Alcohol Study indicate that 28% of white men, 35% of black men, and 22% of Hispanic men report that they abstained from any alcohol use in the year before the survey. Among women, only 36% of white women abstained, compared with 51% of black women and 48% of Hispanic women. On the other end of the drinking spectrum (5 or more drinks, in a single sitting, once a week or more) Hispanic males had the highest prevalence (23%), followed by black males (15%) and white males (12%). Among females, heavy drinking prevalences were considerably lower, with 3% of white females, 5% of black females, and 3% of Hispanic females reporting alcohol use at this level. Trends in alcohol use from 1984 to 1992 suggest that black and Hispanic drinkers who drank heavily in 1984 were more likely than white drinkers to still be heavy drinkers in 1992, that there were greater numbers of blacks and Hispanics than whites who became heavy drinkers during the period, and that the average number of drinks taken among heavy drinkers was generally higher among blacks and Hispanics than among whites, with these differences being particularly prominent among males.13
Relatively high levels of abstinence, coupled with patterns of heavy, sustained use among blacks and Hispanics who do drink, is consistent with the notion that there are “two worlds” of minority alcohol use, a relatively large abstaining and light drinking world, and a much smaller, heavy drinking world.14 This “two worlds” phenomenon may help to explain, at least in part, why black and Hispanic Americans experience higher levels of alcohol-related problems than their white counterparts, although their overall alcohol prevalence rates are comparable with, if not lower than, those of whites. The next section describes the nature and magnitude of racial/ethnic differences in alcohol-related problems and consequences in greater detail.
RACIAL/ETHNIC DIFFERENCES IN THE CONSEQUENCES OF ALCOHOL USE
Black and Hispanic youth and adults disproportionately experience a variety of negative mental, physical, and social consequences of alcohol use, although their levels of use often are comparable with, or even lower than, those of white Americans. For example, a large state-wide study of New York 7th- to 12th-grade students found that the average number of alcohol-related problems black and Hispanic drinkers experienced was higher than the number experienced by white drinkers, although black and Hispanic youth were less likely than were white youth to drink or to be heavy drinkers.15 The findings for black students who drank were particularly striking; these students experienced the highest average number of alcohol-related problems although they consumed the least amount of alcohol.
Similarly, among adults, there are significant racial/ethnic differences in alcohol-related mortality, morbidity, dependence, and negative social consequences, despite similar patterns of use. For example, relative to white people, black people disproportionately suffer many physical consequences of alcohol abuse, including cirrhosis of the liver, esophageal cancer, hypertension, obstructive pulmonary diseases, severe malnutrition and fetal alcohol syndrome.14 For many alcohol-related causes of death other than cirrhosis, Hispanics have been found to have similar or lower mortality rates than whites.3 One important exception to this general conclusion is the finding that the mortality rate among Hispanics from alcohol-related motor vehicle crashes exceeds that of whites and blacks.16
Beyond mortality, a series of recent studies suggest that black and Hispanic drinkers experience significantly higher levels of negative social consequences and a greater number of dependence-related problems than do white drinkers.11 The dependence-related problems that past research has examined include admission to public substance abuse treatment centers, the salience of alcohol seeking behavior, relief drinking, impaired control and symptoms of tolerance and withdrawal; the social consequences include financial problems, belligerence, legal problems, health problems, spousal problems, problems with other people, and job-related problems.11,,14,17 Longitudinal analyses of racial/ethnic disparities in alcohol-related problems suggest that relative to whites, the experience of problems is more chronic among blacks and Hispanics, that there has been a greater increase in the percentage of blacks and Hispanics who experienced alcohol-related problems, and that the magnitude of the racial/ethnic disparities in several of the problems actually have increased over time.18
In summary, although patterns of alcohol and other drug use do not differ greatly across racial/ethnic groups, there are significant racial/ethnic disparities in the experience of problems and negative social consequences associated with the use of alcohol and other substances. Although the disproportionate experience of negative alcohol-related consequences among blacks and Hispanics has been reliably established, explanations for these findings are limited. Most research that seeks to explain racial/ethnic differences in substance use tends to focus on individual and interpersonal risk factors. What I suggest below, however, is that many of the racial/ethnic disparities in alcohol and other drug use patterns are attributable to racial/ethnic differences in socioeconomic status (SES) and to contextual level risk factors to which black and Hispanic Americans are disproportionately exposed.
RACIAL/ETHNIC DIFFERENCES IN RISK FACTORS FOR ALCOHOL AND OTHER DRUG ABUSE
There is a large and growing body of research on the risk factors and correlates of alcohol and other drug use and problems.7,,9 These risk factors can be categorized into at least three broad domains: individual factors, interpersonal factors, and contextual factors. Individual-level risk factors include genetic predisposition, temperament, and personality characteristics such as sensation-seeking and positive attitudes toward and beliefs about substance use; interpersonal risk factors include substance use among family members and friends. Key contextual factors include laws and norms favorable to substance use, the availability of substances, and neighborhood poverty and disorganization.9 As noted above, most empirical research on racial/ethnic differences in alcohol and other drug use has focused on individual and interpersonal risk factors as key explanators for racial/ethnic subgroup disparities in use and problems. More recently, however, researchers have hypothesized and begun to test empirically models that suggest that much of the racial/ethnic disparity in heavy substance use and the disproportionate experience of substance-related problems are linked to: 1) racial/ethnic differences in various indicators of SES; and 2) racial/ethnic differences in exposure to contextual-level risk factors.
There are substantial racial/ethnic differences in virtually every measure of SES including income, employment, poverty, net worth, and return on educational investment. In short, relative to white Americans, black and Hispanic Americans have lower incomes, are more likely to be unemployed, have less wealth, receive less pay for equal years of education, and are much more likely to live in poverty.19 For example, only 11% of white Americans live at or below the federal poverty level, compared with 28% of black Americans and 29% of Hispanic Americans. For children younger than age 18, the race gap in poverty rates is even greater, with 16% of white children living at or below poverty, compared with 40% of black and Hispanic children.1 Given the fact that extreme economic deprivation has been found to be an important correlate of substance use and problems, a disproportionate number of black and Hispanic children, youth, and families clearly are at elevated risk.
Socioeconomic factors have been found to be important in helping to explain black–white differences in substance use and problems. In fact, recent research suggests that black adults' disproportionate experience of negative substance use related outcomes are strongly related to their economic disadvantage. For example, national data reveal that although economically disadvantaged black men experience more alcohol-related problems and consequences than do disadvantaged white men, high SES black men actually experience significantly fewer alcohol problems and consequences than high SES white men.18,,20 Examining the relationship between SES (ie, educational attainment) and substance use among women, another recent study found that although similar proportions of black and white women who had not completed high school were heavy drinkers, black women with 12 years of education or more were significantly less likely than were their white counterparts to be heavy drinkers.21 Further, controlling for sociodemographic differences explained black women's initially higher likelihood to have a history of, or current, alcohol disorder.
Related to racial/ethnic differences in SES, there are significant differences in the social contexts and community environments in which black, white, and Hispanic Americans live. In addition to being more likely than white families to be poor, black and Hispanic families are significantly more likely to live in rural and urban areas of concentrated poverty—communities in which at least 20% of the residents are poor. In fact, four times as many blacks and three times as many Hispanics live in poverty areas than live outside of them.22
Research on contextual risk factors for substance abuse, such as community-level indicators of poverty, laws, and norms that encourage use and the high levels of drug availability, clearly indicate the black and Hispanic Americans are at higher risk than white Americans. A recent study that examined the relationship between alcohol problems and racial/ethnic differences in individual and community-level poverty found that black and Hispanic men were twice as likely as white men to be in the lower classes and four times as likely to live in poor neighborhoods. Black and Hispanic drinkers in poor neighborhoods reported higher numbers of alcohol-related problems than did white drinkers in poor neighborhoods, but only the difference between black and white men was statistically significant.23 Insight into the higher levels of alcohol problems experienced by black men was provided through additional investigation of the characteristics of the high-poverty communities. Relative to white and Hispanic high-poverty areas, black poverty areas were characterized by lower family incomes, higher unemployment, higher population density, and greater numbers of retail alcohol outlets.23
High levels of alcohol availability through the physical location of retail outlets is just one form of availability that characterizes black and Hispanic communities disproportionately. Past research has identified at least three forms of alcohol availability: physical, social, and economic.24 Important aspects of physical availability are the location, number, and density of retail outlets that sell alcoholic beverages, and whether beverages are sold for off-premises use only or for on-premises consumption.24The on-premise/off-premise distinction may be important in that the drinking styles and consumption patterns associated with each are potentially very different. For example, on-premise establishments such as restaurants and taverns may sell alcohol but because of the relatively high per ounce cost of alcoholic beverages in these establishments and because the patrons of these establishments typically consume food along with their alcohol, excessive consumption and drunkenness may be less likely to occur. On the other hand, off-premise establishments such as “package” or liquor stores sell alcohol in large quantities, chilled, and ready for immediate consumption, be it on the street corner, in a nearby park, or in a motor vehicle. This type of drinking pattern is more likely to result in excessive drinking, public drunkenness, automobile crashes, and perhaps even physical altercations that result in injury or homicide. In fact, a study published recently found a strong relationship between the level of assaultive violence and the density of retail alcohol outlets in the community.25
Two other important aspects of physical availability are the form and size of alcoholic beverage containers and the concentration of ethanol in the beverages.24 Both of these aspects of physical availability are disproportionately marketed toward blacks and Hispanics in the form of high alcohol content 40 ounce, and more recently 64 ounce, malt liquor bottles.
The social availability of alcohol refers to the promotion of alcoholic beverages at the point of purchase, within the community, and in the mass media.24 Both the scientific research literature and the popular press suggest that the social availability of alcohol is disproportionately high in black and Hispanic communities. For example, a report on the 25 largest urban markets indicates that >70% of the advertising money spent for the eight sheet billboards is directed at black Americans, and alcohol advertisements account for nearly 40% of that amount, second only to the amount for cigarettes.26Similarly, recent studies of billboard content found that black and Hispanic communities have significantly more billboards that feature alcohol and tobacco products than do other communities.27,,28
In addition to billboards, black- and Hispanic-oriented print media are another avenue through which alcohol producers increase the social availability of alcohol. A content analysis of 42 national magazines found that the four black-oriented magazines included in their sample exposed readers to almost 12% of the alcohol ads in the total sample, a percentage almost twice than expected, assuming that the advertisements were distributed equally across magazines.29 Based on these findings, the authors concluded, “readers of these magazines [Ebony,Jet, Black Enterprise, Essence] are indeed exposed to a higher than expected number of alcohol ads” (p 458).29 The study also revealed that alcohol advertisements in black-oriented magazines were 1) more likely than general audience magazines to expose readers to human models versus just the alcoholic product itself; 2) more likely to feature black models, a strategy that might enhance the readers' likelihood to identify with and thus emulate the model; and 3) more likely to use celebrity models, persons who “serve as powerful role models for inducing imitative behavior” (p 459).
The social availability of alcohol in black and Hispanic communities extends beyond billboard and magazine advertisements. Alcoholic beverage producers give their products high levels of social availability through their support of more black- and Hispanic-oriented charities, cultural activities, and community service efforts than perhaps any other private industry. Alcohol industry-sponsored activities include special history promotions, national concert tours, athletic competitions, bus tours, college scholarships, and other civic and cultural events targeted specifically toward blacks and Hispanics.26,,30,31
In addition to its social availability, alcohol's economic availability is also germane to the present discussion. Economic availability refers to the real price of alcoholic beverages in relation to disposable income and the cost of other beverages.24 Cheap wine and malt liquors are widely available and aggressively marketed in black communities.26 The physical, social, and economic “hyperavailability” of alcohol is clearly a contextual-level risk factor to which black and Hispanic Americans are disproportionately exposed.
Related to the availability of alcohol and other drugs is the racial/ethnic differences in exposure and opportunities that community residents, including youth, have to acquire and use drugs. Past research indicates that relative to white youth, black and Hispanic youth are more likely to 1) perceive that marijuana, cocaine, or heroin would be fairly easy or very easy to obtain in their community; 2) have seen someone selling drugs in their community occasionally or more often; and 3) report seeing people who are drunk or high in their community occasionally or more often.11 Demonstrating the importance of racial/ethnic differences in availability as a key risk factor for racial/ethnic differences in use, a recent study found that higher crack cocaine use among blacks and Hispanics relative to whites was completely explained away when community-level availability of the drug was controlled.32
Laws governing who can and cannot use what drugs and under what circumstances are another set of contextual-level influences on substance use behavior. Ostensibly, the alcohol and other drug-related laws to which white, black, and Hispanic Americans are exposed are identical. And although this expectation may be true in theory, there is evidence that the ways in which the laws are applied vary depending on the racial/ethnic group to which one belongs. For example, there is evidence that retailers are significantly more likely to sell licit drugs to minors in black communities and to sell them to black minors, irrespective of community racial composition.33
Policies that seek to minimize illicit drug use and drug-related harm also are often differentially applied across racial/ethnic groups. For example, despite laws mandating reporting of all women testing positive for drug use during pregnancy, doctors in Florida reported pregnant drug-using black women to authorities at 10 times the rate that they reported white women, although the women had similar levels of drug use.34 Another example is provided by findings that highway police in Maryland used race as a primary characteristic by which to determine persons who should be stopped and searched. Between January 1995 and September 1996, 73% of I-95 motorists detained and searched by Maryland state police were black (20% were white) although black motorists made up only 18% of the motorists violating traffic laws and despite the fact that, statewide, equal proportions of black (28.4%) and white (28.8%) motorists were found with drugs.35 Still another example of the ways in which the application of substance-related laws vary across race is the finding that black and white men were equally likely to have been arrested for driving under the influence of alcohol, although 27% of white men compared with only 10% of black men reported that they had driven a car when they were drunk enough to be in trouble if stopped by the police.36 This disparity suggests that the communities in which black people live may be policed more heavily than the are communities in which white people live.
RACIAL/ETHNIC IDENTITY AND RESILIENCE AGAINST ALCOHOL AND OTHER DRUG USE
Although many of the factors that protect people from substance use and its related problems are probably the same regardless of racial/ethnic group membership, ethnic identity may be a particularly salient protective mechanism against the various contextual risk factors for alcohol and other drug use to which black and Hispanic Americans are disproportionately exposed. Key components of ethnic identity include common ancestral origin, common language, common religion, the use of ethnic media, membership in ethnic voluntary organizations, participation in ethnic social networks, and an attachment or affinity to the ethnic group to which an individual belongs.37,,38
According to Herd and Grube's37 conceptual framework, social characteristics such as age, gender, immigration status, region of residence, and place of birth are hypothesized to influence ethnic identity; ethnic identity is hypothesized to influence cultural norms and values; and cultural norms and values are hypothesized to influence substance use behaviors. Consistent with their conceptual framework, Herd and Grube37 found that the effects of the ethnic identity measures on blacks' drinking were primarily mediated through drinking norms and religiosity. More specifically, greater involvement in black social networks and higher levels of black awareness predicted more conservative drinking norms and higher levels of religiosity, both of which related to lower levels of alcohol use. Interestingly, exposure to black media tended to increase drinking, including heavy drinking. In consideration of the earlier discussion of the hyperavailability of alcohol in black-oriented media, this finding highlights the potential impact that advertising has on black Americans' alcohol use.
Recent research on the relationship between ethnic identity and substance use among Hispanics has focused heavily on the issue of acculturation,37 which in this context generally refers to taking on the attitudes, beliefs, norms, preferences, and ultimately behavioral characteristics of the larger United States (ie, white) society. Although the specific impacts of acculturation vary by sex, age, and birthplace, the general effect of acculturation on Hispanics has been to liberalize their drinking.37 Specifically, highly acculturated Hispanics have more liberal attitudes and norms toward alcohol use than do those who are less acculturated, and on average they are more likely to drink and to drink more heavily than their less acculturated counterparts.37
In short, research on the relationship between racial/ethnic identity and substance use suggest that black and Hispanic Americans who hold more tightly to their traditional cultural norms, values, beliefs, and behaviors are less likely than their more acculturated peers to use substances and, as a result, might be less likely to experience substance-related problems. The role of racial/ethnic identity as a protective factor against alcohol and other drug use is clearly an important topic for future research, with potentially significant implications for the design of culturally specific preventive interventions.
Research on the use of alcohol and other drugs suggests that although racial/ethnic differences in the epidemiology of alcohol and other drug use are not large, there are significant racial and ethnic differences in the experience of negative mental, physical, and social health consequences associated with the use and abuse of drugs. Because substance-related problems impact black and Hispanic adults disproportionately, black and Hispanic young people, particularly those who are children of substance abusers, are at elevated risk for myriad problems. Although researchers typically focus on differences in individual and interpersonal factors as explanations for racial/ethnic disparities in substance use outcomes, recent research suggests that socioeconomic and contextual factors may be as important, if not more important, explanatory variables.
Although this article generally has taken racial/ethnic differences in SES and exposure to contextual risk factors for substance use as givens, persons concerned with racial/ethnic disparities in health and well-being must question why these differences exist. Undoubtedly, racial/ethnic differences in poverty and community-level living conditions are rooted in the historical and contemporary racialized nature of American society. The racialized nature of American society is demonstrated by the fact that it has in the past, and continues to in the present, categorize, stereotype, prejudge, and differentially treat people based on their physiognomy—ie, physical features such as skin color, hair texture, and so forth.39 The racialized nature of American society has systematically created and maintained significant differences in the social conditions and contexts of the various people of African, Latin, and European descent categorized as “black” and “Hispanic” and “white.”40
Historical and contemporary racialized practices and ideologies inherent in American society influence racial/ethnic differences in substance use outcomes both directly and indirectly through their influence on the communities in which people of different racial/ethnic groups are placed, their influence on structure and process of people's interpersonal relationships, and through the impact that they have on individuals' psychology and behavior.41 And thus, although the emphasis of pediatricians' and many other helping professionals' work focuses on individuals and individual-level behaviors, these behaviors can be only properly examined, diagnosed, and treated when they are understood in view of the community and societal contexts in which they occur.
- SES =
- socioeconomic status
- ↵US Bureau of the Census. Statistical Abstract of the United States: 1996. 116th ed. Washington, DC: US Bureau of the Census; 1996
- McGinnis JM,
- Foege WH
- ↵US Dept of Health and Human Services. Eighth Special Report to the US Congress on Alcohol and Health. Washington, DC: NIH Publication No 94-3699; 1994
- ↵Wallace JM, Bachman JG, Johnston LD, O'Malley PM. Racial/ethnic differences in adolescent drug use: exploring possible explanations. In: Botvin G, Schinke S, Orlandi M, eds. Multi-ethnic Drug Abuse Prevention. Thousand Oaks, CA: Sage Publications; 1995
- Wallace JM Jr.,
- Bachman JG
- ↵Johnston L, Bachman J, O'Malley P. National survey results on drug use from the Monitoring the Future study, 1975–1995. Rockville, MD: National Institute on Drug Abuse, US Dept of Health and Human Services, Public Health Service, National Institutes of Health; 1996
- ↵US Dept of Health and Human Services. Drug Use Among Racial/Ethnic Minorities. Washington, DC: NIH Publication No 95-3888; 1995
- ↵Herd D. The epidemiology of drinking patterns and alcohol-related problems among US Blacks. In: Alcohol Use Among US Ethnic Minorities. National Institute on Alcohol Abuse and Alcoholism Research Monograph No 18. DHHS Publ No (ADM) 89-1435. Washington, DC: US GPO; 1989:3–50
- ↵Jones-Webb R, Hsiao C, Hannan P. Relationship between socioeconomic status and drinking problems among Black and White men. Alcoholism: Clin Exp Res. 1995;19:623–627
- ↵US Bureau of the Census. Statistical Brief: Poverty Areas. Economic and Statistics Division. Washington, DC: US GPO; 1995
- ↵Hacker AG, Collins R, Jacobson M. Marketing Booze to Blacks. Washington, DC: Center for Science in the Public Interest; 1987
- Altman DG,
- Schooler C,
- Basil MD
- Landrine H,
- Klonoff E,
- Alcaraz R
- ↵Wilkins RL vs the Maryland State Police, Civil Action No CCB-93-468; 1996
- ↵Omi M, Winant H. Racial Formation in the United States. From the 1960's to the 1990's. 2nd ed. New York, NY: Routledge; 1994
- ↵Oliver ML, Shapiro TM. Black Wealth/White Wealth: A New Perspective on Racial Inequality. New York, NY: Routledge; 1995
- ↵Wallace JM Jr. Explaining race differences in adolescent and young adult drug use: the role of racialized social systems. Drugs Soc. 1999;14(No. 1/2):21–36
- Copyright © 1999 American Academy of Pediatrics