Perceived temptation to use drugs and actual drug use among women Hugh Klein; Kirk W Elifson; Claire E Sterk 11,036 words 1 January 2003 Journal of Drug Issues GJDI 161 Volume 33, Issue 1; ISSN: 0022-0426 English Copyright (c) 2003 ProQuest Information and Learning. All rights reserved. Copyright Florida State University for and on behalf of The Florida State University Board of Trustees Winter 2003 Much research has been conducted to examine the relationship between various psychological and psychosocial factors and substance use/abuse. Whereas such topics as depression, bipolar disorder, anxiety, self-esteem, optimism/ pessimism, coping, and stress/tension have been studied fairly extensively, others have received much less attention. One such understudied psychosocial factor is perceived level of temptation to use drugs under specified circumstances. This research is based on a study of 125 adult women drug users residing in the Atlanta, Georgia metropolitan area, interviewed between August 1997 and August 2000. Street outreach efforts were used to identify potential study participants, with further expansion of the sample done via targeted sampling and ethnographic mapping procedures. The present study examines 16 specific items assessing temptations to use drugs. After describing which circumstances people think will be most likely to bring about greater illegal drug usage, the authors compare perceptions to actual drug use behaviors. Multivariate analyses are conducted to examine the role that perceived temptations to use drugs play in predicting actual drug use when the effects of demographic variables, background experiences, childhood maltreatment experiences, other psychosocial measures, and exposure to substance abusers are taken into account. A multivariate model explaining nearly one-half of the variance in actual drug abuse is derived, and retained several of the temptations-to-use-- drugs items. INTRODUCTION During the past 15 years, research has been undertaken to examine the relationship between a variety of psychological and psychosocial variables and substance use. Among others, constructs such as depression, bipolar disorder, anxiety, self-esteem, optimism or pessimism about the future, coping skills, and stress/tension have been investigated for their relationship to substance use. Such studies have presented mixed findings, but generally have shown that these states are related to drug use. In many studies, depression has been linked to drug use, but the issue of causality has been very problematic for researchers to disentangle. That is, does drug use/ abuse lead to depression? Does experiencing depression lead to greater problems associated with substance use? Do the two phenomena co-occur temporally and have a mutual (i.e., recursive) influence upon one another? The answer to Page 1 of 27

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these questions depends entirely upon whose research one consults. For example, a number of researchers have reported that the causal relationship should be conceived as drug use/abuse <-> depression even in people who were not experiencing depressive symptoms prior to their drug use. This has been reported for cannabis (Bovasso, 2001), alcohol (McMahon, Malow, & Loewinger, 1999; Swendsen & Merikangas, 2000), codeine (Sproule, Busto, Somer, Romach, & Seller, 1999), MDMA / Ecstasy (Hammersley, Ditton, Smith, & Short, 1999), and cocaine (McMahon et al., 1999). Conversely, others have concluded that the causal relationship should be conceived as depression <-> drug use/abuse in those who were not using or abusing drugs prior to experiencing depressive symptoms. Abraham and Fava (1999), for instance, studied people experiencing clinical depression and, by conducting life history interviews, determined that depression preceded all types of drug abuse (except LSD, which temporally cooccurred with the depression), typically by several years. Merikangas and Avenevoli (2000) reported that premorbid depression increases the chances that substance abuse disorders will develop. Others, whose work has focused on chemical dependency treatment outcomes, have reported that depression is associated with relapse among alcohol-addicted men (Strowig, 2000) and that reducing depression during the treatment process led to better treatment outcomes for methadone maintenance patients (Avants, Warburton, & Margolin, 2000). To complicate matters even further, still other researchers have found that alcohol dependence and depression were nearly evenly divided in terms of which came first among persons studied (Compton, Cottler, Phelps, Abdallah, & Spitznagel, 2000). Consistent with this research, many studies have examined substance abuse disorders and depression, only to conclude that there is a substantial overlapping in these two diagnoses, that the two conditions often co-occur, and that temporally, they appear to form a relationship best conceptualized as: drug use/abuse <-> depression This view of substance use/abuse and depression as having a comorbid or recursive relationship has been reported by McDowell and Clodfelter (2001); Mehrabian (2001); Melanin and Isometsae (2000); Paraherakis, Charney, Palacios-Boix, and Gill (2000); and Swendsen and Merikangas (2000), among many others. Research has also been inconclusive with regard to the relationship between substance use/abuse and bipolar disorder. Some studies have reported that people suffering from bipolar disorder are more likely to develop substance abuse problems (Goldberg, 2001; Merikangas & Avenevoli, 2000). Other researchers have reported that substance abuse worsens bipolar disorder manifestations and the course and prognosis of bipolar disorder disease (Goldberg, Garno, Leon, Kocsis, & Portera, 1999; Sonne & Brady, 1999; Strakowski, DelBello, Fleck, & Arndt, 2000). Still others have reported that substance use/abuse and bipolar disorder are comorbid conditions, with no Page 2 of 27 © 2012 Factiva, Inc. All rights reserved.

apparent or easily-determined causality (Goldberg, 2001; MacQueen & Young, 2001; Sonne & Brady, 1999; Strakowski et al., 2000; Tohen, Greenfield, Weiss, Zarate Jr., & Vagge, 1998; Vieta et al., 2000). One study even drew four conclusions: for some people, substance abuse causes bipolar disorder; for others, bipolar disorder leads to substance abuse problems; for some people, an external factor causes both substance abuse problems and bipolar disorder to cooccur; and finally, for others, bipolar disorder may lead to substance use as a form of self-medication (Strakowski & DelBello, 2000). Relatively similar mixed findings have been reported in the literature for the relationship of anxiety (i.e., general anxiety disorder, social anxiety disorder, or generalized anxiety) to substance use/abuse. A number of researchers have reported these conditions to be comorbid (Mehrabian, 2001; Mitchell & Pollard, 1999; Myrick & Brady, 2001; Sproule et al., 1999). Some authors have cited specific drugs whose use is associated with greater anxiety (e.g., alcohol or tobacco [Degenhardt, Hall, & Lynskey, 2001], cannabis [Best et al., 1999], MDMA/ Ecstasy [Wareing, Fisk, & Murphy, 2000]). Studies of causality between substance use/abuse and anxiety disorders have been relatively scarce, but generally seem to conclude that drug abuse or dependence predates and/or causes anxiety disorders (Compton et al., 2000; Newcomb, Vargas-Carmona, & Galaif, 1999). Treatment-related research has shown that persons suffering from anxiety show fewer improvements in drug treatment (Franken, Hendriks, Haffmans, & Van Der Meer, 2001) and are more likely to drop out of treatment (Hiller, Knight, & Simpson, 1999) compared to persons who do not suffer from anxiety. Furthermore, there is a growing literature that cessation of use may lead to increased symptoms of anxiety among drug-dependent persons, at least in the short-term (Kajdasz, Moore, Donepudi, Cochrane, & Malcolm, 1999; Kouri & Pope, 2000). Research focusing on the relationship between self-esteem and substance use/ abuse among adults has been relatively sparse over the years.1 Generally speaking, these studies have found associations between lower self-esteem and substance abuse-related problems (Lewis & O'Neill, 2000; Taylor & Del Pilar, 1992). Some research has been conducted to examine the impact that entering drug treatment has on self-esteem levels, typically finding that success in treatment corresponds to improvements in self-esteem (Gutierres, Russo, & Urbanski, 1994; Hill & Durm, 1997; Hiller, Rowan-Szal, Bartholomew, & Simpson, 1996) or, conversely, that lower self-esteem is associated with failure in drug treatment (Magura, Siddiqi, Freeman, & Lipson,1991). What the studies on self-esteem and drug use/abuse have addressed only to a limited extent is the temporal ordering of these variables-that is, whether low self-esteem is the underlying source of the subsequent substance abuse problems, whether the substance use/abuse problems lead to subsequent lowering of self-esteem levels, or whether these variables have a purely recursive relationship with one another. Far less has been written on the relationship between optimism/pessimism and substance use/abuse. One study reported that there was an association between lower levels of optimism toward the future and greater substance abuse (Somlai et al., 2000). Another found that lower levels of optimism were observed among heroin users with a recent experience with overdosing than among those who had not overdosed recently (McGregor, Darke, Ali, & Christie, 1998). Jason et al. (1997) noted that, compared to those who dropped out of treatment, those who remained in treatment were less pessimistic about the future. Little else has appeared in the scholarly substance use/abuse literature on the concepts of optimism or pessimism during the past decade. Most of the published literature focusing on the nexus of substance Page 3 of 27

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use/abuse and coping skills has been based on drug treatment studies, specifically examining the role that enhancing coping skills has on affecting abstinence rates. Typically, researchers have found that programs that were successful in improving coping skills were also successful in improving drug abuse and/or abstinence rates. This was true for alcohol-related outcomes (Conrod et al., 2000; Walton, Blow, & Booth, 2000), cocaine abuse (Monti, Rohsenow, Michalec, Martin, & Abrams, 1997), and drug-related outcomes in general (Conrod et al., 2000; Miller, Meyers, & Hiller-Sturmhoefel, 1999; Moggi, Ouimete, Moos, & Finney, 1999; Schonfeld et al., 2000). Generally speaking, research focusing on the relationship between coping skills and substance use/abuse in nontreatment settings has been lacking. Consistent with a Social Stress Model of substance abuse, much of the research examining the relationship between stress/tension and drug use/abuse has shown that many people turn to drug use during times of stress. Greater stress has been shown to be related to increased alcohol use (Sinha, Fuse, Aubin, & O'Malley, 2000), increased cravings for cocaine (particularly among cocaine abusers) (Sinha, Catapano, & O'Malley, 1999), and the increased usage of illegal drugs in general (Sinha et al., 2000). In particular, work-related stress, which plays a large role in many people's daily lives, has been shown to be associated with greater drug use (Bray, Fairbank, & Marsden, 1999; Moisan et al., 1999; Storr, Trinkoff, & Anthony, 1999). Many authors discussing the interplay of stress and substance use have addressed the co-occurrence of these phenomena, without ascribing causality to one or the other (Lehman, Farabee, Holcom, & Simpson, 1995; Lindenberg et al., 1999; O'Hare & Sherrer, 2000). As one might expect, the drug treatment literature has shown that stress plays an adverse role in the recovery process. It leads to a greater likelihood of relapse during treatment, and to greater drug use when people are reinterviewed several months after treatment entry (McMahon, 2001). Stress, even when minor, has been found to lead to increased drug cravings among people in treatment (Ames & Roitzsch, 2000), thereby making their attempts to recover more difficult when compared to people experiencing less stress. Despite this large and ever-accumulating body of literature on the relationship between psychological and psychosocial factors and substance use/abuse, other related factors have received little attention in the scholarly literature. One example is assertiveness and the roles that having self-assertion skills and being assertive (versus passive) play in drug abuse. Another example, which is the focal point for the present study, is temptations to use drugs. Here, we are considering the extent to which people think that they would be tempted to use drugs in specific circumstances, and how those beliefs/perceptions correspond to actual drug usage. Intuitively, we would expect a strong correspondence between these factors, as much research has shown that beliefs and attitudes are good predictors of related behaviors, especially when drug-related beliefs, attitudes, and behaviors are in question (Armitage, Conner, Loach, & Willetts, 1999; Boyd, 2000; Laflin, Moore-Hirschl, Weis, & Hayes, 1994). In fact, the Health Belief Model and the Theory of Reasoned Action, which have been so popular in the social sciences field throughout the past 10-20 years or so, are premised on this very notion. It is somewhat surprising, then, that virtually nothing has been written on the relationship between psychosocial measures assessing people's temptations to use drugs in specified circumstances and the actual drug use behaviors that follow. The only relevant inquiries appearing in the published literature are studies pertaining to drug use triggers and drug cravings. Regarding the former, research has addressed situation-specific "cues" for addicted persons to use drugs (i.e., triggers) and has focused on the importance of helping substance abusers to identify their environmental, situational, and emotional triggers so that they can learn to avoid using drugs and Page 4 of 27 © 2012 Factiva, Inc. All rights reserved.

relapsing (Childress et al., 1994; Cooney et al., 1997; Gerwe, 2000; Kirby et al., 1995; Palij, Rosenblum, Magura, Handelsman, & Stimmel, 1996). The drug cravings literature generally has addressed the notion that some drug abusers, particularly those using opiates and/or cocaine, continue to use drugs because they experience intense physical or emotional cravings for their drugs of choice (Elman, Karlsgodt, & Gastfriend, 2001; Franken, De Haan, Van Der Meer, Haffmans, & Hendriks, 1999; Preston, Umbricht, & Epstein, 2000; Sinha et al., 2000), even during periods when they are trying to become abstinent. Only a few studies (De Vos, Van Wilgenburg, Van Den Brink, Kaplan, & De Vries, 1996; Kelaher & Ross, 1999) have addressed the notion of cravings being situation-specific, and typically they have not provided much information regarding the specific situations in which drug cravings lead to drug use. While both the drug triggers and drug cravings research studies are important for their implications for persons trying to recover from drug abuse problems, such studies have failed to address the general relationship between temptations to use drugs under certain circumstances and actual drug use in nondependent, non-recovery-oriented persons facing their ordinary, day-to-day behavioral decisions. In the present study, we examine 16 specific temptations-to-use-drugs measures and study how these items relate to actual drug use in a sample of urban women. We address three principal research questions in this study: (1) Under what circumstances do women think they would be tempted to use drugs? (2) What is the relationship between temptations to use drugs and actual drug usage? (3) Does the relationship between temptations to use drugs and actual drug use remain significant when the effects of other relevant variables (e.g., demographic characteristics, background experiences, other psychosocial measures, relationships with others, exposure to substance users) are taken into account? METHODS OVERVIEW AND DESIGN The data for this study came from Project FAST, which was conducted between August 1997 and August 2000 in the Atlanta, Georgia metropolitan area. One of the goals of this intergenerational drug use study was to examine substance use, psychological and psychosocial functioning, and a variety of HIV-related risk behaviors among women and their adult-aged daughters. Four research-related dyad groups were identified for the study, with approximately-equal numbers of women being recruited into each dyad group. These were: (1) drug-using mothers who had drug-using daughters, (2) drug-using mothers with non-using daughters, (3) drug-using daughters with non-using mothers, and (4) non-using mothers who had non-using daughters. Women in the four dyads were matched in terms of the community from which they were recruited, the number of household members residing with them, the number of adults in their household of residence, and the generations represented in the household. In all, 250 women participated in the study. Data for the 125 women who reported at least some illicit drug use during the month prior to interview are used in the present research. ELIGIBILITY In order to participate in the study, several eligibility criteria had to be met. Both the woman and daughter in each dyad had to live in one of the study's catchment areas. Both had to be aged 18 or Page 5 of 27

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older and be able to conduct their interview in English. In addition, in order to ensure that a noninstitutionalized sample was obtained, women could not be enrolled in a substance abuse treatment program, incarcerated in a prison or jail, or be living in any other institutional setting at the time of their participation. Only women whose mother/daughter also agreed to participate could be enrolled in the project; and women who had a dual diagnosis of substance abuse and any other psychiatric disorder were excluded from the study. Finally, in order for women to be considered "drug users" in the research dyad designations used in this study, they had to have used an illicit drug at least once during the six months prior to interview. Approximately one-sixth of these persons (17.9%) reported daily drug use; nearly one-third (31.7%) used drugs less than on a daily basis but at least weekly, on average; and the remainder of the women classified as drug users in these analyses used illegal drugs less often than that. RECRUITMENT Women were recruited into the study by outreach workers, who conducted initial screening interviews "on the street" to confirm potential participants' eligibility for the study. The initial recruitment was based largely on targeted sampling, including ethnographic mapping (Sterk, 1999; Watters & Biernacki, 1989). The targeted neighborhoods were chosen because they were "hot spots" of local drug activity characterized by frequent drug sales and widespread drug use. Within these community "hot spots," the outreach workers targeted places where women were known to gather (e.g., laundromats, stores, playgrounds, churches, and activity centers), so as to maximize their recruitment efforts. As the study progressed, a chain referral sampling technique was used to identify additional participants. After completion of the interview, each woman was asked to refer the research team to other women who might be interested in participating in the study. On average, interviews took two hours to complete. At the completion of the interview, each woman was paid $15 for her participation and offered referrals to local health/social service agencies, as appropriate. MEASURES USED All of the data in Project FAST were based on self-reports. Sixteen items assessing women's level of temptation to use drugs under various circumstances served as the principal independent variables in these analyses. These items were derived from the work of Budney and Higgins (1998), in their discussion of identifying triggers that lead people to use drugs. People were asked to use a five-point scale ranging from "would not be tempted" to "would be tempted a lot" to indicate how tempted they would be to use drugs in a variety of situations (e.g., while relaxing, when happy and celebrating, when waking up in the morning and facing a tough day, when bored, during family arguments, etc.). The dependent measure used in these analyses assessed the total amount of illegal drug use reported during the 30 days prior to interview. Study participants were asked separate questions about their use of crack cocaine, powder cocaine, heroin, speedball, methadone, other opiates, amphetamine, marijuana, and a catchall "other drugs" category. For each item, they indicated the number of days on which they used each drug during the preceding month and the average number of times per day they used each drug type. The frequency-of-use and times-per-day responses were multiplied for each drug type (to determine the number of times that each drug type Page 6 of 27 © 2012 Factiva, Inc. All rights reserved.

was used during the month prior to interview), and then summed across all drug types (to determine the total amount of illegal drug use reported during the month prior to interview). This summative measure was the dependent variable used in these analyses. Values ranged from 0 (indicating no drug use during the previous month) to 910 (indicating an average of slightly more than 30 times using drugs per day) (mean = 75.5, SD = 156.3). In addition to examining the temptations-to-use-drugs items, we also looked at a number of other variables that might be associated with the amount of drug use people reported. The items chosen for consideration were based on the findings of numerous published studies indicating the relevance of these factors to understanding differences in drug usage among women. Demographic and background variables used included age (coded as a continuous variable), race (coded as African American or other-than-African American), educational attainment (an ordinal measure coded as less than high school graduate, high school graduate or equivalent, or at least some college education), marital status (coded as married or living as married versus other-than-married), religiosity (three variables: a five-point ordinal scale measuring frequency of attending worship services, a four-point ordinal scale measuring the perceived impact of religion on one's behavior, and an interaction term combining the effects of the previous two), and homelessness status (coded as homeless or domiciled). Also included here was the amount of alcohol used during the 90 days prior to interview (coded as a continuous measure). Childhood maltreatment variables examined included sexual abuse, physical abuse, emotional abuse, neglect,2 and one additional measure that indicated whether or not the person had been victimized in all four of these ways. Three psychosocial measures were also examined, including assessments of self-esteem (a continuous scale measure based on Rosenberg's [1965] self-esteem scale)(Cronbach alpha = .82), depression (a continuous scale measure based on the Depression and Anxiety Stress Scale 42 [DASS 42] developed by Lovibond & Lovibond [1995])(Cronbach alpha = .87), and coping with everyday stresses (a continuous scale measure derived from the Ways of Coping Questionnaire [Folkman & Lazarus, 1988])(Cronbach alpha = .72). Four measures assessing relationships with others were also included in the analyses. Among these were measures examining living with any persons) using illegal drugs (coded yes/no), having two parents with substance abuse problems (coded yes/no), and the number of family members with alcohol and/or other drug problems (a continuous measure). Additionally, the overall closeness of the relationships the respondent had with close family members and friends was assessed in the form of a scale measure, derived from Armsden & Greenberg's (1987) Inventory of Parent and Peer Attachment Questionnaire (Cronbach alpha = .78). ANALYSIS A stepwise multiple regression approach was used to examine the relationship between the temptations-to-use-drugs variables and women's actual drug use.3 Initially, each of the temptations-to-use-drugs variables was entered into simple regression equations, to determine if they were statistically significant predictors of the outcome measure. Next, those found to be related to amount of drug use reported were entered simultaneously into a stepwise multiple regression equation, to determine which variables) should be retained in further steps as we developed the multivariate drug use prediction model. Next, the bivariate relationships between the other predictor variables listed earlier were examined one by one, using Student's t tests whenever the independent variable was dichotomous, analysis of variance whenever the independent variable was categorical or ordinal in nature with fewer than five response levels, and simple Page 7 of 27

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regression whenever the independent variable was ordinal in nature with five or more response levels, or if it was continuous in nature. Items that were found to be marginally- or statistically-significant predictors in these bivariate analyses were selected for entry into the multivariate equation.' This was done one category at a time, following the sequence listed in the previous subsection, until items from all of the categories of independent variables had been examined.' Results are reported as statistically significant whenever p<.05. RESULTS PREVALENCE OF TEMPTATIONS TO USE DRUGS Overall, the women surveyed felt that they would not be very tempted to use drugs under the 16 different circumstances specified (see Table 1). The percentage of women who said that they would be "not at all" or "a little bit" tempted to use drugs ranged from 55.7% to 74.0%, depending upon the situation mentioned. They reported being least tempted to use drugs when they were: talking and relaxing (74.0%), experiencing withdrawal symptoms (73.3%), waking up and facing a difficult day (70.7%), and less physically active and generally unconcerned about their health (70.2%). Conversely, depending upon the measure in question, anywhere from 14.6% to 38.5% of the women said that they would be tempted "quite a bit" or "a lot" to use drugs given the circumstances specified. Women reported their greatest temptations to use drugs when they were: with a partner or close friend who was using drugs (38.5%), seeing another person using and enjoying drugs (36.1%), in a place where everyone was using drugs (35.3%), feeling extremely anxious and stressed (35.0%), feeling frustrated because things were not going the way they wanted (30.9%), hanging around in their neighborhood (27.9%), at a party with their friends (27.6%), feeling bored (26.0%), or missing the drug habit and everything that goes with it (25.4%). STEP 1 - TEMPTATIONS-TO-USE-DRUGS When examined in bivariate analyses, 15 of the 16 temptations-to-use-drugs items were found to be associated with actual drug use. These were: while with friends at a party (p<.001), while talking and relaxing (p<.001), while with a partner or close friend who is using drugs (p<.001), while hanging around the neighborhood (p<.001), when happy and celebrating (p<.001), when seeing someone using and enjoying drugs (p<.05), when waking up and facing a tough day (p<.001), when extremely anxious and stressed (p<.001), when bored (p<.001), when frustrated because things are not going one's way (p<.001), when there are arguments in one's family (p<.05), when in a place where everyone is using drugs (p<.001), when one lets down concerns about one's health (p<.05), when really missing the drug habit and everything that goes with it (p<.0 1), and while experiencing withdrawal symptoms (p<.01). The only item that was not associated with the amount of drugs women used was "when one realized that stopping drugs was extremely difficult." Because all items were statistically significant or marginally significant, all were entered into a multiple regression equation. The results are presented in Table 2. Six of the temptations-to-use-drugs items were retained in the multivariate model. Together, they explained nearly half of the variance (47.3%) in women's drug use. These items included women's temptation to use drugs: while hanging around in the neighborhood, when happy and celebrating, when seeing someone else use and enjoy drugs (inversely Page 8 of 27 © 2012 Factiva, Inc. All rights reserved.

related), when waking up and facing a tough day, when in a place where everyone is using drugs, and when letting down one's concerns about one's health (inversely related). STEP 2 - DEMOGRAPHIC AND BACKGROUND VARIABLES Two of the religiosity measures were found to be statistically-significant predictors of the amount of drugs women used. Greater frequency of religious service attendance corresponded with less drug use (p<.001). Similarly, the interaction term combining the effects of worship service attendance and impact of religion on behavior was related inversely to amount of drug use reported (p<.001). Additionally, marital status was associated weakly with drug use (p<.13), with married women reporting more drug use than women in other marital status categories. None of the other demographic or background variables examined was found to be a statistically-significant or marginally-significant predictor of drug use. Next, the two religiosity measures and marital status were entered into the multiple regression equation along with the temptations-to-use-drugs measures retained in Step 1. Neither frequency of worship service attendance nor the interaction term was significant when included in the multivariate model. Consequently, these terms were excluded from further consideration. STEP 3 - CHILDHOOD MALTREATMENT Despite previous research findings to the contrary, in the present study, none of the childhood maltreatment variables was found to be related to women's drug use. Consequently, these items were excluded from further consideration and no changes were made to the multivariate model in Step 3. STEP 4 - PSYCHOSOCIAL VARIABLES Women's responses to the coping-with-everyday-stresses scale items were found to predict their amount of drug use (p<.05), such that better coping corresponded to less drug use. Self-esteem and depression were not related to drug use. Coping was entered into the multivariate model with the items retained in Step 2. It was a marginally-significant contributor to the multivariate model and therefore was retained. STEP 5 - RELATIONSHIPS WITH OTHERS Of the four measures examined here, only one - living with substance abusers - was predictive (marginally) of women's amount of drug use. Women who lived with a substance abuser reported somewhat more drug use than women who said that they did not live with any substance abusers. Having two substance-abusing parents, the number of family members with substance abuse problems, and the overall quality of relationships with friends and close family members were not found to be related to the amount of drug use women reported. The living-with-substance-abusers variable was added to the Page 9 of 27 © 2012 Factiva, Inc. All rights reserved.

multivariate model. It was not found to contribute significantly to the model and was, therefore, omitted. The final model was modified to exclude all items not contributing significantly to the prediction of the amount of drug use reported. The last column of Table 2 presents the final multivariate model, which included six of the temptations-to-use-- drugs items and the marital status variable. Together, these items explained 49.5% of the variance. DiSCUSSION One of the more interesting findings of the present analyses was that only one variable other than the temptations-to-use-drugs items - namely, marital status-- remained statistically significant as a predictor of women's drug use in the multivariate model. Women's age, race, educational attainment, childhood maltreatment history, psychosocial profiles, exposure to substance abusers, and interpersonal relationship qualities had no significant impact upon the amount of drugs they used, once the effects of their levels of temptation to use drugs and marital status were known and taken into account. It may be the case that these other variables actually are important factors influencing the extent to which women use drugs, but that they are temporally more remote than the temptations items. That is, the effects of women's temptations to use drugs under specified circumstances may be related more closely to the actual contexts in which they find themselves having to make decisions about whether or not to use drugs than other variables that could also affect such decisions. Accordingly, items assessing their temptation level are more salient to their drug use process than, say, whether or not they belonged to a particular racial/ethnic group, whether or not they have strong interpersonal support networks, and so forth. Also worthy of note was the excellent ability of the seven items retained in the multivariate model to predict women's amount of drug use (R^sup 2^ = 49.5%). It is relatively uncommon to identify such a small group of items that account for such a large proportion of variance in a complex dependent measure such as amount of drug use. When one considers the myriad factors that determine how much someone uses drugs, the amount of variance explained by these items is even more impressive. Several of the items contributing to the final multivariate model have specific implications for substance abuse treatment efforts and intervention programs striving to reduce illicit drug use. We will discuss what we consider to be the five most important of these. First, in this study, women who were married or living as married reported nearly twice the amount of drug use than women whose marital status was other-than-- married. This finding is consistent with some published studies that have reported greater drug use and/or treatment resistance among married women, particularly if they have spouses who are substance abusers (Riehman, Hser, & Zeller, 2000; Westermeyer & Boedicker, 2000; Windle, 1997). It is also consistent with the research done by Calhoun, Parker, and Weaver (1995), which found that married persons expressed less concern about drug use than unmarried persons did. These findings, coupled with our own, suggest that drug abuse prevention programs and intervention efforts would be wise to target married women and to provide them with special educational materials and services that can help them reduce their use of illegal drugs. Such approaches appear likely to be effective, in light of published research that has demonstrated that, compared to unmarried persons, married persons were more likely to demonstrate early entry into drug treatment (Schuetz, Rapiti, Vlahov, & Anthony, 1994), better rates of treatment retention (Mertens & Weisner, 2000), and a greater Page 10 of 27 © 2012 Factiva, Inc. All rights reserved.

capability of stopping the use/abuse of illegal drugs (Labouvie, 1996; White & Bates, 1995). Second, we found that greater drug use was reported by people who said that they would be tempted to use drugs if they were hanging around in their neighborhood. Project FAST was conducted in neighborhoods where drug use/ abuse rates were high, where socioeconomic conditions were adverse, and where most of the local residents were racial minority group members. Drug use occurs in such communities, oftentimes publicly, because of a lack of functionally-equivalent activities-that is, healthy, legal, and socially-acceptable activities that can occupy people's time without the involvement of drugs. Communities such as those in which Project FAST was conducted need to provide places like community centers where people can socialize and have productive, prosocial things to do without the presence of drugs. Providing neighborhood sports activities, church-based activity programming, child-centered recreational activities for young people and their parents, and even offering educational opportunities to learn more about substance use and other topics salient to the lives of inner-city minority residents are examples of the types of things that could be implemented in an effort to reduce community-- wide rates of drug use. Studies examining the impact of providing such services in economically-disadvantaged neighborhoods have reported that drug use rates do tend to decrease when alternative activities are made available to local residents (Marcus, 2000; Van Etten, Higgins, Budney, & Badger, 1998). Not surprisingly, when there are worthwhile, enjoyable things for people to do besides "hang out" and get high together, many will choose these positive activities rather than those involving drug usage. Third, we discovered that greater drug use was reported by women who said that they would be tempted to use drugs when they were celebrating and feeling happy. If, instead of pertaining to illegal drugs, we were obtaining this finding with regard to alcohol use, it would be of far lesser concern than it is in the present study/context, where illegal drug use is the focus. Increased alcohol use in conjunction with celebratory occasions is generally considered to be a proper, socially-- accepted use of alcoholic beverages because it falls into the ceremonial or hedonistic categories of drinking (Bales, 1991). When illegal drugs are used in the same manner, though, greater concern is raised because, as a culture, we do not want people to use illegal drugs, let alone to help them feel happy or to celebrate special occasions. The implication of this particular finding for prevention and intervention programs is straightforward: Women who use drugs when they are feeling happy or to help celebrate something need to be shown other drug-free ways to feel good, and they need to be taught how to celebrate and enjoy life's good happenings and accomplishments without turning to illegal substance use to enhance the situation. Fourth, women who said that they would be tempted to use drugs when they were waking up and facing a difficult day reported more drug use than those who said that they would not be tempted to use drugs under such a circumstance. By itself, this finding is not very surprising, since it is well-documented in the scientific literature that poor coping skills are associated with greater drug use (El-Bassel et al., 1996; Grunbaum, Tortolero, Weller, & Gingiss, 2000) and that enhancing coping skills is likely to lead to reduced drug use (Avants, Warburton, & Margolin, 2000; Bish, Golombok, Hallstrom, & Fawcett, 1996; Monti et al., 1997). Nevertheless, our finding here does have important implications for substance abuse prevention and treatment programs. It highlights the need to teach people non-drug-involved ways to cope with their daily stresses. It illustrates the importance of enhancing self-efficacy, especially since research has found that programs that increase selfefficacy Page 11 of 27 © 2012 Factiva, Inc. All rights reserved.

tend to enjoy concomitant improvements in substance abuse-related outcomes as well (Maisto, Connors, & Zywiak, 2000; Rounds-Bryant, Flynn, & Craighead, 1997; Stephens, Wertz, & Roffman, 1995). Our finding here also highlights the importance of reducing pessimism levels among women, since undoubtedly it is their negative expectation about what the day holds in store for them that leads many of them to use drugs. Other researchers have reported that success in substance abuse treatment was greater among people who scored lower on measures of pessimism6 (Bishop, Jason, & Ferrari, 1998; Goldbeck, Myatt, & Aitchison, 1997), and that greater pessimism is associated with greater amounts of drug use (Prescott, Neale, Corey, & Kendler, 1997). By working with women to reduce their level of pessimism about their daily lives, we would expect to see their rates of drug use decline. Two promising ways to accomplish this would be to provide them with improved job skills and parenting training. Previous studies have shown these to be effective ways of improving related outcomes (Camp & Finkelstein, 1997; Hiebert-Murphy & Richert, 2000; Hser, Polinsky, Maglione, & Anglin, 1999; Messina, Nemes, Wish, & Wraight, 2001; Sung, 2001). Fifth, we discovered that the greatest drug use was reported by women who felt that they would be tempted to use drugs if they found themselves in a place where everyone else was using drugs. Most, if not all, drug treatment programs emphasize the importance of changing environment and the people with whom at-risk persons come into regular contact if they wish to reduce harm and bring about positive lifestyle changes. Researchers, too, have commented on the need to change environments if one wishes to ameliorate substance abuse problems (Kadushin, Reber, Saxe, & Livert,1998). Teaching women such as those in the present study to change how, with whom, and where they spend their time so as to minimize their involvement in drug-focused situations/environments would, in all likelihood, be beneficial to them. Personnel working in the drug treatment field conceptualize the issue here as pertaining to "triggers" for using drugs. They try to teach their clients to identify their drug-use triggers and to prepare a specific set of behavioral responses when confronted by their drug-use triggers, so that they can avoid the situational pitfalls that often lead to drug use and/or relapse. Researchers, on the other hand, usually cast the issue at hand using key principles of the Harm Reduction Model. They explain that drug abuse and associated problems can be reduced if people learn to identify environments where their drug usage is likely to be greater and/or abusive in nature, and on that basis develop a personal action strategy to employ when they are confronted by such situations (Wilmot & Royer, 2000). Whichever way the matter is viewed, one thing is clear: Many of the women participating in this study need to learn to change the environments and situations in which they place themselves, so that they have less exposure to drug users and drug use. If they can accomplish this, there is good reason to believe that their own drug use will decrease. In summary, our findings suggest that there is a close relationship between temptations to use drugs in specific circumstances and actual drug usage. Women who reported the greatest amounts of drug use tended to have the greatest need for training/education to help them to acquire the skills to avoid using drugs in various situations in which they found themselves in their daily lives. Basically, the women in our study were in need of developing (1) better coping skills, (2) behavioral repertoires that would enable them to avoid using drugs when directly confronted with drug-use situations and active drug users, and (3) friendships/relationships with persons who were not going to place them in drug-involved situations in the first place. Drug treatment programs working with women-particularly African American women-as well as community-based substance abuse prevention programs can be expected to achieve better results if they develop their treatment/ prevention approaches with these findings in mind. Page 12 of 27

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POTENTIAL LIMITATIONS OF THIS RESEARCH We would like to acknowledge three potential limitations of this research. First, the data collected as part of Project FAST were all based on uncorroborated self-- reports. Therefore, the extent to which respondents underreported or overreported their involvement in risky behaviors is unknown. In all likelihood, the self-reported data can be trusted, as numerous authors have noted that persons in their research studies (which, like the present study, have included fairly large numbers of substance abusers) have provided accurate information about their behaviors (Anglin, Hser, & Chou, 1993; Higgins et al., 1995; Miller, Turner, & Moses, 1990; Nurco, 1985). A second possible limitation pertains to recall bias. Respondents were asked to report about their beliefs, attitudes, and behaviors during the past 30 days, the past 90 days, and the past year, depending upon the measure in question. These time frames were chosen specifically (1) to incorporate a large enough amount of time in the risk behavior questions' time frames so as to facilitate meaningful variability from person to person, and (2) to minimize recall bias. The exact extent to which recall bias affected the data cannot be assessed although other researchers collecting data similar to that captured in Project FAST have reported that recall bias is sufficiently minimal that its impact upon study findings is likely to be small (Jaccard & Wan, 1995). A third possible limitation of these data comes from the sampling strategy used. All interviews were conducted in the Atlanta, Georgia metropolitan area. There may very well be local or regional influences or subcultural differences between these women and those residing elsewhere that could affect the generalizability of the data. Additionally, the chain referral sampling approach used to identify study participants is not a random sampling strategy,' and there may be inherent biases in those not identified as potential study participants in Project FAST. ACKNOWLEDGMENTS This research was supported by a grant from the National Institute on Drug Abuse (ROI-DA09819). The authors wish to acknowledge, with gratitude, the contributions made by Katherine Theall to the development of this manuscript. HUGH KLEIN, KIRK W. ELIFSON, CLAIRE E. STERK Kirk W. Elifson is a professor of sociology at Georgia State University. He is currently conducting research on intergenerational aspects of drug use, the link between drug use and mental health, drug trends, and gender-specific HIV risk-reduction interventions. Hugh Klein is a senior researcher in the Rollins School of Public Health at Emory University. He has conducted research on the viability of the female condom; the portrayal of alcoholic beverages in animated cartoons; the efficacy of adolescent drug treatment programs; college students' beliefs, attitudes, behaviors, and problems resulting from alcohol use; and HIV risk behaviors among users of crack cocaine and injected drugs. Claire E. Sterk is a professor in the Department of Behavioral Sciences and Health Education at the Rollins School of Public Health at Emory University. Currently, she conducts research on intergenerational aspects of drug use, the link between drug use and mental health, drug trends, and gender-specific HIV risk-reduction Page 13 of 27 © 2012 Factiva, Inc. All rights reserved.

interventions. Footnotes: 1 There have been a number of published studies addressing the relevance and/ or results of implementing self-esteem enhancement interventions and prevention programs targeting children and adolescents, as drug abuse prevention efforts. 2 All four of these measures were based on experiences prior to age 18 and were coded as "happened" or "did not happen." These constructs were assessed using items from Bernstein et al.'s (1994) Childhood Trauma Questionnaire. 3 During the preliminary analytical stages, a factor analysis was conducted to determine whether the temptations-to-use-drugs items operated independently of one another or whether they comprised factors. The factor analysis revealed that two factors with Eigenvalues of 9.52 and 1.08, respectively, could be derived, both with good reliability coefficients (Cronbach's alpha = .933 and .897). When these factors were scored using a complete estimation technique and used instead of the individual items, the multivariate models performed much more poorly, explaining less than half as much variance in the dependent variable as when the individual items were used. Further analysis of the data suggested that some of the items comprising the factors operated in a positive direction whereas others operated in a negative direction, thereby reducing the overall factors' explanatory power. Consequently, it was decided that the preferable course of action would be to use the individual items rather than the factors in the analyses, since they did a superior job of explaining variations in the dependent measure than the composite factors did. This approach also enables us to isolate the specific components in the temptations-to-use-drugs scale. 4 To make sure that "masking effects" were not overlooked in performing these analyses, all items that were found to be significant at p<.15 were included in these equations initially. As it turned out, none of the items that were in the .15>p>.05 range was retained in any of the multivariate equations as a significant predictor. 5 To ensure that the order in which items were considered for inclusion in the development of the final multivariate equation did not influence the results obtained, the analyses were conducted using a stepwise forward selection procedure and a backward elimination procedure. The same results were obtained in the final model regardless of which approach was adopted. 6 Since optimism and pessimism are ostensibly opposites of one another, some studies included measures focusing on one construct rather than the other. Our assumption is that lower levels of optimism equate with greater levels of pessimism, and that lower levels of pessimism equate with greater levels of optimism. 7 A good discussion of the issues pertinent to this concern may be found in Heckathorn (1997), along with strategies that can be employed to minimize any bias that could result from the use of a chain-referral sampling approach. Page 14 of 27

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