Challenging Dogma

...Using social sciences to improve the practice of public health

Monday, April 30, 2007

The Flaws of Applying the Health Belief Model to the “War on Drugs”: a Critique of America's Use of the Prison System in the “War”- Heather Brand

The increase in the availability of illicit drugs in the last half of the 20th century has become a tremendous problem for the United States. In 2005, a reported 22.5 million Americans were diagnosed with substance abuse and dependence (Substance abuse and Mental Health Services Administration in 1). America’s “War on Drugs” has largely been carried out by the deployment of the criminal justice system to punish those who take part in drug-related activities. However, placing the emphasis on drug use as an immoral, illegal act one voluntarily chooses to engage in has actually exacerbated America’s drug problem and, furthermore, has prevented effective treatment strategies from being implemented on a grand scale. America's use of the prison system as a means to combat drug use is a failure because it is based on the health belief model, which does not address the environmental and social determinants of illegal drug use and is not based on the scientific evidence that drug use is an addiction that requires comprehensive treatment to overcome.

Our individual behavior, including the activity of engaging in drug- related behavior, is shaped by our environment and the social interactions we participate in, a fact that the health-belief model fails to account for. Many social and public health problems associated with illicit drugs are concentrated in disadvantaged urban communities, marked by poverty, high unemployment rates, low levels of education attainment, and social disorganization, and the risk of using increases dramatically with the number of risk factors present in a community (2). Poverty is inextricably related to drug use (2,3,4,5) which has become yet another facet of the ever-expanding divide separating the plush, comfortable existence of the upper-class from the harsh realities endured by the lower economic class. Drug use in impoverished communities is appealing because it provides a means of enjoyment and escape from the unmerciful social realities they find themselves engrossed in. The prison system, of which drug- related offences account for roughly 35% of the 1.4 million Americans incarcerated, actually contributes to the poverty that plagues disadvantaged, drug- stricken communities. The innercity residents who enter the correctional system, mostly African Americans and Latinos, are removed from their communities and transferred to facilities in predominantly white, exurban communities. The inmates are then counted in the national census as residents of those communities, which results in decreased subsidies for urban areas while increasing federal aid and grants for the prison communities.

The low levels of educational achievement that characterize many disadvantaged communities make finding and maintaining a well-paying job near impossible, leading many individuals to become involved in the sale and distributions of drugs, given the large amount of profit to be gained in short periods of time. The prison system confounds this problem by releasing uneducated, unskilled ex-inmates back into urban areas, where they are confronted once again by the business of drug sales and other criminal activities, and where access to a viable, satisfying, conventional way of life is hard to come by (4).

It is interesting to note that as local and state governments decreased spending on programs intended to raise the public health, education and employment of the poor, funds for the construction and maintenance of prison systems increased; in the 1990s, spending on employment and training programs were cut 50%, while money for correctional facilities increased by 521% (4). Communities are at an increased risk to become socially disorganized when there is a lack of social service institutions, leading to the unabated emergence of drug use, crime and delinquency, and violence in the community (2). Neighborhood and community social organization is crucial in mediating the impact of broader environmental influences, such as social inequality resulting from low socio-economic status.

Yet socio-economic status and neighborhood environment are not the only variables that exert an effect on one’s life. J.S. Coleman’s Social Capital Theory focuses on how the quality (time and effort), structure (attachments formed), and content of social relationships- including those formed in the family, work, school, neighborhood, and community environments- affect the transmission of resources (capital) across generations that shape opportunities and life trajectories (6). The effects of social capital are cumulative, that is, individuals carry lessons learned with them throughout their life and apply them to all varieties of relationships and social interactions.

Social Capital Theory recognizes the family as perhaps the most fundamental vessel through which social capital flows, so is used here to exemplify the three important ways “capital” is transmitted. Firstly, parents transmit social capital to their offspring by investing time and effort in their children’s lives, the ultimate goal being to raise socially competent youth who are psychologically adjusted and behaviorally appropriate. Forging strong family attachments is the most effective means by which to achieve these goals and is the second necessity for high social capital to accumulate. Studies have shown that even in the presence of other risk factors, an intact family life may act as a barrier against drug abuse (3). Conversely, studies have found an increase in the incidence of dysfunctional family environments among drug users, and have also concluded that exposure to child abuse and neglect increases the likelihood of substance abuse (3). Therefore, it is important that the content of the messages reinforces prosocial behavior patterns, as it is evident that certain forms of capital may actually facilitate criminal involvement (6).

The reliance on the criminal justice system to address drug abuse removes individuals from their families and communities, the very sources of social capital and social support critical to helping them overcome their addiction. According to the social capital theory, the most promising solution would be to utilize the resources and social support of the community they are connected to. By isolating them in the prison environment, their social support ceases to exist and along with it any chances of they had of successfully dealing with their addiction.

By applying the social capital theory, it is easy to see how the social environment created within the American prison system has exacerbated America’s drug problem. Several studies have shown that drug use is widely accepted as a normal part of the correctional system, so by placing users in a socially isolated subculture where drug use is the norm, their substance abuse is not only maintained, but often increased (7). With 1 of every 138 Americans incarcerated, it is no wonder that the social capital accumulated while in prison has been brought to the streets, particularly affecting disadvantaged communities and African Americans, who account for 50% of the prison population. In these communities marked by low social capital where traditional family caretakers and role models have disappeared, moral authority has been transferred to “street smart” individuals, whose power and oppression instilled in them from the their experience in the prison system is brought to the streets and used as a source of influence over others to maintain the cycle of violence and drug use, an activity that has become glamorized in these communities; “doing time” is considered a rite of passage (4). By ignoring the pressing environmental and social determinants of drug use, America has failed to help its drug abusing citizens and has only worsened their plight through the use of the prison system.

The application of the health belief model has lead policy makers to the decision that the criminal justice system is the best means by which to deter individuals from engaging in drug activity. This decision is based on the assumption that drug users are rational individuals who will calculate the cost versus the benefits of criminal activity, i.e. their drug use, and decide not to engage in the activity due to the threat of a criminal conviction and punishment. However, this is hardly the case. Studies show that dug users are impulsive and sensation-seeking, and the crimes they commit are often violent and unpremeditated; this is because certain drugs, especially one like PCP and amphetamines, have pharmacological properties that directly influence areas of the brain responsible for aggressive, impulsive behavior (3). Furthermore, there is considerable evidence that particular genetic, biochemical, physiological, and psychological features may influence drug taking behaviors and the possibility of addiction. Many crimes perpetrated by drug users are attributed to the drug cravings, frenzy, and withdrawal resulting from addiction, further debunking the “rational decision” theory expressed in the health belief model (3). The stigma surrounding drug users and addiction is largely unwarranted, as it is imperative to remember that many individuals in society are at risk for becoming addicted to alcohol and other drugs. However, in the presence of a deleterious environment the risk for drug abuse among individuals with existing psychopathology is substantially compounded (3).

As humans, we are conditioned to steer away from situations perceived as painful and towards situations perceived as pleasurable. Environmental cues assist us in recognizing these situations. Once an individual has been exposed to a drug of abuse, the drug serves as a powerful reward to the brain that spirals beyond the control of the user. Not only do drug users become addicted to the euphoric chemical effect of the drug, but also to the behaviors and paraphernalia associated with the drug. For example, cocaine users report extreme drug craving when they see a dollar bill, talcum powder, or a drug- taking peer (3). The ubiquity of social cues, even in the absence of the drug itself, makes addiction extremely difficult to overcome. In fact, without treatment 9 out of 10 drug using offenders will re-offend and return to drug use after leaving prison, with most being rearrested within 3 years (7).

The use of the prison system has stigmatized individuals who are addicted to drugs, labeling them as criminals and creating a barrier to recovery. According to stigma theory, because they are stigmatized, they lose self-esteem and self-respect, things which we know are powerful risk factors for drug use (8). So the prison system intensifies, rather than ameliorates the factors that are leading to drug abuse in the first place. Furthermore, labeling theory holds that a person, once labeled, tends to fulfill the expectations of that label (9). By labeling drug users as criminals, they may pick up the identity of a criminal. Spending time in jail may make them more likely to identify themselves as a criminal, rather than deter them from future drug use. We must abandon the pernicious moral stance that drug use results from an unwillingness to control voluntary behavior and revoke the use of the criminal justice system in “the war on drugs”.

The application of the health belief model to solve America’s drug problem could not be a more obvious mistake. By placing the solution to drug abuse in the hands of the criminal justice system instead of in the hands of comprehensive treatment programs, individuals, families, neighborhoods, and communities at large have suffered immensely. Its use has lead the social and environmental factors contributing to drug use to go unnoticed. The psychological and addictive qualities central to one’s drug using behavior have been diminished to a level of minuscule importance. If the health belief model maintains its role in America’s “war on drugs”, these crucial factors will remain invisible and the problems associated with drug use will continue to paralyze our communities and strip individuals of numerous opportunities for a healthy, fulfilling life.


1. French, M.T., Homer, J.F., Nielsen, A.L. Does America spend enough on addiction treatment? Results from public opinion surveys. Journal of Substance Abuse Treatment. Vol. 31 (3). 2006. 245-254.
2. Aguirre-Molina, M., Gorman, D.M. Community-Based approaches for the prevention of alcohol, tobacco, and other drug use. Annual Review of Public Health. 1996. 337-358.
3. Fishbein, D.H. Medicalizing the drug war. Behavioral Sciences and the Law. (9). 1991. 323-344.
4. Golembeski, C., Fullilove, R. Criminal (in)justice in the city and its associated health consequences. American Journal of Public Health. Vol. 95 (10). 2005. 1701-1706.
5. Rehm, J. The importance of environmental modifiers of the relationship between substance use and harm. Addiction. (99). 2004. 663-666.
6. Wright, J.P., Cullen, F.T., Miller, J.T. Family social capital and delinquent involvement. Journal of Criminal Justice. Vol. 29 (1). 2001. 1-9.
7. O’Callaghan, F., Sonderegger, N., Klag, S. Drug and crime cycle: evaluating traditional methods versus diversion strategies for drug-related offences. Australian Psychologist. Vol. 39 (3). 2004. 188-200.
8. Goffman, E. Stigma: Notes on Management of Spoiled Identity. New Jersey: Prentince Hall, 1963. 3.
9. Akers, R.L. Labeling Theories. Criminological Theories. 1997. chap. 6.

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