WHAT IS ALREADY KNOWN ON THIS TOPIC

Self-stigma has a negative impact on the well-being of individuals with alcohol use disorder (AUD). Research has shown that self-stigma is associated with depression, anxiety, shame, low self-esteem, hopelessness, low social support, reduced help-seeking and low drinking refusal self-efficacy.

WHAT THIS STUDY ADDS

Without controlling for the aforementioned factors associated with well-being, this study explores the relationship between self-stigma and correlates of alcohol use. It demonstrates that higher levels of self-stigma are associated with more severe AUD and more obsessive thoughts and compulsive behaviours towards drinking.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICYIntroduction

Alcohol consumption and alcohol use disorder (AUD) impose enormous socioeconomic and health-related burdens in the USA and worldwide. There are many factors that influence the identification, treatment and recovery of AUD.1–3 One increasingly relevant factor is stigma. Alcohol-related stigmatisation is a complex issue because in many societies, moderate alcohol consumption is widely accepted and at times encouraged. However, as individuals increase their alcohol intake and/or begin to develop AUD, this behaviour becomes more stigmatised. While alcohol use is generally glamorised or normalised in society, having an AUD is highly stigmatised.4

Stigma is a broad concept that encompasses negative views of a certain trait or topic. Stigma uses a label (eg, ‘alcoholic’ or ‘addict’) and an associated stereotype (eg, unworthy, unpredictable, out of control) to produce a negative response (eg, biased policies, discrimination, social rejection).5 Stigma has a wide-ranging impact, and intersectionality can further compound its effect on different populations. Studies have found that stigma related to substance use can be impacted by age, education, gender, race and other comorbidities.6 7 However, these results are mixed, and further research investigating the intersectionality of stigma should be conducted. Stigma is also a factor contributing to the low percentage of individuals who receive treatment for mental health conditions, with stigma being linked to reduced help-seeking, especially among racial/ethnic minorities, young people, and those in military and health professions.8 Stigmatising labels also influence medical care and healthcare professionals’ perceptions of individuals with substance use disorders.9 Individuals with AUD experience different types of stigma, including public, institutional and internalised (self) stigma.10 Self-stigma, also known as internalised stigma, refers to the negative attitudes a person has towards themselves.11 AUD is typically accompanied by self-stigmatisation, as negative societal attitudes and stereotypes towards unhealthy alcohol use become internalised and affect self-perception.12

Self-stigma is associated with negative alcohol-related outcomes, such as increased levels of alcohol use and harmful drinking patterns.13 Although some findings have been mixed, stigma is also thought to be a barrier to seeking treatment among individuals with AUD given the possibility of being met with judgement, discrimination and more stigma.14 Additionally, internalised stigma can encourage substance use to cope with low self-regard and social isolation, suggesting a potential reciprocal influence.15

The Self-Stigma and Alcohol Dependence Scale (SSAD) was developed to quantify and operationalise self-stigma in relation to alcohol use.16 It consists of four steps of self-stigma (aware, agree, apply and harm). A cross-sectional study of patients hospitalised for alcohol misuse treatment demonstrated the validity and reliability of the SSAD and found that higher self-stigma was associated with lower drinking refusal self-efficacy.16 While this study and others suggest a link between self-stigma and substance misuse,12 17 few studies have empirically examined the possible association between self-stigma and the severity of AUD, alcohol craving and drinking. To our knowledge, our study is the first to examine these potential associations. To help address the gap in the literature regarding the relationship between self-stigma and alcohol-related outcomes, we hypothesised that higher self-stigma would be associated with higher severity of alcohol use and other alcohol-related outcomes. Our primary aim was to investigate the association between alcohol-related self-stigma, quantified by the SSAD, and the severity of alcohol use, measured via the Alcohol Use Disorders Identification Test (AUDIT). As a secondary aim, we also investigated whether alcohol-related self-stigma scores would be associated with levels of alcohol consumption, alcohol obsession and compulsion, and alcohol craving.

MethodsSetting and participants

Data used for this study were collected from two alcohol-related human laboratory studies conducted at the National Institutes of Health Clinical Center, Bethesda, Maryland, USA (ClinicalTrials.gov NCT03152760 and NCT02707055). The inclusion/exclusion criteria of the two parent studies are presented in the online supplemental appendices 1 and 2. Most participants had a current diagnosis of AUD according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. All participants had a negative urine drug test for illegal drugs, a body mass index ≥18.5 kg/m2 and <40 kg/m2, and no significant medical or psychiatric comorbidities. Other eligibility criteria were geared toward the specifics of each parent study. Assessments used for the present study were all administered at baseline (before any intervention or experimental procedure was conducted).

AssessmentsSelf-Stigma and Alcohol Dependence Scale

The SSAD measures the four steps of self-stigma (aware, agree, apply and harm). For this analysis, we used the ‘Apply’ subscale. The SSAD-Apply subscale is a 16-question scale on statements one applies stereotypes to oneself.16 Each question is ranked on a scale from 1 (‘strongly disagree’) to 7 (‘strongly agree’). For example, sample items include: ‘Because I have alcohol problems, I am unreliable’; ‘Because I have alcohol problems, I am below average intelligence’; and ‘Because I have alcohol problems, I am disgusting’. Responses are then totalled to provide an overall score, with higher scores signifying higher levels of self-stigma. Total scores range from 16 to 112.

Alcohol Use Disorders Identification Test

The AUDIT is used to measure the severity of alcohol use over the course of the past year.18 This assessment is a 10-item multiple choice questionnaire asking about the quantity and frequency of alcohol consumption, drinking behaviour, and alcohol-related problems or reactions. A total AUDIT score between 1 and 7 denotes low-risk alcohol consumption, 8–14 hazardous or harmful alcohol consumption and 15–40 likelihood of alcohol dependence (moderate-to-severe AUD).

Alcohol Timeline Follow-Back

The Alcohol Timeline Follow-Back (TLFB) provides an alcohol drinking history through a calendar that starts the day before the participant is enrolled and typically goes back 90 days.19 Based on an interview with a trained research staff member, the number of standard drinks consumed each day is recorded (one standard drink=14 g of alcohol≈12 oz beer, 5 oz wine or 1.5 oz hard liquor) and various summary variables are generated. For this analysis, the average number of standard drinks a person drank per drinking day and the number of heavy drinking days over the past 90-day period were used. Heavy drinking was defined as consuming more than four drinks for males and more than three drinks for females.20

Obsessive-Compulsive Drinking Scale

The Obsessive-Compulsive Drinking Scale (OCDS) reflects obsession and compulsivity related to craving and drinking behaviour over the course of the past week.21 It has 14 questions scored on a scale from 0 to 4. Total scores range from 0 to 56, with higher scores indicating more obsessive thoughts and compulsive behaviours.

Penn Alcohol Craving Scale

The Penn Alcohol Craving Scale (PACS) is a five-item self-administered questionnaire designed to measure alcohol craving over the course of the past week.22 Each item is scored from 0 (no craving) to 6 (high craving), so the total score ranges from 0 to 30, with higher scores indicating more craving for alcohol. Questions measure frequency, intensity and duration of thoughts about drinking, along with ability to resist drinking. The final question asks the participant to provide an average rating of their craving.

Analyses

Descriptive statistics were used to summarise demographic characteristics of the study sample and other variables of interest. Normal distribution was tested for using Kolmongorov-Smirnov test. Due to most variables of interest significantly deviating from normal distribution, we performed bivariate Spearman correlations to explore possible associations between SSAD scores and alcohol-related measures, including AUDIT, TLFB, OCDS and PACS scores. Based on the results, separate regression analyses were then performed with SSAD scores as an independent variable and AUDIT and OCDS scores as the outcome, with and without controlling for demographic variables. R2 values were calculated to determine the proportion of the outcomes that was predicted by the SSAD score, with values ranging from 0 to 1. We also calculated the variance inflation factors (VIFs) to test for multicollinearity in the regression models; VIF scores higher than 5 generally indicate problematic multicollinearity. We did not adjust for multiple testing mainly because the four alcohol-related measures were selected a priori and examine relatively separate aspect of drinking behaviour; generating hypotheses for future research was an objective of this work given the paucity of literature; and our two-tier analytical approach selected the most important variables for our main analyses, that is, regressions.23 24 IBM SPSS Statistics V.28 (IBM) was used, and the significance level was set as p<0.05 (two tailed) for all analyses.

FindingsDemographic characteristics and summary statistics

Only participants with complete SSAD data were included in the present study. Out of the 77 individuals enrolled in the two parent studies, 7 participants did not have SSAD data and 2 participants had outlying alcohol TLFB data (defined as total drinks >3500 drinks in a 90-day period), so they were removed from all analyses. This step was taken to ensure data quality/reliability, as the nature of these responses to the TLFB may indicate less reliable responses to the other scales as well. Additionally, four participants had participated in both parent studies and, therefore, only their most recent data were used. This resulted in 64 total participants being included in the present analysis (online supplemental figure 1). Participants were, on average, 48.6 years old (SD=11.0), and predominately male (73.4%), non-Hispanic (95.3%) and white (59.4%). Means and SDs of all continuous variables and n (%) of all categorical variables are presented in table 1. Two participants had missing data for PACS, resulting in an n=62 for this scale.

Table 1

Demographic variables and summary statistics

Associations between self-stigma and alcohol-related measures

Results of bivariate correlations for all variables are presented in table 2. Self-stigma scores were positively correlated with AUDIT scores, average drinks per drinking day, heavy drinking days and OCDS scores (p<0.001, p=0.014, p=0.011 and p<0.001, respectively), with moderate-to-strong correlation coefficients,25 but not with PACS scores.

Table 2

Bivariate correlations of alcohol-related variables with self-stigma scores

Table 3 summarises the results of the multiple regression analyses. All VIFs were under 5, indicating no multicollinearity that warranted further investigation. Separate regressions were run for each outcome and the full results can be found in the online supplemental appendix 3. Self-stigma scores were a significant predictor of AUDIT and OCDS scores, with and without controlling for demographic variables. When controlling for demographics, the regression models explained 29.8% of the variance in AUDIT scores and 32.8% of the variance in OCDS scores. Regression models excluding individuals without a diagnosis of AUD found similar results (online supplemental appendix 4).

Table 3

Summary of multiple regression analyses with self-stigma score as an independent variable

Discussion

This study aimed to investigate the relationship between self-stigma and various alcohol-related outcomes within a clinical context. Specifically, we examined the association between alcohol-related self-stigma, as assessed by the SSAD, and the severity of alcohol use, levels of alcohol consumption, alcohol obsession and compulsion, and alcohol craving. Our hypothesis proposed that higher levels of self-stigma would be associated with an increased severity of alcohol use and its related consequences. Notably, our findings revealed significant positive correlations between self-stigma scores and several crucial variables related to AUD, including the severity of alcohol use disorder, alcohol consumption, and obsessive and compulsive thoughts towards drinking. Moreover, our study demonstrated that self-stigma scores emerged as a significant predictor of both the severity of AUD (measured with the AUDIT) and the intensity of obsessive thoughts and compulsive behaviours about drinking (measured with the OCDS). These outcomes underscore the critical potential role of self-stigma in shaping alcohol-related behaviours.

Our study contributes to the growing body of literature pointing to potential associations between self-stigma and alcohol-related outcomes.13 This observed association between higher self-stigma and poorer alcohol-related outcomes can be explained by several mechanisms. First, individuals burdened by self-stigma may internalise negative societal attitudes and stereotypes surrounding AUDs, leading to diminished self-worth and self-perception. This negative self-perception may contribute to a cycle of self-destructive behaviours, reinforcing and perpetuating problematic alcohol use. Second, self-stigma may act as a barrier to seeking help and accessing appropriate treatment for AUD. Individuals who experience self-stigma may feel shame, fear judgement and anticipate discrimination, which can hinder their willingness to engage in treatment-seeking behaviours. Consequently, the lack of timely intervention and support may exacerbate the severity of alcohol use and its associated consequences. As the direction of the effect is not established, it is also possible that people with more severe AUD may feel worse about themselves and are therefore more prone to internalising stigma. It is likely that this relationship between self-stigma and alcohol-related outcomes is ultimately bidirectional. It is also important to note that stigma is just one of the factors influencing this multifaceted disorder. Other potential factors, such as neurobiological factors and psychiatric comorbidities, could also be influencing this relationship.

Existing literature underscores the detrimental impact of higher levels of self-stigma on multiple aspects of the lives of individuals with AUD, encompassing domains such as interpersonal relationships, mental wellness and self-worth.26 Interventions targeting self-stigma can potentially enhance both alcohol-related outcomes and the overall quality of life for individuals with AUD.27 28 Notably, therapeutic approaches like group-based acceptance and commitment therapy have demonstrated effectiveness in diminishing self-stigma associated with substance use disorders.28 29 These findings provide promising evidence that self-stigma can be effectively reduced in populations with substance use disorder, emphasising the importance of developing and implementing programmes, such as acceptance-based treatment, to mitigate self-stigma in individuals with AUD.

Our findings also suggest that people with higher levels of self-stigma have a more severe AUD, which is particularly concerning given that existing literature highlights self-stigma as one of the barriers to treatment-seeking.14 A systematic review identified stigma as one of the top three barriers to treatment-seeking among individuals with a substance use disorder in the majority of quantitative studies examined. Moreover, other studies have shown stigma to be the most influential barrier in preventing individuals with AUD from seeking treatment, even when access is facilitated, such as through telephone-delivered treatment.30 These studies underscore the role stigma has on hindering treatment-seeking and the detrimental impact of self-stigma on the severity of AUD. Additionally, stigma contributes to the barriers that hinder the integration of multidisciplinary approaches in the treatment of AUD and its medical consequences, including alcohol-related organ damage.31

Another notable finding of this study was lack of significant correlation between self-stigma scores and PACS scores, despite the significant relationship observed with OCDS scores. This result is intriguing considering that both questionnaires are often referred to as measuring craving.32 One possible explanation for this discrepancy is that OCDS and PACS assess different aspects of the complex phenomenon of craving. Recent studies have argued that the OCDS is not necessarily representative of craving, but instead focuses on obsession (preoccupation with alcohol) and compulsion (behavioural and motivational aspects of alcohol consumption).33 The OCDS may also better align with themes in the self-stigma scale, such as weakness and instability, than the PACS. Nevertheless, further research is necessary to gain a deeper understanding of the relationship between self-stigma and alcohol craving.

To our knowledge, this is the first study that looked at the SSAD-Apply subscale in relation to severity of AUD, alcohol consumption, craving, and obsession and compulsion towards alcohol. One cross-sectional study of 153 patients hospitalised for alcohol misuse treatment used this scale to test drinking refusal self-efficacy in relation to self-stigma. They demonstrated that higher self-stigma scores are related to lower drinking refusal self-efficacy, thus showing a link between self-stigma and worse alcohol-related outcomes.16 However, this study differed from ours in that it looked specifically at individuals undergoing treatment for AUD and did not investigate the relationship between self-stigma and any other alcohol-related variables.

The study presented here has several limitations. Our study had a relatively small sample size and used predominately male participants around the age of 50 years. Because this was a secondary analysis, some of the inclusion and exclusion criteria were specific to each parent study (for example, exclusion of females with childbearing potential). Due to the small sample size and limited demographics, the results may not be generalisable to other populations. This is particularly important because studies have found that the risk factors for developing alcohol-related self-stigma differ among demographic groups.34 Therefore, future studies should focus on comparing the relationship between self-stigma and alcohol-related outcomes among various demographic factors. Relatedly, there are several confounding variables, such as socioeconomic status, social support, attitude towards treatment and mental health status that could have impacted these results. Future studies should try to control for these variables to truly assess the relationship between self-stigma and alcohol-related outcomes. Additionally, this study was a secondary analysis of previous studies, although this limitation is mitigated by the fact that the data here analysed were collected at baseline, so before any study procedures or study medications. As a cross-sectional study, our findings cannot establish causality and while important and clinically relevant associations were demonstrated, longitudinal studies are required to better understand the potential causal link between self-stigma, AUD and alcohol-related outcomes. Finally, while the SSAD-Apply subscale has demonstrated validity and reliability, it only looks at one aspect of stigma, self-stigma. Future studies would benefit from assessing multiple types of stigma, including public, perceived and institutional stigma, which may help provide insight into a larger relationship between stigma in general and AUD.

Overall findings suggest that higher levels of self-stigma relate to more severe AUD, higher amounts of alcohol consumption, and more obsession and compulsion towards alcohol. These results further highlight the need for stigma reduction programmes and interventions to potentially increase the number of individuals with AUD who seek treatment. This study also emphasises the importance of stigma reduction and policies in improving the well-being of individuals with AUD. Further perspective research that looks at larger sample sizes and more diverse populations is needed to provide a deeper understanding of the relationship between self-stigma and alcohol-related outcomes.

Data availability statement

Data are available from the corresponding author upon reasonable request.

Ethics statementsPatient consent for publication

Not required.

Ethics approval

This study involves human participants. Data used for this study were collected from two alcohol-related human laboratory studies conducted at the National Institutes of Health (NIH) Clinical Center, Bethesda, Maryland, USA. Both studies were approved by the appropriate NIH Institutional Review Board. All participants provided written informed consent and were compensated for their time and participation in the respective studies.

Acknowledgments

We thank the clinical and research staff involved in patient care, data collection/analysis and technical support in the joint NIDA/NIAAA Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, the NIAAA clinical programme of the Division of Intramural Clinical and Biological Research (DICBR) and the NIH Clinical Center. We would also like to express our gratitude to the participants who took part in these studies.