**Abstract**

Disparities in substance use disorders (SUD) and access to treatment among individuals identified as Latino/Hispanic have become a significant public health issue in the United States. National efforts to identify, understand, and eliminate such disparities have highlighted the role of structural racism in Latino health. In this chapter, we offer a critical review of how Latino substance use and access to care may be impacted by discrimination, acculturation stress, and other mechanisms of structural racism. As structural racism is represented by policies, systems, structures, and norms that deny and/or minimize cultural strengths and disempower culturally diverse groups and their attempts to invest in their wellness, we highlight how cultural competence may reduce the risk of SUD and may enhance access to treatment among Latinos. We conclude by highlighting policies and responsive organizational practices that may improve Latino health.

**Keywords:** structural racism, cultural competence, substance use, Latino, disparities

## **1. Introduction**

According to the U.S. Census Bureau [1], 62.1 million Americans identified as Hispanic, Latino, or Latinx (hereafter Latino) in 2020, comprising approximately 19% of the total population [2]. More than half (51.1%) of the total U.S. population growth during the last decade came from growth in the Latino population [3]. Latinos, people with a historical origin in Latin American countries where Spanish language is spoken, have become the largest ethnic minority group in the United States [1]. The Latino population in the United States is diverse in national origin and acculturation status. The U.S. Latino population is largely urban and has been concentrated in large metro areas, although the population of Latinos in smaller cities and rural areas is increasing as well [4]. In 2020, the poverty rate for Latinos was 17.0 percent accounting for 10.4 million individuals [3]. Latinos constitute a young population, with 40% under the age of 20 [5]. Two-thirds of U.S. Latinos are first- or second-generation immigrants [5].

Many of the risk factors for Latino substance use are associated with rejection from their environment and associated stressors. This may be construed as bias,

discrimination, and/or racism in social, educational, and government institutions. There may be an indirect relationship between structural racism in the United States and Latino substance use. As such, we explore in this chapter, substance use patterns among individuals identified as Latino and how services and practices that consider the cultural and linguistic backgrounds of Latinos may combat the influence of structural racism on Latino substance use and access to needed treatment.

### **2. Prevalence of substance use and substance use disorders among Latinos**

Among U.S. adults, the rate of illicit drug use during the prior month among persons aged 12 or older was 9.7% among Latinos compared to a national average of 11.7% [6]. Although Latinos have a lower drug use prevalence compared to other racial and ethnic groups in the United States, this level of drug use still has serious consequences for morbidity and mortality among Latinos. Particularly concerning is that the use of illicit drugs continues to increase among Latinos [7]. Regional patterns are also noticeable; in the Southwest, Latinos report more amphetamine use [8], whereas in the Midwest and East, Latinos report increased use of heroin [9].

U.S. Latinos are significantly less likely than Whites to have been diagnosed with a drug use disorder during their lifetime or the prior year [10]. However, during the last 40 years, reported substance use disorders (SUD) among Latinos have continued to increase in the United States [11, 12]. About 20.8 million people aged 12 or older had a SUD during the prior year [13]. SUD among U.S.-born Latinos (18.9%) are more prevalent than among all Latinos (11.3%, [14]). Among U.S. adolescents, Latinos have historically reported similar levels of substance use to those of Whites. In the last few years, however, Latinos have reported the highest rates of use of any illicit drug in 8th, 10th, and 12th grades, primarily due to their increase in marijuana use. Among 12th graders, Latinos have the highest prevalence of use of several substances, including marijuana, synthetic marijuana, inhalants, hallucinogens, LSD, cocaine, crack, methamphetamine, and crystal methamphetamine. Among 8th graders, Latinos report more use of nearly all classes of drugs compared to Whites and African Americans. However, Latino adolescents have a lower prevalence of misusing prescription drugs compared to Whites [15]. Experimenting with any use of substance during early adolescence has been related to a greater likelihood of SUD in adulthood [16–18].

#### **3. Historical contexts**

Throughout history, people of various cultures have used substances for reasons, such as altering or healing the mind [19–21]. Cultural beliefs have influenced SUD across many racial and ethnic minority groups, including Latinos living in the United States [19, 21]. Substance use behavior is defined as a human behavior motivated by sociocultural beliefs, peer and family influence, and environmental exposure [20]. The general notion is that culture shapes beliefs that lead to behavior and social norms, hence certain cultural beliefs may influence an individual's motivation to engage in substance use [19]. Cultural beliefs are also embedded in the history of Latinos in North America.

The history of drug use among Latinos has been strongly influenced by the U.S. indigenous nations that have relied on substances to heal several ailments, including abuse of other substances [22]. For example, cannabis has had a long history as both a folk medicine and as an intoxicant. This complex history includes the

*Cultural Competence as a Response to Structural Racism in Latino Substance Use and Access… DOI: http://dx.doi.org/10.5772/intechopen.103710*

system of legal control that has been instituted in both the U.S. and Latin American countries to regulate the substance. Another cogent example is a substance derived from peyote, a small spineless cactus, that has been used as a psychoactive drug in Northern Mexico to treat chronic alcohol addiction [23]. Native American churches have also used this substance for the spiritual treatment of chronic alcohol addiction [24]. Many indigenous cultures have used tobacco medicinally and spiritually for thousands of years, whereas in the mainstream U.S. culture, tobacco is considered a recreational and addictive substance [25]. These are important contextual conditions to consider when exploring substance use risk factors among Latino populations.

### **4. Risk and protective factors for substance use**

Many of the risk and protective factors associated with substance use among Latinos are the same factors associated with substance use across multiple racial and ethnic groups, yet acculturation stress, in particular, plays a critical role in the risk of SUD among Latinos. Overall risk factors include substance use by friends or family members, perceived social norms about substance use, access to drugs, psychological comorbidities, impulsive or risk-taking personality traits, and coping skills [26]. Protective factors include antidrug social norms, parental monitoring, and bonding with prosocial mentors and institutions [27]. However, because of their ethnic minority status, immigration histories, and socioeconomic disparities, Latinos also might face additional risk factors for substance use [28]. Especially significant among Latinos is acculturation stress that stems from the circumstances of adapting to the dominant American culture. This persists and is compounded in stressors tied to tensions between the first and succeeding generations within Latino communities. Acculturation stress, which is related to immigrants' perceptions of discrimination by mainstream Americans, increases the risk of SUD among Latinos [29].

The prevalence of SUD in the Latino population is affected by other psychosocial and emotional factors associated with unemployment, immigration, limited access to education, living in disadvantaged communities, family conflict, and racial and income discrimination [8, 11, 12]. Empirical evidence has revealed interesting relationships with substance use. For instance, Latinos are more likely to use illicit drugs and develop SUD if they do not have a strong connection with their ethnic and cultural background [12, 30, 31]. The importance of family connectedness and living in safe neighborhoods have been emphasized that may contribute to acculturation stress and play a role in Latinos' substance use [30, 31].

#### **5. Acculturation: U.S. orientation and Latino orientation**

Because of the recognition of the centrality of acculturation stress as a risk factor for Latino SUD, a deeper understanding of acculturation is warranted. Most Latinos, even those born in the United States, have some degree of contact or identification with their Latino culture of origin, although this can vary widely across individuals. Latinos living in the United States also have some degree of contact and identification with U.S. culture. The extent to which their practices, values, and identification align with one or both cultures defines their acculturation status [32]. Early theories of acculturation assumed that immigrants replace their heritage culture with a new culture [33]. Later acculturation theories [32] propose that individuals can adopt aspects of the new culture but still identify strongly with the heritage culture. Several studies have concluded

that acquisition of U.S. culture is associated with an increased risk of substance use among Latino adolescents [34, 35].

More recent research has drawn a more nuanced conclusion—that the loss of protective aspects of Latino culture, rather than the acquisition of U.S. culture, increase the risk of substance use. Latino adolescents who assimilate into U.S. culture without maintaining a connection to Latino culture are at greater risk of substance use [36] than Latino adolescents who maintain their Latino cultural orientation, especially those who simultaneously participate in U.S. culture and maintain ties with Latino culture [27, 37]. As emphasized above, the role of acculturation stress and rejection from mainstream society plays a central and significant role in Latinos' higher risk of abusing alcohol and other substances. For example, higher acculturation is related to a higher risk of alcohol and illegal drug abuse as compared to less acculturated Latinos and Whites [38]. Acculturated Latinos reported a 7.2% increase in alcohol and illegal drug use during the previous month, compared to less than 1% of less acculturated Latinos and 6.4% of Whites [38]. Less acculturated Latinos had recently immigrated to the United States and therefore reported higher family values and lower rates of alcohol and drug use [29].

#### **6. Acculturation discrepancies between parents and children**

Acculturation occurs in a family system, with adolescents and their parents acculturating at different rates. Immigrant children typically learn and adopt a new culture more rapidly than their parents [33]. Children of immigrants grow up immersed in the receiving culture and are exposed to the heritage culture only secondhand. If families and communities do not maintain and support attributes of the heritage culture, adolescents might reject, forget, or never learn about their culture of origin, leading to acculturation discrepancies between adolescents and parents [33]. Acculturation discrepancies between parents and children can lead to family conflict, which can increase the likelihood that adolescents will experience emotional distress and turn to risky peer groups and risky behaviors in an attempt to cope with that stress [39, 40]. In addition, when parents are less acculturated to U.S. culture than their children, parents must rely on their children for help navigating U.S. culture [41]. This can undermine parental authority, place excessive stress on children, and boost youth's risk of involvement in problem behaviors, such as substance use [27, 33, 41].

### **7. Ethnic identity**

Ethnic identity includes knowing about one's ethnic group, perceiving the value and emotional significance of that membership, and feeling a sense of belonging and commitment to the ethnic group [42]. Some studies have shown that a strong ethnic identity protects against substance use [43, 44]. However, this association has been inconsistent across studies, with some finding that a strong ethnic identity is a risk factor for substance use or that no association exists between ethnic identity and substance use [45, 46].

#### **8. Cultural values**

Cultural values are attitudes and priorities that are emphasized and encouraged by members of a culture. Endorsement of specific values varies widely across members

*Cultural Competence as a Response to Structural Racism in Latino Substance Use and Access… DOI: http://dx.doi.org/10.5772/intechopen.103710*

of a culture, but cultural values are those generally viewed as positive in the culture. For example, individualist cultures encourage and reward outstanding achievements by individuals, whereas collectivist cultures encourage and reward the well-being and prosperity of the group. Certain cultural values might protect against substance use (e.g., obedience to parents, not ingesting intoxicating substances, and regarding one's body as sacred), whereas other cultural values might increase the risk of substance use (e.g., glamorization of adolescent individualism and rebelliousness, expectations of intoxication in certain social contexts). The Latino cultural value of familism emphasizes the interdependence of family members [47]. This can involve a duty to take care of family members and serve as a resource and role model for family members—responsibilities that tend to be incompatible with substance use. However, *familismo* could be a risk factor for substance use if the family members are substance users and encourage other family members to use substances with them. *Respeto* emphasizes a child's duty to respect and obey parents and other authority figures [48]. Previous studies have found that familism and respeto protect against adolescent substance use [49, 50].

## **9. Discrimination**

Ethnic discrimination is differential treatment based on membership in a minority or lower-status group. It includes overt acts such as violence, harassment by police, discourteous treatment by store clerks, and subtler aggressions such as condescending speech [51]. Ethnic discrimination can be understood as one of the core mechanisms of structural racism. It is through the policies, arrangements, practices, designs, spaces, narrative, and other mechanisms that structural racism gives way to separate, exclude, and ultimately discriminate individuals and/or groups [52]. Perceived discrimination can cause emotional distress, and repeated experiences with discrimination can deplete coping resources and increase the attractiveness of avoidant coping strategies, such as substance use [53]. Perceived discrimination by the dominant culture also can signal to minority group members that they will be blocked from opportunities, which may lead them to identify with oppositional subcultures featuring antisocial norms [54]. Perceptions of discrimination have been associated with the use of tobacco, alcohol, and other substances [55] and with depression [56].

#### **10. Immigration and substance use**

Substance abuse has been regarded as a complex phenomenon due to the biological, sociocultural, and historical concepts involved. Therefore, as highlighted above, understanding substance abuse in a target population requires considering its history and context that includes the experience of immigration. This critical factor contributes to substance abuse in Latinos' complex history that encompasses immigration, migration, or changes of state, such as among Mexicans living in territory acquired by the United States in the early 20th century. These individuals faced new sociocultural values in their host country or new national context. This is most pertinent to Mexicans, who represent more than 65% of the total population of Latinos in the United States [19, 21]. Migration status and experiences are a proxy for the stress, trauma, and potential destitution or disenfranchisement associated with immigrants. Again, this stress has been associated with a higher risk of SUD behaviors.

Previous research indicated that Latinos who move to the United States are more likely to be at risk of illicit substance use compared to those who stay in their home country [38, 57–59]. Mexican migrants residing in the United States are more likely to experience deficient health care and treatment compared to their U.S.-born Mexican counterparts, specifically women relative to access to treatment [60]. Mexico is one of the largest countries to experience return migration from 2009 to 2012 [61]. Mexicans who migrate to the United States and then return either voluntarily or by deportation for criminal activities to Mexico (i.e., transnational Mexicans) have reported an increased rate of substance use [30, 57, 58, 62, 63].

In addition, transnational Mexicans' family members (i.e., including relatives who did not migrate) are more likely to use substances (e.g., alcohol, marijuana, and other illicit substances) as compared to other Mexicans [62]. This population often does not seek treatment as readily as Mexicans who did not migrate to the United States [57, 58]. Furthermore, the high risk of substance abuse among transnational Mexicans has negative effects on the quality of life of residents in both countries [58, 64]. Although this may be the case, increasing concern is centered on alcohol and tobacco use among Mexicans living in Mexico [57, 58]. Similarly, compared to men, women reported particular increases in the use of marijuana and cocaine from 2008 to 2011 in Mexico [65].

Marijuana consumption is increasing among adolescents and adults living in Mexico [66]. In Mexico, frequent alcohol use and drinking in large quantities are most common [67]. It appears that this drinking behavior is passed on to adolescents, a substantial number of whom report becoming problem drinkers [68, 69]. Mexico's National Addictions Survey has shown an increasing proportion of the population needs to seek SUD treatment and learn how to moderate alcohol intake and avoid reoccurring patterns of binge drinking [67].

In Mexico, approximately 13 million Mexicans have reported using at least 100 cigarettes during their lifetime and more than 53,000 deaths occur each year due to tobacco-related diseases [67, 68, 70]. Older adults with higher education are more likely to use tobacco than older adults with a lower education level [71]. Youth are also affected by tobacco use in Mexico because initiation occurs at 13.7 years old on average [67]. This further contributes to the increase in public and social health concerns in Mexico, which have not started to shift away from cigarette use, potentially contributing to an increase in substance use among adolescents [71].

Increasing understanding of how migration affects SUD would help inform epidemiological efforts to reduce substance use behaviors and lead to better treatment outcomes [72]. It is also important to connect translational migrants with their networks and communities to bring about SUD behavior change in the Mexican population [62, 72]. Research has suggested that ecological factors are associated with substance use (e.g., marijuana, other illicit substances; [73]); however, these relationships need to be studied further, specifically in the context of migration [74], family networks, and substance use. Previous studies have recognized that Mexican migrants typically have additional risk factors for substance use, such as low socioeconomic status, immigration status, and social isolation [75, 76]. Therefore, it is still unclear whether substance use is a consequence of the stress of being a Mexican migrant or a manifestation of these other risk factors. This emerging evidence suggests the importance of continuing to explore substance use factors among Mexican transnationals [58] to inform public health efforts to reduce SUD in broad populations, including those in Mexico and the United States. Increasing efforts to understand SUD in other countries will help identify ecological factors and risk factors that affect multiple populations, informing the development and implementation of SUD treatment programs that help alleviate symptoms across a spectrum of populations and communities.

*Cultural Competence as a Response to Structural Racism in Latino Substance Use and Access… DOI: http://dx.doi.org/10.5772/intechopen.103710*
