Stages of Involvement With Alcohol and Heroin: Analysis of the Effects of Marketing on Addiction

Peter J. DePaulo, University of Missouri-St. Louis
Mary Rubin, University of Missouri-St. Louis
Brentan Milner, University of Missouri-St. Louis
ABSTRACT - Involvement with addictive drugs such as alcohol and heroin occurs in a series of stages starting with trial and possibly progressing to addiction, treatment, and relapse. Motives, social groups, and other influences differ markedly from stage to stage. This model can provide a basis for research on the effects of drug-related marketing efforts such as advertisements for alcoholic beverages and media campaigns against substance abuse. Whereas prior research has tended to examine the effects of marketing efforts on usage in general, future studies should attempt to pinpoint the specific effects on users in particular stages.
[ to cite ]:
Peter J. DePaulo, Mary Rubin, and Brentan Milner (1987) ,"Stages of Involvement With Alcohol and Heroin: Analysis of the Effects of Marketing on Addiction", in NA - Advances in Consumer Research Volume 14, eds. Melanie Wallendorf and Paul Anderson, Provo, UT : Association for Consumer Research, Pages: 521-525.

Advances in Consumer Research Volume 14, 1987      Pages 521-525

STAGES OF INVOLVEMENT WITH ALCOHOL AND HEROIN: ANALYSIS OF THE EFFECTS OF MARKETING ON ADDICTION

Peter J. DePaulo, University of Missouri-St. Louis

Mary Rubin, University of Missouri-St. Louis

Brentan Milner, University of Missouri-St. Louis

ABSTRACT -

Involvement with addictive drugs such as alcohol and heroin occurs in a series of stages starting with trial and possibly progressing to addiction, treatment, and relapse. Motives, social groups, and other influences differ markedly from stage to stage. This model can provide a basis for research on the effects of drug-related marketing efforts such as advertisements for alcoholic beverages and media campaigns against substance abuse. Whereas prior research has tended to examine the effects of marketing efforts on usage in general, future studies should attempt to pinpoint the specific effects on users in particular stages.

INTRODUCTION

The impact of marketing efforts on the consumption of addictive substances has been the subject of two separate, major areas of investigation. In one area, scholars have attempted to examine the effects of the marketing of alcohol and legal drugs on substance use and abuse. One example of inquiry in this area is the study of the effect of over-the-counter drug advertising on the use of both legal and illegal drugs (Shimp and Dyer 1979). Drug commercials, it is feared, portray taking medicine as the way to solve life's problems, and (inadvertently) encourage overuse of drugs in general. Another example is the research on the effects of the marketing of alcoholic beverages on the overall incidence of alcohol use and abuse (Popper 1986). In the other major area, researchers have evaluated the anti-drug and anti-alcohol-abuse advertising and public information campaigns that have been launched over the past two decades (Bandy and President 1983). The work has sought to determine whether these social marketing efforts actually do accomplish their objectives in mitigating substance abuse and addiction.

All three review articles cited above have characterized the relevant empirical studies as generally inconclusive. Also, all three articles identify methodological difficulties, such as the need to rely on user self-reports (of questionable validity), as key reasons for the lack of definitive data on the effects of marketing on substance abuse.

We propose that an additional reason for the inconclusiveness of these studies is that the data usually have been collected without regard to the particular stage of an individual's involvement with an addictive substance. As will be explained in detail in this paper, stages of drug involvement include trial, non-addictive use, addictive use, cessation (with possible treatment), and relapse back into addictive use. A drug-related marketing effort may have a different effect on individuals in one of these stages than on individuals in other stages.

BACKGROUND INFORMATION AND TERMINOLOGY

For the benefit of readers who are unfamiliar with this topic, a brief introduction is in order.

The addiction literature includes contributions from a variety of disciplines, including psychology, psychiatry, sociology, social work, and anthropology. Perhaps due to this wide range of perspectives, there is no consensus with regard to how such basic terms as drug, substance abuse, and addiction should be defined.

Abuse and addiction are often used synonymously, but some writers use the label "abuse" in a more general sense to include not only addiction but also noncompulsive problem behaviors such as the use of inhalants or prescription drugs for dangerous or inappropriate purposes. However, there is general agreement that alcohol is indeed a drug (Levison, Gerstein, and Maloff 1983; Miller 1980), despite the tradition of referring to alcohol as separate from other drugs (as in the expression "drug and alcohol abuse"). There is also general agreement that people are "addicted" to a drug if the following phenomena are evident in their behavior: tolerance, withdrawal, and strong craving.

Tolerance has developed if the euphoria or other effect of a particular dosage of the drug is not as strong as it once was before the addiction developed, and a larger dosage is now needed to produce a strong effect. Whereas tolerance refers to effects of a drug that is in the bloodstream, withdrawal symptoms are unpleasant aftereffects. In the case of opiates, withdrawal symptoms include nausea, tremors, cramps, rapid heartbeat, chills, sweating, gooseflesh, violent yawning, muscle spasms, depression, and anger (Jaffe 1980). Although these symptoms can persist for more than a week in severe cases, they can be eliminated quickly by consuming the drug again. Because these withdrawal symptoms appear when

I the drug wears off, and disappear when the drug is again ' ingested, the individual is said to have developed a ! dependence on the drug. The unpleasantness of withdrawal is presumed to be the basis for the craving, which, in the case of heroin, is commonly assumed to compel some addicts to commit crime in order to obtain a constant supply. It should be noted, however, that some theorists believe that environmental factors are more important than withdrawal in motivating the heavy consumption of the alcoholic or drug addict (Falk, Dews, and Schuster 1983).

In treating the addicted individual, the first step typically is detoxification - during which ingestion of the drug is stopped (or gradually reduced). During detoxification, medical assistance is provided to alleviate discomfort while the withdrawal syndrome runs its course. The next step is outpatient counseling or psychotherapy, or in some cases temporary residence in "halfway houses or therapeutic communities" (e.g., Phoenix House). The purpose of this step is to aid in the transition from inpatient care to being on one's own.

STAGES IN THE ADDICTION PROCESS

The seven-stage model described below is a minor adaptation of a five-stage sequence outlined by Lettieri, Sayers, and Pearson (1980). This model is specifically formulated to depict alcoholism and opiate addiction, which are the most heavily researched compulsive behaviors. Although the model might also be helpful in the analysis of addiction to other drugs (e.g., amphetamines and barbiturates), and in the study of some non-drug habits such as 'running addiction" (Sachs and Pargman 1984) and compulsive gambling, we will restrict our discussion to opiates and alcohol.

Stage 1: Trial

The first stage includes the events and influences leading up to, and including, the individual's initial use of the substance. For most users, initial trial occurs in adolescence. The novice is typically introduced to the substance by a more experienced user who happens to be a peer (Kandel and Maloff 1983).

As a rule, novice opiate users have already had experience with other addictive and/or illicit drugs. The most common developmental sequence followed by an individual is as follows: (1) beer and/or wine, (2) cigarettes and/or hard liquor, (3) marijuana, and (4) other illicit drugs such as cocaine and heroin (Kandel and Maloff 1983). Of course, use of the substances that typically come early in this sequence does not inexorably lead to use of the later substances. While social drinking is the norm in American society, relatively few individuals proceed to cocaine and heroin.

Stage 2: Light Use

Usage of an addictive substance does not necessarily lead to addiction. The development of dependence appears to require sustained, heavy usage. Most people who regularly consume alcohol never become addicted either physically or psychologically. Even in the case of heroin, which is regarded as highly addictive, there are some users who don't seem to develop a compelling physical dependence.

At this stage, mild withdrawal symptoms may occur at the end of a particular usage occasion, e.g., a hangover in the case of alcohol. However, if the individual does not find it difficult to resist further consumption, then the person would not be considered addicted.

If usage after trial is sufficiently heavy, Stage 2 may be skipped and the development of dependence in Stage 3 may begin.

Stage 3: Transition to Addictive Use.

As noted above, if usage is sufficiently heavy, then the individual will experience progressively stronger withdrawal symptoms and more powerful craving to consume the drug. Individuals seem to vary in the amount of consumption that is necessary for producing addiction, and to some degree this individual variation may be genetic (McClearn }983).

There is no definite dividing line between light use (Stage 2) and the beginning of the transition to addiction. Likewise, there is no clear point of separation between craving that is strong but manageable (end of Stage 3), and craving that is so compelling that the individual would be considered addicted. The inclusion of this stage in the model is in recognition of the fact that dependence and addiction are not all-or-none phenomena.

Stage 4: Addictive Use

In this stage the individual is so involved with the addictive substance that job performance and family life may be severely compromised. From the point of view of the non-addicted observer, it seems that these negative consequences far outweigh any benefit that the individual could possibly receive from the substance. Hence, addictive behavior is commonly characterized sc irrational (Falk. Dews. and Schuster 1983).

Stage 5: Cessation of Addictive Use

This stage begins when an individual makes a serious attempt to break away from dependence. The individual may try to quit without help, or with some formal program of assistance. Formal assistance can include support groups such as Alcoholics Anonymous and Narcotics Anonymous, a stay at a detoxification center, residence in a relatively isolated therapeutic community such as Phoenix House, or some combination of these approaches. According to Miller and Hester (1980), most people who come into an alcohol treatment program already have tried some kind of self-help measure in an attempt to cope. but without adequate success.

Stage 5 ends when the withdrawal syndrome from the last bout of consumption has run its course and, in the case of an individual who enters a therapeutic community, when the individual leaves the community. Some clients leave these communities before completing the recommended course of therapy; the probability of relapse for these individuals is higher than for those who complete the therapy (Holland and Evenson 1984).

State 6: Post-Cessation

In this stage, the individual attempts to refrain from any further use of the-addictive substance (abstinence), or to consume it in such small and infrequent amounts that dependence is not reinstated (controlled consumptions). While abstinence has traditionally been the goal of formal support groups and treatment services, some controversial programs attempt to teach clients controlled consumption (Harding et al. 1980; Miller and Caddy 1977). The assumption behind strict-abstinence programs is expressed in the adage, once an addict, always an addict.' Specifically, it is assumed that formerly-dependent individuals will always be more susceptible to the effects of the relevant substance than individuals who have never been dependent on it. Thus, even a small amount of the substance might trigger a strong craving, which in turn could motivate further consumption. This snowball effect would result in the reinstatement of strong dependence. In contrast, the proponents of controlled consumption maintain that complete abstinence is an unrealistic goal, and that small amounts of the substance need not have a snowballing effect for individuals who have been given appropriate guidance (review: Cummings, Gordon, and Marlatt 1980).

Formerly-dependent individuals often are advised to avoid circumstances where the substance is likely to be consumed. One reason why exposure to these circumstances may be risky is that these circumstances include stimuli that could evoke craving as a Pavlovian conditioned response. Studies of opiate addicts (Grabowski and O'Brien 1980) and alcoholics (Ludwig et al. 1977) have suggested that the kinds of cues encountered consistently during consumption (the sight of the substance, drug containers, drug-using companions, etc.) have become conditioned elicitors of psychological craving, and possibly some physical withdrawal symptoms (review: Donegan et al. 1983).

This stage and the one that follows (post-cessation and relapse) are of special concern because recidivism rates are so discouragingly high. Surveys of treatment facilities indicate that most current clients have already been to the same clinic for treatment at least once. The person's chances of avoiding relapse are assumed to depend on what transpires in the post-cessation stage (review: Cummings, Gordon, and Marlatt 1980).

Stage 7: Relapse-Repeat Dependence

Although no stage in this sequence is inevitable, it is noteworthy that many individuals go through repeated episodes of treatment and relapse no matter what kind of treatment they may have had. Such individuals have been labeled 'hard core or "treatment-resistant" alcoholics or addicts.

RELATIONSHIP TO FIELD-THEORETIC MODELS

Several field-theoretic models of the various types of influences on drug use, such as family, peers, mass media, school, church, needs, and values, have been proposed (Shimp and Dyer 1979). According to Shimp and Dyer, for example, the various fields of influence affect the likelihood, frequency, and circumstances of drug consumption, as well as the types of drugs used. The 7-stage model proposed here is not an alternative to these field-theory frameworks, but rather a supplement to them. Specifically, the fields of influence proposed by these models can influence the drug user in all stages of the addictive process outlined above. However, as will be illustrated below, the important factors within these fields of influence differ from one stage to the next. We will focus this discussion mainly on motivation and social group influences.

VARIATIONS IN INFLUENCES BETWEEN STAGES

In Stages 1 and 2, motivation to try and occasionally consume a particular drug could involve either positive incentives or negative (escapist) motives. The positive factors include sensual pleasure (e.g., euphoria of getting high), social reinforcement (peer group influence is almost always critical), desire for a change of pace, or "immediate gratification" in general (Lang 1983). Negative motives include helping to cope with anxiety or stress.

However, negative desires may be relatively more important in motivating the individual to consume heavily enough to build a strong dependence (Stage 3). With regard to alcohol, the tension-reduction hypothesis (Marlatt 1976) implies that the people most likely to consume enough alcohol to become addicted are those who happen to have a relatively high amount of stress or anxiety in their lives. Although the evidence in support of a "simple" tension-reduction hypothesis is mixed, an individual's expectation that alcohol provides relief for various stresses and discomforts does appear to play a role in the etiology of alcoholism (Nathan 1980). A related view is that alcoholics are individuals who are low in self-esteem and have little confidence in social interactions. Therefore, they drink to forget about their perceived personal deficiencies (Cutter and O'Farrell 1984). With regard to opiates, the importance of escapist motivation in Stage 3 is suggested by the finding that individuals who come from broken homes, drop out of school, get arrested, and have a prior history of using other drugs are especially likely to progress from trial of heroin to addiction (Graven and Shaef 1978; Robins et al. 1980).

In Stage 4, strong physical dependence has developed, and an important source of motivation to continue heavy consumption of the drug may now be the extreme discomfort of the withdrawal syndrome, although the empirical evidence on the role of this motivation with regard to non-opiate addictive substances is not clear (Cappell and LeBlanc 1979). Avoiding withdrawal is indeed a "negative' motive, but it is different in character from the negative motives presumed important in Stage 3. Furthermore, addicted users may no longer be motivated by some of the factors that originally instigated trial in Stage 1. For example, the drug experience is no longer a change of pace, and tolerance assures that the euphoria of the drug high is diminished or absent. As observed by Allport (1937), compulsive behaviors (such as addiction) tend to assume a "functional autonomy" by which the motives initiating the behavior often bear little relation to those responsible for its continuation.

Most drug use starts in adolescence. As addicts mature, more and more of them try to quit their habits (Stage 5. Common motives for attempting to quit include the need to fulfill family responsibilities (Rosenbaum 1979), and the restoration of self-esteem (which is likely to have reached a low ebb due to the social stigma of addiction; Carmichael et al. 1977). Again, these kinds of motives are not applicable to earlier stages.

Key influencer groups also differ in this stage. Whereas peers may have the biggest impact leading to initial use, quitting or entering treatment typically is influenced by family members, employers, pharmacists, doctors, clergy, emergency medical personnel, police, courts, etc. (The power of some of these groups, of course, may be coercive.) Indeed, these influential groups may be more receptive to anti-addiction information from the media than the addicts themselves.

In Stage 6 (post-cessation), most individuals occasionally consume small amounts of the substance on which they were formerly dependent, even if they have been advised by counselors and support groups to remain totally abstinent. When violating the abstinence rule, they may risk starting the snowball effect leading to relapse. Motives for abstinence violation include reducing stresses of various kinds, conforming to social norms by partaking of the additive substance in a group, and testing one's own ability to control one's habit. The assumption of once an addict, always an addict, which is based on the supposition that even a small amount of the substance can trigger a binge leading to rapid reinstatement of physical dependence, implies that a motive which is not strong enough to lead to the development of addiction (in Stage 2) may be sufficient to lead to relapse into addiction in Stage 6.

Since one motive for violating the abstinence rule includes conforming to social norms by partaking of the addictive substance in a group, social companions are a relevant reference group (Cummings, Gordon, and Marlatt 1980). Although social pressure to consume small amounts would not have been sufficient to generate initial dependence in Stage 3, the same level of social pressure in Stage 6 could start the snowball effect, leading to relapse.

Another possible source of motivation for violating the abstinence rule is the elicitation of craving reactions by Pavlovian conditioned stimuli. As noted earlier, laboratory and survey research has suggested that stimuli which were present during drug taking occasions (Stage 4) have acquired the capacity to evoke psychological craving and possibly also physical withdrawal symptoms (Donegan et al. 1983). Such stimuli can include the drug containers (drinking glasses, syringes) or the companions with whom one has consumed the drug in the past. The individual may encounter such stimuli at social gatherings with ones' peers. Some of the conditioned stimuli, particularly in the case of alcohol, appear regularly on television. Hence, even though the withdrawal syndrome from the individual's last ingestion of the addictive substance may have run its course long ago, conditioned craving (psychological and/or physiological) may be elicited by drug-related environmental stimuli. It may be hard to avoid these stimuli.

ANALYSIS OF EFFECTS OF MARKETING ON DRUG USE

In this section we present examples of some implications of the multi-stage drug involvement model for the study of drug-related marketing efforts.

Anti-Drug-Abuse Media Campaigns

As a hypothetical example, consider an informational campaign which explains the hazards of drug use and shows pictures of drug paraphernalia (e.g., syringes, cocaine powder). And suppose that such a campaign gets some exposure to individuals in all stages, even if was intended only for individuals in Stages 1-3. The campaign may indeed have the desired effect (reduction of trial and usage) on individuals in Stages 1-3. However, Stage 6 individuals who are trying to remain abstinent might experience some conditioned withdrawal symptoms as a result of seeing the drug paraphernalia. In some cases, this might precipitate relapse. Individuals in Stage 3 may not be affected at all, because they will learn little that they don't already know about the drug they currently consume, and because the effects of conditioned stimuli in the campaign probably would not add anything more to the effects of the actual drug stimuli they encounter regularly. Hence, the net effect of the campaign on overall drug usage should depend on how those individuals reached by the advertisements happen to be distributed across the stages; if many are in Stage 6, then the campaign actually could be counterproductive.

The Marketing of Beer

Consider, for example, television commercials for beer, which have been criticized for contributing to alcoholism. These advertisements, it is said, encourage alcohol abuse by their portrayals of drinking as fun, glamorous, socially expected, etc. Stage 1 individuals may indeed be motivated to try alcoholic beverages, as a result of viewing these ads. But do these commercials lead to the heavy, frequent consumption that culminates in physical dependence in Stage 3? Arguably, these commercial-s encourage the kind of moderate drinking that does not lead to dependence. The actors in the commercials do not appear to be drunk, and their drinking seems to be motivated by social interaction, not by stress reduction (a motive thought to be responsible for consumption sufficient to lead to dependence).

However, for formerly dependent alcohol users in Stage 6, exposure to beer commercials may result in the elicitation of conditioned withdrawal symptoms, and these symptoms could motivate relapse. Another mechanism that might increase the probability of relapse would be the tendency of these advertisements to encourage moderate, social drinking. Although this encouragement may tend to prevent the development of addiction in Stage 3, in Stage 6 this same influence might precipitate relapse in these presumably susceptible individuals.

The above analysis implies that the effects of beer advertising on the prevalence of addictive drinking may depend on which group is larger--the number of Stage 3 individuals who have been influenced not to drink heavily enough to become addicted, or the number of Stage 6 individuals for whom relapse is precipitated by the same advertising.

DESIGNING ANTI-SUBSTANCE-ABUSE CAMPAIGNS

The main purpose of this paper is to espouse a particular way of conducting research on effects of drug-related advertising, i.e., individuals in different stages should be analyzed separately. However, it should be noted that the multi-stage model described here also serves a related purpose--to aid in designing anti-substance-abuse media campaigns. Specifically, the model can be used as a segmentation variable in these public service efforts. Successful anti-addiction advertising requires careful targeting of specific audiences (Schmeling and Wotring 1980).

A comprehensive discussion of the practical implications for anti-addiction marketing would be beyond the scope of this paper, but one application will be described here to exemplify the potential usefulness of the model. As discussed earlier, it is possible that advertisements which contain usage cues such as shot glasses and syringes could elicit conditioned withdrawal reactions in individuals who are in Stage 6 (post cessation), and such reactions might in turn precipitate relapse. Thus, such cues should be avoided in anti-addiction advertisements which will be encountered by an appreciable number of Stage 6 individuals. However, it might be beneficial to show drug-usage stimuli in advertisements intended for other audiences. For example, there may be educational value in providing information on drug-use circumstances to non-users in Stage 1. Also, such advertising may be helpful to parents, who must be able to recognize drug paraphernalia in order to detect substance abuse among their children. In such cases media selection and scheduling should be done so as minimize exposure of Stage 6 individuals to the advertisements containing the usage cues.

LIMITATIONS

One major limitation of the analytical approach advocated in this paper is that there will often be uncertainties in the classification of individuals by stage. For example, it would be especially difficult to define cut-off points operationally for distinguishing among Stages 2, 3, and 4. These uncertainties would be the basis for increased error variance in research using the model.

However, we maintain that research which attempts to use these stages as a basis for analysis, despite a fair amount of classification error, will be more productive than research which simply lumps individuals in all the stages together. It should also be noted that classification uncertainties are common in the addiction literature.

CONCLUSIONS

Research on the effects of marketing efforts on addictive behavior must take into account the stage of the addiction process that an individual has reached. A particular marketing effort that may have beneficial effects on individuals in one stage of the process can have detrimental effects on individuals in another stage. These differential effects may be masked when drug users from different stages are analyzed as a single group.

REFERENCES

Allport, G. (1937), 'The Functional Autonomy of Motives,' American Journal of Psychology, 50, 141-156.

Bandy, Patricia and Patricia Alford President (1983), "Recent Literature on Drug Abuse Prevention and Mass Media: Focusing on Youth, Parents, Women and the Elderly," Journal of Drug Education, 13 (3), 255-271.

Cappell, H. and A. E. LeBlanc (1979), "Tolerance to, and Physical Dependence on, Ethanol: Why Do We Study Them?" Drug and Alcohol Dependence, 4, 15-31.

Carmichael, J. S., M. W. Linn, T. C. Pratt, and N. L. Webb (1977), "Self-Concept and Substance Abuse Treatment," Comprehensive Psychiatry, 18, 357-362.

Cummings, Claudette, Judith R. Gordon, and G. Alan Marlatt (1980), "Relapse: Prevention and Prediction," in Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, Smoking, and Obesity, ed. William R. Miller, Oxford, England: Pergamon Press.

Cutter, H. S. G. and T. J. O'Farrell (1984), "Relationship between Reasons for Drinking and Customary Drinking Behavior," Journal of Studies on Alcohol, 45 (4), 321-325.

Donegan, Nelson H., Judith Rodin, Charles P. O'Brien, and Richard L. Solomon (1983), "A Learning Theory Approach to Commonalities," in Commonalities in Substance and Habitual Behavior, eds. Peter R. Levison, Dean R. Gerstein, and Deborah R. Maloff, Lexington, MA: Lexington.

Falk, John L., Peter B. Dews, and Charles R. Schuster (1983), "Commonalities in the Environmental Control of Behavior," in Commonalities in Substance Abuse and Habitual Behavior, eds. Peter R. Levison, Dean R. Gersrein and Deborah R. Maloff. Lexington. MA: Lexington.

Grabowski, J. and C. P. O'Brien (1980), "Conditioning Factors in Opiate Use,' in Advances in Substance Abuse, Vol. 2, ed. N. K. Mello, Greenwich, Conn: JAI Press.

Graven, D. B. and R. D. Schaef (1978), "Family Life and Levels of Involvement in an Adolescent Heroin Epidemic," International Journal of the Addictions, 13, 747-771.

Harding, W. M., N. E. Zinberg, S. M. Stelmack, and M. Barry (1980), "Formerly-Addicted-Now-Controlled Opiate Users," International Journal of the Addictions, 15, 47-60.

Holland, Richard A. and Richard C. Evenson (1984), "Prediction of Readmission in a Cohort of Alcoholics," The International Journal of the Addictions, 19 (5), 585-590.

Jaffe, J. H. (1980), "Drug Abuse and Drug Addiction," in The Pharmacological Basis of Therapeutics (sixth edition), eds. A. G. Goodman, L. S. Goodman, and A. Gilman. New York: MacMillan.

Kandel, Denise B. and Deborah R. Maloff (1983), 'Commonalities in Drug Use: A Sociological Perspective, in Commonalities in Substance Abuse and Habitual Behavior, eds. Peter K. Levison, Dean R. Gerstein, and Deborah R. Maloff. Lexington, MA: Lexington.

Lang, Alan R. (1983), Addictive Personality: A Viable Construct?' in Commonalities in Substance Abuse and Habitual Behavior, eds. Peter K. Levison, Dean R. Gerstein, and Deborah R. Maloff, Lexington, MA: Lexington.

Lettieri, Dan J., Mollie Sayers, and Helen Wallenstein Pearson (1980), Theories on Drug Abuse: Selected Contemporary Perspectives (NIDA Research Monograph 230), Rockville, MD: National Institute on Drug Abuse.

Levison, Peter K., Dean R. Gerstein, and Deborah R. Maloff (1983), Commonalities in Substance Abuse and Habitual Behavior, Lexington, MA: Lexington.

Ludwig, A. M., R. B. Cain, A. Wikler, R. M. Taylor, and F. Bendfeldt (1977), "Physiological and Situational Determinants of Drinking Behavior,' in Alcohol Intoxication and Withdrawal, Vol. 3b: Studies in Alcohol Dependence, ed. M. M. Gross, New York: Plenum.

McClearn, Gerald E. (1983), "Commonalities in Substance Abuse: A Genetic Perspective," in Commonalities in Substance Abuse and Habitual Behavior, eds. Peter K. Levison, Dean R. Gerstein, and Deborah R. Maloff, Lexington, MA: Lexington.

Marlatt, G. Alan (1976), "Alcohol, Stress, and Cognitive Control," in Stress and Anxiety, Vol. 3., ed. I. G. Sarason and C. D. Spielberger, Washington, D. C.: Hemisphere.

Miller, William R. (1980), The Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, Smoking, and Obesity, Oxford, England: Pergamon.

Miller, William R. and Reid K. Hester (1980), "Treating the Problem Drinker: Modern Approaches," in The Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, and Obesity, ed. William R. Miller, Oxford, England: Pergamon.

Miller, William R. and G. R. Caddy (1977), "Abstinence and Controlled Drinking in the Treatment of Substance Abuse," Journal of Studies on Alcohol, 38, 986-1003.

Nathan, Peter E. (1980), "Etiology and Process in the Addictive Behaviors," in The Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, Smoking, and Obesity, ed. William R. Miller, Oxford, England: Pergamon.

Popper, Edward T. (1986), "The Effects of Alcoholic Beverage Advertising and Marketing Practices: The Current State of Affairs," in Advances in Consumer Research, Vol. 13, ed. Richard J. Lutz, Provo, UT: Association for Consumer Research, 442-445.

Robins, L. N., J. E. Helzer, M. Hesselbrock, and E. Wish (1980), 'Vietnam Veterans Three Years After Vietnam: How Our Study Changed Our Views on Heroin," in The Year- book of Substance Use and Abuse, Vol. II, eds. L. Brill and C. Winick, New York: Human Sciences.

Rosenbaum, M. (1979), "Becoming Addicted: The Woman Addict," Contemporary Drug Problems, 8, 141-167.

Sachs, M. L. and D. Pargman (1984), "Running Addiction,-' in Running as Therapy: An Integrated Approach, eds. M. L. Sachs and G. W. Buffone, Lincoln, Nebraska: University of Nebraska Press.

Schmeling, David G. and C. Edward Wotring (1980), Making Anti-Drug-Abuse Advertising Work, Journal of Advertising Research, 20 (June), 33-37.

Shimp, Terence A. and Robert F. Dyer (1979), The Pain-Pill-Pleasure Model and Illicit Drug Consumption, Journal of Consumer Research, 6 (June), 36-46.

----------------------------------------