the smoker you drink, the player you get

I heard many fine presentations at a Robert Wood Johnson Foundation gathering last week, but the most provocative likely came from James Jackson, a University of Michigan psychologist. I don't want to blog any work in progress, so I'll limit this post to his 2010 American Journal of Public Health article, "Race and Unhealthy Behaviors: Chronic Stress, the HPA Axis, and Physical and Mental Health Disparities Over the Life Course."

Professor Jackson's basic hypothesis is that people cope with chronically stressful environments by engaging in unhealthy behaviors like smoking, drinking, and eating comfort foods -- and that these physically unhealthy behaviors might actually have protective mental-health effects. Of course, unhealthy behaviors eventually catch up to us, contributing to physical health problems that show up as morbidity and mortality disparities among the social groups who partake at varying rates.

Professor Jackson suggests that this hypothesis might help explain why African Americans generally have higher rates of physical health problems than non-Hispanic Whites but similar or lower rates of mental health problems, such as major depression. If a group uses unhealthy behaviors to cope with chronic stress, they might gain a short-term boost in mental health but pay a long-term physical health penalty. That said, the hypotheses isn't really about race differences, so much as the differential distribution of chronic stressors and the differential availability of healthy and unhealthy coping mechanisms.

Most data I've seen show that Whites do more drinking and smoking than African Americans, but Professor Jackson is hypothesizing race differences in effects rather than race differences in the prevalence or incidence of use. And this is what he found in the AJPH article. The figure below shows how the relationship between stressors and major-depression criteria varies by the level of unhealthy behaviors for African Americans (in panel a) and for Whites (in panel b). Stress was more strongly linked to depression among African American abstainers who had not engaged in unhealthy behaviors (the zero group) but stressors were unrelated to depression for African Americans who reported at least two of the unhealthy behaviors. For non-Hispanic Whites, on the other hand, the situation was reversed: those with the fewest unhealthy behaviors actually coped the best with stressors, perhaps due to their greater access to healthier stress-reducing alternatives.

I'd still be cautious about the race interaction until it is consistently replicated, but I'm more convinced by the argument about the protective mental health effects of unhealthy behaviors. Why else would parolees risk going back to prison and football stars risk million dollar contracts over minor substance use? They aren't partying (well, not all of them), they are dealing with stress in a way that, for better or worse, functions for them.

At this point, the hypothesis is intriguing and the evidence provisionally supportive, but the matter is far from settled. The first policy conclusion, of course, is to dial back the stressors in the first place -- reduce discrimination, improve living conditions, provide job opportunities, and reduce poverty for the most disadvantaged. With fewer stressors, there is less need or motivation for unhealthy coping. A second policy conclusion might involve finding or facilitating healthier alternative coping strategies.