Prevalence and risk factors associated with substance use in children: A questionnaire-based survey in two cities of Uttar Pradesh, India.

BACKGROUND: There is a sharp increase of substance use, particularly tobacco and alcohol, among schoolchildren. AIMS: A study was undertaken to assess the prevalence, age of initiation, and determinants for the uptake of tobacco and alcohol habits among ever-user students. SETTINGS AND
DESIGN: This was a cross-sectional study conducted among school students.
MATERIALS AND METHODS: Information on alcohol and tobacco use, age at initiation, peer influence, reason of initiation, etc., was collected from students of class 7th-12th(ages: 11-19 years) studying in schools of Noida and Ghaziabad cities, through a pretested self-administered questionnaire through multistage sampling design. Univariate analysis was done to assess the significance of various determinants.
RESULTS: "Ever use of substance" (alcohol or tobacco) was found in 14.3% students and was 1.2 times more among boys in comparison to girls (P < 0.05). About 29.5% of these students initiated the habit before 11 years of age and its prevalence was significantly more among boys from government schools as compared to private schools. The habits were 2.2, 3.8, and 4.6 fold higher among students if the father, mother, siblings, or friends also used substances. Substance use was less frequent among children of white-collared father and more educated parents. One-third of students up took the habit to make friends.
CONCLUSION: The rising prevalence of substance use among students is a threat to the society. Introducing a "substance use prevention policy" in schools to educate students about various adverse effects and refusal skills may help curb this menace. Copyright:

INTRODUCTION

Substance use (drug use) refers to a pattern of harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs.[1] Substance use earlier considered being a problem of street children, working and trafficked children, has now become widespread among school going children from different socioeconomic and educational backgrounds.[2]

According to a study, for Protection of Child Rights, the common substances of use among adolescents are tobacco and alcohol, followed by inhalants and cannabis[3] and it has also been reported that in India around 20 million children a year and nearly 55,000 children a day start using tobacco. The initiation of alcohol intake is also seen generally in adolescence due to tobacco use[4] and is the most often used psychoactive substance among them.[5] In 2002, the WHO estimated that the use of alcohol and illicit drugs contibuted to 4.0% of the disease burden in the 15–29 years age group in low- and middle-income countries.[6] With the change in social qualities and economic status, the consumption of substances has increased tremendously. New trends in the use of substances have emerged with multiple substance use becoming common and tobacco habit increasing among adolescent girls.[7]

Adolescence and late childhood being the impressionable phase of life, students often experiment with the new activities under peer pressure and parental influence. They easily fall prey to the habit of substance use, particularly tobacco and alcohol, owing to their easy availability and disposable pocket money. Early uptake of these substances increases their likelihood to adopt other risk behaviors as well at a later age, such as multiple substance use, violence, and delinquency.[8]

Although tobacco use, alcohol drinking, and use of other substances (namely ganja and charas) are often initiated at a young age, only a few epidemiological studies have assessed the prevalence of substance use and the prevalence of “exclusive alcohol” among children in developing countries. The present study was planned to assess the prevalence, age of initiation, and determinants of tobacco and alcohol use among school students in two cities of Uttar Pradesh, India.

MATERIALS AND METHODS

Information on tobacco and alcohol use was collected from students of class 7–12 (ages: 11–19 years) studying in different schools of Noida and Ghaziabad (two cities of Uttar Pradesh, India) through a pretested, closed, and open-ended self-administered questionnaire through multistage sampling design with no identification (name of the student, roll number, etc.) during a 6-month period. We conducted the survey initially in the city of Noida, but later on, on the advice of our expert group, the survey was conducted in the satellite city of Ghaziabad for comparison purpose.

The methodology for the selection of schools, classes, and students for administering questionnaire is depicted in Flowchart [Illustration 1].

Illustration 1

Flow chart depicting the methodology for survey among school students. R.S.: Random Sampling

A total of 7224 questionnaires were distributed to all eligible students of schools (Noida: 4786 and Ghaziabad: 2438). The data were collected on sociodemographic profile, occupation, and literacy status of their parents. The use of these substances by parents and siblings, peer influence, reason of initiation, places of consumption, etc., was also recorded. The study was approved by the Institutional ethics and review committee. The principals of the schools were informed in writing about the importance of survey. Students were told to participate in the study voluntarily and informed consent from the students and school authorities was obtained.

The health questionnaire about tobacco use was prepared based on a questionnaire from the Global Youth Tobacco Survey.[9] No changes were made in questions about tobacco, but some were excluded. On the similar lines of tobacco, questions on alcohol use were incorporated. The questionnaire was provided in English to private school students and was translated in Hindi for government school students. The translated version was validated before the survey. Letter codes were used to the link the respondents to the questionnaires'. The key containing the name to code linkage information was stored separately from the questionnaires. Although the names/addresses of respondents were not included in the questionnaires, the students were assured that all information would be kept confidential. The detailed methodology has been explained elsewhere.[10]

The habits were classified as “Ever substance users” (used any one of the substances, i.e., tobacco in any form or alcohol or both irrespective of time and frequency in lifetime), “Ever use of alcohol” (the use of alcohol even once, in any form during life time, including current use), “Ever use of tobacco” (the use of tobacco in the form of smoking or smokeless tobacco or use of both forms even once, during lifetime, including current use), and “Ever use of combined tobacco and alcohol” (use of tobacco and use of alcohol simultaneously irrespective of time and frequency in lifetime).

Statistical analysis

Univariate analysis was done to assess the significance of various parameters. Data were analyzed using Epi-info 6.04 Dos version (free software downloaded from internet) and SPSS (version 21 SPSS South Asia (P) Ltd., Bangalore, India) software. Differences in proportions between the various groups, namely between girls and boys and between ever users and never users, were tested using Pearson's Chi-square test or Fisher's exact test, as appropriate along with odds ratio (OR) and 95% confidence intervals (CIs). For all the statistical tests, “P” < 0.05 was considered statistically significant.

RESULTS

A total of 8546 questionnaires were distributed to students of both cities and from that 7224 students filled the questionnaire. Of the remaining 1322 (15.5%) students, some were absent on the day of collection, while the remaining declined to participate because of parental refusal. The response rate was 84.5% (Noida – 85.0% and Ghaziabad – 84.0%).

Of the 7224 students (boys: 4116 [57%] and girls: 3108 [43%]), 4786 were enrolled from Noida (boys: 2360 [49.3%] and girls: 2426 [50.7%]) and 2438 (boys: 1756 [72.0%] and girls: 682 [28.0%]) from Ghaziabad.

The prevalence of ever use of any substance (tobacco or alcohol) was found in 1031 of 7224 students (14.3%). It was 1.2 times significantly more among boys in comparison to girls (P < 0.05). The prevalence of “Ever use of tobacco,” “Ever use of alcohol,” and “Ever use of combined tobacco and alcohol” was 670 (9.3%), 564 (7.8%), and 203 (2.8%), respectively; this was 2.0 times, 1.3 times, and 1.6 times significantly more among boys in comparison to girls (P < 0.001, P < 0.001 and P < 0.05). The prevalence of ever use of substance was found to be 1.3 times more among boys from the government schools in comparison to private school (P < 0.05), whereas alcohol use was 1.5 times more among girls from government schools in comparison to girls from private schools (P < 0.05) [Table 1]. No statistically significant difference was found in the age of initiation of these habits among the boys <11 years from two types of schools [Table 2].

Table 1

Gender-wise prevalence of ever use of substance

Habit	Gender		Total (n=7224), n (%)	P	OR (95% CI)
	Boys (n=4117), n (%)	Girls (n=3107), n (%)
Ever use of tobacco (smoking or chewing tobacco)	401 (9.7)	269 (8.7)	670 (9.3)	<0.001*	2.0 (1.66-2.30)
Ever use of alcohol	358 (8.7)	206 (6.6)	564 (7.8)	0.001*	1.3 (1.12-1.60)
Ever use of tobacco and alcohol simultaneously	138 (3.4)	65 (2.1)	203 (2.8)	0.002*	1.6 (1.20-2.19)
Ever use of substance (tobacco or alcohol)	621 (15.1)	410 (13.2)	1031 (14.3)	0.03*	1.2 (1.02-1.33)
Never substance users	3536 (57.1)	2657 (42.9)	6193 (85.7)

*Significant. OR – Odds ratio; CI – Confidence interval

Table 2

Prevalence of ever use of substance according to the type of schools and gender

Habit	Gender
	Boys				Girls
	Government (n=1817), n (%)	Private (n=2300), n (%)	P	OR (95% CI)	Government (n=1335), n (%)	Private (n=1772), n (%)	P	OR (95%CI)
Ever use of tobacco (smoking or chewing tobacco)	199 (49.6)	202 (50.4)	0.02*	1.3 (1.04-1.57)	108 (40.1)	161 (59.9)	0.9	0.9 (0.68-1.14)
Ever use of alcohol	191 (53.4)	167 (46.6)	<0.001*	1.5 (1.21-1.87)	107 (51.9)	99 (48.1)	0.007*	1.5 (1.11-1.95)
Ever use of tobacco and alcohol simultaneously	81 (58.7)	57 (41.3)	<0.001*	1.8 (1.30-2.59)	29 (44.6)	36 (55.4)	0.78	1.1 (0.65-1.76)
Ever use of substance (tobacco or alcohol)	309 (49.8)	312 (50.2)	0.002*	1.3 (1.1-1.55)	186 (45.4)	224 (54.6)	0.3	1.1 (0.91-1.38)

*Significant. OR - Odds ratio; CI – Confidence interval

About 31.2% (168) of the substance-using (ever use of substanc) boys initiated the habit before attaining the age of 11 years in comparison to 26.8% (89) of girls (P < 0.05, OR = 1.4, CI: 1.06–1.93) (P < 0.05). The number of girls taking up the substance habit increased with the increasing age of initiation, but the trend was not statistically significant (P > 0.05). More number of boys from government schools was found to initiate substance use in the age group of 12–13 years in comparison to boys from private schools.(P < 0.05) [Table 3].

Table 3

Sex-wise distribution of ever tobacco or alcohol users according to the age at the initiation of these substance and type of school

Age group at initiation (years)	Gender						Total (%) (boys + girls)	Comparison between boys and girls P (OR, 95% CI)
	Boys			Girls
	Private n (%)	Government n (%)	P (OR 95% CI)	Private n (%)	Government n (%)	P (OR, 95% C.I.)
≤11	85 (32.2)	83 (30.3)	0.6 (1.1, 0.76-1.57)	50 (14.3)	39 (40.7)	0.7 (0.9, 0.56-1.49)	257 (29.5)	0.02* (1.4, 1.06-1.93)
12-13	88 (33.3)	121 (44.2)	0.01* (0.6, 0.49-0.90)	80 (28.6)	41 (18.5)	0.02* (1.7, 1.08-2.74)	330 (37.9)	0.48 (1.1, 0.83-1.47)
≥14	91 (34.5)	70 (25.5)	0.02* (1.5, 1.06-2.23)	62 (57.1)	60 (40.7)	0.049* (0.6, 0.41-1.00)	283 (32.5)	0.04* (0.7, 0.55-0.98)
Total	264 (49.1)	274 (50.9)		192 (57.8)	140 (42.2)		870

*Significant. OR – Odds ratio; CI – Confidence interval

Tobacco and alcohol use by parents (father: OR: 2.2, CIs: 1.92–2.51, mother: OR: 3.8, CIs: 2.71–5.31) and siblings or friends (OR: 4.6, CI's: 3.98–5.25) had a significant association with student's substance use (P < 0.001) [Table 4]. Students whose parents were less educated and those whose fathers were in blue-collared jobs reported a significantly higher prevalence of substance use against those whose parents were more educated and had fathers in white-collared jobs (P < 0.001, P < 0.001, and P < 0.05, respectively) [Table 5].

Table 4

Substance consumption in students according to the similar habits of their parents, friends, and siblings

Tobacco and alcohol habits among students	Father's habit				Mother's habit				Friends/sibling habit
	Yes, n (%)	No, n (%)	Total, n (%)	P, OR (CIs)	Yes, n (%)	No, n (%)	Total, n (%)	P, OR (CIs)	Yes, n (%)	No, n (%)	Total, n (%)	P, OR (CIs)
Present	512 (21.0)	519 (10.8)	1031 (14.3)	<0.001*2.2	57 (37.7)	974 (13.8)	1031 (14.3)	<0.001*3.8	649 (27.9)	382 (7.8)	1031 (14.3)	<0.00146 (3.98-5.25)
Absent	1921 (79.0)	4272 (89.2)	6193 (85.7)	(1.92-2.51)	94 (62.3)	6099 (86.2)	6193 (85.7)	(2.71-5.31)	1678 (72.1)	4515 (92.2)	6193 (85.7)	(3.98-5.25)
Total	2433 (33.7)	4791 (66.3)	7224		151 (2.1)	7073 (97.9)	7224		2327 (38.9)	4897 (67.8)	7224

*Significant. OR – Odds ratio; CI – Confidence interval

Table 5

Distribution of tobacco- and alcohol-using students according to the occupation and education of parents

Habit of alcoholand tobacco among students	Fathers’ occupation				Mothers’ occupation
	Blue collared, n (%)	White collared, n (%)	Total, n (%)	P, OR (CIs)	Working, n (%)	Housewives, n (%)	Total, n (%)	P, OR (CIs)
Present	196 (16.8)	835 (13.8)	1031 (14.3)	0.006*, 1.3	225 (13.6)	806 (14.5)	1031 (14.3)	0.4, 0.9
Absent	968 (83.2)	5225 (86.2)	6193 (85.7)	1425 (86.4)	4768 (85.5)	6193 (85.7)		(0.80-1.10)
Total	1164 (16.1)	6060 (83.9)	7224		1650 (22.8)	5574 (77.2)	7224
Habit of alcoholand tobacco among students	Fathers’ education				Mothers’ education
	Graduate		Total	P, OR (CIs)	Graduate		Total, n (%)	P, OR (CIs)
	No, n (%)	Yes, n (%)			No, n (%)	Yes, n (%)
Present	572 (16.2)	459 (12.4)	1031 (14.3)	<0.001*, 1.4 (1.20-1.56)	733 (16.0)	298 (11.2)	1031 (14.3)	<0.001*, 1.5 (1.31-1.75)
Absent	2955 (83.8)	3238 (87.6)	6193 (85.7)	3835 (84.0)	2358 (88.8)	6193 (85.7)
Total	3527 (48.8)	3697 (51.2)	7224		4568 (63.2)	2656 (36.8)	7224

*Significant. OR – Odds ratio; CI – Confidence interval

Among ever substance users, 45.1% of the students spent part or all their pocket money on buying substances. About 31.2%, 5.3%, and 11.2% of the students procured these substances from friends, siblings, and relatives, respectively. Nearly 31.8% of the boys and 42% of the girls adopted these habits to make friends, whereas 12.9% of the students felt that one looks smart if using these substances. It was observed that majority of the students preferred using these substances at public places, whereas only 12% of the students used these substances at home.

More than 40% of the substance users liked and adopted the habit by watching celebrities using these products. About 80%, 90%, and 58% of the substance-using students reported that they got the information about harmful effects of substances from family members, media campaigns, and being taught in the school, respectively. Only 10.7% of substance-using students thought that they would continue using these products while majority wanted to quit in future.

DISCUSSION

The present study found the prevalence of self-reported ever use of substance (tobacco or alcohol) among students to be 14.3% which is similar to other studies conducted in Delhi (13.4%)[11] and Vadodra[12] (18%) but is lower than that reported from other parts of India (27.4%–60%).[13141516] The high prevalence found in latter studies could be because of the use of other types of substances or students being of the higher age group.

We observed the prevalence of self-reported ever use to be 9.3% for tobacco and 7.8% for alcohol. Similar observations were made in a study done on students from West Bengal[7] and rural Kerala.[17] The overall prevalence of ever use of alcohol in our study is lower in comparison to studies carried out in Manipur[15](29%) and Sambalpur[18](14.7%). Easy accessibility and social acceptability of consumption of these substances could be the reasons for the high prevalence in these areas. In respect of the multiple substance use (namely tobacco and alcohol), only 2.8% of the students reported this habit in our study, whereas Qadri et al.[16] and Medhi et al.[19] reported a much higher figure of 29.13% and 27.4%, respectively.

Substance use was 1.2 times more prevalent among male students as compared to female students (P < 0.05) in this study. The possible reasons could be the higher level of exposure, the peer pressure, and social acceptance among boys as compared to girls. Similar results have been reported in other studies as well.[11182021]

The substance use was significantly more prevalent among male students from government schools (17%) in comparison to the private schools (13.6%) in our study. In contrast, a study from Himachal Pradesh, India,[13] reported the prevalence to be less in government school students as these schools were located in the villages where it was easy to spot the students abusing a substance. His fear factor might have kept the student away from indulging in substance use.

Majority (37.9%) the students in the present survey initiated substance use in the age group of 12–13 years. Another study[16] has reported the age of uptake of substance use to be 13–16 years, the age when the behavioral changes from childhood to adolescence take place. As reported by Stockings et al.,[22] we also found a decreasing trend in the initiation of substance with the increasing age. The initiation of substance use at a young age is a matter of concern as earlier the age at which student experiment with the first substance, the higher are the rates of addiction and the greater the risk of suffering from health problems in adulthood.[23] There is therefore a rational need to target the students in this age bracket to effectively tackle the problem.

The use of tobacco and alcohol by parents and influence of addicted friends and siblings were the key determinants in adopting the habit of substance use. Other authors have also cited that peer and parental influences are synergistic, with the maximum rates of substance use observed among children of substance-abusing parents, siblings, and friends.[715]

Students with low parental education level and blue-collared fathers reported a significantly higher prevalence of substance use in comparison to students with parents possessing higher education and white-collared fathers. This emphasizes the importance of parental monitoring to reduce the likelihood of substance use of student. However, a study done in Assam had contrary results and did not reveal any correlation between students' substance use behavior with parents' education and occupational status.[24]

The main reason reported by students for adopting the substance habit in our study was to make friends and to look smart, whereas other authors[711] have highlighted enjoyment, curiosity, and socialization as the most common reasons for substance use by adolescents.

Similar to our study, a study from West Bengal[25] also cited disposable pocket money to be an important determinant for acquiring these habits. Awareness regarding substance being harmful to health was observed in 90% of the students in our study which is comparable to 96% found in a study from Kerala.[26] The students reported being taught in the school about adverse effects of these substances.

In the present study, 70.7% of the substance users expressed their desire to quit the habit. A similar intention of quitting has been reported among substance-using adolescents from Dehradun[14] and Eastern India.[20] These findings highlight the need of introducing preventive methods to counsel and assist these self-motivated students in quitting habits.

The study was based on a self-administered questionnaire, and findings might have been influenced by the reliability of response. The school dropouts and students who were not present on the day of the survey were not included. Thus, the data interpretation might not reflect the true prevalence among students.

CONCLUSION

Substance use is increasingly being recognized as a public health problem among the school students of India. The alarming increase in the prevalence of tobacco and alcohol use among students has been ascribed to multiple factors. The adolescents spend quality time at school where they are influenced by their instructors and companion students. Therefore, it is important to design and implement school-based health education programs targeting students to make them aware of various adverse health effects of substance use and to teach them refusal skills. The availability of these products near educational institutions should be banned by strict enforcement of laws. These measures are likely to reduce the prevalence of substance use, thereby reducing the extent of this emerging problem in our country.

Strengths and limitations

The strengths of our survey include a randomly selected class sample and that all students of a selected class were asked to participate. The appropriate sample size and valid measures of tobacco use further add to the credibility of the study. The study also has some weaknesses. A major limitation is that tobacco use was self-reported. Poor memory, misunderstanding questions, or intentional deception can interfere with the results in such a study. The actual prevalence of tobacco use in the study was less than anticipated, probably due to fewer than estimated number of responders.

Limitation

Generalzation: the study enrolled students from the schools in Noida and Ghaziabad only. It may not be prudent to generalize these results.

This article deals only ever use tobacco and alcohol among students. The current use has not been taken into account which may influence the outcome of the survey.

The other limitation is that the prevalence of substance use has been done in “non-probability” sampling.

The response rate was 85% in the present study. Since the characteristics of nonresponders (15%) who were present in the class but did not answer the questionnaire were not studied, it would be an important limitation in the interpretation of the findings of the study. The use of self-reported age of onset from cross-sectional data is another limitation. Longitudinal studies have demonstrated that older adolescents tend to report a later age of smoking onset than younger ones.[17] The smoking behavior mentioned in the questionnaire may differ from the actual smoking habit. The potential bias resulting from some students being absent on the day of the survey is another limitation as these students might have higher rates of health risk behaviors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.