Abstracts

Introduction

Adolescence is marked by considerable existential conflicts as well as exposure and vulnerability to substance abuse. Young people have greater problems regarding alcohol intake. Moreover, early initiation in alcohol use is one of the most important predictors of future health, socio-cultural and economic problems¹1. Strauch ES, Pinheiro RT, Silva RA, Horta BL. Uso de alcohol por adolescentes: estudio de base poblacional. Rev Saude Publica 2009; 43(4):647-655.. The following factors are considered facilitators of alcohol use among adolescents: lifestyle, high levels of stress and anxiety, low self-esteem, depressive symptoms, susceptibility to peer pressure and problems associated with school²2. Copeland WE, Angold A, Shanahan L, Dreyfuss J, Dlamini I, Costello EJ. Predicting persistent alcohol problems: a prospective analysis from the Great Smoky Mountain Study. Psychol Med 2012; 42(9): 1925-1935.

3. Marsiglia FF, Ayers S, Gance-Cleveland B, Mettler K, Booth J. Beyond primary prevention of alcohol use: a culturally specific secondary prevention program for Mexican heritage adolescents. Prev Sci 2011; 13(3):241-251.^-44. Richmond MJ, Merelstein RJ, Metzger A. Heterogeneous friendship affiliation, problem behaviors, and emotional outcomes among high-risk adolescents. Prev Sci 2012; 13(3):267-277..

Even in small amounts, alcohol use has a number of consequences, such as risky sexual behavior, increased suicide rate, violence, juvenile delinquency, familial conflicts, conflicts with friends, a greater risk of accidents and illicit drug use and is therefore considered a serious public health problem²2. Copeland WE, Angold A, Shanahan L, Dreyfuss J, Dlamini I, Costello EJ. Predicting persistent alcohol problems: a prospective analysis from the Great Smoky Mountain Study. Psychol Med 2012; 42(9): 1925-1935.^,33. Marsiglia FF, Ayers S, Gance-Cleveland B, Mettler K, Booth J. Beyond primary prevention of alcohol use: a culturally specific secondary prevention program for Mexican heritage adolescents. Prev Sci 2011; 13(3):241-251.^,55. Doku D, Koivusilta L, Rimpelä A. Socioeconomic differences in alcohol and drug use among Ghanaian adolescents. Addict Behav 2011;13(3):357-360.

6. Lee C, Rose JS, Engel-Rebitzer E, Selya A, Dierker L. Alcohol dependence symptoms among recent onset adolescent drinkers. Addict Behav 2011; 36(12):1160-1167.

7. Hipwell A, Stepp S, Chung T, Durand V, Keenan K. Growth in alcohol use as a developmental predictor of adolescent girls' sexual risk-taking. Prev Sci 2012; 13(2):118-128.^-88. Costa JL, Troncoso ES, Gallego MP, Maza VTS, Barcenilla AC, Cubells CL, San Molina L. Perfil de los adolescentes que acuden a urgencias por intoxicación enólica aguda. An Pediatr (Barc) 2011; 76(1):30-37.. Alcohol is the only psychotropic drug accepted and even encouraged by society⁹9. Malta DC, Sardinha LMV, Mendes I, Barreto SM, Giatti L, Castro IRR, Moura Ld, Dias AJ, Crespo C. Prevalence of risk health behavior among adolescents: results from the 2009 National Adolescent School-based Health Survey (PeNSE). Cien Saude Colet 2010; 15(Supl. 2):3009-3019., which allows early contact (even prior to 11 years of age) and increases the risk of future dependence¹⁰10. Malta DC, Mascarenhas MDM, Porto DL, Duarte EA, Sardinha LM, Barreto SM, Morais Neto OL. Prevalence of alcohol and drug consumption among adolescents: data analysis of the National Survey of School Health. Rev Bras Epidemiol 2011; 14(1):136-146.^,1111. World Health Organization (WHO). About global alcohol database. Geneva: WHO; 2002.. In a study carried out in Australia, 19.2% of adolescents reported consuming one or more drinks in the previous three months¹²12. Hodder RK, Daly J, Freund M, Bowman J, Hazell T, Wiggers J. A school-based resilience intervention to decrease tobacco, alcohol and marijuana use in high school students. BMC Public Health 2011; 11:722.. In Portugal, approximately 50% of adolescents report having experimented with alcohol¹³13. Fraga S, Sousa S, Ramos E, Dias S, Barros H. Alcohol use among 13-year-old adolescents: associated factors and perceptions. Public Health 2011; 125(7):448-456.. In the United States, it is estimated that 4.6% of adolescents between 12 and 17 years of age have a dependence on alcohol¹⁴14. Caetano R, Babor T. Diagnosis of alcohol dependence in epidemiological surveys: an epidemic of youthful alcohol dependence or a case of measurement. Addiction 2006; 101(1):111-114.. Studies carried out in Brazil report prevalence values of alcohol experimentation ranging from 48.3 to 71.4% in adolescence, as well as a 27.3% frequency of regular use, 22.1% frequency of drunkenness at some time in life and 8.9% frequency of heavy use¹⁰10. Malta DC, Mascarenhas MDM, Porto DL, Duarte EA, Sardinha LM, Barreto SM, Morais Neto OL. Prevalence of alcohol and drug consumption among adolescents: data analysis of the National Survey of School Health. Rev Bras Epidemiol 2011; 14(1):136-146.^,1515. Galduróz JC, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLA, Carlini EA. Factores asociados al uso pesado de alcohol entre estudiantes de las capitales brasileras. Rev Saude Publica 2010; 44(2):267-273..

There are few alcohol prevention programs in Brazil and rules restricting the advertising of alcoholic beverages are questionable¹⁶16. Faria R, Vendrame A, Silva R, Pinsky I. Propaganda de alcohol y asociación al consumo de cerveza por adolescentes. Rev Saude Publica 2011; 45(3):441-447.. As in other countries, alcohol use among Brazilian adolescents is an under-explored issue that needs to be discussed. The determination of the epidemiological profile of alcohol use and analysis of behaviors, attitudes and associated factors could contribute toward a better understanding of this complex problem and guide the drafting of health programs aimed at the prevention and combating of alcohol use in adolescence.

The aim of the present study was to assess the association between attitudes and behaviors regarding alcohol use and analyze associated factors among adolescents at public schools in northeastern Brazil.

Methods

A cross-sectional study was carried out involving 574 male and female adolescents between 10 and 19 years of age at public schools in the city of Campina Grande, state of Paraíba, Brazil. The participants were selected from a population of 11,228 students, with the sample corresponding to 5.11% of this population. Campina Grande had approximately 386 thousand inhabitants and is divided into six districts. It is an industrialized city with considerable cultural, social and economic disparities. Mean monthly income per capita is 110 US dollars and the human development index is 0.72¹⁷17. Instituto Brasileiro de Geografia e Estatística (IBGE). Primeiros resultados do Censo 2010. [página na Internet]. [cited 2010 May 30 ]. Available from: http://www.censo2010.ibge.gov.br/dadosdivulgados/index.php?uf=25.
http://www.censo2010.ibge.gov.br/dadosdi... .

Two-stage sampling was performed to ensure representativity. Schools were randomly selected from each district of the city in the first stage and schoolchildren were randomly selected from each school in the second stage. The sample size was calculated based on a 5% margin of error, 95% confidence level and an expected prevalence value of 50%. A 1.3 correction factor was applied to compensate for the design effect. The minimal sample was estimated to be 496 schoolchildren, to which 20% was added to compensate for possible losses, totaling 596 schoolchildren.

Eligibility criteria

. Adolescents aged 10 to 19 years, enrolled in the schools selected for the study, who authorized (adults) or whose parents/guardians (minors) authorized their participation by signing a statement of informed consent.

Data acquisition

Data acquisition was carried out between August and December 2010 by three previously calibrated researchers using a self-administered semi-structured questionnaire previously used by the Brazilian Information Center on Psychotropic Drugs¹⁸18. Galduróz JC, Noto AR, Nappo SA, Carlini EA. Use of psychotropic drugs in Brazil: household survey in the 107 biggest Brazilian cities-2001. Rev Lat Am Enfermagem 2005; 13(Spec issue):888-895.. The questions addressed the use of alcohol (intake pattern, type of beverage, company, location of use and purchasing of alcoholic beverages) and associated factors (gender, age group, schooling, work, religion, practice of sports, relationship with parents and parents' profile). Alcohol intake was defined based on the following categories:

Contact with the school was initially made to schedule the data acquisition procedure and deliver the statements of informed consent. The reliability of the responses was tested using the "face validation" method on 10% of the interviewees. For such, the researcher asked the respondents to explain what they understood by each question in their own words¹⁹19. Frankfort-Nachimias C, Nachimias D. Research methods in the social sciences. 4th Edition. London: Edward Arnold; 1992.. None of the interviewees exhibited any difficulty in answering the items on the questionnaire. Test-retest reliability was determined with a seven-day interval between applications of the questionnaire. Agreement between tests was 80%.

The administration of the questionnaire lasted a period of 10 minutes. After the questionnaires were returned to the researchers, an educational lecture was given on the consequences of alcohol use.

All data were analyzed using the Statistical Package for Social Sciences (SPSS for Windows, version 18.0, SPSS Inc, Chicago, IL, USA). The chi-squared test and Fisher's exact test were used to determine associations between the variables and experience with alcohol, with the level of significance set to 5% (p < 0.05).

Ethical considerations

Authorization from the State of Paraíba Secretary of Education was obtained prior to the survey carried out at the schools. This study received approval from the Human Research Ethics Committee of the Universidade Estadual da Paraíba (Brazil), in compliance with Resolution 196/96²⁰20. Brasil. Resolução 196, de 10 de outubro de 1996. Diretrizes e Normas Regulamentadoras de Pesquisas Envolvendo Seres Humanos. Diário Oficial da União 1996; 12 out. of the Brazilian National Health Council. Participants over 18 years of age and parents/guardians of participants under 18 years of age signed a statement of informed consent prior to the onset of the study. Anonymity was ensured in all cases.

Results

A total of 574 schoolchildren participated in the present study. Twenty-two individuals refused to participate, corresponding to a loss rate of 3.7%. Table 1 displays the characterization of the sample with regard to age, gender, schooling and alcohol use. The majority of the adolescents were between 13 to 15 years (53.8%), female (53.5%) and attended elementary school (87.6%). A total of 54.5% had experimented with alcohol, 6.7% of whom made heavy use of this substance. The largest portion of the sample began drinking between 11 and 14 years of age (42.8%). Friends offered alcoholic beverages the first time (43.1%) and were the most frequent form of company during alcohol consumption (40.3%).

A total of 26.3% had purchased alcoholic beverages personally. The most cited location of purchase was the supermarket (45.7%). Beer was the most often cited type of alcohol (43.8%) and 29.7% drank three or more glasses (Table 2).

In the bivariate analysis, experience with alcohol was associated with age group, religion, type of religion, schooling, scholastic delay, number of days absent from school and work (Table 3).

Significant associations were found between the use of alcoholic beverages and relationship with one's father, relationship with one's mother and relationship between parents (Table 4).

After the adjustment of the model, the risk of drinking was greater among those participants between 16 and 19 years of age, those without religion and those with a fair/poor relationship with their father (Table 5).

Discussion

Alcohol is the first psychotropic substance consumed by children and adolescents and abuse of this drug can have a negative effect on development¹⁰10. Malta DC, Mascarenhas MDM, Porto DL, Duarte EA, Sardinha LM, Barreto SM, Morais Neto OL. Prevalence of alcohol and drug consumption among adolescents: data analysis of the National Survey of School Health. Rev Bras Epidemiol 2011; 14(1):136-146.. High alcohol intake in this phase of like and the consequences of this practice constitute a phenomenon seen worldwide⁸8. Costa JL, Troncoso ES, Gallego MP, Maza VTS, Barcenilla AC, Cubells CL, San Molina L. Perfil de los adolescentes que acuden a urgencias por intoxicación enólica aguda. An Pediatr (Barc) 2011; 76(1):30-37.^,2121. Malone PS, Northrup TF, Masyn KE, Lamis DA, Lamont AE. Initiation and persistence of alcohol use in United States black, Hispanic, and white male and female youth, Addict Behav 2012; 37(3):299-305..

In the present study, 54.5% of the adolescents had contact with alcoholic beverages. Despite the high prevalence, this figure is lower than that found in the recent Brazilian National School Health Survey, which reports a prevalence value of 71.4% among adolescent schoolchildren¹⁰10. Malta DC, Mascarenhas MDM, Porto DL, Duarte EA, Sardinha LM, Barreto SM, Morais Neto OL. Prevalence of alcohol and drug consumption among adolescents: data analysis of the National Survey of School Health. Rev Bras Epidemiol 2011; 14(1):136-146.. Analyzing the frequency of use, 8.6% and 6.7% of those who had contact with alcohol made frequent and heavy use of this substance, respectively. The high consumption of alcohol among adolescents has been reported in a number of studies, with prevalence values ranging from 3.3% to 16.4%²2. Copeland WE, Angold A, Shanahan L, Dreyfuss J, Dlamini I, Costello EJ. Predicting persistent alcohol problems: a prospective analysis from the Great Smoky Mountain Study. Psychol Med 2012; 42(9): 1925-1935.^,66. Lee C, Rose JS, Engel-Rebitzer E, Selya A, Dierker L. Alcohol dependence symptoms among recent onset adolescent drinkers. Addict Behav 2011; 36(12):1160-1167.^,88. Costa JL, Troncoso ES, Gallego MP, Maza VTS, Barcenilla AC, Cubells CL, San Molina L. Perfil de los adolescentes que acuden a urgencias por intoxicación enólica aguda. An Pediatr (Barc) 2011; 76(1):30-37.^,1212. Hodder RK, Daly J, Freund M, Bowman J, Hazell T, Wiggers J. A school-based resilience intervention to decrease tobacco, alcohol and marijuana use in high school students. BMC Public Health 2011; 11:722.^,1515. Galduróz JC, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLA, Carlini EA. Factores asociados al uso pesado de alcohol entre estudiantes de las capitales brasileras. Rev Saude Publica 2010; 44(2):267-273.^,2222. Campos JA, Almeida JC, Garcia PPNS, Faria JB. Alcohol consumption among high school students in the municipality of Passos - MG. Cien Saude Colet 2011; 16(12):4745-4754.^,2323. Cordova D, Huang S, Pantin H, Prado G. Do the effects of a family intervention on alcohol and drug use vary by nativity status? Psychol Addict Behav 2012; 26(3):655-660.. Moreover, one cannot discount the possibility of the occurrence of information bias, as a stigma is attached to alcohol use due to the fact that it is illegal for minors. It is therefore possible that this practice was under-reportEdição. However, the self-administered questionnaire with the assurance of anonymity may have minimized this possibility.

The lowest age reported regarding the first experimentation with alcohol was five years and the most common age range at which alcohol was first used was between 11 and 14 years. The increasingly earlier initiation into alcohol use has been described in previous studies⁸8. Costa JL, Troncoso ES, Gallego MP, Maza VTS, Barcenilla AC, Cubells CL, San Molina L. Perfil de los adolescentes que acuden a urgencias por intoxicación enólica aguda. An Pediatr (Barc) 2011; 76(1):30-37.^,1010. Malta DC, Mascarenhas MDM, Porto DL, Duarte EA, Sardinha LM, Barreto SM, Morais Neto OL. Prevalence of alcohol and drug consumption among adolescents: data analysis of the National Survey of School Health. Rev Bras Epidemiol 2011; 14(1):136-146.^,1313. Fraga S, Sousa S, Ramos E, Dias S, Barros H. Alcohol use among 13-year-old adolescents: associated factors and perceptions. Public Health 2011; 125(7):448-456.^,2323. Cordova D, Huang S, Pantin H, Prado G. Do the effects of a family intervention on alcohol and drug use vary by nativity status? Psychol Addict Behav 2012; 26(3):655-660.. These findings underscore the need for educational and prevention programs in the school setting aimed at combating alcohol use beginning at an early age, as occurs with anti-smoking campaigns in schools.

The influence of friends was clearly expressed when the participants were asked who offered alcoholic beverages the first time and the location at which they drank with greater frequency. A possible explanation for this is the need for acceptance and the imitation of habits practiced by peers, which are common aspects of adolescence. Similar circumstances are reported in the literature⁴4. Richmond MJ, Merelstein RJ, Metzger A. Heterogeneous friendship affiliation, problem behaviors, and emotional outcomes among high-risk adolescents. Prev Sci 2012; 13(3):267-277.^,2424. Duncan AE, Agrawal A, Bucholz KK, Sartor CE, Madden PAF, Heath AC. Deconstructing the architecture of alcohol abuse and dependence symptoms in a community sample of late adolescent and emerging adult women: An item response approach. Drug Alcohol Depend 2011; 116(1-3):222-227.^,2525. Manrique-Abril FG, Ospina JM, Garcia-Ubaque JC. Children and adolescents' alcohol and tobacco consumption in Tunja, Colombia. Rev Salud Publica 2011; 13(1):89-101..

In Brazil, the sale of alcoholic beverages to minors is prohibited by Article 243 of the Child and Adolescent Statute (Law 8.069/90²⁶26. Brasil. Lei 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União 1990; 16 jul.) and article 63 of the Penal Misdemeanors Law. Moreover, prohibiting the sale of alcohol to minors is among the measures proposed by the World Health Organization for reducing alcohol consumption among this portion of the population²⁷27. Romano M, Duailib S, Pinsky I, Laranjeira R. Alcohol purchase survey by adolescents in two cities of State of Sao Paulo, Southeastern Brazil. Rev Saude Publica 2007; 41(4):495-501.. Nonetheless, 26.3% of the participants reported purchasing alcoholic beverages personally and 45.7% of these individuals bought the substance from supermarkets. The lack of monitoring the sale of alcoholic beverages to minors is a problem reported in other countries as well²⁸28. Freisthler B, Gruenewald PJ, Treno AJ, Lee J. Evaluating alcohol access and the alcohol environment in neighborhood areas. Alcohol Clin Exp Res 2003; 27(3):477-484..

Beer was the most often cited type of alcoholic beverage (43.8%), as reported in previous studies involving this age group²⁹29. Perera B, Torabi M, Kay NS. Alcohol use, related problems and psychological health in college students. Int J Adolesc Med Health 2011; 23(1):33-37.. In this respect, it seems that adolescents are influenced by the media and tend to associate alcohol intake with pleasure²⁸28. Freisthler B, Gruenewald PJ, Treno AJ, Lee J. Evaluating alcohol access and the alcohol environment in neighborhood areas. Alcohol Clin Exp Res 2003; 27(3):477-484.. There is no rigorous control in Brazil regarding the times alcoholic beverages are advertised on television, which may contribute to this influence. Moreover, young people tend not to associate beer with alcoholism¹⁶16. Faria R, Vendrame A, Silva R, Pinsky I. Propaganda de alcohol y asociación al consumo de cerveza por adolescentes. Rev Saude Publica 2011; 45(3):441-447..

Based on restrictive measures regarding the sale of alcohol to minors, there is a tendency toward binge drinking among adolescents, which is characterized by four or more drinks for females and five or more drinks for males on a single occasion³⁰30. Miller JW, Naimi TS, Brewer RD, Jones SE. Binge drinking and associated health risk behaviors among high school students. Pediatrics 2007; 119(1):76-85.. In the United States, 90% of youths demonstrate this behavior³¹31. Brewer RD, Swahn MH. Binge drinking and violence. JAMA 2005; 294(5):616-618.. A study carried out in Brazil reports that 11.37% of the schoolchildren surveyed exhibited this type of behavior once a week and 1.65% participated in binge drinking nearly every day²²22. Campos JA, Almeida JC, Garcia PPNS, Faria JB. Alcohol consumption among high school students in the municipality of Passos - MG. Cien Saude Colet 2011; 16(12):4745-4754.. In the present study, 22.3% of those who had experimented with alcohol exhibited this behavior. It should be stressed that binge drinking can lead to alcohol intoxication and an increase in the incidence of stroke³²32. Puddey IB, Rakic V, Dimmitt SB, Beilin LJ. Influence of pattern of drinking on cardiovascular disease and cardiovascular risk factors: a review. Addiction 1999; 94(5):649-663.. This type of behavior has also been associated with an increase in violence, cigarette smoking, illicit drug use, traffic accidents, risky sexual behavior, depression and suicide³⁰30. Miller JW, Naimi TS, Brewer RD, Jones SE. Binge drinking and associated health risk behaviors among high school students. Pediatrics 2007; 119(1):76-85.^,3131. Brewer RD, Swahn MH. Binge drinking and violence. JAMA 2005; 294(5):616-618.^,3333. Kwan MY, Cairney J, Faulkner GE, Pullenayegum EE. Physical activity and other health-risk behaviors during the transition into early adulthood a longitudinal cohort study. Am J Prev Med 2012; 42(1):14-20..

The literature reports associations between alcohol intake and age group, gender, religion, level of schooling, scholastic problems (scholastic delay, number of absences from school in previous 30 days), financial autonomy, the practice of sports and familial problems¹⁵15. Galduróz JC, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLA, Carlini EA. Factores asociados al uso pesado de alcohol entre estudiantes de las capitales brasileras. Rev Saude Publica 2010; 44(2):267-273.. In the present study, however, the adjusted model revealed that only the following variables were associated with alcohol intake: age group, type of religion, work and relationship with one's father.

Students between 16 and 19 years of age were at greater risk for alcohol use (OR = 4.44; 95% CI: 2.81-7.86; p < 0.001), which corroborates findings reported in previous studies¹1. Strauch ES, Pinheiro RT, Silva RA, Horta BL. Uso de alcohol por adolescentes: estudio de base poblacional. Rev Saude Publica 2009; 43(4):647-655.. It appears that familial monitoring is reduced with the increase in the age of adolescents and independence and increased confidence may be possible causes of a greater propensity toward drinking.

Based on findings reported in previous studies, greater alcohol consumption was expected among the male gender²²22. Campos JA, Almeida JC, Garcia PPNS, Faria JB. Alcohol consumption among high school students in the municipality of Passos - MG. Cien Saude Colet 2011; 16(12):4745-4754.^,3030. Miller JW, Naimi TS, Brewer RD, Jones SE. Binge drinking and associated health risk behaviors among high school students. Pediatrics 2007; 119(1):76-85.^,3434. Horta RL, Horta BL, Pinheiro RT, Morales B, Strey MN. Tobacco, alcohol, and drug use by teenagers in Pelotas, Rio Grande do Sul State, Brazil: a gender approach. Cad Saude Publica 2007; 23(4):775-783.. However, this gender predilection was not found in the present study, which is in agreement with findings described in a previous study conducted in southern Brazil¹1. Strauch ES, Pinheiro RT, Silva RA, Horta BL. Uso de alcohol por adolescentes: estudio de base poblacional. Rev Saude Publica 2009; 43(4):647-655.. Moreover, similarity in alcohol intake between genders is reported in a national survey³⁵35. Carlini EA, Galduróz JCF, Silva AAB, Noto AR, Fonseca AM, Carlini CM, Oliveira LC, Nappo SA, Moura YG, Sanchez ZvM. II Levantamento domiciliar sobre o uso de drogas psicotrópicas no Brasil: estudo envolvendo as 108 maiores cidades do país, 2005. Brasília: SENAD; 2007.. This may reflect greater permissiveness regarding alcohol use on the part of the female gender¹1. Strauch ES, Pinheiro RT, Silva RA, Horta BL. Uso de alcohol por adolescentes: estudio de base poblacional. Rev Saude Publica 2009; 43(4):647-655.. On the other hand, one must bear in mind that adolescence is a difficult period of conflicts in which bio-psychosocial changes occur and youths are prone to having new experiences, regardless of gender³⁶36. Sampaio Filho FJL, Sousa PRM, Vieira NFC, Nóbrega MFB, Gubert FA, Pinheiro PNC. Perception of risk of school adolescents in relation to alcohol consumption and sexual behavior. Rev Gaucha Enferm 2010; 31(3):508-514..

It is believed that practicing a religion binds individuals to a group with shared values and norms, in which there is an explicit condemnation of drug use³⁷37. Gryczynski J, Ward BW, Social norms and the relationship between cigarette use and religiosity among adolescents in the United States. Health Educ Behav 2011; 38(1):39-48.. In the present study, adolescents who reported having no religion were at greater risk for alcohol use (OR = 4.36; 95% CI: 1.10-17.09; p = 0.002). Although the participants were not asked whether they practiced their religion, it seems that belief in religious values alone may have had a positive influence over these adolescents. Previous studies report religious attitudes as a protective factor against alcohol use¹⁵15. Galduróz JC, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLA, Carlini EA. Factores asociados al uso pesado de alcohol entre estudiantes de las capitales brasileras. Rev Saude Publica 2010; 44(2):267-273.^,3737. Gryczynski J, Ward BW, Social norms and the relationship between cigarette use and religiosity among adolescents in the United States. Health Educ Behav 2011; 38(1):39-48.^,3838. Haber JR, Grant JD, Jacob T, Koenig LB, Heath A. Alcohol milestones, risk factors, and religion/spirituality in young adult women. J Stud Alcohol Drugs 2012; 73(1):34-43.. In the present study, adolescents pertaining to an evangelist church had a lower risk of alcohol consumption (OR = 1.97; 95% CI: 0.51-7.71; p = 0.002). This is in agreement with a national study that reports that evangelist adolescents are more conservative and tend to drink less alcohol³⁹39. Moreno RS, Ventura RN, Brêtas JR. The use of alcohol and tobacco by adolescents in the municipality of Embu, São Paulo, Brazil. Rev Esc Enferm USP 2010; 44(4):969-977..

Authors report a higher level of schooling as a risk factor for alcohol use³⁹39. Moreno RS, Ventura RN, Brêtas JR. The use of alcohol and tobacco by adolescents in the municipality of Embu, São Paulo, Brazil. Rev Esc Enferm USP 2010; 44(4):969-977.. However, despite the association between these variables in the bivariate analysis, level of schooling did not remain associated with alcohol use in the final model. It is therefore likely that the level of schooling is dependent upon age, which remained associated with alcohol use³⁹39. Moreno RS, Ventura RN, Brêtas JR. The use of alcohol and tobacco by adolescents in the municipality of Embu, São Paulo, Brazil. Rev Esc Enferm USP 2010; 44(4):969-977..

Regarding scholastic delays, studies indicate a weak association or an absence of an association between this variable and alcohol use¹1. Strauch ES, Pinheiro RT, Silva RA, Horta BL. Uso de alcohol por adolescentes: estudio de base poblacional. Rev Saude Publica 2009; 43(4):647-655.^,3434. Horta RL, Horta BL, Pinheiro RT, Morales B, Strey MN. Tobacco, alcohol, and drug use by teenagers in Pelotas, Rio Grande do Sul State, Brazil: a gender approach. Cad Saude Publica 2007; 23(4):775-783.. In agreement with such findings, no association was detected between scholastic delay and alcohol use in the present study. It is likely that the lack of scholastic yield is associated with the need to work, as the sample was composed exclusively of public school students, with a consequently less privileged socioeconomic status and possibly a need to work. Truancy on the part of adolescents who make use of alcohol has been reported in the literature¹1. Strauch ES, Pinheiro RT, Silva RA, Horta BL. Uso de alcohol por adolescentes: estudio de base poblacional. Rev Saude Publica 2009; 43(4):647-655.^,55. Doku D, Koivusilta L, Rimpelä A. Socioeconomic differences in alcohol and drug use among Ghanaian adolescents. Addict Behav 2011;13(3):357-360.^,1010. Malta DC, Mascarenhas MDM, Porto DL, Duarte EA, Sardinha LM, Barreto SM, Morais Neto OL. Prevalence of alcohol and drug consumption among adolescents: data analysis of the National Survey of School Health. Rev Bras Epidemiol 2011; 14(1):136-146.^,1515. Galduróz JC, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLA, Carlini EA. Factores asociados al uso pesado de alcohol entre estudiantes de las capitales brasileras. Rev Saude Publica 2010; 44(2):267-273.. In the present study, however, the number of absences in the previous 30 days lost its significance in the model after controlling for confounding variables. Similar to what occurred regarding scholastic delays, it is likely that another aspect, such as having a job, may have influenced this variable, as absence from school may reflect a necessity to work⁴⁰40. Noal RB, Menezes AMB, Araújo CL, Hallal PC. Experimental use of alcohol in early adolescence: the 11-year follow-up of the 1993 Pelotas (Brazil) birth cohort study. Cad Saude Publica 2010; 26(10):1937-1944..

Adolescents who held jobs were at greater risk for alcohol use (OR = 2.13; 95% CI: 1.18-3.83; p = 0.012). Financial independence and increased contact with adults in the workplace are reported to be possible causal factors of alcohol intake among working adolescents¹⁵15. Galduróz JC, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLA, Carlini EA. Factores asociados al uso pesado de alcohol entre estudiantes de las capitales brasileras. Rev Saude Publica 2010; 44(2):267-273.^,2222. Campos JA, Almeida JC, Garcia PPNS, Faria JB. Alcohol consumption among high school students in the municipality of Passos - MG. Cien Saude Colet 2011; 16(12):4745-4754.. Moreover, the stress caused by labor activities as well as parties and leisure activities in the company of workmates may also play an important role.

As reported in previous studies¹1. Strauch ES, Pinheiro RT, Silva RA, Horta BL. Uso de alcohol por adolescentes: estudio de base poblacional. Rev Saude Publica 2009; 43(4):647-655.^,4141. Tavares BF, Beria JU, Lima MS. Factors associated with drug use among adolescent students in southern Brazil. Rev Saude Publica 2004; 38(6):787-796., no association was found between the practice of sports and alcohol use. This is likely due to the negative effects alcohol can have on physical endurance and strength⁴²42. Rodrigues ESR, Cheik NC, Mayer AF. Level of physical activity and smoking in undergraduate students. Rev Saude Publica 2008; 42(4):672-678..

Having a fair/poor relationship with one's father denoted a greater risk for alcohol use (OR = 2.18; 95% CI: 1.21-3.94; p = 0.010). Authoritarian parental attitudes and a poor relationship with one's father are reported to have a positive association with alcoholism in adolescence¹⁵15. Galduróz JC, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLA, Carlini EA. Factores asociados al uso pesado de alcohol entre estudiantes de las capitales brasileras. Rev Saude Publica 2010; 44(2):267-273.^,4343. Piko BF, Balázs MA. Authoritative parenting styleand adolescent smoking and drinking. Addict Behav 2012; 37(3):353-356.^,4444. Malbergier A, Cardoso LRD, Amaral RA. Adolescent substance use and family problems. Cad Saude Publica 2012; 28(4):678-688.. Despite the importance of mothers in the nuclear family and the fact that they are very often responsible for transmitting societal values²²22. Campos JA, Almeida JC, Garcia PPNS, Faria JB. Alcohol consumption among high school students in the municipality of Passos - MG. Cien Saude Colet 2011; 16(12):4745-4754., the influence of the relationship with one's mother lost its significance in the analysis in the present study. Studies report that a united family, the following of familial values, the discussion of problems at home and parental monitoring are protective factors against exposure to alcohol¹⁰10. Malta DC, Mascarenhas MDM, Porto DL, Duarte EA, Sardinha LM, Barreto SM, Morais Neto OL. Prevalence of alcohol and drug consumption among adolescents: data analysis of the National Survey of School Health. Rev Bras Epidemiol 2011; 14(1):136-146.^,2323. Cordova D, Huang S, Pantin H, Prado G. Do the effects of a family intervention on alcohol and drug use vary by nativity status? Psychol Addict Behav 2012; 26(3):655-660.^,2525. Manrique-Abril FG, Ospina JM, Garcia-Ubaque JC. Children and adolescents' alcohol and tobacco consumption in Tunja, Colombia. Rev Salud Publica 2011; 13(1):89-101.^,4545. Schenker M, Minayo MCS. Risk and protective factors and drug use among adolescence. Cien Saude Colet 2005; 10(3):707-717., suggesting that the family plays an important role in controlling substance abuse.

It should be stressed that alcohol is one of the most consumed drugs in the country and causes considerable harm to the Brazilian population. However, preventive measures have been inconsistent, which has allowed increasingly sophisticated advertising campaigns to promote the consumption of this substance⁴⁶46. Noto AR, Galduróz JCF. O uso de drogas psicotrópicas e a prevenção no Brasil. Cien Saude Colet 1999; 4(1):145-151..

The results of the present study underscore the complexity of this issue and the need to pay particular attention to the adolescent population. Prohibitive national measures in recent decades have had little effect. Public policies with preventive educational campaigns are needed, but alone are not sufficient. Therefore, complementary interventions involving individuals and the environment in which they live are necessary⁴⁶46. Noto AR, Galduróz JCF. O uso de drogas psicotrópicas e a prevenção no Brasil. Cien Saude Colet 1999; 4(1):145-151.. Support from one's family, school and society is essential to combating early alcohol use and its consequences. Considerable progress has been made in relation to tobacco use, as there has been a clear reduction in smoking over the years. Similar progress could be made in relation to alcohol use among adolescents. These issue merit deep reflection, as there has been an increase in alcohol use among youths over the years in Brazil, which has been associated with an increase in the prevalence of disease as well as traffic accidents, violence and a consequent increase in the risk of death⁴⁶46. Noto AR, Galduróz JCF. O uso de drogas psicotrópicas e a prevenção no Brasil. Cien Saude Colet 1999; 4(1):145-151.^,4747. Galduróz JCF, Noto AR, Nappo SA, Carlini EA. Trends in drug use among students in brazil: analysis of foru surveys in 1987, 1989, 1993 and 1997. Braz J Med Bio Res 2004; 37(4):523-531..

Considering the few studies on this topic, there is a need for periodic population-based investigations in different regions of Brazil, which could increase the capacity for monitoring alcohol use and further contribute to the discussion on this issue³⁴34. Horta RL, Horta BL, Pinheiro RT, Morales B, Strey MN. Tobacco, alcohol, and drug use by teenagers in Pelotas, Rio Grande do Sul State, Brazil: a gender approach. Cad Saude Publica 2007; 23(4):775-783.. In this regard, the findings of the present study can contribute to outlining programs aimed at reducing alcohol consumption in adolescence, which is a vulnerable period of life with regard to experimentation with both licit and illicit drugs, especially alcohol and tobacco³⁶36. Sampaio Filho FJL, Sousa PRM, Vieira NFC, Nóbrega MFB, Gubert FA, Pinheiro PNC. Perception of risk of school adolescents in relation to alcohol consumption and sexual behavior. Rev Gaucha Enferm 2010; 31(3):508-514..

Despite the limitations imposed by the cross-sectional study design, which does not allow the determination of causality, the present study offers a representative profile of alcohol intake among adolescent schoolchildren in the city of Campina Grande in northeastern Brazil. Further studies are needed to broaden knowledge regarding this serious public health problem.

Conclusion

Based on the findings of the present study, the prevalence of experimentation with alcohol was high among the adolescents surveyed, with an early initiation into this practice. Age group, religion, work and the relationship with one's father were significantly associated with experimentation with alcoholic beverages. There is a need for educational and prevention programs aimed at combating the early use of alcohol and its consequences.

Collaborations

MA Clementino, GLA Ribeiro, NCM Gomes and Firmino RT participated in the literature review, methodology, analysis and discussion of the data and drafting the article; MBLD Smith participated in the analysis and discussion of data, drafting and correction of the article; AF Granville-Garcia devised directed and coordinated the study, participated in the analysis and discussion of data, drafting and correcting the article.

References

Publication Dates

History