Abstracts

Introduction

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), inhalant drugs are psychotropic substances divided into four groups based on their action mechanism: volatile solvents, aerosols, gases and nitrites¹1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th Edition. Text revision (DSM IV TR) . Washington: American Psychiatric Association; 2000.. Ethyl chloride (found in lança perfume - an ether-based drug used in Brazil), benzene derivatives (solvents found in some glues and paints), ether, benzene and chloroform are examples of common psychoactive inhalants.

Many of these substances are widely available, easily obtained and relatively inexpensive, which likely contributes to the high prevalence of use in the overall population²2. Ridenour TA. Inhalants: not to be taken lightly anymore. Curr Opin Psychiatry 2005; 18(3):243-247. ^{, 3}3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272. and may also account for their popularity among adolescents⁴4. Carlini EA, Galduróz JCF, Noto AR, Nappo SA. I Levantamento Domiciliar Nacional sobre o uso de drogas psicotrópicas no Brasil - 2001. São Paulo: Centro Brasileiro de Informações sobre Drogas Psicotrópicas (CEBRID); 2002. ^{, 5}5. Freedenthal S, Vaughn MG, Jenson JM, Howard MO. Inhalant use and suicidality among incarcerated youth. Drug Alcohol Depend 2007; 90(1):81-88.. Moreover, research suggests that first contact with drugs often occurs in adolescence, which is a period of significant physiological, social and psychological change and vulnerability⁶6. Pratta EMM, Santos MA. Adolescência e uso de substâncias psicoativas: o impacto do nível. Rev Latino-am Enfermagem 2007; 15(Special Issue):806-811.

7. Schenker M, Minayo MCS. Fatores de risco e de proteção para o uso de drogas na adolescência. Cien Saude Colet 2005; 10(3):707-717. ^{- 8}8. Rebolledo EA, Medina NMO, Pillon SC. Factores de riesgo asociados al uso de drogas em estudian tes adolescentes. Rev Latino-am Enfermagem 2004; 12(Special Issue):369-375..

In 2005, researchers conducted a household survey in Brazil involving approximately 8000 individuals between 12 and 65 years of age in 108 cities with populations of more than 200,000 inhabitants. A total of 6.1% of the sample reported having used inhalants, which constituted the second most frequently consumed illicit drug after marijuana⁹9. Brasil. Secretaria Nacional de Política sobre Drogas. Relatório brasileiro sobre drogas. Brasília: Presidência da República Federativa do Brasil; 2009.. In surveys conducted by the Brazilian Information Center on Psychotropic Drugs (CEBRID) in 1987, 1989, 1993 and 1997 with representative samples of adolescents enrolled at elementary and high schools in ten Brazilian state capitals, inhalants had the highest reported use (over 13% of the samples)¹⁰10. Galduróz JCF, AR, Fonseca AM, Carlini EA. Trends in drug use among students in Brazil: analysis of four surveys in 1987, 1989, 1993 and 1997. Braz J Med Biol Res 2004; 37(4):523-531.. According to data from a survey conducted in 2010 by the US National Institute on Drug Abuse published in a report entitled "Monitoring the Future," 14.5% of eighth grade students reported having used inhalants at least once, which was a higher usage rate than that reported for marijuana, amphetamines, hallucinogens, cocaine and heroin¹¹11. Johnson LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the future: national survey results on drug use, 1975 - 2006. Bethesda: National Institute on Drug Abuse; 2007. ^{, 12}12. Johnson LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the future: national survey results on drug use, 1975 - 2010. Bethesda: National Institute on Drug Abuse; 2011..

Inhalants cause dependence¹³13. Perron BE, Howard MO. Adolescent inhalant use, abuse and dependence. Addiction 2009; 104(7):1185-1192. and can lead to brain damage, heart problems, liver problems, kidney failure and death, including suicide⁵5. Freedenthal S, Vaughn MG, Jenson JM, Howard MO. Inhalant use and suicidality among incarcerated youth. Drug Alcohol Depend 2007; 90(1):81-88. ^{, 13}13. Perron BE, Howard MO. Adolescent inhalant use, abuse and dependence. Addiction 2009; 104(7):1185-1192.

14. Ridenour TA. Inhalants: not to be taken lightly anymore. Curr Opin Psychiatry 2005; 18(3):243-247.

15. Garland EL, Howard MO. Adverse consequences of acute inhalant intoxication. Exp Clin Psychopharmacol 2011; 19(2):134-144.

16. Anderson CE, Loomis GA. Recognition and prevention of inhalant abuse. Am Fam Physician 2003; 68(5):869-874. ^{- 17}17. Howard MO, Perron BE, Sacco P, Ilgen M, Vaughn MG, Garland E, Freedentahl S. Suicide ideation and attempts among inhalant users: results from the national epidemiologic survey on alcohol and related conditions. Suicide Life Threat Behav 2010; 40(3):276-286.. These drugs can also contribute to personality, mood and anxiety disorders¹⁸18. Wu LT, Howard MO. Psychiatric disorders in inhalant users: results from The National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend 2007; 88(2-3):146-155.

19. Wu LT, Howard MO, Pilowsky DJ. Substance use disorders among inhalant users: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addict Behav 2008; 33(7):968-973. ^{- 20}20. Johnson EO, Schiitzb CG, Anthonya JC, Ensminger ME. Inhalants to heroin: a prospective analysis from adolescence to adulthood. Drug Alcohol Depend 1995; 40(2):159-164. as well as broader social problems, such as violence and vandalism¹⁵15. Garland EL, Howard MO. Adverse consequences of acute inhalant intoxication. Exp Clin Psychopharmacol 2011; 19(2):134-144.. Historically, alcohol, tobacco and marijuana have been considered the "gateway drug" of choice. This progression is followed by inhalants, which can lead to the use of harder substances, such as heroin and crack³3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272.. A number of studies also report the use of inhalants in combination with other drugs, especially marijuana, tobacco and alcohol³3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272. ^{, 20}20. Johnson EO, Schiitzb CG, Anthonya JC, Ensminger ME. Inhalants to heroin: a prospective analysis from adolescence to adulthood. Drug Alcohol Depend 1995; 40(2):159-164.. This combined drug use needs to be investigated further to assist in the establishment of more effective public policies. Research also suggests that adolescents who use inhalants receive poorer grades at school and have higher scholastic failure, absenteeism and dropout rates²¹21. Tavares BF, Béria JU, Lima MS. Prevalência do uso de drogas e desempenho escolar entre adolescentes. Rev Saude Publica 2001; 35(2):150-158. ^{, 22}22. Horta RL, Horta BL, Pinheiro RT, Morales B, Strey MN. Tabaco, álcool e outras drogas entre adolescentes em Pelotas, Rio Grande do Sul, Brasil: uma perspectiva de gênero. Cad Saude Publica 2007; 23(4):775-783..

This study was undertaken to identify groups that are more vulnerable to using psychoactive substances and multiple drugs, as such individuals are more susceptible to the combined use of inhalants and heavier drugs. Moreover, the identification of associated factors can help guide public policies regarding effective strategies aimed at inhibiting the use of inhalants and other drugs³3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272. ^{, 22}22. Horta RL, Horta BL, Pinheiro RT, Morales B, Strey MN. Tabaco, álcool e outras drogas entre adolescentes em Pelotas, Rio Grande do Sul, Brasil: uma perspectiva de gênero. Cad Saude Publica 2007; 23(4):775-783.

23. Uchtenhagen A. How effective is substance abuse prevention?. World Psychiatry 2005; 4(1):33. ^{- 24}24. Selby P, Vaccarino F. Substance abuse prevention: practical strategies for psychiatrists in the 21st century. World Psychiatry 2005; 4(1):32-33.. Thus, the aim of the present study was to determine the prevalence of inhalant use among adolescents at public and private schools in the city of Belo Horizonte, Brazil, and investigate associations with marijuana use, alcohol consumption, socioeconomic status and gender.

Methods

Study design and participants

A cross-sectional study was carried out addressing lifetime inhalant use and its association with socioeconomic status, lifetime marijuana use and lifetime binge drinking among 936 adolescents aged 15 to 19 years enrolled at public and private schools in the city of Belo Horizonte between August 2009 and February 2010. Belo Horizonte is the state capital of Minas Gerais, Brazil. The city has approximately 2.4 million residents and is geographically divided into nine administrative districts²⁵25. Brazilian Institute of Geography and Statistics (IBGE). Brazilian population recensus and estimative. [Internet]. Brasilia: IBGE. [cited 2012 Jun 10] Available from: http://www.ibge.gov.br/home/estatistica/ populacao/contagem
Available from: http://www.ibge.gov.br/h... .

The sample was randomly selected using two-stage stratified cluster sampling. The sample size was calculated to yield a standard error of 4.0%. To ensure representativeness, the percentage distribution of students from 15 to 19 years was proportional to the actual distribution of students in the nine administrative districts of the city. One public and one private school were selected from each district. A 50% prevalence rate of inhalant use was assumed for the calculation of the sample. The minimum sample size was estimated to be 600 individuals, to which 20% was added to compensate for possible losses (n = 720). A correction factor of 1.3 was then applied to increase the precision, since multistage sampling was employed rather than random sampling, leading to a total of 936 adolescents. The proportion of refusals and losses resulting from incomplete questionnaires was 4.8% (45 adolescents) and the final sample comprised 891 adolescents.

Survey

A self-administered questionnaire was distributed in the classrooms by a researcher and assistant. To guard against bias that may occur due to the variability in reading proficiency among the students, the principal investigator (K.O.J.) read each question aloud. The students were told that the questionnaire would be anonymous and the responses would be treated confidentially. After completing the task, the students placed the questionnaires into opaque envelops, which were collected by the assistant. Students could refuse to participate and return incomplete questionnaires in the envelopes.

Inhalants, marijuana and binge drinking

Information on inhalant use, marijuana use and binge drinking was collected using two self-administered questionnaires: the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the Alcohol Use Disorders Identification Test (AUDIT C), both of which have been validated for use in Brazil²⁶26. Henrique IFS, Micheli D, Lacerda RB, Formigoni MLOS. Validação da versão brasileira do teste de triagem do envolvimento com álcool, cigarro e outras substâncias (ASSIST). Rev Assoc Med Bras 2004; 50(2):199-206. ^{, 27}27. Lima CT, Freire AC, Silva AP, Teixeira RM, Farrell M, Prince M. Concurrent and construct validity of the audit in an urban Brazilian sample. Alcohol 2005; 40(6):584-589..

The use of inhalants and marijuana was determined using the ASSIST (version 3.0). This measure was developed by the World Health Organization and an international research team of experts in the field of substance abuse who sought to create a simple method for mapping the use of psychoactive substances, such as alcohol, tobacco, marijuana, cocaine, crack cocaine, stimulants, hypnotics, sedatives, hallucinogens, opiates and inhalants. The questions address the frequency of lifetime use, use in the previous three months, problems related to substance use, concerns about use raised by individuals close to the user, impaired performance of tasks, unsuccessful attempts to cease or reduce use, sense of compulsion and use by injection. After answering the questionnaire, a risk score ranging from 0 to 4 is provided for each substance, which is then summed across all categories to yield a total score ranging from 0 to 20. The scores are grouped as follows: 0 to 3 indicates occasional use; 4 to 15 implies substance abuse; and 16 or higher suggests dependence²⁸28. Reinert DF, Allen JP. The alcohol use disorders identification test: an update of research findings. Alcohol Clin Exp Res 2007; 31(2):185-199..

For this study, the AUDIT C (first 3 questions of the AUDIT instrument related to the frequency and amount of alcohol consumed) was also used due to the fact that this measure can be effectively employed as a "stand-alone" screening measure to detect hazardous drinking among adolescents²⁸28. Reinert DF, Allen JP. The alcohol use disorders identification test: an update of research findings. Alcohol Clin Exp Res 2007; 31(2):185-199. ^{, 29}29. Chung T, Colby S, Barnett N, Rohsenow D, Spirito A, Monti P. Screening adolescents for problem drinking: performance of brief screens against DSM-IV alcohol diagnoses. J Stud Alcohol 2000; 61(4):579-587.. Binge drinking was assessed with the question "How often do you have five or more drinks on one occasion?" The response options range from "never" to "daily." Binge drinking was used as the measure of alcohol use because this practice can result in more negative consequences than low to moderate amounts of drinking³⁰30. Courtney K, Polich J. Binge drinking in young adults: data, definitions, and determinants. Psychol Bull 2009; 135(1):142-156..

Socioeconomic status

The Social Vulnerability Index (SVI) measures social exclusion in each neighborhood of the city of Belo Horizonte and was used in the present study as an indicator of socioeconomic status. The city hall database of SVI scores was used based on the address of each student³¹31. Nahas MI, Ribeiro C, Esteves O, Moscovitch S, Martins VL. O mapa da exclusão social de Belo Horizonte: metodologia de construção de um instrumento de gestão urbana. Cad Cienc Soc 2000; 7(10):75-88.. This index has 20 variables grouped into five "dimensions of citizenship": (a) access to housing and basic infrastructure; (b) access to education; (c) access to income and employment; (d) access to legal assistance; and (e) access to health, food security and welfare³⁰30. Courtney K, Polich J. Binge drinking in young adults: data, definitions, and determinants. Psychol Bull 2009; 135(1):142-156.. Residential areas are categorized into five classes (Classes I to V). Class I indicates the highest degree of social vulnerability (poorest housing, schooling, income, jobs, legal assistance and health) and Class V indicates the lowest degree of social vulnerability (most advantageous conditions)³¹31. Nahas MI, Ribeiro C, Esteves O, Moscovitch S, Martins VL. O mapa da exclusão social de Belo Horizonte: metodologia de construção de um instrumento de gestão urbana. Cad Cienc Soc 2000; 7(10):75-88..

Mother's education level (reported by the participants) was chosen as an indicator of individual socioeconomic status due to its association with illicit drug use among adolescents³²32. Humensky JL. Are adolescents with high socioeconomic status more likely to engage in alcohol and illicit drug use in early adulthood? Subst Abuse Treat Prev Policy 2010; 5(1):19-29.. Respondents who reported that their mothers had studied for 0 to 7 years were coded as 0 and those who reported that their mothers had studied for 8 or more years were coded as 1. The cutoff point was selected by the median.

The participant's type of school (public or private) was also used as a socioeconomic indicator. This variable has been used effectively in a large number of Brazilian epidemiological studies³²32. Humensky JL. Are adolescents with high socioeconomic status more likely to engage in alcohol and illicit drug use in early adulthood? Subst Abuse Treat Prev Policy 2010; 5(1):19-29.

33. Moreira PVL, Rosenblatt A, Passos IA. Prevalência de cárie em adolescentes de escolas públicas e privadas na cidade de João Pessoa, Paraíba, Brasil. Cien Saude Colet 2007; 12(5):1229-1236.

34. Hoffman RHS, Cypriano S, Sousa MLR, Wada RS. Experiência de cárie dentária em crianças de escolas públicas e privadas de um município com água fluoretada. Cad Saude Publica 2004; 20(2):522-528. ^{- 35}35. Maltz M, Barbachan e Silva B. Relação entre cárie, gengivite e fluorose e nível socioeconômico em escolares. Rev Saude Publica 2001; 35(2):170-176.. Moreover, the authors of a recent study concluded that type of school is a useful socioeconomic indicator in studies involving children in Brazil³⁶36. Piovesan C, Pádua MC, Ardenghi TM, Mendes FM, Bonini GC. Can type of school be used as an alternative indicator of socioeconomic status in dental caries studies? A cross-sectional study. BMC Med Research Methodol 2011; 11(1):37-43..

Ethical considerations

This study received approval from the Human Research Ethics Committee of the Universidade Federal de Minas Gerais (Brazil). Authorization to approach the students was obtained from the directors of the selected schools. The participants and their parents/guardians signed a statement of informed consent. The participants were assured anonymity and confidentially in their answers.

Statistical analysis

Data analysis was performed using the Statistical Package for Social Sciences (SPSS for Windows, v. 17.0, SPSS Inc., Chicago, IL, USA). Descriptive and bivariate analyses were performed using the chi-square test (p < 0.05). Logistic regression was used in the multivariate analysis. The criterion for inclusion in the model was a p-value < 0.20 in the outcome of the bivariate analysis.

Results

The response rate was 98.5%. Non-responses were mainly due to refusals on the part of the adolescents or non-authorization from parents/guardians. The final sample was made up of 891 adolescents [352 males (39.5%) and 539 females (60.5%)], with a mean age of 16.3 ± 1.0 years. A total of 80.5% attended public schools and 19.5% attended private schools. Seventy adolescents (7.9%) reported lifetime inhalant use and 30 (3.9%) reported having used this drug in the previous three months. Regarding the ASSIST scores for inhalant use, 99.1% (n = 883) of the participants were in the low risk range (0 to 3 points) for health and other problems stemming from the current pattern of use and 0.8% (n = 7) were in the moderate risk range (4 to 15 points).

Table 1 shows the distribution of the sample according to the prevalence of lifetime inhalant use and the independent variables. Lifetime inhalant use was associated with type of school (p = 0.001), mother's education level (p = 0.023), less socially vulnerable residential area based on the SVI (p < 0.001), lifetime marijuana use (p < 0.001) and lifetime binge drinking (p < 0.001).

Table 2 displays the results of the logistic regression analysis. After adjusting for age, gender, type of school, mother's education level and SVI, adolescents who reported lifetime inhalant use had increased odds of lifetime binge drinking (adjusted OR: 5.02; 95% CI: 2.57 to 9.81) and lifetime marijuana use (adjusted OR: 4.61; 95% CI: 2.27 to 9.36).

Discussion

The prevalence of inhalant use among adolescents enrolled at public and private schools in the city of Belo Horizonte (Brazil) was 7.9%. The use of inhalants was positively associated with marijuana use and binge drinking in the multivariate regression model. A national household survey involving adolescents aged 12 to 17 years reports a 3.4% prevalence rate of inhalant use, with a higher rate among individuals aged 18 to 24 years (10.8%).⁹9. Brasil. Secretaria Nacional de Política sobre Drogas. Relatório brasileiro sobre drogas. Brasília: Presidência da República Federativa do Brasil; 2009. However, the study cited did not specify in detail how the collection process was carried out. Moreover, due to the fact that the investigation was a household survey, the prevalence of drug use among adolescents may have been somewhat underestimated. For instance, if the parent/guardian of an adolescent between 12 and 17 years of age was at home at the time of the interview, the respondent may have been more reluctant to respond honestly. Moreover, a household survey may be considered less impersonal and the findings may therefore seem less confidential, leading an adolescent to fear that the researcher could inform his/her parents/guardians regarding the use of illicit drugs.

A number of studies published in the literature report higher prevalence rates of inhalant use among Brazilian adolescents. In a study conducted in 10 major cities in Brazil¹⁰10. Galduróz JCF, AR, Fonseca AM, Carlini EA. Trends in drug use among students in Brazil: analysis of four surveys in 1987, 1989, 1993 and 1997. Braz J Med Biol Res 2004; 37(4):523-531., the authors report that 13.8% of the sample population had used inhalants, including a 9% prevalence rate in the city of São Carlos⁶6. Pratta EMM, Santos MA. Adolescência e uso de substâncias psicoativas: o impacto do nível. Rev Latino-am Enfermagem 2007; 15(Special Issue):806-811., which is close to the figure found in the present study (7.9%). Much higher prevalence rates of inhalant use were also found in studies conducted in the cities of Florianópolis (18.2%)³⁷37. Baus J, Kupek E, Pires M. Prevalência e fatores de risco relacionados ao uso de drogas entre escolares. Rev Saude Publica 2002; 36(1):40-46. and Palhoça (18.9%)³⁸38. Sanceverino SL, Abreu JLC. Aspectos Epidemiológicos do uso de drogas entre estudantes do ensino médio no Município de Palhoça 2003. Cien Saude Colet 2004; 9(4):1047-1056.. The high prevalence of inhalant use among adolescents may be explained by the wide availability of these substances, which are relatively inexpensive and of easy access²2. Ridenour TA. Inhalants: not to be taken lightly anymore. Curr Opin Psychiatry 2005; 18(3):243-247.

3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272.

4. Carlini EA, Galduróz JCF, Noto AR, Nappo SA. I Levantamento Domiciliar Nacional sobre o uso de drogas psicotrópicas no Brasil - 2001. São Paulo: Centro Brasileiro de Informações sobre Drogas Psicotrópicas (CEBRID); 2002. ^{- 5}5. Freedenthal S, Vaughn MG, Jenson JM, Howard MO. Inhalant use and suicidality among incarcerated youth. Drug Alcohol Depend 2007; 90(1):81-88.. Moreover, adolescence is a stage when an individual may be psychologically and socially more vulnerable and more susceptible to experimentation, since there is a need for approval and self-affirmation. Indeed, the first contact with psychotropic substances commonly occurs in this stage of life⁶6. Pratta EMM, Santos MA. Adolescência e uso de substâncias psicoativas: o impacto do nível. Rev Latino-am Enfermagem 2007; 15(Special Issue):806-811.

7. Schenker M, Minayo MCS. Fatores de risco e de proteção para o uso de drogas na adolescência. Cien Saude Colet 2005; 10(3):707-717. ^{- 8}8. Rebolledo EA, Medina NMO, Pillon SC. Factores de riesgo asociados al uso de drogas em estudian tes adolescentes. Rev Latino-am Enfermagem 2004; 12(Special Issue):369-375..

Studies in the international literature reveal prevalence rates of inhalant use similar to that found in the present investigation. In a survey conducted in Peru with nationally representative data, the authors report inhalant use among 6.1% of adolescents enrolled in schools around the country, listing inhalants among the most prevalent illicit drugs, along with marijuana³⁹39. Perú . Comisión Nacional para el Desarrollo y Vida sin Drogas . Estudio nacional Prevención y consumo de drogas en estudiantes de secundaria 2005. Lima: Comisión Nacional para El Desarrollo y Vida sin Drogas; 2006.. A similar study conducted in Chile in 2009 reports inhalant use among an estimated 8.9% of the adolescent population⁴⁰40. Chile. Consejo Nacional para el Control del Estupefacientes (CONACE). Octavo estudio nacional de drogas en población escolar de Chile. Santiago: Consejo Nacional para el Control del Estupefacientes; 2009.. In the United States, the latest "Monitoring the Future" report indicates a prevalence rate of 14.5% among eighth graders and 12% among tenth graders¹¹11. Johnson LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the future: national survey results on drug use, 1975 - 2006. Bethesda: National Institute on Drug Abuse; 2007..

The use of illicit drugs has been largely associated with the male gender²¹21. Tavares BF, Béria JU, Lima MS. Prevalência do uso de drogas e desempenho escolar entre adolescentes. Rev Saude Publica 2001; 35(2):150-158.. However, the same is not true for inhalants, for which prevalence rates are often similar between males and females³⁸38. Sanceverino SL, Abreu JLC. Aspectos Epidemiológicos do uso de drogas entre estudantes do ensino médio no Município de Palhoça 2003. Cien Saude Colet 2004; 9(4):1047-1056. ^{, 39}39. Perú . Comisión Nacional para el Desarrollo y Vida sin Drogas . Estudio nacional Prevención y consumo de drogas en estudiantes de secundaria 2005. Lima: Comisión Nacional para El Desarrollo y Vida sin Drogas; 2006.. In the present study, no statistically significant difference in the use of inhalants was found between genders among the individuals who reported drug use at some point in life (7.1% for males and 8.3% for females). Studies carried out in Peru and Chile also report no significant difference in the prevalence of substance abuse between genders³⁹39. Perú . Comisión Nacional para el Desarrollo y Vida sin Drogas . Estudio nacional Prevención y consumo de drogas en estudiantes de secundaria 2005. Lima: Comisión Nacional para El Desarrollo y Vida sin Drogas; 2006. ^{, 40}40. Chile. Consejo Nacional para el Control del Estupefacientes (CONACE). Octavo estudio nacional de drogas en población escolar de Chile. Santiago: Consejo Nacional para el Control del Estupefacientes; 2009.. However, a study carried out in Spain found that males were two times more likely to abuse drugs than females (3.6% vs. 1.8%, respectively)⁴¹41. España. Delegación del Gobierno para el Plan Nacional Sobre Drogas. Encuesta estatal sobre uso de drogas em Estudiantes de enseñanzas secundarias, 1994-2008. Madrid: Delegación del Gobierno para el Plan Nacional Sobre Drogas; 2009.. Likewise, a household survey in Brazil reports figures of 10.3% for males and 3.3% for females⁹9. Brasil. Secretaria Nacional de Política sobre Drogas. Relatório brasileiro sobre drogas. Brasília: Presidência da República Federativa do Brasil; 2009.. In contrast, the US report "Measuring the Future" found a higher prevalence rate of substance abuse among girls aged eight and ten years (16.3% and 12.2%, respectively) in comparison to males of the same age (12.4% and 10.9%, respectively)¹¹11. Johnson LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the future: national survey results on drug use, 1975 - 2006. Bethesda: National Institute on Drug Abuse; 2007.. This report has been published annually since 1975 and the data show a progressive increase in drug use among females, even surpassing that of males in some cases.¹¹11. Johnson LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the future: national survey results on drug use, 1975 - 2006. Bethesda: National Institute on Drug Abuse; 2007. Two hypotheses may be put forth to explain these findings: 1) it may be that females have their first contact with drugs earlier than males²²22. Horta RL, Horta BL, Pinheiro RT, Morales B, Strey MN. Tabaco, álcool e outras drogas entre adolescentes em Pelotas, Rio Grande do Sul, Brasil: uma perspectiva de gênero. Cad Saude Publica 2007; 23(4):775-783. or 2) the greater independence obtained by women in recent decades may have led to an increase in the use of psychotropic substances among females²²22. Horta RL, Horta BL, Pinheiro RT, Morales B, Strey MN. Tabaco, álcool e outras drogas entre adolescentes em Pelotas, Rio Grande do Sul, Brasil: uma perspectiva de gênero. Cad Saude Publica 2007; 23(4):775-783.. In the health field, the female gender as a social group may require more attention in substance abuse studies due to the noted expansion of consumption indices and the problems arising from the use of psychoactive substances in this population⁴²42. Costa-e-Silva VL, Koifman S. Smoking in Latin America: a major public health problem. Cad Saude Publica 1998; 14(3):99-108.. However, it should be stressed that prevalence studies split along gender lines only offer a descriptive analysis for the use of inhalants. Moreover, no statistically significance associated was found between illicit drug use and gender in a study involving adolescents in Pelotas, Brazil, as the prevalence was 14.6% among males and 13.9% among females²¹21. Tavares BF, Béria JU, Lima MS. Prevalência do uso de drogas e desempenho escolar entre adolescentes. Rev Saude Publica 2001; 35(2):150-158..

To debunk another myth, many also believe that drugs are more commonly used among individuals belonging to lower social strata. However, the literature provides conflicting findings on this issue. While some studies positively link drug use to a lower socioeconomic status⁷7. Schenker M, Minayo MCS. Fatores de risco e de proteção para o uso de drogas na adolescência. Cien Saude Colet 2005; 10(3):707-717., others report a positive correlation with a higher status²¹21. Tavares BF, Béria JU, Lima MS. Prevalência do uso de drogas e desempenho escolar entre adolescentes. Rev Saude Publica 2001; 35(2):150-158.. In the present study, no statistically significant association was found between the use of inhalants and socioeconomic factors in the multivariate analysis. There is a certain difficulty in comparing studies that investigate the association between drug use and socioeconomic factors due to the lack of standardization regarding the analysis of socioeconomic status⁴³43. Kandel DB, Yamaguchi K, Chan K. Stages of progression in drug involvement from adolescence to adulthood: Further evidence for the gateway theory. J Stud Alcohol 1992; 53(5):447-457.. Some studies use indirect indicators of socioeconomic status, such as parental education level, place of residence, household income and type of school⁶6. Pratta EMM, Santos MA. Adolescência e uso de substâncias psicoativas: o impacto do nível. Rev Latino-am Enfermagem 2007; 15(Special Issue):806-811. ^{, 21}21. Tavares BF, Béria JU, Lima MS. Prevalência do uso de drogas e desempenho escolar entre adolescentes. Rev Saude Publica 2001; 35(2):150-158. ^{, 44}44. Blaze-Temple D, Lo SK. Stages of drug use: A community survey of Perth teenagers. Br J Addict 1992; 87(2):215-225.. As a result, there is no consensus on the association between the use of inhalants and socioeconomic status⁹9. Brasil. Secretaria Nacional de Política sobre Drogas. Relatório brasileiro sobre drogas. Brasília: Presidência da República Federativa do Brasil; 2009. ^{, 22}22. Horta RL, Horta BL, Pinheiro RT, Morales B, Strey MN. Tabaco, álcool e outras drogas entre adolescentes em Pelotas, Rio Grande do Sul, Brasil: uma perspectiva de gênero. Cad Saude Publica 2007; 23(4):775-783. ^{, 33}33. Moreira PVL, Rosenblatt A, Passos IA. Prevalência de cárie em adolescentes de escolas públicas e privadas na cidade de João Pessoa, Paraíba, Brasil. Cien Saude Colet 2007; 12(5):1229-1236.

34. Hoffman RHS, Cypriano S, Sousa MLR, Wada RS. Experiência de cárie dentária em crianças de escolas públicas e privadas de um município com água fluoretada. Cad Saude Publica 2004; 20(2):522-528.

35. Maltz M, Barbachan e Silva B. Relação entre cárie, gengivite e fluorose e nível socioeconômico em escolares. Rev Saude Publica 2001; 35(2):170-176. ^{- 36}36. Piovesan C, Pádua MC, Ardenghi TM, Mendes FM, Bonini GC. Can type of school be used as an alternative indicator of socioeconomic status in dental caries studies? A cross-sectional study. BMC Med Research Methodol 2011; 11(1):37-43.. Further studies on this association are needed.

Alcohol, cigarettes and marijuana have historically been regarded gateway drugs³3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272. ^{, 45}45. Chen X, Unger JB, Cruz TB, Johnson CA. Smoking patterns of Asian- American youth in California and their relationship with acculturation. J Adolesc Health 1999; 24(5):321-328. ^{, 46}46. Kandel DB, Yamaguchi K. Stages and pathways of drug involvement: Examining the Gateway hypothesis. New York: Cambridge University Press; 2002.. Scientific evidence shows a progression from these early stage gateway drugs to a more advanced stage, which may involve heavier drugs, such as cocaine, heroin and crack, or multiple drug use³3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272. ^{, 44}44. Blaze-Temple D, Lo SK. Stages of drug use: A community survey of Perth teenagers. Br J Addict 1992; 87(2):215-225.

45. Chen X, Unger JB, Cruz TB, Johnson CA. Smoking patterns of Asian- American youth in California and their relationship with acculturation. J Adolesc Health 1999; 24(5):321-328. ^{- 46}46. Kandel DB, Yamaguchi K. Stages and pathways of drug involvement: Examining the Gateway hypothesis. New York: Cambridge University Press; 2002.. As mentioned above, first contact with gateway drugs often occurs in adolescence and there is no basis on which to establish the position of inhalant substances in the progression of drug use³3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272. ^{, 6}6. Pratta EMM, Santos MA. Adolescência e uso de substâncias psicoativas: o impacto do nível. Rev Latino-am Enfermagem 2007; 15(Special Issue):806-811.. However, Ding et al.³3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272. demonstrated that smoking initiation followed by the consumption of alcohol, marijuana and inhalants is a common progression. Moreover, a number of studies report the combined use of inhalants with other drugs, particularly alcohol, cigarettes and marijuana³3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272. ^{, 20}20. Johnson EO, Schiitzb CG, Anthonya JC, Ensminger ME. Inhalants to heroin: a prospective analysis from adolescence to adulthood. Drug Alcohol Depend 1995; 40(2):159-164. ^{, 47}47. Carlini-Marlatt B, Gazal-Carvalho C, Gouveia N, Souza MFM. Drinking practices and other health-related behaviors among adolescents of Sao Paulo City, Brazil. Subst Use Misuse 2003; 38(7):905-932.

48. Isralowitz R, Reznik A. Ethnicity and inhalant use among high risk adolescents in Israel. J Ethn Subst Abuse. 2012; 11(2):192-196. ^{- 49}49. Driscoll DL, Dotterrer B, Collins D, Ogilvie K, Grube J, Johnson K. Demographic and contextual factors associated with inhalant use among youth in rural Alaska. Int J Circumpolar Health 2012; 71:1-4., as reported in the present investigation. The findings of these studies demonstrate that inhalant use does not generally occur in an isolated fashion. Indeed, individuals who report having used inhalants some time in life have generally also used other substances and there is a strong association between the use of inhalants and cigarettes, alcohol and marijuana³3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272. ^{, 47}47. Carlini-Marlatt B, Gazal-Carvalho C, Gouveia N, Souza MFM. Drinking practices and other health-related behaviors among adolescents of Sao Paulo City, Brazil. Subst Use Misuse 2003; 38(7):905-932. ^{, 50}50. Reid LW, Elifson KW, Sterk CE. Ecstasy and gateway drugs: Initiating the use of ecstasy and other drugs. Ann Epidemiol 2007; 17(1):74-80., as reported for a sample involving 12-year-olds in the United States.³3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272. According to data from a study by Carlini-Marlatt et al.⁴⁷47. Carlini-Marlatt B, Gazal-Carvalho C, Gouveia N, Souza MFM. Drinking practices and other health-related behaviors among adolescents of Sao Paulo City, Brazil. Subst Use Misuse 2003; 38(7):905-932., high school students who report using alcohol and those who report having engaged in binge drinking had an increased risk of using inhalants (OR: 2.20; 95% CI: 1.13 - 4.27 and OR: 2.70; 95% CI: 1.27 - 5.74 respectively). The present data are in agreement with these findings, since the inhalant use was associated with marijuana use (OR: 4.61; 95% CI: 2.27 - 9.36) and binge drinking (OR: 5.02; 95% CI: 2.57 - 9.81).

Few studies in the literature describe the harmful effects of inhalant drugs. Associations are reported between the use of psychotropic drugs (including inhalants) and school absenteeism, scholastic failure and dropout rates among adolescents²¹21. Tavares BF, Béria JU, Lima MS. Prevalência do uso de drogas e desempenho escolar entre adolescentes. Rev Saude Publica 2001; 35(2):150-158. ^{, 22}22. Horta RL, Horta BL, Pinheiro RT, Morales B, Strey MN. Tabaco, álcool e outras drogas entre adolescentes em Pelotas, Rio Grande do Sul, Brasil: uma perspectiva de gênero. Cad Saude Publica 2007; 23(4):775-783.. These substances are also associated with mental problems, such as personality, mood and anxiety disorders¹⁸18. Wu LT, Howard MO. Psychiatric disorders in inhalant users: results from The National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend 2007; 88(2-3):146-155. ^{, 19}19. Wu LT, Howard MO, Pilowsky DJ. Substance use disorders among inhalant users: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addict Behav 2008; 33(7):968-973., as well as social problems (violence and vandalism)¹⁴14. Ridenour TA. Inhalants: not to be taken lightly anymore. Curr Opin Psychiatry 2005; 18(3):243-247.. Inhalant drugs can cause addiction¹³13. Perron BE, Howard MO. Adolescent inhalant use, abuse and dependence. Addiction 2009; 104(7):1185-1192. and physical harm, such as brain damage, liver failure and kidney failure⁵5. Freedenthal S, Vaughn MG, Jenson JM, Howard MO. Inhalant use and suicidality among incarcerated youth. Drug Alcohol Depend 2007; 90(1):81-88. ^{, 13}13. Perron BE, Howard MO. Adolescent inhalant use, abuse and dependence. Addiction 2009; 104(7):1185-1192.

14. Ridenour TA. Inhalants: not to be taken lightly anymore. Curr Opin Psychiatry 2005; 18(3):243-247.

15. Garland EL, Howard MO. Adverse consequences of acute inhalant intoxication. Exp Clin Psychopharmacol 2011; 19(2):134-144.

16. Anderson CE, Loomis GA. Recognition and prevention of inhalant abuse. Am Fam Physician 2003; 68(5):869-874. ^{- 17}17. Howard MO, Perron BE, Sacco P, Ilgen M, Vaughn MG, Garland E, Freedentahl S. Suicide ideation and attempts among inhalant users: results from the national epidemiologic survey on alcohol and related conditions. Suicide Life Threat Behav 2010; 40(3):276-286.. Along this same line, studies have reported increased prevalence rates of psychiatric disorders among individuals who abuse substances such as marijuana, alcohol, cigarettes and inhalants¹⁷17. Howard MO, Perron BE, Sacco P, Ilgen M, Vaughn MG, Garland E, Freedentahl S. Suicide ideation and attempts among inhalant users: results from the national epidemiologic survey on alcohol and related conditions. Suicide Life Threat Behav 2010; 40(3):276-286. ^{, 18}18. Wu LT, Howard MO. Psychiatric disorders in inhalant users: results from The National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend 2007; 88(2-3):146-155. ^{, 51}51. Garland EL, Howard MO. Adverse consequences of acute inhalant intoxication. Exp Clin Psychopharmacol 2011; 19(2):134-144.. There is also evidence of a greater risk of death and suicide among users of psychoactive drugs⁵5. Freedenthal S, Vaughn MG, Jenson JM, Howard MO. Inhalant use and suicidality among incarcerated youth. Drug Alcohol Depend 2007; 90(1):81-88. ^{, 17}17. Howard MO, Perron BE, Sacco P, Ilgen M, Vaughn MG, Garland E, Freedentahl S. Suicide ideation and attempts among inhalant users: results from the national epidemiologic survey on alcohol and related conditions. Suicide Life Threat Behav 2010; 40(3):276-286. ^{, 51}51. Garland EL, Howard MO. Adverse consequences of acute inhalant intoxication. Exp Clin Psychopharmacol 2011; 19(2):134-144.. The combined use of psychoactive drugs is potentially the most harmful. It is therefore important to investigate this aspect further and offer data that can contribute to more coherent preventive measures.

The present study has limitations that should be addressed. Although the data collection was performed with self-reported questionnaires and the assurance of anonymity and confidentiality in the responses, the actual use of inhalants among the students could have been under-reported or even exaggerated. Moreover, the study only involved adolescents enrolled in schools and those who had dropped out were therefore not included. This is a particular problem, since research indicates a higher prevalence rate of the inhalant use among dropouts¹⁵15. Garland EL, Howard MO. Adverse consequences of acute inhalant intoxication. Exp Clin Psychopharmacol 2011; 19(2):134-144.. As described in the methodology, this study was a cross-sectional investigation, which does not allow the establishment of causality among the variables⁵²52. Kawashi I, Subramanian SV, Almeida-Filho N. A glossary for health inequalities. J Epidemiol Community Health 2002; 56(9):647-652.. Therefore, the authors cannot state with absolute confidence that the use of inhalants was the cause of marijuana use or binge drinking or vice-versa. However, inhalant use was associated with marijuana use and binge drinking, as clearly demonstrated in the logistic regression following the necessary adjustments made for confounding factors. Moreover, longitudinal or experimental studies are needed to test the causality between drug use and socioeconomic status⁵²52. Kawashi I, Subramanian SV, Almeida-Filho N. A glossary for health inequalities. J Epidemiol Community Health 2002; 56(9):647-652..

The findings of the present study demonstrate that preventive public policies should be strengthened and focused on adolescents, considering the high prevalence rate of inhalant use in this group³3. Ding K, Chang GA, Southerland R. Age of inhalant first time use and its association to the use of other drugs. J. Drug Education 2009; 39(3):261-272. ^{, 6}6. Pratta EMM, Santos MA. Adolescência e uso de substâncias psicoativas: o impacto do nível. Rev Latino-am Enfermagem 2007; 15(Special Issue):806-811. ^{, 9}9. Brasil. Secretaria Nacional de Política sobre Drogas. Relatório brasileiro sobre drogas. Brasília: Presidência da República Federativa do Brasil; 2009.

10. Galduróz JCF, AR, Fonseca AM, Carlini EA. Trends in drug use among students in Brazil: analysis of four surveys in 1987, 1989, 1993 and 1997. Braz J Med Biol Res 2004; 37(4):523-531. ^{- 11}11. Johnson LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the future: national survey results on drug use, 1975 - 2006. Bethesda: National Institute on Drug Abuse; 2007. ^{, 21}21. Tavares BF, Béria JU, Lima MS. Prevalência do uso de drogas e desempenho escolar entre adolescentes. Rev Saude Publica 2001; 35(2):150-158. ^{, 37}37. Baus J, Kupek E, Pires M. Prevalência e fatores de risco relacionados ao uso de drogas entre escolares. Rev Saude Publica 2002; 36(1):40-46.

38. Sanceverino SL, Abreu JLC. Aspectos Epidemiológicos do uso de drogas entre estudantes do ensino médio no Município de Palhoça 2003. Cien Saude Colet 2004; 9(4):1047-1056.

39. Perú . Comisión Nacional para el Desarrollo y Vida sin Drogas . Estudio nacional Prevención y consumo de drogas en estudiantes de secundaria 2005. Lima: Comisión Nacional para El Desarrollo y Vida sin Drogas; 2006. ^{- 40}40. Chile. Consejo Nacional para el Control del Estupefacientes (CONACE). Octavo estudio nacional de drogas en población escolar de Chile. Santiago: Consejo Nacional para el Control del Estupefacientes; 2009.. Moreover, the associations with marijuana use and binge drinking demonstrate the need to address multiple drug use.

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