Abstract

This descriptive cross-sectional research sample was consisted of 613 high school students in Eastern Turkey. Data were collected by using the Questionnaire on Substance Use and its Causes and Self-Efficacy in the Prevention of Substance Abuse Scale (SEAPSAS). Data were analyzed with percentiles, Chi-Square, ANOVA, Kruskal Wallis, correlation and regression. Almost 40% of the students had tried smoking and 21.7% of them smoked sometimes or regularly. The mean age of students’ first cigarette use was 13.5. More than 60% of the students had tried alcohol and almost 50% of them drink alcohol sometimes or regularly. The mean score of SEAPSAS was 93.61 ± 18.99. Lower self-efficacy scores were found in males, in students who perceived themselves as unsuccessful at school, in those with negative family and friendship relations, in students who smoked, drank alcohol, who had a drug user in the family and who experienced traumatic events in a lifetime.

Adolesence; High school; Prevention; Self-efficacy; Substance use

Resumo

Esta amostra de pesquisa descritiva transversal foi composta por 613 estudantes do ensino médio no leste da Turquia. Os dados foram coletados por meio do Questionário de Uso de Substâncias e suas Causas e Autoeficácia na Escala de Prevenção de Abuso de Substâncias (SEAPSAS). Os dados foram analisados com percentis, Qui-Quadrado, ANOVA, Kruskal Wallis, correlação e regressão. Quase 40% dos estudantes tentaram fumar e 21,7% deles fumaram às vezes ou regularmente. A idade média do primeiro uso de cigarro pelos estudantes foi de 13,5. Mais de 60% dos estudantes experimentaram álcool e quase 50% deles bebem álcool às vezes ou regularmente. O escore médio do SEAPSAS foi de 93,61 ± 18,99. Menores escores de autoeficácia foram encontrados em homens, em estudantes que se consideravam mal-sucedidos na escola, naqueles com relações familiares e de amizade negativas, em estudantes que fumavam, bebiam álcool, usuários de drogas na família e que vivenciavam eventos traumáticos na vida.

Adolescência; Ensino médio; Prevenção; Autoeficácia; Uso de substâncias

Introduction

Substance addiction is a major public health problem throughout the world and is among the preventable causes of current illnesses and deaths. However, the stages of substance use and the types of substances used vary according to countries and regions. The primary reasons for referral to treatment centers include marijuana use in Asia, marijuana and alcohol in Europe ¹1. Center of Disease Control and Prevention (CDC) . Youth and Tobacco Use . 2015 . [ cited 2015 Jan 12 ]. Available from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/2015
http://www.cdc.gov/tobacco/data_statisti...

2. Milne B , Bell J , Lampropoulos B , Towns S . Alcohol, drugs and Australian young people . Int J Adolesc Med Health 2007 ; 19 ( 3 ): 245 - 253 .^-33. United Nations Office on Drugs and Crime (UNODC) . World Drug Report, United Nations Office on Drugs and Crime . Viena : UNODC ; 2015 . . In Eastern and Southeastern European countries, however, the prevalence of use of intravenous substances was stated to be 4.6 times higher than the world average ¹1. Center of Disease Control and Prevention (CDC) . Youth and Tobacco Use . 2015 . [ cited 2015 Jan 12 ]. Available from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/2015
http://www.cdc.gov/tobacco/data_statisti... .

Substance use, as in the rest of the world, is a significant problem among young people in Turkey as well ⁴4. Evren C , Ogel K , Demirci A.C , Evren B , Yavuz B.G , Bozkurt M. Prevalence of lifetime tobacco, alcohol and drug use among 10th grade students in Istanbul . Klinik Psikofarmakoloji Bülteni 2014 ; 24 ( 3 ): 201 - 210 . . However, a national and regional database on substance use in Turkey is limited. Studies on the prevalence of substance use in Turkey are limited for various reasons. These include budget constraints for this work which is carried out mainly by academics, a lack of interagency coordination, and negligence in government policy regarding public health concerns. These limitations complicate the comparison of the frequency of substance use in Turkey, including smoking and alcohol, with other regions of the world. Nevertheless, despite the lack of regular data collection and monitoring at the national level, the prevalence of substance use in the young population in Turkey has been revealed in some studies. In a study by the Parliamentary Investigation Commission in 2008, the rate of smokers at secondary education schools was found to be 15.6% (21.8% in males, 7.5% in females), the rate of alcohol use in the previous month was 16.5% (31.5% in males, 10.6% in females), and the rate of use of drugs/stimulants in the last three months was 2.9% (4.3% in males, 1.0% in females), (Report of Parliamentary Investigation Commission, 2008). In addition, a study conducted by the Turkish Monitoring Centre for Drugs and Drug Addiction (TUBİM) determined that 8.3% of the students in high schools were smoking cigarettes, and 9.7% were using alcohol ⁵5. Turkey Monitoring Centre of Drug and Drug Use (TUBİM) . Turkish Drug Report 2014 . [ cited 2015 Jan 12 ]. Available from: http://www.kom.pol.yt/tubim/SiteAssets/Sayfalar/Türkiye-Uyuşturucu-Raporu/TUBIM%202014
http://www.kom.pol.yt/tubim/SiteAssets/S... . In general, cigarette and alcohol use among young people in Turkey were more common, whereas the use of illegal substances was lower than the world average. However, compared with previous years, there has been a reported increase in the use of these substances ⁴4. Evren C , Ogel K , Demirci A.C , Evren B , Yavuz B.G , Bozkurt M. Prevalence of lifetime tobacco, alcohol and drug use among 10th grade students in Istanbul . Klinik Psikofarmakoloji Bülteni 2014 ; 24 ( 3 ): 201 - 210 .^,55. Turkey Monitoring Centre of Drug and Drug Use (TUBİM) . Turkish Drug Report 2014 . [ cited 2015 Jan 12 ]. Available from: http://www.kom.pol.yt/tubim/SiteAssets/Sayfalar/Türkiye-Uyuşturucu-Raporu/TUBIM%202014
http://www.kom.pol.yt/tubim/SiteAssets/S... .

Since there are multiple risks that affect substance use in adolescents, knowing the risk factors is key to prevention. The most studied variables, for their relationship to substance use, are age, gender, marital status, socio-economic status, using illegal substances with friends, suicidal tendencies, psychological factors, and the impact of media and family ¹1. Center of Disease Control and Prevention (CDC) . Youth and Tobacco Use . 2015 . [ cited 2015 Jan 12 ]. Available from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/2015
http://www.cdc.gov/tobacco/data_statisti... ^,66. Conway K.P , Vullo GC , Nichter B , Wang J , Compton WM , Iannotti RJ , Simons-Morton B. Prevalence and patterns of polysubstance use in a nationally representative sample of 10th graders in the United States . J Adolesc Health 2013 ; 52 ( 6 ): 716 - 723 .^,77. Van Ryzin MJ , Fosco GM , Dishion TJ . Family and peer predictors of substance use from early adolescence to early adulthood: an 11-year prospective analysis . Addict Behav 2012 ; 37 ( 12 ): 1314 - 1324 . . Although the above-mentioned variables have also been addressed in small sample studies in Turkey, the effect of these variables on different cultural groups has not been adequately studied.

Rather than a single factor, substance use behavior has a complex structure caused by many factors such as genetic, family, environment, and culture. For example, as a result of cultural tolerance, specifically in our eastern region of Turkey, children and young people often become acquainted with cigarette and alcohol use on some special occasions. Although there is some social acceptance for cigarette and alcohol use within Turkish society, there is an addiction risk in this regard, which constitutes a step in the transition to substance use ¹1. Center of Disease Control and Prevention (CDC) . Youth and Tobacco Use . 2015 . [ cited 2015 Jan 12 ]. Available from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/2015
http://www.cdc.gov/tobacco/data_statisti... . Multiple substance use can lead to injury, violence, risky sexual behaviors, drunk driving, drug overdose, poisoning, and death ⁸8. National Centre for Social Research , National Foundation for Educational Research . Smoking, Drinking and Drug Use among Young People, 2012 . London : UK Data Service ; 2013 . . Therefore, the prevention of substance use in adolescents and delaying their introduction to these substances as much as possible is important in preventing addiction ⁹9. Chakravarthy B , Shah S , Lotfipour S . Adolescent drug abuse - Awareness & prevention . Indian J Med Res 2013 ; 137 ( 6 ): 1021 - 1023 . . In this regard, the prevention of early contact with addictive substances would be beneficial in terms of reducing their consequences. From this perspective, there is a need for culturally-sensitive prevention programs in Turkey.

Turkey has a multi-cultural profile, and it is important to know how the behavior of substance use changes within different cultural groups. The majority of people in Turkey are Muslim, yet many of them also claim various ethnic and religious identities. The substance use patterns of young people in eastern Turkey have not yet been well studied. Thus the subjective risk factors are not well known. In addition, this region has a different cultural and ethnic structure than other parts of the country, especially in the Province of Tunceli, where the study took place. Considering that Tunceli was the unhappiest Province according to “Life Satisfaction at the Provincial Level” data of a Turkish statistical agency, it is of great importance to know the substance use status in young people as well as the risk factors ¹⁰10. Türkish Statistical Institute (Türk Istatistik Kurumu- TUİK) . Life Satisfaction at the provincial level . 2013 . [ cited 2015 Jan 12 ]. Available from: http://www.tuik.gov.tr/PreHaberBultenleri
http://www.tuik.gov.tr/PreHaberBultenler... . The social and religious diversity of Tunceli and the lack of job and social opportunities for young people in Tunceli are considered among the risk factors that increase substance use. The study results may guide families, schools, and social workers towards creating prevention programs. Therefore, the purpose of this study was to determine substance use patterns, risk factors, and the self-efficacy status of the young people in the high schools of the province of Tunceli in Turkey.

Research Questions

1.What is the prevalence of substance use of high-school students?

2. Which risk factors affect substance addiction status of students?

3. What is the self-efficacy status of students against substance use?

Methods

Study design: This study was a descriptive cross-sectional design.

Setting and sample: The study population consisted of 1772 students from ten high schools located in Tunceli. All of the schools were public schools with lower-middle income group students. Due to a lack of financial resources and to avoid returning to schools, which disrupts class routines, a sample was quickly selected. All these high schools were included in the sampling, and one branch was selected from each grade using the clustered sampling method. In deciding the branches, special attention was given to a sample similar percentages from the numerical, verbal and equiponderant branches. To prevent research error, all high schools were included in the study and the sample was done heterogeneously. In this regard, 616 students (34.7% of all students) were included in the study, of which 225 were 9th graders, 167 were 10th graders, 139 were 11th graders and 85 were 12th graders, respectively. However, after the data collection, three students’ questionnaires were deemed invalid due to incomplete scales, and the study was then completed with 613 students.

Ethical considerations: This study was approved by the Research Ethical Committee of Tunceli University. Written permission from the Educational Directorate and Governorship of Tunceli was also obtained to conduct the research. In addition, data collection was on a voluntary basis in accordance with the Declaration of Helsinki.

Instruments: Data were collected using the “Questionnaire on Substance Use and its Causes”, and “Self- Efficacy Scale in the Prevention of Substance Abuse (SEAPSAS)”. The “Questionnaire on Substance Use and its Causes” consists of 41 items; it was created by the researchers after reviewing the literature ⁴4. Evren C , Ogel K , Demirci A.C , Evren B , Yavuz B.G , Bozkurt M. Prevalence of lifetime tobacco, alcohol and drug use among 10th grade students in Istanbul . Klinik Psikofarmakoloji Bülteni 2014 ; 24 ( 3 ): 201 - 210 .

5. Turkey Monitoring Centre of Drug and Drug Use (TUBİM) . Turkish Drug Report 2014 . [ cited 2015 Jan 12 ]. Available from: http://www.kom.pol.yt/tubim/SiteAssets/Sayfalar/Türkiye-Uyuşturucu-Raporu/TUBIM%202014
http://www.kom.pol.yt/tubim/SiteAssets/S...

6. Conway K.P , Vullo GC , Nichter B , Wang J , Compton WM , Iannotti RJ , Simons-Morton B. Prevalence and patterns of polysubstance use in a nationally representative sample of 10th graders in the United States . J Adolesc Health 2013 ; 52 ( 6 ): 716 - 723 .^-77. Van Ryzin MJ , Fosco GM , Dishion TJ . Family and peer predictors of substance use from early adolescence to early adulthood: an 11-year prospective analysis . Addict Behav 2012 ; 37 ( 12 ): 1314 - 1324 .^,99. Chakravarthy B , Shah S , Lotfipour S . Adolescent drug abuse - Awareness & prevention . Indian J Med Res 2013 ; 137 ( 6 ): 1021 - 1023 . . In Turkey, there was not a standart questionnaire that measures the substance use bahaviour of adolescents. Therefore, the researchers were prepared the questionnaire themselves. It came into final form after a pilot application with ten students. The first 20 items of the 41-item questionnaire are the socio-demographic characteristics of the students, and their relationship with the environment, whereas other items refer to cigarette and alcohol use and other addictive substances. Age, gender, grade, school achievement, parents’ education, parents being alive, and trauma experience constituted the independent variables of the study. Trauma was evaluated as an event that the student experienced in the past and had not forgotten. The dependent variables were cigarette use, use/trial of alcohol and other addictive substances, and self-efficacy in the prevention of substance abuse. Independent variables of the study were decided according to the literature.

SEAPSAS

The purpose of the scale, which was developed by Eker et al. ¹¹11. Eker F , Akkuş D , Kapısız Ö . The development and psychometric evaluation study of self-efficacy for protecting adolescences from Substance Abuse Scale . Psikiyatri Hemşireliği Dergisi 2013 ; 4 ( 1 ): 7 - 12 . is to evaluate the self-efficacy perceptions of high school students regarding resisting substance abuse. The SEAPSAS was developed in Turkish Language. SEAPSAS was used because there is not a validity and reliability scale that measures the resistance of the students against the substance in Turkey. The SEAPSAS was first applied to 9th, 10th and 11th graders in three major high schools in the province of Düzce in Turkey. For internal consistency reliability of the scale, Cronbach’s alpha coefficient method was used. The Cronbach internal consistency coefficient of the whole scale was found to be 0.81. The internal consistency of subscales ranged from 0.45 to 0.87. The test-retest correlation was significant (p < 0.001) and positively correlated. Because a Turkish version of scales that measure the self-efficacy of youth against substance use could not be found, this scale was used. In this study, Cronbach’s Alpha value was found to be 0.79.

Data collections: The study data was collected on February 25, 2015, by visiting the high schools. Questionnaires were given to students on the same day in order to increase the reliability of the data. In order to get the correct answers during data collection, the purpose of the study was explained to students by researchers, and teachers were not allowed in the classrooms during data collection. During the data collection, the researcher did not check the questionnaires, but just gave the answer to the student’s question. Students needed approximately 20 minutes to answer all the questions.

Data analysis: Data were analyzed using the computer-based SPSS version 18 statistical package program with percentages and means. The Chi-square test was used to examine the relationship between certain variables and substance use status. The F test, t test and Multiple Regression Analysis was used to examine the relationship between certain variables and SEAPSAS. According to the value of Skewness, KW nonparametric tests were used for abnormal distribution. In this analysis, p-value less than 0.05 was considered to indicate statistical significance. Scale questions which were not completed by students were not included in the analysis. To prevent Type I error, multiple regression analysis was used.

Results

Introductory characteristics of the students

The average age of the students in the study was 16.24 ± 1.18, and 50.8% were female, 36.5% were 9th graders, 27.1% were 10th graders, 22.6% were 11th graders, and 13.8% were 12th graders. The average monthly income of families was found to be 1759.31 ± 1246.68 TL. (581.31 ± 411.78 $) and the average weekly allowance of the students was 29.39 ± 27.46 TL. Antidepressant / antipsychotic / anxiolytic drugs were being used by 3.2% of the students.

Of the total number of students included in the research, 36.2% had tried smoking cigarettes. The average age for beginning cigarette use was 13.54 ± 2.93. Twelve percent of students under the age of ten had tried cigarette smoking, and 65% had tried smoking between 11 and 15 years of age. Primary reasons cited for trying cigarette use were curiosity, whim, and the influence of friends. The percentage of occasional smokers was 11.5%, and 10.2% of the students were regular smokers ( Table 1 ). Although not included in the table, it was remarkable that the vast majority (69.6%) had at least one smoker in their family.

Our study results found that 60.2% of the students had tried alcohol. The average age for first use of alcohol was 13.65 ± 2.63, yet 12.4% of the students had tasted alcohol when they were under ten years old. First-time use of alcohol occurred for 66.1% of students between 11-15 years of age. Special occasions and curiosity were the primary reasons for the first use of alcohol. Nearly half (47.3%) of students mentioned recent occasional use of alcohol ( Table 2 ).

Although not included in the table, illegal drugs had been tried by 4.2% of study participants. Eleven students had tried marijuana, six had tried bonzai, three had tried pills, three had tried 3,4-Methylenedioxymethamphetamine (MDMA), also known as ecstasy (E), and three students had tried heroin. Furthermore, 13.8% of the students stated that some of their school friends had used other addictive substances other than alcohol and cigarettes, and 13.2% stated that they have friends outside of school, who use these other addictive substances.

Study participants (67.3%) knew the names of addictive substances, and the most well-known substances were bonzai, cigarettes, marijuana, which is also known as weed-bucket, alcohol, and pills. Though fewer in number, some of the substances were known by the street names. When asked about the sources of information for these substances, 58.8% of students indicated television as a source, 54.0% got information from their close circle of friends, and 12.8% learned information from the Internet.

The relationship between certain variables, substance use, and when students choose to use drugs

The frequency of cigarette use for both female and male students was found to be similar (X ² = 0.337, SD = 2, p = 0.310). Students with low school achievement (X ² = 7.051, p = 0.029), with college graduate parents (X ² = 14.466, p < .001), who had experienced trauma (X ² = 22.386, p < .001), and who had family problems (X ² = 39.912, p < .001) were found to smoke more. Looking at the relationship between current use of alcoholic beverages and certain variables, males (X ² = 13.078, p < .001), 11th and 12th graders (X ² = 22.311, p < .001), those who perceived lower school achievement (X ² = 7.684, p = 0.021), those who experienced trauma (X ² = 11.367, p < .001), those who had alcohol users in the family (X ² = 15.733, p < .001) and among close friends (X ² = 57.412, p < .001), those who smoked (X ² = 44.095, p < .001) and those who had friends outside of school that use addictive substances (X ² = 21.997, p < .001) were found to use alcohol more, with a statistically significant difference.

Looking at the relationship between some variables and students who were a part of the study who tried other addictive substances, the current cigarette user (X ² = 51.727, p < .001) and alcohol user (X ² = 19.360, p < .001) students also tried other addictive substances, and the difference was statistically significant in this regard.

SEAPSAS and relationship with certain variables

The mean SEAPSAS of the students was found to be 93.61 ± 18.99. Considering the mean sub-scale scores of the scale, the mean score in avoiding drugs/psychotropic substances was 51.26 ± 11.07. The mean score in avoiding drugs/psychotropic substances under pressure was 16.93 ± 4.12; the mean score in seeking help about drugs/psychotropic substances was 13.71 ± 5.15; and the mean score in supporting a friend about drugs/psychotropic substances was 11.45 ± 3.62, respectively.

Looking at the relationship between the mean self-efficacy score and some variables, the self-efficacy was found to be lower in males (89.94 ± 21.08) versus females (97.03 ± 16.76) (t = 21.234, p < .001); cigarette users (80.33 ± 24.08) versus non-users (95.85 ± 16.48) (t = 56.698, p < .001); alcohol users (90.27 ± 20.17) versus non-users (98.85 ± 16.18) (t = 29.938, p < .001), students who perceived lower school achievement (F = 20.245, p < .001), those who had alcohol users in the family (88.21 ± 20.93) versus non-users in the family (95.81 ± 17.82) (t = 16.348, p < .001), students who expressed a negative relationship with the family (F = 3.895, p = 0.001), those who had substance use experience outside of smoking and alcohol (67.29 ± 25.81) versus non-experience (94.92 ± 17.51) (t = 54.68, p < .001), and those who had trauma experience (91.24 ± 20.21) versus non-experience (96.03 ± 18.12) (t = 9.250, p < .001) ( Table 3 ). These factors were assessed in combination in the multiple regression analysis, and the significances were verified for cigarette user (β = -.20, t = -3.831, p < .005) and alcohol user (β = .01, t = 2.365, p < .005), male (β = -.08, t = -2.313, p < .005), trauma experience (β = .98, t = 1.919, p < .005), and negative relationship with the family (β = -.22, t = -4.036, p < .005) (R ² = 0.2) ( Table 4 ).

Discussion

The results of this study are very important for the different social and cultural groups represented to evaluate the prevalence and affecting factors of substance use. Limitations of the study included a lack of funds, which allowed study data to be gathered in only one city. Another limitation was that Tunceli has a varied historical and cultural background when compared to other regions of Turkey. Thus, generalizations for the entire country cannot be made.

Our study results found that more than one-third of the students had tried cigarettes, the average age of the first cigarette experience was 13.5 years, and approximately one-fifth of students smoked regularly or occasionally. The average age of starting to smoke was found to be lower than some previous studies, while it was higher than some other studies. In a study conducted in Chile, the age of first cigarette use experience was found to be 12.3 years ¹²12. Valdivia G , Simonetti F , Cumsille P , Ramírez V , Hidalgo CG , Palma B , Carrasco J . Smoking habit in school age children, in Chile . Rev Med Chil 2004 ; 132 ( 2 ): 171 - 182 . and in a study conducted in Iran, the age was 14.35 years ¹³13. Khajehdaluee M , Zavar A , Alidoust M , Pourandi R . Smoking among high school students of an area with medium socioeconomic status . J Pak Med Assoc 2014 ; 64 ( 3 ): 291 - 295 . . Also in another study carried out in the USA, 34.4% of the substance users had begun using substances before the age of 16 ¹⁴14. Moss HB , Chen CM , Yi HY . Early adolescent patterns of alcohol, cigarettes, and marijuana polysubstance use and young adult substance use outcomes in a nationally representative sample . Drug Alcohol Dependence 2014 ; 136 : 51 - 62 . . Approximately one-eighth of the students in this study stated that they had tried cigarette use before ten years of age, and this poses an important issue for Turkey. According to a Turkish report by the Monitoring Centre for Drugs and Drug Addiction ⁵5. Turkey Monitoring Centre of Drug and Drug Use (TUBİM) . Turkish Drug Report 2014 . [ cited 2015 Jan 12 ]. Available from: http://www.kom.pol.yt/tubim/SiteAssets/Sayfalar/Türkiye-Uyuşturucu-Raporu/TUBIM%202014
http://www.kom.pol.yt/tubim/SiteAssets/S... (2014), the average age for first cigarette use by school children was 13,8. At the same time, our study showed that the number of students who smoke is lower than other countries except Asian countries. In a Brazilian study, the prevalence of cigarette use in adolescents was found to be 18.9% ¹⁵15. Jorge KO , Cota LO , Ferreira EF , Vale MP , Kawachi I , Zarzar PM . Tobacco use and friendship networks: a cross-sectional study among Brazilian adolescents . Cien Saude Colet 2015 ; 20 ( 5 ): 1415 - 1424 . . Yet the number was found to be higher than those of other studies conducted in Turkey ¹⁶16. Erdamar G , Kurupınar A . The habit of drug addiction and prevalence among the secondary school students: sample of Bartın city . Sosyal Bilimler Dergisi 2014 ; 16 ( 1 ): 65 - 84 .^,1717. Demirbaş H . Substance and alcohol use in young adults in Turkey as indicated by the CAGE questionnaire and drinking frequency . Nöropsikiyatri Arşivi 2015 ; 52 ( 1 ): 29 - 35 . . Again, as mentioned earlier, students’ reasons for cigarette use included curiosity, whim, and the influence of friends, and these reasons were in line with the literature.

More than half of the students included in the study had tried alcohol, and almost half of them stated that they used alcohol occasionally. The average age for the first contact with alcohol was found to be 13.6. In this study, the rates of trying and using alcohol were found to be higher than other studies conducted with secondary school students in Turkey ¹⁷17. Demirbaş H . Substance and alcohol use in young adults in Turkey as indicated by the CAGE questionnaire and drinking frequency . Nöropsikiyatri Arşivi 2015 ; 52 ( 1 ): 29 - 35 .^,1818. Turkey . Report of Parliamentary Investigation Commission . The Grand National Assembly of Turkey The Parliamentary Inquiry Commission Established to Search for Problems Regarding Substances, Specifically Drugs, Dependence, Drug Trafficking and to Discern the Necessary Precaution . Ankara : TBMM Publication ; 2009 . . The Erdamar and Kurupınar ¹⁶16. Erdamar G , Kurupınar A . The habit of drug addiction and prevalence among the secondary school students: sample of Bartın city . Sosyal Bilimler Dergisi 2014 ; 16 ( 1 ): 65 - 84 . study determined that 35.2% of the students (n = 192) had used alcohol at least once, and 24.4% of them (n = 131) still continued to use alcohol. In another study conducted in western Turkey, the rate of alcohol use among high school students was found to be 34.2% ⁴4. Evren C , Ogel K , Demirci A.C , Evren B , Yavuz B.G , Bozkurt M. Prevalence of lifetime tobacco, alcohol and drug use among 10th grade students in Istanbul . Klinik Psikofarmakoloji Bülteni 2014 ; 24 ( 3 ): 201 - 210 . . In Turkey most of the population is Muslim and the use of alcohol is forbidden in accordance with Islam. Therefore the rate of alcohol usage in Turkey is lower than in European countries and the USA. Nevertheless, this study’s results showed alcohol consumption to be higher than previous studies conducted in Turkey. This result may be related to regional and cultural background differences. Alcohol consumption in Tunceli is more readily tolerated than in other parts of Turkey. It is possible that special holidays such as the New Year celebrations and birthdays, which are characterized by increased tolerance to the use of substances, can more easily pave the way for an introduction to addictive substances. The risk of addiction decreases with the delayed introduction to substances.

Results of this study found that the rate of use of addictive substances was 4.2%. This is lower than that of the European countries and the USA ¹1. Center of Disease Control and Prevention (CDC) . Youth and Tobacco Use . 2015 . [ cited 2015 Jan 12 ]. Available from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/2015
http://www.cdc.gov/tobacco/data_statisti... , yet it is higher than the values reported in other Turkish studies ⁵5. Turkey Monitoring Centre of Drug and Drug Use (TUBİM) . Turkish Drug Report 2014 . [ cited 2015 Jan 12 ]. Available from: http://www.kom.pol.yt/tubim/SiteAssets/Sayfalar/Türkiye-Uyuşturucu-Raporu/TUBIM%202014
http://www.kom.pol.yt/tubim/SiteAssets/S... ^,1616. Erdamar G , Kurupınar A . The habit of drug addiction and prevalence among the secondary school students: sample of Bartın city . Sosyal Bilimler Dergisi 2014 ; 16 ( 1 ): 65 - 84 .^,1818. Turkey . Report of Parliamentary Investigation Commission . The Grand National Assembly of Turkey The Parliamentary Inquiry Commission Established to Search for Problems Regarding Substances, Specifically Drugs, Dependence, Drug Trafficking and to Discern the Necessary Precaution . Ankara : TBMM Publication ; 2009 . . Particularly noteworthy was that more than one-tenth of the students stated that they have friends both in and outside of school who use other addictive substances. The ease with which students told of their friends’ substance use status may be an important indication regarding the use of illegal substances in the Province of Tunceli. However, the margin of error must not be ignored in the surveys when interpreting these results for both self-report and reports about substance use of their friends. For example, a decrease in smoking in young people was reported due to the effective anti-smoking policy implemented in Turkey in recent years, however, it was emphasized that there was also an increase in the use of marijuana and synthetic drugs ⁵5. Turkey Monitoring Centre of Drug and Drug Use (TUBİM) . Turkish Drug Report 2014 . [ cited 2015 Jan 12 ]. Available from: http://www.kom.pol.yt/tubim/SiteAssets/Sayfalar/Türkiye-Uyuşturucu-Raporu/TUBIM%202014
http://www.kom.pol.yt/tubim/SiteAssets/S... . In this study, the substance used most often by the students was reported to be marijuana. As in other Western societies, the increasing prevalence of marijuana increases the risk of comorbidity ¹⁹19. Leatherdale ST , Robin B . The substance use profile of Canadian youth: exploring the prevalence of alcohol, drug and tobacco use by gender and gradet . Addict Behav 2012 ; 37 ( 3 ): 318 - 322 . . In fact, indications are that the use of alcohol and smoking entails a potential risk for transition to other substances as well.

Within the scope of the study, students’ knowledge about the names of the addictive substances was investigated as well as their sources for this information. Some of the students knew the correct names of these substances, yet they also knew some substances by their street names. Marijuana, bonzai, Methylenedioxymethamphetamine (MDMA), popularly called ecstasy(E), and heroin were among the most addictive substances known. The most common sources of knowledge about these substances were from television, the environment, and the Internet. Similar to this study, a study conducted in Iran also reported that the environment and media were the most common sources of information ¹³13. Khajehdaluee M , Zavar A , Alidoust M , Pourandi R . Smoking among high school students of an area with medium socioeconomic status . J Pak Med Assoc 2014 ; 64 ( 3 ): 291 - 295 . .

The relationship between certain variables and substance use conditions of the students

There are complex correlations for the causes of substance use among young people. This study showed a statistically significant correlation between the first time use of alcohol, cigarettes, and the students’ grade level, whether the father was alive, parents’ education, trauma status, school achievement, interaction in the family, and family history of substance use. Amongst the students who had experienced trauma, 13.4% of students had stated that they used the substance for relaxation. With regard to smoking, the rate of substance use in Turkey is lower in females ⁴4. Evren C , Ogel K , Demirci A.C , Evren B , Yavuz B.G , Bozkurt M. Prevalence of lifetime tobacco, alcohol and drug use among 10th grade students in Istanbul . Klinik Psikofarmakoloji Bülteni 2014 ; 24 ( 3 ): 201 - 210 .^,2020. Bülbül S.H , Güçlü M , Mısıroğlu E.D . Factors affecting the use of tobacco and alcohol in Kırıkkale elementary and high school students . Turkish Journal of Pediatric Disease 2013 ; 4 : 168 - 172 .

21. Unlu A , Evcin U , Dalkilic A , Pumariega A.J . Substance Use Prevalence according to Public High School Types in Istanbul . Addictive Disorder & Their Treatment 2013 ; 13 ( 2 ): 75 - 86 .^-2222. Zarzar PM , Jorge O , Vale MP , Ferreira EF , Kawachi I . Association between binge drinking, type of friends and gender: a cross-sectional study among Brazilian adolescents . BMC Public Health 2012 ; 12 : 257 . . The difference between the genders was found to be less in this study.

The findings of this study are supported by other studies regarding the relationship between the use of alcohol, cigarette use and grade level, substance-addicted friends and a friendship network ⁴4. Evren C , Ogel K , Demirci A.C , Evren B , Yavuz B.G , Bozkurt M. Prevalence of lifetime tobacco, alcohol and drug use among 10th grade students in Istanbul . Klinik Psikofarmakoloji Bülteni 2014 ; 24 ( 3 ): 201 - 210 .^,2222. Zarzar PM , Jorge O , Vale MP , Ferreira EF , Kawachi I . Association between binge drinking, type of friends and gender: a cross-sectional study among Brazilian adolescents . BMC Public Health 2012 ; 12 : 257 . , cigarette use and alcohol use in the family ¹²12. Valdivia G , Simonetti F , Cumsille P , Ramírez V , Hidalgo CG , Palma B , Carrasco J . Smoking habit in school age children, in Chile . Rev Med Chil 2004 ; 132 ( 2 ): 171 - 182 . , interaction in the family ¹⁷17. Demirbaş H . Substance and alcohol use in young adults in Turkey as indicated by the CAGE questionnaire and drinking frequency . Nöropsikiyatri Arşivi 2015 ; 52 ( 1 ): 29 - 35 . , and low school achievement ²³23. Bradley B , Green A.C . Do health and education agencies in the United States share responsibility for academic achievement and health? A review of 25 years of evidence about the relationship of adolescents’ academic achievement and health behaviors . J Adolesc Health 2013 ; 52 ( 5 ): 523 - 532 . .

This study also determined a statistically significant difference with the students who tried cigarettes and alcohol and then later experimented with other illegal addictive substances. Additional literature findings report that cigarette and alcohol use increases the risk of trying other substances ¹1. Center of Disease Control and Prevention (CDC) . Youth and Tobacco Use . 2015 . [ cited 2015 Jan 12 ]. Available from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/2015
http://www.cdc.gov/tobacco/data_statisti... ^,33. United Nations Office on Drugs and Crime (UNODC) . World Drug Report, United Nations Office on Drugs and Crime . Viena : UNODC ; 2015 . .

Self-efficacy status of the students against substance use and relationship with certain variables

A young person’s level of self-efficacy is one of the decisive factors in the prevention of substance use. It is especially important for children and young people to resist the pressure from friends and to know how and where to seek help. In this study, the mean self-efficacy score for substance use prevention was found to be 93.61 ± 18.99. However, we are not able to compare this figure with other studies due to the low number of studies on the level of self-efficacy in the prevention of substance use in the children and young people of Turkey. International studies have reported that the self-efficacy scores were lower in drug users ²⁴24. Dorard G , Bungener C , Corcos M , Berthoz S . Self-esteem, coping, perceived social support and substance use in young adults with a cannabis dependence disorder . Encephale 2014 ; 40 ( 3 ): 255 - 262 .^,2525. Smorti M . Sensation seeking and self-efficacy effect on adolescents risky driving and substance abuse . Procedia Social Behavioral Science 2014 ; 140 : 638 - 642 . . We found the self-efficacy scores of this study to be lower in males, users of alcohol and smokers, students who perceived lower school achievement, those with negative relationship with friends and the family, those with a family history of substance use, and those who had experienced a trauma. These risks are among the risks reported in the literature in terms of creating a predisposition to substance use ¹⁷17. Demirbaş H . Substance and alcohol use in young adults in Turkey as indicated by the CAGE questionnaire and drinking frequency . Nöropsikiyatri Arşivi 2015 ; 52 ( 1 ): 29 - 35 .^,2626. Kasapıla W , Kasapıla M , Tapiwa , S . Drinking and smoking habits among college students in Malawi . European Journal of Social Science 2010 ; 15 ( 3 ): 441 - 448 .^,2727. Toker T , Tiryaki A , Özçürümez G , Iskender B . The relationship between traumatic childhood experiences and proclivities towards substance abuse, self-esteem and coping strategies . Turk Psikiyatri Derg 2011 ; 22 ( 2 ): 83 - 92 . .

Conclusions

In this study, the rate of cigarette and alcohol use were higher than the national average. Alcohol, cigarettes, and marijuana were the most common substances tried by young people. Curiosity, whim, and special occasions were the reasons most often cited which led youth to experiment with substance use. It was found that the self-efficacy scores in substance-use prevention were lower in males, users of alcohol and cigarettes, those with negative family relationships, and those who had experienced a trauma.

Implication for Policy and Practices

In line with these study results, there is an urgent need to develop culturally-sensitive programs for the prevention of substance use in Turkish youth, especially those most at risk. Ideally, such programs should provide up-to-date and accurate information to both students and their families and to the general public. In this regard, school nurses and healthcare staff working in primary health care units should be a resource for students and families whose shared main goal would be to improve the self-efficacy of children and youth in the prevention of substance use.

References

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History