Abstract

The aim of this study was to analyze the factors associated with concurrent alcohol, tobacco and illicit drug use among Brazilian schoolchildren aged 13-17. We conducted a cross-sectional study using data from the 2019 National School-Based Health Survey. The outcome was use of the three substances during the last 30 days. Hierarchical multiple logistic regression was carried out with independent variables grouped into four blocks: sociodemographic characteristics; family context; behavioral aspects; and stressors. Variables with p<0.05 were retained in the final model. The prevalence of concurrent substance use was 3.3%. Being male, living in the Midwest, South and Southeast, skipping school without parent permission, parents not knowing what their children do in their free time, having parents who smoke, having experienced physical aggression from parents, feeling that life is not worth living, trying drinking and illicit drugs before the age of 13, and having friends who drink alcohol, smoke and use drugs in their presence remained associated with the outcome in the final model. The findings reveal high prevalence of concurrent alcohol, cigarette and illicit drug use among adolescents and that poly use is associated with sociodemographic, family, and behavioral factors and stressors.

Key words:
Adolescent; Students; Illicit Drugs; Risk Factors

Introduction

Psychoactive substance use is one of the most common risk behaviors in adolescents, being particularly worrying in youth who engage in concurrent use of drugs, a pattern known as polysubstance use¹1 Banks DE, Rowe AT, Mpofu P, Zapolski TCB. Trends in typologies of concurrent alcohol, marijuana, and cigarette use among US adolescents: An ecological examination by sex and race/ethnicity. Drug Alcohol Depend 2017; 179:71-77.. Polysubstance use is defined as the use of more than one type of non-prescribed licit or illicit psychoactive substance concurrently - the use of two or more substances on different occasions within a month, year or other period of time - or simultaneously - involving the use of two or more substances at the same time²2 Nóbrega MPSS, Simich L, Strike C, Brands B, Giesbrecht N, Khenti A. Policonsumo simultâneo de drogas entre estudantes de graduação da área de ciências da saúde de uma universidade: implicações de gênero, sociais e legais, Santo André - Brasil. Texto Contexto Enferm 2012; 21(n. esp.):25-33..

Epidemiological data from different countries show that polysubstance use prevalence rates in school-age youth vary according to sample size, study period and definition of polysubstance use. Cross-sectional studies found prevalence rates of 18.0% in Canada between 2018 and 2019³3 Zuckermann AME, Williams GC, Battista K, Jiang Y, Groh M, Leatherdale ST. Prevalence and correlates of youth poly-substance use in the COMPASS study. Addict Behav 2020; 107:106400., 13.9% in Spain in 2011⁴4 Font-Mayolas S, Gras ME, Cebrián N, Salamó A, Planes M, Sullman MJ. Types of polydrug use among Spanish adolescents. Addict Behav 2013; 38(3):1605-1609. and 5.1% in Malaysia in 2017⁵5 Rodzlan Hasani WS, Saminathan TA, Ab Majid NL, Miaw Yn JL, Mat Rifin H, Abd Hamid HA, Lourdes, TGR, Ahmad A, lsmail H, Abd Rashid R, Yusoff MFM. Polysubstance use among adolescents in Malaysia:Findings from the National Health and Morbidity Survey 2017. PLoS One 2021; 16(1):e0245593..

Recent studies on polysubstance use among adolescents in Brazil used latent class analysis to identify groups of adolescents according to patterns of use. One of these studies performed a latent transition analysis of data from a longitudinal study with 6,391 students in six cities between 2014 and 2015, revealing three distinct patterns of drug use behavior: abstainers/low users (81.54% at baseline, 70.61% after 21 months), alcohol users/binge drinkers (16.65% at baseline, 21.45% after 21 months) and polydrug users (1.80% at baseline, 7.92% after 21 months)⁶6 Valente JY, Cogo-Moreira H, Swardfager W, Sanchez ZM. A latent transition analysis of a cluster randomized controlled trial for drug use prevention. J Consult Clin Psychol 2018; 86(8):657-665.. Another study using data from 5,213 school-age youth in three cities collected in 2019 and employing the same type of latent class analysis identified three classes of users: abstainers/low users (63.4%), alcohol users/binge drinkers (29.5%) and polydrug users (7.1%)⁷7 Garcia-Cerde R, Valente JY, Sanchez ZM. Attitudes are associated with the drug use profiles of middle school adolescents: A latent class analysis. Psychiatry Res 2021; 295:113592..

Despite studies of polysubstance use among adolescents in Brazil⁶6 Valente JY, Cogo-Moreira H, Swardfager W, Sanchez ZM. A latent transition analysis of a cluster randomized controlled trial for drug use prevention. J Consult Clin Psychol 2018; 86(8):657-665.^,77 Garcia-Cerde R, Valente JY, Sanchez ZM. Attitudes are associated with the drug use profiles of middle school adolescents: A latent class analysis. Psychiatry Res 2021; 295:113592., national data remains scarce. None of the editions of the National School-Based Health Survey (PeNSE), the main survey in Brazil addressing risk and protective factors for chronic diseases among schoolchildren⁸8 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar. Rio de Janeiro: IBGE; 2009.

9 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2012. Rio de Janeiro: IBGE; 2013.

10 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016.^-1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2019. Rio de Janeiro: IBGE; 2021., present a detailed analysis of polysubstance use, which is the proposal of the present study.

From a health care perspective, understanding the factors that influence polydrug use among adolescents is essential given the well-known social and health impacts, including risky sexual behavior¹²12 Kokkevi A, Kanavou E, Richardson C, Fotiou A, Papadopoulou S, Monshouwer K, Matias J, Olszewski D. Polydrug use by European adolescents in the context of other problem behaviours. Nord Stud Alcohol DR 2014; 31(4):323-342., academic failure¹³13 Kelly AB, Evans-Whipp TJ, Smith R, Chan GC, Toumbourou JW, Patton GC, Hemphill SA, Hall WD, Catalano RF. A longitudinal study of the association of adolescent polydrug use, alcohol use and high school non-completion. Addiction 2015; 110(4):627-635., delinquency¹²12 Kokkevi A, Kanavou E, Richardson C, Fotiou A, Papadopoulou S, Monshouwer K, Matias J, Olszewski D. Polydrug use by European adolescents in the context of other problem behaviours. Nord Stud Alcohol DR 2014; 31(4):323-342., increased risk of suicide¹⁴14 Reyes JC, Robles RR, Colón HM, Negrón JL, Matos TD, Calderón JM. Polydrug use and attempted suicide among Hispanic adolescents in Puerto Rico. Arch Suicide Res 2011; 15(2):151-159. and fatal and non-fatal overdose¹⁵15 Liu S, Vivolo-Kantor A. A latent class analysis of drug and substance use patterns among patients treated in emergency departments for suspected drug overdose. Addict Behav 2020; 101:106142..

Studies with representative samples of adolescents are therefore essential to construct epidemiological profiles and guide the formulation of drug prevention policies targeting this group. The aim of this study was therefore to analyze the factors associated with concurrent alcohol, cigarette and illicit drug use among Brazilian schoolchildren aged between 13 and 17 who participated in the 2019 National School-Based Health Survey (PeNSE).

Methods

We conducted an analytical cross-sectional study using data from the fourth edition of the 2019 PeNSE on schoolchildren aged 13-17 years from 6,612 classes (seventh year of junior high school to the third year of high school) distributed throughout 4,242 public and private schools, including technical colleges. The sample is representative of Brazil, its five regions, states, capital cities and the Federal District¹¹11 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2019. Rio de Janeiro: IBGE; 2021.. Further details on the sample can be found in a previous publication¹¹11 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2019. Rio de Janeiro: IBGE; 2021. and the data are publicly available on the website of the Brazilian Institute of Geography and Statistics (IBGE) (www.ibge.gov.br).

For the purposes of this study, we selected only students who replied “yes” or “no” to questions about current alcohol, cigarette and illicit drug use, resulting in a sample loss rate of 4.2%.

The PeNSE data were collected in 2019 using a questionnaire answered by the students using a smartphone. The data used in the present study were obtained in August 2022 from the IBGE website (https://biblioteca.ibge.gov.br).

The outcome was “concurrent alcohol, cigarette and illicit drug use”. Adolescents who replied “yes” to the questions about use of the three substances in the past 30 days were deemed to be poly users. Use was assessed and categorized using the following indicators:

To assess associated factors, the independent variables were grouped into four blocks: 1) Sociodemographic characteristics; 2) Family context; 3) Stressors; and 4) Behavioral aspects (Figure 1).

The variables were described using frequencies (percentages and 95% confidence intervals - 95%CI) and associations were assessed. Prevalence of polysubstance use was calculated by dividing the number of students who replied “yes” to concurrent alcohol, cigarette and illicit drug use by the total number of students who answered the questions, excluding those who did not reply to at least one of the questions.

The analysis of the factors associated with prevalence of concurrent alcohol, cigarette and illicit drug use was performed using a four-block hierarchical model (first block, sociodemographic characteristics; second block, family context; third block, stressors; and fourth block, behavioral aspects) (Figure 1).

The Wald chi-squared test was used to identify the factors associated with polysubstance use. All variables that obtained a p-value of<0.20 in the bivariate analysis were retained in the multivariate model. The effect measure was the prevalence ratio with 95% confidence interval (95%CI), calculated using Poisson’s regression. The reference categories were the lowest polysubstance use prevalence rates. Variables with a p-value of>0.05 were removed one by one from the hierarchical models including variables from the same block using the backward elimination method, resulting in four regression models.

In Model 1, the variables from block 1 were adjusted separately, retaining those that were statistically significant (p-value<0.05); in Model 2, the variables from block 2 were adjusted against each other and the statistically significant variables from Model 1; in Model 3, the variables from block 3 were adjusted against each other and the statistically significant variables from Model 2 (p-value<0.05); in Model 4 (the final model), the variables were adjusted against each other and the variables from block 3, retaining those that were statistically significant (p-value<0.05).

The statistical analyses were performed using SPSS (Statistical Package for the Social Sciences) 20.0, considering the design effect for complex samples.

Ethical considerations

The 2019 PeNSE was approved by the National Research Ethics Committee (Conep - reference number 3.249.268, de 08.04.2019).

Results

A total of 124,654 students responded the questions about alcohol, cigarette and illicit drug use. A total of 4,110 adolescents (3.3%) reported using the three substances during the past 30 days, without distinction as whether use was concurrent or simultaneous (Table 1).

Table 1 shows the crude prevalence rates, revealing that prevalence of concurrent alcohol, cigarette and illicit drug use was highest in the following groups: adolescents aged 16 and 17 years (PR=2.71; 95%CI: 2.55-2.88); boys (PR=1.19; 95%CI: 1.13-1.27); black schoolchildren (PR=1.50; 95%CI: 1.37-1.65); adolescents whose mothers did not have any schooling (PR=1.24; 95%CI: 1.04-1.47); students form public schools (PR=1.25; 95%CI: 1.17-1.33); students from urban schools (PR=1.72; 95%CI: 1.44-2.06); and students living in the South (PR=2.36; 95%CI: 2.15-2.60), Southeast (PR=2.09; 95%CI: 1.92-2.29) and Midwest (PR=1.92; 95%CI: 1.75-2.11).

Table 2 shows the associations found for family variables. Not living with their mother or father increased the prevalence of polysubstance use by 62% and 63%, respectively. The following variables also showed a significant association (p<0.001) with concurrent alcohol, cigarette and illicit drug use: adolescents who reported skipping classes/school at least once without parent permission (PR=3.22; 95%CI: 3.03-3.43); those whose parents did not know what they were doing in their free time (PR=2.09; 95%CI: 1.92-2.29); those whose parents/guardians smoked (PR=2.05; 95%CI: 1.92-2.18); those whose parents/guardians drank (PR=1.65; 95%CI: 1.54-1.77); and those whose experienced physical aggression from their parents/guardians (PR=1.87; 95%CI: 1.76-1.99).

Table 3 shows the associations found for stressors. Prevalence of polysubstance use was higher in adolescents who had been touched, manipulated, kissed or had parts of their body exposed against their will and who had been threatened, intimidated or forced to have sex or perform any other type of sexual act against their will than in those who had not (PR=2.54; 95%CI: 2.38-2.71 and PR=3.11; 95%CI: 2.87-3.36, respectively). In addition, the prevalence of polysubstance use was higher among adolescents who were bullied (PR=1.19; 95%CI: 1.12-1.27), felt no one cared about them (PR=1.78; 95%CI: 1.67-1.90) and felt that life was not worth living (PR=2.20; 95%CI: 2.08-2.34).

With regard to behavioral aspects, there was a significant association between concurrent alcohol, cigarette and illicit drug use (p<0.001) and trying drinking and drugs before the age of 13 (Table 3). Prevalence of polysubstance use was also higher among adolescents who reported having friends who drank (PR=22.29; 95%CI: 19.61-25.25), smoked (PR=21.80; 95%CI: 19.88-23.92) and used illicit drugs (PR=51.98; 95%CI: 46.85-57.66) in their presence.

Table 4 shows the results of the hierarchical analysis. The following variables remained associated with polysubstance use in the final model: being male; living in the Midwest, South and Southeast; skipping school without parent/guardian permission; parents/guardians not knowing what children do in their free time; having parents/guardians who smoked; experiencing physical aggression from parents/guardians; feeling that life is not worth living; trying drinking and drugs before the age of 13; and having friends who drank, smoked and used drugs in their presence. The variables in the final model with the highest PR were adolescents whose friends used drugs (PR=3.94; 95%CI 3.50-4.43) and drank (PR=2.22; 95%CI 1.93-2.54) in their presence.

Discussion

Prevalence of concurrent alcohol, cigarette and illicit drug use was highest among boys and adolescents living in the Midwest, South, Southeast and North, who slip school without parent/guardian permission, whose parents/guardians did not know what they were doing in their free time, whose parents/guardians smoke, and who experienced physical aggression from parents/guardians. Other factors associated with polysubstance were feeling that life is not worth living, trying drinking and illicit drugs before the age of 13, and having friends who drink, smoke and use illicit drugs in their presence. These findings indicate that polysubstance use is multifactorial and requires close attention from a public health perspective. In this sense, understanding patterns of adolescent substance use is essential to develop effective prevention and harm reduction strategies.

Prevalence of concurrent alcohol, cigarette and illicit drug use in the present study (3.3%) was similar to the rate found by a national study investigating the association between peer victimization and polysubstance use and violent behavior carried out in 2012, in which 3.1% of adolescents reported using three substances¹⁶16 Horta CL, Horta RL, Levandowski DC, Teixeira VA, Lisboa CSM. Efeitos da vitimização por pares sobre o uso de substâncias psicoativas e comportamentos violentos em adolescentes. Estud Psicol (Natal) 2019; 24(4): 402-413.. In addition, the findings of the III national drug use survey conducted in 2015 showed that more than one million adolescents drank and smoked during the 12 months prior to the survey and almost 400,000 drank and used at least one illicit substance¹⁷17 Bastos FIPM, Vasconcellos MTL, Boni RB, Reis NB, Coutinho CFS. III Levantamento Nacional sobre o Uso de Drogas pela População Brasileira. Rio de Janeiro: ICICT/Fiocruz; 2017.. These data are worrying given that concurrent substance use among adolescents leads to increased risk for negative health and social consequences¹1 Banks DE, Rowe AT, Mpofu P, Zapolski TCB. Trends in typologies of concurrent alcohol, marijuana, and cigarette use among US adolescents: An ecological examination by sex and race/ethnicity. Drug Alcohol Depend 2017; 179:71-77..

Our findings show that prevalence of polysubstance use was higher in boys. A study in the United States also showed that boys were more likely to belong to all typologies of substance use than girls¹1 Banks DE, Rowe AT, Mpofu P, Zapolski TCB. Trends in typologies of concurrent alcohol, marijuana, and cigarette use among US adolescents: An ecological examination by sex and race/ethnicity. Drug Alcohol Depend 2017; 179:71-77.. This was also observed among Malaysian⁵5 Rodzlan Hasani WS, Saminathan TA, Ab Majid NL, Miaw Yn JL, Mat Rifin H, Abd Hamid HA, Lourdes, TGR, Ahmad A, lsmail H, Abd Rashid R, Yusoff MFM. Polysubstance use among adolescents in Malaysia:Findings from the National Health and Morbidity Survey 2017. PLoS One 2021; 16(1):e0245593. and European¹⁸18 Göbel K, Scheithauer H, Bräker AB, Jonkman H, Soell ner R. Substance use patterns among adolescents in Europe: a latent class analysis. Subst Use Misuse 2016; 51(9):1130-1138. adolescents. In contrast, a study in three cities in Brazil reported that girls were more likely to drink heavily and be poly users⁷7 Garcia-Cerde R, Valente JY, Sanchez ZM. Attitudes are associated with the drug use profiles of middle school adolescents: A latent class analysis. Psychiatry Res 2021; 295:113592.. While gender differences may be influenced by cultural changes in the role women play in society¹⁹19 Malta DC, Machado ÍE, Felisbino-Mendes MS, Prado RR, Pinto AMS, Oliveira-Campos M, Souza MFM, Assunção AA. Uso de substâncias psicoativas em adolescentes brasileiros e fatores associados: Pesquisa Nacional de Saúde dos Escolares, 2015. Rev Bras Epidemiol 2018; 21:e180004., both boys and girls may use several different combinations of substances, meaning it is difficult to accurately capture these differences²⁰20 Goodwin SR, Moskal D, Marks RM, Clark AE, Squeglia LM, Roche DJO. A Scoping Review of Gender, Sex and Sexuality Differences in Polysubstance Use in Adolescents and Adults. Alcohol Alcohol 2022; 57(3):292-321..

With regard to regions and polysubstance use, the strength of association was lowest in adolescents living in the Northeast and highest in the Midwest. In the latter region, prevalence of trying and recently using the substances investigated by the study were high. The Federal District ranked first among the country’s states for trying illicit drugs and second for trying water pipes and recent use of illicit drugs¹¹11 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2019. Rio de Janeiro: IBGE; 2021.. Other national studies²¹21 Horta RL, Mola CL, Horta BL, Mattos CNB, Andreazzi MAR, Oliveira-Campos M, Malta DC. Prevalência e condições associadas ao uso de drogas ilícitas na vida: Pesquisa Nacional de Saúde do Escolar 2015. Rev Bras Epidemiol 2018; 21:e180007.^,2222 Malta DC, Mascarenhas MDM, Porto DL, Barreto SM, Morais Neto OL. Exposição ao álcool entre escolares e fatores associados. Rev Saude Publica 2014; 48(1):52-62. have showed that schoolchildren living in regions with higher gross domestic product, such as the Southeast, South and Midwest, showed higher prevalence of alcohol and illicit drug use.

The parental monitoring variables “skips school without parent permission” and “parents did not know what children were doing in their free time” remained associated with polysubstance use. National studies²³23 Valente JY, Cogo-Moreira H, Sanchez ZM. Gradient of association between parenting styles and patterns of drug use in adolescence: A latent class analysis. Drug Alcohol Depend 2017; 180:272-278.^,2424 Valente JY, Cogo-Moreira H, Sanchez ZM. Predicting latent classes of drug use among adolescents through parental alcohol use and parental style: a longitudinal study. Soc Psychiatry Psychiatr Epidemiol 2019; 54(4):455-467. have highlighted the importance of parental monitoring for preventing adolescent drug use, with children whose parents adopt a neglectful parenting style being more likely to be poly users. Paying attention, taking an interest in children’s free time activities and friends²⁴24 Valente JY, Cogo-Moreira H, Sanchez ZM. Predicting latent classes of drug use among adolescents through parental alcohol use and parental style: a longitudinal study. Soc Psychiatry Psychiatr Epidemiol 2019; 54(4):455-467., and open communication²⁵25 Rusby JC, Light JM, Crowley R, Westling E. Influence of parent-youth relationship, parental monitoring, and parent substance use on adolescent substance use onset. J Fam Psychol 2018; 32(3):310-320.^,2626 Chan GC, Kelly AB, Carroll A, Williams JW. Peer drug use and adolescent polysubstance use: Do parenting and school factors moderate this association? Addict Behav 2017; 64:78-81. are considered protective factors. In addition, it is important that school drug prevention programs include activities that target parents to reduce neglectful practices and raise parent awareness of their role²³23 Valente JY, Cogo-Moreira H, Sanchez ZM. Gradient of association between parenting styles and patterns of drug use in adolescence: A latent class analysis. Drug Alcohol Depend 2017; 180:272-278.^,2424 Valente JY, Cogo-Moreira H, Sanchez ZM. Predicting latent classes of drug use among adolescents through parental alcohol use and parental style: a longitudinal study. Soc Psychiatry Psychiatr Epidemiol 2019; 54(4):455-467..

Parent disapproval of drug use has also been highlighted as an important protective factor against polysubstance use, with adolescent drug use being lower in families who set rules restricting the use of substances²⁶26 Chan GC, Kelly AB, Carroll A, Williams JW. Peer drug use and adolescent polysubstance use: Do parenting and school factors moderate this association? Addict Behav 2017; 64:78-81.. In contrast, children of parents who use psychoactive substances themselves are more likely to be polysubstance users²⁷27 Tomczyk S, Isensee B, Hanewinkel R. Latent classes of polysubstance use among adolescents-a systematic review. Drug Alcohol Depend 2016; 160:12-29.. While our study data are cross-sectional, the significant association between having “parents/guardians who smoke” and polysubstance use may be explained by parental influence, as these types of parents reinforce behaviors that are conducive to drug use. It is also worth highlighting that studies²⁸28 Oliveira LMFT, Santos ARM, Farah BQ, Ritti-Dias RM, Freitas CMSM, Diniz PRB. Influence of parental smoking on the use of alcohol and illicit drugs among adolescents. Einstein (São Paulo) 2019; 17(1):eAO4377.^,2929 Negrão AB, Cordeiro Q, Vallada H. Genética, genômica, epigenética e farmacocinética da dependência química. In: Diehl A, Cordeiro D, Laranjeira R. Dependência química: prevenção, tratamento e políticas públicas. 2ª ed. Porto Alegre: Artmed; 2019. p. 30-38. have demonstrated a possible genetic predisposition to substance use/dependency. However, several questions still need to be answered, especially in relation to the epigenetic approach to human development, which suggests that hereditary conditions associated with environmental factors throughout life have an impact on the manifestation of predisposition to chemical dependency.

Also in relation to family context, experiencing physical aggression from parents/guardians was associated with higher prevalence of polysubstance use. A study with adolescents in Spain showed that prevalence of all types of maltreatment was higher among polydrug users, suggesting that drugs may be a way of coping with past experiences of suffering³⁰30 Alvarez-Alonso MJ, Jurado-Barba R, Martinez-Martin N, Espin-Jaime JC, Bolaños-Porrero C, Ordoñez-Franco A, Association between maltreatment and polydrug use among adolescents. Child Abuse Negl 2016; 51:379-389.. Socially constructed beliefs that children should be educated using punishment and humiliation is a worrying risk factor as it normalizes this type of violence³¹31 Magalhães JRF, Gomes NP, Campos LM, Camargo CL, Estrela FM, Couto TM. Expressão da violência intrafamiliar: história oral de adolescentes. Texto Contexto Enferm 2017; 26(4):e1730016..

Although the variables related to sexual abuse did not remain associated with substance use in the final model, it is important to highlight that almost one-third of poly users in the present study reported suffering sexual harassment and around 17% were threatened, intimidated or forced to have sex or perform any other type of sexual act against their will. According to data from the national notifiable diseases information system for the period 2011- 2017, the most commonly reported types of sexual violence against adolescents were rape (70.4%) and sexual harassment (9.9%)³²32 Brasil. Ministério da Saúde (MS). Análise epidemiológica da violência sexual contra crianças e adolescentes no Brasil, 2011 a 2017. Brasília: MS; 2018.. A study with American adolescents showed that youth exposed to both physical and sexual assault were more likely to be polysubstance users³³33 Charak R, Koot HM, Dvorak RD, Elklit A, Elhai JD. Unique versus cumulative effects of physical and sexual assault on patterns of adolescent substance use. Psychiatry Res 2015; 230(3):763-769.. One possible explanation for these findings is that experiencing this type of violence is extremely distressing for the adolescent and can have a negative effect on identity construction, increasing the risk of polysubstance use to cope with these traumatic experiences³⁰30 Alvarez-Alonso MJ, Jurado-Barba R, Martinez-Martin N, Espin-Jaime JC, Bolaños-Porrero C, Ordoñez-Franco A, Association between maltreatment and polydrug use among adolescents. Child Abuse Negl 2016; 51:379-389.^,3434 Mota RS, Gomes NP, Campos LM, Cordeiro KCC, Souza CNP, Camargo CL. Adolescentes escolares: associação entre vivência de bullying e consumo de álcool/drogas. Texto Contexto Enferm 2018; 27(3):e3650017..

A little over half of the polysubstance users in our study reported feeling that life is not worth living. This finding is cause for concern, as according to the report The State of the World’s Children 2021, 17.1% of Brazilian adolescents are living with a mental health condition³⁵35 United Nations Children's Fund (Unicef). The State of the World's Children 2021: On My Mind--Promoting, Protecting and Caring for Children's Mental Health [Internet]. 2021 [cited 2021 jan 13]. Available from: https://www.unicef.org/media/114636/file/SOWC-2021-full-report-English.pdf.
https://www.unicef.org/media/114636/file... . Exposure to problems such as school, violence and mental-health difficulties, which are common in early adolescence, can increase substance use over time and predict subsequent polysubstance use³⁶36 Chau K, Mayet A, Legleye S, Beck F, Hassler C, Khlat M, Choquet M, Falissard B, Chau N. Association between cumulating substances use and cumulating several school, violence and mental health difficulties in early adolescents. Psychiatry Res 2019; 280:112480.. Adolescents may use tabaco, alcohol or drugs to create moments of pleasure and well-being as a way of reducing symptoms of depression or stress⁵5 Rodzlan Hasani WS, Saminathan TA, Ab Majid NL, Miaw Yn JL, Mat Rifin H, Abd Hamid HA, Lourdes, TGR, Ahmad A, lsmail H, Abd Rashid R, Yusoff MFM. Polysubstance use among adolescents in Malaysia:Findings from the National Health and Morbidity Survey 2017. PLoS One 2021; 16(1):e0245593.. The interrelations between polysubstance use and depressive symptoms during adolescence are complex, with symptoms of one disorder promoting symptoms of the other³⁷37 Felton JW, Kofler MJ, Lopez CM, Saunders BE, Kilpatrick DG. The emergence of co-occurring adolescent polysubstance use and depressive symptoms: A latent growth modeling approach. Dev Psychopathol 2015; 27(4 Pt. 1):1367-1383..

Another alarming finding is early drinking, with around half of the poly users reporting having tried drinking before the age of 13. This shows that, despite a ban on the sale of alcoholic beverages to teenagers, it is not hard for youth to get alcoholic drinks, which are easily available at parties or at their own or relatives’ homes³⁸38 Benincasa M, Tavares AL, Barbosa VMM, Lajara MP, Rezende MM, Heleno MGV, Custódio, EM. A influência das relações e o uso de álcool por adolescentes. SMAD 2018; 14(1):5-11. and easy to purchase³⁹39 Carvalho BGC, Andrade ACS, Andrade RG, Mendes LL, Velasquez-Melendez G, Xavier CC, Proietti FA, Caiaffa WT. Densidade de estabelecimentos que comercializam bebidas alcoólicas na área residencial está associada ao consumo de álcool em adolescentes? Rev Bras Epidemiol 2020; 23:e200089.. Besides being the most common used-alone drug, alcohol is present in most of the combinations of substances used by poly drug users and its widespread availability makes it the base substance of these combinations⁴⁰40 Azevedo RCS; Oliveira KD. Poliusuários de substâncias psicoativas. In: Diehl A, Cordeiro D, Laranjeira R. Dependência química: prevenção, tratamento e políticas públicas. 2ª ed. Porto Alegre: Artmed; 2019. p. 214-220..

Around one-quarter of poly users reported having tried illicit drugs before the age of 13. Easy access to socially acceptable drugs (alcohol³⁹39 Carvalho BGC, Andrade ACS, Andrade RG, Mendes LL, Velasquez-Melendez G, Xavier CC, Proietti FA, Caiaffa WT. Densidade de estabelecimentos que comercializam bebidas alcoólicas na área residencial está associada ao consumo de álcool em adolescentes? Rev Bras Epidemiol 2020; 23:e200089. and cigarretes⁴¹41 Szklo AS, Cavalcante TM. Noncompliance with the law prohibiting the sale of cigarettes to minors in Brazil: an inconvenient truth. J Bras Pneumol 2018; 44(5):398-404.) exposes adolescents to increased availability and social influence from other drug users, predisposing them to illicit drug use⁴²42 Pike JR, Fadardi JS, Stacy AW, Xie B. The prospective association between illicit drug use and nonprescription opioid use among vulnerable adolescents. Prev Med 2021; 143:106383.. The earlier the access to these substances, the greater the likelihood of long-term drug use, which can have a permanent effect on the brain⁴³43 Samudio Domínguez GC, Ortiz Cuquejo LM, Soto Meza MA, Samudio Genes CR. Fatores associados ao consumo de drogas ilícitas em uma população adolescente: investigação em zonas marginais de área urbana. Pediatr (Asunción) 2021; 48(2):107-112.. In addition, the effects of these drugs are associated with increased mortality and morbidity during adolescence⁴⁴44 Willoughby T, Good M, Adachi PJ, Hamza C, Tavernier R. Examining the link between adolescent brain development and risk taking from a social-developmental perspective (reprinted). Brain Cognition 2014; 89:70-78.. Strategies to prevent drug use or delay the onset of first use should therefore include the effective restriction of access to alcohol and cigarrettes⁴⁵45 Otten R, Mun CJ, Dishion TJ. The social exigencies of the gateway progression to the use of illicit drugs from adolescence into adulthood. Addict Behav 2017; 73:144-150. and school-based interventions⁷7 Garcia-Cerde R, Valente JY, Sanchez ZM. Attitudes are associated with the drug use profiles of middle school adolescents: A latent class analysis. Psychiatry Res 2021; 295:113592..

Polysubstance use during adolescence takes places mainly in groups, when use is not necessarily determined by the psychoactive effects of the substances as mentioned above, but rather the drug chosen by the group⁴⁰40 Azevedo RCS; Oliveira KD. Poliusuários de substâncias psicoativas. In: Diehl A, Cordeiro D, Laranjeira R. Dependência química: prevenção, tratamento e políticas públicas. 2ª ed. Porto Alegre: Artmed; 2019. p. 214-220.. Adolescents who are more susceptible to peer pressure and whose friends value or use drugs are more likely to use drugs⁴⁶46 Diehl A, Figlie NB, Campos GM. Prevenção ao uso de substâncias. In: Diehl A, Cordeiro D, Laranjeira R, organizadores. Dependência química: prevenção, tratamento e políticas públicas. 2ª ed. Porto Alegre: Artmed; 2019. p. 98-516., although being part of a group that uses or abuses substances does not necessarily mean that individuals make personal use of drugs⁴⁷47 Vázquez Fernández ME, Muñoz Moreno MF, Fierro Urturi A, Alfaro González M, Rodríguez Carbajo ML, Rodríguez Molinero, L. Consumo de sustancias adictivas en los adolescentes de 13 a 18 años y otras conductas de riesgo relacionadas. Rev Pediatr Aten Primaria 2014; 16(62):125-134.. It is also important to highlight that parental supervision and support reduces substance use⁴⁸48 Malta DC, Port DL, Melo FCM, Monteiro RA, Sardinha LMV, Lessa BH. Família e proteção ao uso de tabaco, álcool e drogas em adolescentes. Pesquisa nacional de Saúde dos Escolares. Rer Bras Epidemiol 2011; 14:166-177. and can diminish the negative influence of peers who use drugs²⁶26 Chan GC, Kelly AB, Carroll A, Williams JW. Peer drug use and adolescent polysubstance use: Do parenting and school factors moderate this association? Addict Behav 2017; 64:78-81..

This study has some limitations. First, the data are from a school-based sample and therefore do not show substance use among adolescents who are not at school. Second, while the study analyzed self-reported use during the past 30 days, the questionnaire does not make a distinction between whether the substances were used at the same time or at different points in time. This information would be useful to estimate the prevalence of concurrent and simultaneous polysubstance use among Brazilian adolescents. However, the data presented are relevant given the importance of understanding which groups of schoolchildren are most exposed to polysubstance use. Study strengths include the analysis of data from the 2019 PeNSE on concurrent alcohol, cigarette and illicit drug use, given that studies of this nature are scarce in Brazil as much research is limited to the separate analysis of drugs and other substances without considering the range of variables related to polysubstance use and the context in which adolescents live.

Conclusion

The findings of this study show that the prevalence of concurrent alcohol, cigarette and illicit drug use among Brazilian school-age youth was high and associated with sociodemographic, family and behavioral factors, and stressors. This study has important implications and it is suggested that prevention of illicit drug use and polysubstance use should focus on restricting access to alcohol and tobacco products, which serve as a gateway to other drugs, and actions to prevent concurrent substance use. This requires efforts from families, schools, civil society and the media directed at reinforcing educational actions and pressuring different spheres of government to impose effective restrictive measures.

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