Abstracts

Introduction

The use of psychoactive substances is a global public health problem, significantly impacting physical and social well-being, constituting one of the main causes of disability and death in young people aged 10-24 years ¹1. World Health Organziation. Adolescent mental health: mapping actions of nongovernmental organizations and other international development organizations. Geneva: World Health Organziation; 2012..

Around 284 million people in the 15-64 age group used drugs in 2020, 26% more than in 2010. In many countries, young people are consuming more drugs compared to a generation ago. In Africa and Latin America, people aged under 35 years are the majority of those treated for disorders associated with drug use. Globally, an estimated 11.2 million people were injection drug users and about half were living with hepatitis C; 1.4 million with HIV; and 1.2 million with both ²2. United Nations Office on Drugs and Crime. World Drug Report 2022: 2 - Global overview - drug demand - drug suppy. Vienna: United Nations Office on Drugs and Crime; 2022..

Regardless of the psychoactive substances used, early use contributes to abuse in adult life and is closely associated with physical and mental health problems ³3. Canton H. The Europa Directory of International Organizations 2021. New York: Routledge; 2021., including cognitive impairment, poor performance and truancy; social difficulties, behavioral changes, and depression and anxiety ⁴4. Golpe S, Gómez P, Braña T, Varela J, Rial A. Relación entre el consumo de alcohol y otras drogas y el uso problemático de internet en adolescentes. Adicciones 2017; 29:268-77.^,55. Marinho LCP, Carmo DRP, Souto VT, Pelzer MT, Costa RF. Body, drug and movement. REME Rev Min Enferm 2016; 20:e987..

Although there is extensive research on licit and illicit drug use among young people in developed countries, data on specific socioeconomic classes in developing countries are limited. Thus, this study aimed to verify the prevalence of psychoactive substance use by adolescents from public schools in a city in the central-west region of the São Paulo Metropolitan Area, Brazil.

Methods

Cross-sectional descriptive study that analyzed a random sample of adolescent students in a city in the central-west region of the São Paulo Metropolitan Area. This study was approved by the Research Ethics Committee of the Federal University of São Paulo (protocol n. 2,089,526), in accordance with the Brazilian National Health Council and Declaration of Helsinki.

The municipality in this study has a territory of 179.9km² and estimate of 145,073 inhabitants ⁶6. Instituto Brasileiro de Geografia e Estatística. Censo demográfico 2010. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2013., its Human Development Index (HDI) in 2010 was 0.814, classified as very high ⁷7. Pinto DGC, Costa MAC, Marques MLAC. O índice de desenvolvimento humano municipal brasileiro, 2013. Brasília: Programa das Nações Unidas para o Desenvolvimento/Instituto de Pesquisa Econômica Aplicada/Fundação João Pinheiro; 2013., and the number of students enrolled in the municipal school system was 17,605, with 14.4% in the fifth grade of elementary school, 53.5% in middle school, and 32.1% in high school. For the sample estimation, the following was considered: hypothesized % frequency of outcome factor in the population: 50%+5; confidence limits: +5%; design effect: 1. For the confidence level set at 99%, the required sample would be 640 students (OpenEpi, v.3.0, open-source calculator-SSPropor - http://www.OpenEpi.com).

Recruitment took place from November 2018 to June 2019. Students regularly enrolled in one of the five randomly selected schools were eligible. The sample was stratified by the proportion of students at each education level; thus, 2,760 adolescents were invited to participate in the study. All students who signed an assent form and whose parents or guardians signed an informed consent form were included in the study.

Data was collected via a self-report questionnaire with information on the student’s name, age, sex, and current grade. Ethnicity was defined by the participant’s self-reported color/race according to the Brazilian Institute of Geography and Statistics (IBGE) ⁸8. Osório RG. O sistema classificatório de cor ou raça do IBGE, 2003. Brasília: Instituto de Pesquisa Econômica Aplicada; 2003.. Sexual maturation was assessed by self-assessment validated for the Brazilian population ⁹9. Matsudo SMM, Matsudo VKR. Self‐assessment and physician assessment of sexual maturation in Brazilian boys and girls: concordance and reproducibility. Am J Hum Biol 1994; 6:451-5.. The Brazilian version of the DUSI-R (Drug Use Screening Inventory-Revised) ¹⁰10. De Micheli D, Formigoni MLO. Psychometric properties of the Brazilian version of the drug use screening inventory. Alcohol Clin Exp Res 2002; 26:1523-8. was used to evaluate the abuse of psychoactive substances. The Brazilian Economic Classification Criteria ¹¹11. Associação Brasileira de Empresas de Pesquisa. Critério Brasil 2015 e atualização da distribuição de classes para 2016. São Paulo: Associação Brasileira de Empresas de Pesquisa; 2016. was used for socioeconomic classification.

To facilitate reading and help organize the data, the different substances were categorized as depressants, stimulants, and deregulators of central nervous system activity ¹²12. Julien RM. A primer of drug action: a concise nontechnical guide to the actions, uses, and side effects of psychoactive drugs, revised and updated. 9th Ed. New York: Holt Paperbacks; 2013..

Statistical analysis

IBM SPSS v.23.0 for Windows (https://www.ibm.com/) was used for all analyses. Prevalence was estimated as the relative frequency of nominal variables, followed by a 95% confidence interval (95%CI). Associations between grade, sex, ethnicity, and drug use were analyzed using the chi-squared test (Cramer’s V) and odds ratio (OR). A 5% significance level was set.

Results

Table 1 shows the descriptive characteristics of the sample. The sample consisted of 1,460 students, 51% female, with a mean age of 13.19±2.04 years (95%CI: 13.09-13.30), ranging from 10 to 19 years.

Table 2 shows data on the use of different psychoactive substances. Table 3 shows the results related to the type of use (experimental, abusive, and dependence).

Discussion

This study aimed to describe the prevalence and trends of the behavior of psychoactive substance use among students. We found that at least 20% of adolescents admitted having used one or more substances in the last month. We found that the use of one drug was associated with the use of others, as observed in the 3rd National Survey on Drug Use by the Brazilian Population¹³13. Bastos FIPM, Vasconcellos MTL, De Boni RB, Reis NB, Coutinho CFS. III levantamento nacional sobre o uso de drogas pela população brasileira. Rio de Janeiro: Instituto de Comunicação Científica e Tecnológica em Saúde, Fundação Oswaldo Cruz; 2017..

The level of drug use among young people, especially in the previous year and in the last month, is an indicator of recent and frequent drug use, being higher in the older population. However, the use of substances that have recently emerged or became popular in certain lifestyles is higher among younger people ³3. Canton H. The Europa Directory of International Organizations 2021. New York: Routledge; 2021..

Degenhart et al. ¹⁴14. Degenhardt L, Chiu W-T, Sampson N, Kessler RC, Anthony JC, Angermeyer M, et al. Toward a global view of alcohol, tobacco, cannabis, and cocaine use: findings from the WHO World Mental Health Surveys. PLoS Med 2008; 5:e141. compared the age of onset of alcohol, tobacco, marijuana, and cocaine use among 17 countries (n = 85,052), and found a similar median age of onset of substance use: 16-19 years for alcohol and tobacco, 18-19 years for cannabis, and 21-24 years for cocaine. Thus, children and adolescents must be made aware of consequences of using these substances before reaching the age of onset, via prevention techniques, interventions, and evidence-based policies.

In 2010, the elementary-secondary education survey reported the general use of psychotropic drugs in Brazil ¹⁵15. Carlini ELA, Noto AR, Sanchez ZvdM, Carlini CMA, Locatelli DP, Abeid LR, et al. VI levantamento nacional sobre o consumo de drogas psicotrópicas entre estudantes do ensino fundamental e médio das redes pública e privada de ensino nas 27 capitais brasileiras, 2010. São Paulo: Centro Brasileiro de Informações sobre Drogas Psicotrópicas, Universidade Federal de São Paulo/Brasília: Secretaria Nacional de Políticas sobre Drogas; 2010., and the values found at the national or local level (São Paulo) were lower than those in our study. Thus, we can assume that drug use has greatly increased in recent years, or that we conducted our study in a region endemic for drug use.

Comparing age groups, we found that younger students (up to 14 years) were 2,306 times more likely to consume tobacco when compared with older students (15-17 years-old). According to the Brazilian National Survey of School Health (PeNSE 2015), among ninth grade adolescents, 21% reported having knowledge about the use of cigarettes by schoolmates ¹⁶16. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2016.. A study of tobacco use among elementary, middle and high school students in the United States found that one in each 13 elementary or middle school students and one in each four high school students reported using some tobacco product in the last 30 days ¹⁷17. Singh T, Arrazola RA, Corey CG, Husten CG, Neff LJ, Homa DM, et al. Tobacco use among middle and high school students - United States, 2011-2015. MMWR Morb Mortal Wkly Rep 2016; 65:361-7..

From 2017 to 2019, more than one million adolescents aged 14-17 years started to consume some type of tobacco daily in the United States. This values can be translated into 2,284 new adolescent smokers, every day; most of them using electronic cigarettes/hookah. Moreover, these adolescents showed the same degree of dependence as those who smoke cigarettes daily ¹⁸18. Chadi N, Schroeder R, Jensen JW, Levy S. Association between electronic cigarette use and marijuana use among adolescents and young adults: a systematic review and meta-analysis. JAMA Pediatr 2019; 173:e192574..

Contrary to expectations, we found no significant difference between elementary and middle school students and high school ones (OR = 0.973; 95%CI: 0.759-1.248; p = 0.849) for alcohol use in our study. Other studies report that it is more frequent among older adolescents (16-18 years) ¹⁴14. Degenhardt L, Chiu W-T, Sampson N, Kessler RC, Anthony JC, Angermeyer M, et al. Toward a global view of alcohol, tobacco, cannabis, and cocaine use: findings from the WHO World Mental Health Surveys. PLoS Med 2008; 5:e141.^,1515. Carlini ELA, Noto AR, Sanchez ZvdM, Carlini CMA, Locatelli DP, Abeid LR, et al. VI levantamento nacional sobre o consumo de drogas psicotrópicas entre estudantes do ensino fundamental e médio das redes pública e privada de ensino nas 27 capitais brasileiras, 2010. São Paulo: Centro Brasileiro de Informações sobre Drogas Psicotrópicas, Universidade Federal de São Paulo/Brasília: Secretaria Nacional de Políticas sobre Drogas; 2010.^,1919. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health. Rockville: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2020..

Comparing sexes, we found a moderate association (φc = 0.327; p < 0.001) between alcohol use and males, with men being 3.891 times more likely to consume alcohol in the last 30 days (p < 0.001). According to the World Health Organization (WHO), more than 25% of all people aged 15-19 years consume alcoholic beverages, reaching 155 million adolescents. The worldwide prevalence of alcohol use among adolescents aged 15-19 years was 13.6% in 2016, being higher in Europe (43.8%), followed by the Americas (38.2%). This study reported little difference in prevalence between the sexes; only cases of binge drinking were more prevalent among boys ²⁰20. Aiken A, Clare PJ, Boland VC, Degenhardt L, Yuen WS, Hutchinson D, et al. Parental supply of sips and whole drinks of alcohol to adolescents and associations with binge drinking and alcohol-related harms: a prospective cohort study. Drug Alcohol Depend 2020; 215:108204.. In Brazil, the prevalence of use among ninth graders in the last 30 days was higher among girls, 25.1% vs. 22.5%, respectively ¹⁶16. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2016.. Regarding lifetime use, the use prevalence among girls was also higher at the national and local levels, 62.1% vs. 58.9% and 63% vs. 58.3%, respectively ¹⁵15. Carlini ELA, Noto AR, Sanchez ZvdM, Carlini CMA, Locatelli DP, Abeid LR, et al. VI levantamento nacional sobre o consumo de drogas psicotrópicas entre estudantes do ensino fundamental e médio das redes pública e privada de ensino nas 27 capitais brasileiras, 2010. São Paulo: Centro Brasileiro de Informações sobre Drogas Psicotrópicas, Universidade Federal de São Paulo/Brasília: Secretaria Nacional de Políticas sobre Drogas; 2010..

The results of the 3rd National Survey on Drug Use by the Brazilian Population¹³13. Bastos FIPM, Vasconcellos MTL, De Boni RB, Reis NB, Coutinho CFS. III levantamento nacional sobre o uso de drogas pela população brasileira. Rio de Janeiro: Instituto de Comunicação Científica e Tecnológica em Saúde, Fundação Oswaldo Cruz; 2017. showed that more than half of the population aged 12-65 years reported having consumed alcohol at some point in their lives. About 46 million (30.1%) reported having consumed at least one dose in the last 30 days, and about 2.3 million people met the criteria for alcohol dependence in the last 12 months.

In our sample, tobacco, ecstasy, and marijuana use was more common among boys, with OR of 1.767, 2,618, and 2,224, respectively. In PeNSE ¹⁶16. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2016., among ninth grade students, 5.8% of boys admitted to having smoked in the last 30 days, against 5.4% of girls; in the stratification by age, tobacco use was higher among older boys (16-17 years, 10.1% vs. 13-15 years, 5.3%), whereas the difference was smaller for girls (6.7% vs. 5.6%). In this study, current marijuana use was 4.1% among boys and 3.5% among girls. This use also increased older individuals, 4.2% (13-15 years) and 7.4% (16-17 years), being higher among boys (4.2% and 8.6%) than girls (4.2% and 5.8%).

Considering ethnicity, skin color was not associated with the use of different psychoactive substances. This topic is little explored in the literature, although a national survey conducted in the United States showed few differences among ethnicities. However, young White people are more likely to receive drug abuse treatment, an alarming difference, because they have more access to private health care insurance and undergo substance abuse screening and treatment ¹⁹19. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health. Rockville: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2020..

Some limitations should be considered when interpreting our results. This is a cross-sectional study, not allowing for the detection of developments or changes in the characteristics of the target population, whether at group or individual level. We only conducted this study in public schools, in a single municipality, thus, the results show the context of a specific population. Data on the use of psychoactive substances were collected in the last 30 days, thus, we could not establish an overview of a longer period. However, the robust random sample increases the reliability of our results.

The earlier the use of psychoactive substances, the greater the risk of developing disorders associated with them since the brains of adolescents are still developing and are particularly vulnerable ⁴4. Golpe S, Gómez P, Braña T, Varela J, Rial A. Relación entre el consumo de alcohol y otras drogas y el uso problemático de internet en adolescentes. Adicciones 2017; 29:268-77.. Knowledge sharing can help to better understand substance use patterns, related problems, and support needs in adolescents, thus increasing the likelihood of creating public policies for this population, in line with the UNODC Strategy 2021-2025²¹21. United Nations Office on Drugs and Crimes. UNODC strategy 2021-2025. Vienna: United Nations Office on Drugs and Crime; 2020..

School has been an important scenario in our work, and it is worth remembering that any attempt to reduce the use of psychoactive substances will bring benefits, as well as reducing harmful effects, helping to promote prevention, as it is always more efficient.

Acknowledgments

The authors thank the São Paulo State Education Department, directors, coordinators, and teachers who assisted in the collection of data, and the adolescents and parents/guardians for their valuable assistance.

References

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