Abstract

INTRODUCTION

The proneness to take risks and the search for new sensation in adolescence may be associated with the use of both licit and illicit substances and with potential health problems at long term¹1. Bava S, Tapert SF. Adolescent brain development and the risk for alcohol and other drug problems. Neuropsychol Rev 2010; 20(4): 398-413.. Their susceptibility to alcohol use associated with motivating and/or facilitating factors, such as publicity²2. Faria R, Vendrame A, Silva R, Pinsky I. Propaganda de álcool e associação ao consumo de cerveja por adolescentes. Rev Saúde Pública 2011; 45(3): 441-7.^,33. Jones SC, Magee CA. Exposure to alcohol advertising and alcohol consumption among Australian adolescents. Alcohol Alcohol 2011; 46(5): 630-7., low cost⁴4. Duailibi S, Laranjeira R. Políticas públicas relacionadas às bebidas alcoólicas. Rev Saúde Pública 2007; 41(5): 839-48., consumption and access granted by parents⁵ 5. Vieira PC, Aerts DRGC, Freddo SL, Bittencourt A, Monteiro L. Uso de álcool, tabaco e outras drogas por adolescentes escolares em município do Sul do Brasil. Cad Saúde Pública 2008; 24(11): 2487-98.may be decisive in alcohol experimentation and abuse. Nowadays, experimentation and regular use of alcohol start in early ages worldwide³3. Jones SC, Magee CA. Exposure to alcohol advertising and alcohol consumption among Australian adolescents. Alcohol Alcohol 2011; 46(5): 630-7.^,66. Donath C, Grässel E, Baier D, Pfeiffer C, Karagülle D, Bleich S, et al. Alcohol consumption and binge drinking in adolescents: comparison of different migration backgrounds and rural vs. urban residence-a representative study. BMC Public Health 2011; 11: 84.^,77. Fraga S, Sousa S, Ramos E, Dias S, Barros H. Alcohol use among 13-year-old adolescents: associated factors and perceptions. Public Health 2011; 125(7): 448-56..

In this phase of life, alcohol abuse inhibits neurogenesis and thus impairs brain development and neurocognitive performance. Several mental and psychosocial problems are often seen in young people who abuse alcohol¹1. Bava S, Tapert SF. Adolescent brain development and the risk for alcohol and other drug problems. Neuropsychol Rev 2010; 20(4): 398-413.^,88. Skala K, Walter H. Adolescence and alcohol: a review of the literature. Neuropsychiatr 2013; 27(4): 202-11..

The consumption of alcohol in adolescence may also increase the chances of abuse and addiction in adult life⁹9. Silveira CM, Silveira CC, Silva JG, Silveira LM, Andrade AG, Andrade LHSG. Epidemiologia do beber pesado e beber pesado episódico no Brasil: uma revisão sistemática da literatura. Rev Psiquiatr Clín 2008; 35(Suppl 1): 31-8., as well as be related to concomitant use of illicit substances⁹9. Silveira CM, Silveira CC, Silva JG, Silveira LM, Andrade AG, Andrade LHSG. Epidemiologia do beber pesado e beber pesado episódico no Brasil: uma revisão sistemática da literatura. Rev Psiquiatr Clín 2008; 35(Suppl 1): 31-8.^,1010. Stolle M, Sack PM, Thomasius R. Binge drinking in childhood and adolescence: epidemiology, consequences, and interventions. Dtsch Arztebl Int 2009; 106(19): 323-8.. It has also been associated with traffic accidents⁴4. Duailibi S, Laranjeira R. Políticas públicas relacionadas às bebidas alcoólicas. Rev Saúde Pública 2007; 41(5): 839-48.^,1010. Stolle M, Sack PM, Thomasius R. Binge drinking in childhood and adolescence: epidemiology, consequences, and interventions. Dtsch Arztebl Int 2009; 106(19): 323-8., violence⁴4. Duailibi S, Laranjeira R. Políticas públicas relacionadas às bebidas alcoólicas. Rev Saúde Pública 2007; 41(5): 839-48.^,1010. Stolle M, Sack PM, Thomasius R. Binge drinking in childhood and adolescence: epidemiology, consequences, and interventions. Dtsch Arztebl Int 2009; 106(19): 323-8.^,1111. McCoy SI, Jewell NP, Hubbard A, Gerdts CE, Doherty IA, Padian NS, et al. A trajectory analysis of alcohol and marijuana use among Latino adolescents in San Francisco, California. J Adolesc Health 2010; 47(6): 564-74., low school performance⁹9. Silveira CM, Silveira CC, Silva JG, Silveira LM, Andrade AG, Andrade LHSG. Epidemiologia do beber pesado e beber pesado episódico no Brasil: uma revisão sistemática da literatura. Rev Psiquiatr Clín 2008; 35(Suppl 1): 31-8., risky sexual behavior¹²12. Sanchez ZM, Nappo SA, Cruz JI, Carlini EA, Carlini CM, Martins SS. Sexual behavior among high school students in Brazil: alcohol consumption and legal and ilegal drug use associated with unprotected sex. Clinics (São Paulo) 2013; 68(4): 489-94., and unwanted pregnancy¹⁰10. Stolle M, Sack PM, Thomasius R. Binge drinking in childhood and adolescence: epidemiology, consequences, and interventions. Dtsch Arztebl Int 2009; 106(19): 323-8..

In Brazil, a household survey on the use of psychotropic drugs carried out in 2005 showed that 54.3% of adolescents aging 12 - 17 years had already used alcohol, and that 7% were probably addicted¹³13. Carlini EA, Galduróz JC, Noto AR, Carlini CM, Oliveira LG, Nappo SA, et al. II Levantamento domiciliar sobre o uso de drogas psicotrópicas no Brasil: estudo envolvendo as 108 maiores cidades do país: 2005. São Paulo: Páginas & Letras; 2007.. In other countries, alcohol consumption among adolescents are also concerning. In Coimbra, Portugal, 65% of 12 to 18-year-olds have used alcohol and 19% had already been drunk¹⁴14. Barroso T, Mendes A, Barbosa A. Analysis of the alcohol consumption phenomenon among adolescents: study carried out with adolescents in intermediate public education. Rev Lat Am Enfermagem 2009; 17(3): 347-53.; in New South Wales, Australia, 61% of 12 to 17-year-olds had already tried alcohol³3. Jones SC, Magee CA. Exposure to alcohol advertising and alcohol consumption among Australian adolescents. Alcohol Alcohol 2011; 46(5): 630-7., while in Germany, this frequency was 93% among 15 to 16-year-olds¹⁰10. Stolle M, Sack PM, Thomasius R. Binge drinking in childhood and adolescence: epidemiology, consequences, and interventions. Dtsch Arztebl Int 2009; 106(19): 323-8..

Early use of alcohol and the increased frequency of experimentation of alcoholic beverages and its abuse among adolescents justify the need for studies to identify associated factors. In Brazil, studies on this subject have been performed more frequently in States' capitals¹⁵15. Galduróz JCF, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLS, et al. Fatores associados ao uso pesado de álcool entre estudantes das capitais brasileiras. Rev Saúde Pública 2010; 44(2): 267-73.

16. Malta DC, Mascarenhas MDM, Porto DL, Duarte EA, Sardinha LM, Barreto SM, et al. Prevalência do consumo de álcool e drogas entre adolescentes: análise dos dados da Pesquisa Nacional de Saúde Escolar. Rev Bras Epidemiol 2011; 14(Suppl 1): 136-46.^-1717. Silva SED, Padilha MI. Atitudes e comportamentos de adolescentes em relação à ingestão de bebidas alcoólicas. Rev Esc Enferm USP 2011; 45(5): 1063-9. and metropolitan regions²2. Faria R, Vendrame A, Silva R, Pinsky I. Propaganda de álcool e associação ao consumo de cerveja por adolescentes. Rev Saúde Pública 2011; 45(3): 441-7.^,55. Vieira PC, Aerts DRGC, Freddo SL, Bittencourt A, Monteiro L. Uso de álcool, tabaco e outras drogas por adolescentes escolares em município do Sul do Brasil. Cad Saúde Pública 2008; 24(11): 2487-98., but some social, cultural and demographic factors may influence in adolescents' lifestyle and behavior in the countryside, including alcohol consumption.

The aim of this study was, therefore, to identify the frequency alcohol use in life and its abuse among students from public schools in a municipality of the countryside of Brazil, and the associated factors.

METHODS

This is a cross-sectional study performed in Uberlandia, Minas Gerais, Southeastern Brazil, 546 km distant from Belo Horizonte, capital of the State. Estimated population in the municipality in 2010 was 604,013 inhabitants, according to the census of IBGE (Brazilian Institute of Geography and Statistics). In 2009, 52,303 students were enrolled in public schools, in grades eligible for this study.

Students aging 13 to 17 years old, all of them being enrolled in public schools of the urban or rural regions, were assessed from November 2009 to August 2010. Students in this age group are usually enrolled in the last three grades of elementary school and three grades of high school. Among 27 elementary (ES) and high (HS) schools of the urban area, 10 (37%) were drawn by lot, being 5 located in the central area and 5 in the peripheral area of the city. In each school, a grade was chosen randomly (7^th to 9^th degree in elementary schools and 1^st to 3^rd grade in high schools). Predicting study losses, once students were supposed to agree and be authorized by parents in order to participate, in each school grade 25 students were chosen by lot based on the school's enrollment list, totaling 750 students from central schools and 750 from peripheral schools. Among 13 schools from the rural region, 3 (23.1%) were drawn by lot. Because there were less students enrolled in these schools, all of them aging 13 to 17 years were invited for the study, totaling 150 students.

First, the objective and methods of the study were explained to participants. All students who fulfilled the requirements in relation to ethical issues were included in this study. The first questionnaire applied was developed by the authors of the study, as there was no one validated for Brazil comprising questions aimed at our purposes. It was a structured, self-administered questionnaire composed of 37 items for data collection on personal, social, demographic and familial features (complementary document). Brazilian laws prohibit the consumption and sale of alcoholic beverage for anyone under 18 years old, so we assessed how students had access to alcohol for personal use.

The questionnaire Alcohol Use Disorders Identification Test (AUDIT) - also self-administered - was used to assess alcohol consumption in the past 12 months. AUDIT was developed by the World Health Organization (WHO), consists of 10 questions, and classifies individuals as to alcohol use in low risk or abstinence (score 0 - 7), risk consumption (score 8 - 15), harmful consumption (score 16 - 19), and probable alcohol dependence (score ≥ 20)¹⁸18. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: The Alcohol Use Disorders Identification Test: guidelines for use in primary health care. 2 ed. Geneva: Publication WHO/MSD/MSB; 2001.. This tool has been validated for the Brazilian population¹⁹19. Lima CT, Freire ACC, Silva APB, Teixeira RM, Farrell M, Prince M. Concurrent and construct validity of the AUDIT in an urban Brazilian sample. Alcohol Alcohol 2005; 40(6): 584-9. and has good sensitivity (0.76) and specificity (0.79) for the identification of risk consumption (score ≥ 8) among adolescents²⁰20. Cook RL, Chung T, Kelly TM, Clark DB. Alcohol screening in young persons attending a sexually transmitted disease clinic. Comparison of AUDIT, CRAFFT, and CAGE instruments. J Gen Intern Med 2005; 20(1): 1-6..

The questionnaires were applied by one of the authors (TGR), and students had privacy for filling the questionnaire and took on average 20 minutes for this. Minimal sample size calculated for this study was 382 students, with prevalence of alcohol use estimated in 50%, 5% error and 95% confidence interval (95%CI). The results were analyzed in the software SPSS 17.0 (IBM Inc., Chicago, IL, USA, 2008) and BioStat 5.0^(r) (Brazil). Crude odds ratio (OR_c) and respective 95%CI were directly calculated from the frequencies observed, to identify association between dependent (alcohol use in life and risk consumption) and independent variables. "Use of alcohol in life" was the ingestion of one dose of alcohol beverage (12 g alcohol), corresponding to 150 mL of wine, 350 mL of beer or 35 mL of distilled beverages and spirits at least once.

Independent variables were: school region (urban or rural); age group (13 - 15, 16 - 17 years old); gender; family structure (core or other); family income (≤ 3/> 3 minimum wages - MW); parents' schooling (≤ ES/ ≥ HS); alcohol consumption (yes or no) or use of other drugs (yes or no) by parents; authorization of parent to drink (authorize or indifferent/do not authorize); work (yes or no); age of first contact with alcohol (≤ 12/≥ 13 years old); who offered them alcohol for the first time (parents/friends/siblings or other relative/others) and place of first drink (home/party/relative house/others); home environment (calm/conflicted); religion (practicing/non practicing); sexual relations (yes or no); alcoholic beverage advertisement (attractive/not attractive); intention to drink after watching them (yes or no). Multiple logistic regression test was used for the adjusted OR calculation (OR_a), being considered the variables whose values in crude analysis were p < 0.20; variables not contemplated by this statistical criterion were not considered as confounding. Only questionnaires where all questions involving these variables had been answered were used. Values of p ≤ 0.05 were considered as significant.

Each student signed the informed consent form and required authorization of their parents by signature in order to participate. This study's project was approved by the Ethics Committee of Universidade Federal de Uberlândia. The schools' principals also approved the performance of the study. The authors declare no conflict of interest.

RESULTS

Among 1,650 students invited, 638 (38.7%) participated, being 231 (36.2%) from the central region, 326 (51.1%) from the peripheral region, and 81 (12.7%) from the rural region. No significant differences among analyzed variables from students of peripheral and central schools were found (data not shown), and for this they formed the urban group [n = 557; 306/555 (55.1%) girls; two students did not inform their gender]; sociodemographic characteristics are described in Table 1. In total, 1,012 (61.3%) of the invited students did not participate in the study by reason of not bringing the signed informed consent form, absence to classes in days of questionnaire administration, and one student was not authorized by the mother.

Among all, 516 (80.9%) students had already consumed alcohol. Among 513 students reporting their age of first drink, 269 (52.4%) mentioned they were 10 to 13 years old, 204 (39.8%) 14 to 17 years old, and 40 (7.8%) younger than 10 years old. From 508 students reporting the place of first use of alcohol, 251 (49.4%) reported parties, 99 (19.5%) relatives' houses, 79 (15.6%) home, and 79 (15.6%) mentioned several other places. Among 504 students reporting by whom the alcoholic beverage was offered to them, 236 (46.8%) mentioned friends, 162 (32.1%) siblings/parents, 47 (9.3%) father or mother, and 59 (11.7%) several other sources.

Among students who had already used alcohol, 252 (48.8%) reported believing that alcohol could cause addiction, 232 (45%) said it could generate violence, and 201 (39%) mentioned it could worsen problems; however, 131 (25.4%) reported that there was no risk in alcohol consumption. Out of the 413 students who had taken alcoholic beverage in the last year, 165 (40%) reported drinking to interact with friends, 81 (19.6%) to lose the shyness, 70 (17%) to "forget problems", and 223 (54%) mentioned several other reasons (anxiety, loneliness, sadness or emotions). Their favorite beverages were distilled and spirits [270 (65.4%)], wine [200 (48.4%)], and beer [190 (46%)].

In the bivariate analysis, alcohol use in life was associated with gender (female), age group (16 - 17 years), home environment (conflicting), school region (urban), schooling (≥ HS), and alcohol consumption by the parents (yes). In the multivariate analysis, alcohol use in life was related to conflicting home environment, living in urban area, and, regarding their parents, high educational level and alcohol consumption (Table 2). The use of alcohol in life was not associated (p = 0.14; OR_c = 1.8; 95%CI 0.9 - 3.8) with the use of other drugs by the parents [63/72 (87.5%) versus 397/500 (79.4%)].

Also in the bivariate analysis, risk consumption [115/624 (18,4%) students] was associated with age group (16 - 17 years), age of the first use of alcohol (≤ 12 years), family income (> 3 MW), home environment (conflicting), religion (non practicing), and alcohol consumption by parents (yes). In the multivariate analysis, only age of the first use of alcohol (≤ 12 years) was related to risk consumption (Table 3). In total, 19/504 students (3.8%; IC95% 2.2 - 5.2) made harmful consumption of alcohol or were probable alcohol addicted.

Active sexual life is more frequent (p = 0.00; OR_c = 3.3; IC95% 2.0 - 5.3) among those who had used alcohol in life [224/509 (44%) versus 23/119 (19.3%)]. Under the effects of alcohol, 96/219 (43.8%) students had had at least one sexual relation, 33/222 (14.9%) had had first sex, 25/94 (26.6%) regretted these relations, and 22/103 (21.4%) not always had used condoms.

Overall, 432/442 (97.7%) had been able to buy alcoholic beverages, and 428/441 (97.0%) reported that they never or not always had been questioned about their age by the seller; 115 students had already asked for an adult to buy alcoholic beverages for them and 105/114 (92.1%) reported that adults accepted buying it for them.

Regarding the alcohol use, 290/486 (59.7%) fathers and 265/499 (53.1%) mothers authorized or were indifferent to it; this tolerance was more common (p = 0,00; OR_c = 1.9; 95%CI 1.3 - 2.7) among fathers [232/423 (54.8%) versus 69/177 (39%)] and more frequent (p < 0.00; OR_c = 1.97; 95%CI 1.4 - 2.7) among mothers [166/312 (53.2%) versus 110/300 (36.7%)] who also drink. The intention to drink after watching alcoholic beverage advertisement was more common (p = 0.00; OR_c = 3.6; 95%CI 1.7 - 7.5) between students who had already used alcohol in life [106/511 (20.7%) versus 8/117 (6.8%)], and more frequent (p < 0.00; OR_c = 3.4; 95%CI 2.1 - 5.3) among those who had risk consumption [41/114 (36%) versus 72/506 (14.2%)].

DISCUSSION

The frequency of alcohol use in life (81%) was higher than that observed among adolescents in multicenter studies carried out in Brazil in 2001 (48.3%)²¹ 21. Galduróz JC, Carlini EA. Use of alcohol among the inhabitants of the 107 largest cities in Brazil-2001. Braz J Med Biol Res 2007; 40(3): 367-75.and 2005 (54.3%; 60.8% in Southeast region)¹³13. Carlini EA, Galduróz JC, Noto AR, Carlini CM, Oliveira LG, Nappo SA, et al. II Levantamento domiciliar sobre o uso de drogas psicotrópicas no Brasil: estudo envolvendo as 108 maiores cidades do país: 2005. São Paulo: Páginas & Letras; 2007., higher than those verified in Belo Horizonte, Minas Gerais, in 2009 (74%)¹⁶16. Malta DC, Mascarenhas MDM, Porto DL, Duarte EA, Sardinha LM, Barreto SM, et al. Prevalência do consumo de álcool e drogas entre adolescentes: análise dos dados da Pesquisa Nacional de Saúde Escolar. Rev Bras Epidemiol 2011; 14(Suppl 1): 136-46., and lower than those described among students enrolled in private schools of Sao Paulo in 2008 (88%)²²22. Locatelli D, Sanchez Z, Opaleye E, Carlini C, Noto A. Socioeconomic influences on alcohol use patterns among private school students in São Paulo. Rev Bras Psiquiatr 2012; 34(2): 193-200.. Differences can be due to social, cultural and demographic factors, but also to an increase in the frequency of experimentation of alcoholic beverages. The frequency of use in life is higher than that described in Portugal (50%⁷7. Fraga S, Sousa S, Ramos E, Dias S, Barros H. Alcohol use among 13-year-old adolescents: associated factors and perceptions. Public Health 2011; 125(7): 448-56. and 65%¹⁴14. Barroso T, Mendes A, Barbosa A. Analysis of the alcohol consumption phenomenon among adolescents: study carried out with adolescents in intermediate public education. Rev Lat Am Enfermagem 2009; 17(3): 347-53.) and lower than that observed in Germany (90%)⁶6. Donath C, Grässel E, Baier D, Pfeiffer C, Karagülle D, Bleich S, et al. Alcohol consumption and binge drinking in adolescents: comparison of different migration backgrounds and rural vs. urban residence-a representative study. BMC Public Health 2011; 11: 84..

Early use of alcohol observed in this study was also found in others carried out in Brazil⁵5. Vieira PC, Aerts DRGC, Freddo SL, Bittencourt A, Monteiro L. Uso de álcool, tabaco e outras drogas por adolescentes escolares em município do Sul do Brasil. Cad Saúde Pública 2008; 24(11): 2487-98.^,2323. Sanchez ZM, Santos MG, Pereira AP, Nappo SA, Carlini EA, Carlini CM, et al. Childhood alcohol use may predict adolescent binge drinking: a multivariate analysis among adolescents in Brazil. J Pediatr 2013; 163(2): 363-8., Portugal⁷7. Fraga S, Sousa S, Ramos E, Dias S, Barros H. Alcohol use among 13-year-old adolescents: associated factors and perceptions. Public Health 2011; 125(7): 448-56., and Germany¹⁰10. Stolle M, Sack PM, Thomasius R. Binge drinking in childhood and adolescence: epidemiology, consequences, and interventions. Dtsch Arztebl Int 2009; 106(19): 323-8.. Early consumption of alcoholic beverage may increase the chances of harmful consumption in adolescence²³23. Sanchez ZM, Santos MG, Pereira AP, Nappo SA, Carlini EA, Carlini CM, et al. Childhood alcohol use may predict adolescent binge drinking: a multivariate analysis among adolescents in Brazil. J Pediatr 2013; 163(2): 363-8., and, in our sample, students who are already risk consumption had the first experimentation of alcohol more often before 12 years of age.

High frequencies of alcohol use in life and risk consumption were similar between boys and girls. Female body is more prone to the harmful effects of alcohol²⁴24. Masters SB. Os álcoois. In: Katzung BG. Farmacologia básica e clínica. 8 ed. Rio de Janeiro: Guanabara Koogan; 2003. p. 334-40., its use may cause negligence with contraception and even its use can occur during pregnancy. Other studies showed higher frequencies of experimentation of alcohol among girls⁷7. Fraga S, Sousa S, Ramos E, Dias S, Barros H. Alcohol use among 13-year-old adolescents: associated factors and perceptions. Public Health 2011; 125(7): 448-56.^,1616. Malta DC, Mascarenhas MDM, Porto DL, Duarte EA, Sardinha LM, Barreto SM, et al. Prevalência do consumo de álcool e drogas entre adolescentes: análise dos dados da Pesquisa Nacional de Saúde Escolar. Rev Bras Epidemiol 2011; 14(Suppl 1): 136-46., but drunken episodes¹⁶16. Malta DC, Mascarenhas MDM, Porto DL, Duarte EA, Sardinha LM, Barreto SM, et al. Prevalência do consumo de álcool e drogas entre adolescentes: análise dos dados da Pesquisa Nacional de Saúde Escolar. Rev Bras Epidemiol 2011; 14(Suppl 1): 136-46., risk²⁵25. Campos JADB, Almeida JC, Garcia PPNS, Faria JB. Consumo de álcool entre estudantes do ensino médio do município de Passos - MG. Ciênc Saúde Colet 2011; 16(12): 4745-54. and regular⁷7. Fraga S, Sousa S, Ramos E, Dias S, Barros H. Alcohol use among 13-year-old adolescents: associated factors and perceptions. Public Health 2011; 125(7): 448-56. consumption were more common among boys.

First contact with alcohol was more commonly in parties, the drinks had been offered by friends and used for social interaction. Relationship with friends who make use of alcohol is a predisposing factor to its use⁵5. Vieira PC, Aerts DRGC, Freddo SL, Bittencourt A, Monteiro L. Uso de álcool, tabaco e outras drogas por adolescentes escolares em município do Sul do Brasil. Cad Saúde Pública 2008; 24(11): 2487-98.^,77. Fraga S, Sousa S, Ramos E, Dias S, Barros H. Alcohol use among 13-year-old adolescents: associated factors and perceptions. Public Health 2011; 125(7): 448-56.^,2626. Ferreira MM, Torgal MC. Tobacco and alcohol consumption among adolescents. Rev Lat Am Enfermagem 2010; 18(2): 255-61.^,2727. Stickley A, Koyanagi A, Koposov R, McKee M, Roberts B, Murphy A, et al. Binge drinking among adolescents in Russia: prevalence, risk and protective factors. Addict Behav 2013; 38(4): 1988-95., and the drinks are often used to make social interaction easier¹⁷17. Silva SED, Padilha MI. Atitudes e comportamentos de adolescentes em relação à ingestão de bebidas alcoólicas. Rev Esc Enferm USP 2011; 45(5): 1063-9.. Many students believe that there are no risk in alcohol consumption, and it was also observed in 13.3% of adolescents from Porto, Portugal²⁶26. Ferreira MM, Torgal MC. Tobacco and alcohol consumption among adolescents. Rev Lat Am Enfermagem 2010; 18(2): 255-61.. This highlights the need for awareness programs aimed at adolescents, since the knowledge of the possible harmful effects of alcohol is considered preventive factor against drunkenness¹⁴14. Barroso T, Mendes A, Barbosa A. Analysis of the alcohol consumption phenomenon among adolescents: study carried out with adolescents in intermediate public education. Rev Lat Am Enfermagem 2009; 17(3): 347-53..

Favorite beverages were distilled and spirits, which may be related to low cost and high alcohol concentration, leading the adolescents to feel the effects faster and more intensely, with higher risk of intoxication. Fruit flavors added to these drinks may also contribute with such fact, especially among girls. After adjusted analysis, family income and structure, and work were not associated with the patterns analyzed for alcohol consumption. These results differ from other studies, where adolescents with lower income²⁸28. Pinsky I, Sanches M, Zaleski M, Laranjeira R, Caetano R. Patterns of alcohol use among Brazilian adolescents. Rev Bras Psiquiatr 2010; 32(3): 242-9., who work¹⁵15. Galduróz JCF, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLS, et al. Fatores associados ao uso pesado de álcool entre estudantes das capitais brasileiras. Rev Saúde Pública 2010; 44(2): 267-73.^,2525. Campos JADB, Almeida JC, Garcia PPNS, Faria JB. Consumo de álcool entre estudantes do ensino médio do município de Passos - MG. Ciênc Saúde Colet 2011; 16(12): 4745-54.^,2828. Pinsky I, Sanches M, Zaleski M, Laranjeira R, Caetano R. Patterns of alcohol use among Brazilian adolescents. Rev Bras Psiquiatr 2010; 32(3): 242-9. and have separated parents¹⁵ 15. Galduróz JCF, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLS, et al. Fatores associados ao uso pesado de álcool entre estudantes das capitais brasileiras. Rev Saúde Pública 2010; 44(2): 267-73.had more chances of using or abusing alcohol. Among students enrolled in private schools of Sao Paulo, higher rates of alcohol use were observed among those from higher social groups²²22. Locatelli D, Sanchez Z, Opaleye E, Carlini C, Noto A. Socioeconomic influences on alcohol use patterns among private school students in São Paulo. Rev Bras Psiquiatr 2012; 34(2): 193-200..

Use of alcohol in life, but not risk consumption, was associated with conflicting home environment. It is possible that due to psychological distress adolescents use alcoholic beverages as an escape to their problems¹⁷17. Silva SED, Padilha MI. Atitudes e comportamentos de adolescentes em relação à ingestão de bebidas alcoólicas. Rev Esc Enferm USP 2011; 45(5): 1063-9.. Other studies also showed that conflicting family environments is a predisposing factor to heavy drinking⁹9. Silveira CM, Silveira CC, Silva JG, Silveira LM, Andrade AG, Andrade LHSG. Epidemiologia do beber pesado e beber pesado episódico no Brasil: uma revisão sistemática da literatura. Rev Psiquiatr Clín 2008; 35(Suppl 1): 31-8.^,1010. Stolle M, Sack PM, Thomasius R. Binge drinking in childhood and adolescence: epidemiology, consequences, and interventions. Dtsch Arztebl Int 2009; 106(19): 323-8.^,1515. Galduróz JCF, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLS, et al. Fatores associados ao uso pesado de álcool entre estudantes das capitais brasileiras. Rev Saúde Pública 2010; 44(2): 267-73.. Although religiosity and spirituality have been reported to be protective factors against alcohol use and abuse¹⁵15. Galduróz JCF, Sanchez ZM, Opaleye ES, Noto AR, Fonseca AM, Gomes PLS, et al. Fatores associados ao uso pesado de álcool entre estudantes das capitais brasileiras. Rev Saúde Pública 2010; 44(2): 267-73.^,2828. Pinsky I, Sanches M, Zaleski M, Laranjeira R, Caetano R. Patterns of alcohol use among Brazilian adolescents. Rev Bras Psiquiatr 2010; 32(3): 242-9.^,2929. Piko BF, Kovacs E, Kriston P, Fitzpatrick KM. "To believe or not to believe?" Religiosity, spirituality, and alcohol use among Hungarian adolescents. J Stud Alcohol Drugs 2012; 73(4): 666-74., this association was not evident in this study. Adolescents living in urban areas more often use alcohol in life, but risk consumption is similar to that observed in rural areas. In a national study, frequencies of alcohol abuse or addiction were similar among adolescents living in urban and rural areas, but drunkenness was more common in urban areas³⁰30. Madruga CS, Laranjeira R, Caetano R, Pinsky I, Zaleski M, Ferri CP. Use of licit and illicit substances among adolescents in Brazil - a national survey. Addict Behav 2012; 37(10): 1171-5.. In rural areas, the low availability of social activities and access to alcohol may hinder adolescents from experimenting, but once alcohol consumption is initiated, it tends to be similar to that observed in urban areas. In Germany⁶6. Donath C, Grässel E, Baier D, Pfeiffer C, Karagülle D, Bleich S, et al. Alcohol consumption and binge drinking in adolescents: comparison of different migration backgrounds and rural vs. urban residence-a representative study. BMC Public Health 2011; 11: 84. and France³¹31. Legleye S, Janssen E, Spilka S, Le Nézet O, Chau N, Beck F. Opposite social gradient for alcohol use and misuse among French adolescents. Int J Drug Policy 2013; 24(4): 359-66., risk consumption and drunkenness are more common among adolescents living in rural areas, which may reflect a cultural pattern or modes of socialization.

Use of alcohol in life is more frequent among students whose parents have higher schooling, as also observed in Portugal⁷7. Fraga S, Sousa S, Ramos E, Dias S, Barros H. Alcohol use among 13-year-old adolescents: associated factors and perceptions. Public Health 2011; 125(7): 448-56.. One may suppose that higher schooling, and consequently higher income would make access to alcohol easier for adolescents; however, we did not find relations between alcohol use and family income in our study.

Experimentation is more frequent among adolescents whose parents drink, as also observed in a municipality in Southern Brazil⁵5. Vieira PC, Aerts DRGC, Freddo SL, Bittencourt A, Monteiro L. Uso de álcool, tabaco e outras drogas por adolescentes escolares em município do Sul do Brasil. Cad Saúde Pública 2008; 24(11): 2487-98.. In this situation, the adolescent may consider alcohol use as a natural activity. Also, fathers and mothers who use alcohol are more likely to authorize their son's drinking. On the other hand, other studies showed that rules and monitoring by parents are protective factors against alcohol use initiation²⁷27. Stickley A, Koyanagi A, Koposov R, McKee M, Roberts B, Murphy A, et al. Binge drinking among adolescents in Russia: prevalence, risk and protective factors. Addict Behav 2013; 38(4): 1988-95.^,3232. Stoolmiller M, Wills TA, McClure AC, Tanski SE, Worth KA, Gerrard M, et al. Comparing media and family predictors of alcohol use: a cohort study of US adolescents. BMJ Open 2012; 2: e000543..

Active sexual life is more frequent among those who already used alcohol in life, as also seen in Portugal²⁶26. Ferreira MM, Torgal MC. Tobacco and alcohol consumption among adolescents. Rev Lat Am Enfermagem 2010; 18(2): 255-61.. This may be due to the effects of disinhibition caused by alcohol. Many adolescents reported regretting sexual relation under alcohol effect, as also observed in girls from Germany¹⁰10. Stolle M, Sack PM, Thomasius R. Binge drinking in childhood and adolescence: epidemiology, consequences, and interventions. Dtsch Arztebl Int 2009; 106(19): 323-8.. Alcohol also decreases a person's critical capacity, so they can behave differently than they would when sober. Many students under the effect of alcohol mentioned not always using condoms, and adolescents under alcohol effect are the ones who more practice unprotected sex¹²12. Sanchez ZM, Nappo SA, Cruz JI, Carlini EA, Carlini CM, Martins SS. Sexual behavior among high school students in Brazil: alcohol consumption and legal and ilegal drug use associated with unprotected sex. Clinics (São Paulo) 2013; 68(4): 489-94..

Almost all students who tried to buy alcoholic beverages and over 90% of those who asked for an adult to do it for them were successful. It shows the need of population awareness about the risks involving early alcohol use, and the need of compliance with laws prohibiting alcohol for people less than 18 years old.

The intention to use alcohol after watching alcoholic beverage advertisings is more common among those who already experimented alcoholic beverages. The cross-sectional design of this study cannot be relied on to conclude whether these advertisings stimulate drinking or those who already drink give more attention to them. These advertisings are said to strongly influence alcohol consumption, and the reduction of this type of publicity could cause a decline in consumption²2. Faria R, Vendrame A, Silva R, Pinsky I. Propaganda de álcool e associação ao consumo de cerveja por adolescentes. Rev Saúde Pública 2011; 45(3): 441-7.^,3333. Pinsky I, El Jundi SARJ. O impacto da publicidade de bebidas alcoólicas sobre o consumo entre jovens: revisão da literatura internacional. Rev Bras Psiquiatr 2008; 30(4): 362-74..

Among the limitations of the study are the cross-sectional design, which not always enables to establish a cause-effect relation, but allows to conclude the existence or not of a relation among the analyzed variables. The use of a questionnaire makes information omission easier; however, as responses were anonym, participants could feel more comfortable to write down personal matters. The urban schools included in this study were drawn by lot, not conglomerate; however, we believe that this had no influence on the results, once there were no differences between students of these schools for any of the variables studied. We did not assess the frequency of condom use among abstainers, which do not permit verifying the influence of alcohol in negligence of its use. There was a important loss in study due to refusal of students in participating, but the final sample was higher than the minimal sample size calculated for this study, with similar number of boys and girls. Students enrolled in public schools and present in the classroom at questionnaire administration, who agreed to participate, were assessed; thus, results may not reflect the reality of students from private schools, of students who are usually absent in school, of those not enrolled in schools, or even those who stopped attending school. Our findings are more likely to represent what happens in other countryside cities of Brazil than to be atypical, and it should be confirmed by further studies in other regions of the country.

CONCLUSION

We observed a frequent and early consumption of alcohol among the students assessed. After variables adjustment, only early alcohol consumption was significantly associated with risk consumption. Parents' authorization and easy access to alcohol also contribute with its use. Results show the need to implement awareness programs on the risks of alcohol consumption in adolescence for the population, especially young people and parents/caregivers. Prevention programs should be implemented in all schools. We must also demand compliance with the laws prohibiting the sale and consumption of alcoholic beverage for those under 18 years old.

ACKNOWLEGDMENTS

We thank the students who participated in the research and their parents; the schools´staff for kindly collaborating with the performance of the study; the Foundation for Supporting Research in the States of Minas Gerais (Fapemig) for the grant of a Master's scholarship; and the Professor PhD. Morun Bernardino Neto for orienting the researchers in statistical analyses.

References

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