Substance use among school-going adolescents in India: Results from a nationwide survey

INTRODUCTION

It is well established that substance use debuts during adolescence.¹ This stage is characterized by rapid physical, cognitive, and social transformations with an inclination to engage in risky behaviours, including the use of tobacco, alcohol, or other substances.² Early initiation of psychoactive substances has been reported as a risk factor for alcohol use disorders,³ binge drinking,⁴ injection drug use,⁵ and drug use problems⁶ in later life. Developed countries such as the USA,⁷ and Canada⁸ conduct periodic surveys on substance use among school students to monitor prevalence and trends. For Europe, the European School Survey Project on Alcohol and Other Drugs collects comparable data on substance use and other forms of risk behaviour from 35 European countries.⁹ In India, among school-going adolescents, there have been single point regional studies on substance use;^10,11 a nationwide study¹² focusing only on tobacco use and another on substance use among out-of-school children,¹³ Though National Household Surveys^14–16 conducted earlier included the adolescent age group, the findings may not be reflective of the real situation as household surveys do not provide the necessary privacy to assess substance use among adolescents. This may result in under-reporting of the problems.¹⁷

Under the aegis of a recently completed national survey on the magnitude of substance use in India¹⁵ (primary), a focused thematic study on tobacco, alcohol, and other substances was conducted among school students to supplement information on adolescent substance use. This cross-sectional nationwide school student survey was conducted in 10 cities spread across all regions of India. We report on the extent and pattern of substance use and related factors among school students.

METHODS

RESULTS

Data were finally available for 5920 students (boys 52.4%), with each centre contributing between 6.8% and 11.8% to the sample. The mean (SD) age of the sample was 14.7 (1.6) years; boys 14.7 (1.6) and girls 14.6 (1.6) years. Grade VIII (34%) and IX (37%) students had more representation than grade XI/XII (29%) students. The mean (SD) age of VIII grade students was 13.4 (1.0) years, IX grade 14.4 (1.0) years and XI/XII grade 16.5 (1.2) years, respectively. The prevalence of current (past month) and ever use of various substances is given in Table 1. The average age of initiation for any substance was 12.9 (2.8) years. It was lowest for inhalants (11.3 [2.8] years) followed by heroin (12.3 [2.3] years) and opioid pharmaceutical (without prescription; 12.5 [3.3] years). Overall, 15.1% participants reported lifetime use, 10.3% reported past year use, and 7.2% reported use in the past month of any substance. The most common substances used in the past year, after tobacco (4%) and alcohol (3.8%), were opioids (2.8%), followed by cannabis (2%) and inhalants (1.9%). Use of non-prescribed pharmaceutical opioids was most common among opioid users (90.2%). Similar pattern of use of all substances (in terms of most common to least common) was present among past month users, though in the category of past one month use, use of inhalants was more prevalent than cannabis.

The rates of substance use (any) among boys were significantly higher than those of girls for substance use (ever), use in the past year and use in the past 30 days (Table 2). Compared to grade VIII students, grade IX students were more likely, and grade XI/XII students were twice as likely to have used any substance (ever). The likelihood of past year use of any substance was also higher for grade IX students and for grade XI/XII students as compared to grade VIII students.

Among past year substance users, significantly higher use was observed among boys for tobacco (p<0.01), Cannabis (any product; p<0.05), Charas/ganja (p<0.001) while inhalant (p<0.001) and pharmaceutical opioid use was higher among girls (p<0.05). Significant differences in substance use between the three grades were observed only for tobacco (p<0.05) which was higher in grade IX and alcohol (p<0.01) which was higher in grade XI/XII (Table 3).

In the questions introduced to detect under-reporting, 53.1% students reported that they would choose not to disclose cannabis use if they were using, and 47.8% mentioned that they would choose not to reveal heroin use and lie in their responses.

Among the students who reported the use of any substance in the past month, in terms of the frequency of use, most substances were used occasionally, although daily or almost daily use of opium, heroin and ganja/charas was more common among participants (Fig. 1).

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FIG 1.

Substance specific frequency of use among past month users (%)

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DISCUSSION

The present study, as part of a recent national survey,¹⁵ had a student sample from 10 cities, different regions (both rural and urban) of India. It included both genders and diverse strata (government and private), but is not a nationally representative sample of the school-going adolescent population of the country. Despite that, the results hold great importance in the absence of nationwide data on the school-going adolescent population.

The results provide an updated understanding of the substance use situation among school-going adolescents. Overall, 10% students reported use of a substance (any) in the past year, and about half of those who had ever taken a substance were also using it in the past month, thus indicating continued use. The substances used in order of frequency of use were tobacco, alcohol, opioids (mainly pharmaceutical), cannabis, inhalants, and sedatives. This study also demonstrates lower past-year tobacco use rates among students compared to the Global Youth Tobacco survey¹² and Monitoring the Future survey⁷ and higher alcohol (past 12 months) use rates compared to adolescents in the household study by National Noncommunicable Disease Monitoring Survey.¹⁶ Similarly, inhalant use was higher compared to adolescents assessed in the primary household survey,¹⁵ but lower than in the other studies.^7,19,20 Past year use of cannabis and opioids was higher than that reported in the primary household survey (cannabis 2% as compared to 0.9%, opioids 2.8% as compared to 1.8%). This difference could be due to the difference in minimum age groups of the sample (13 years in the current study compared to 10 years in the primary household survey)¹⁵ and probably under-reporting of substance use by adolescents in the household setting. However, both the current study and the primary survey¹⁵ found the prevalence of opioids to be higher than cannabis, but the present study also found higher past year use rates of pharmaceutical opioids (2.5%) as compared to heroin (0.3%) among opioids.

The age of initiation of substance use (any) was 12.9 years (range 11–14 years), similar to the other Indian studies²¹ and lower than other reports.²² This suggests prevention and intervention are needed at ages 12 and earlier, as for each delayed year of initiation of substance use, the likelihood of substance use disorder decreases.²³

As most 11- and 12-year-olds are in middle school, these findings suggest a need for earlier interventions, as early as primary school. Our data also showed substance use increased in higher grades, with grade XI/XII students two times more likely to report ever use of substances when compared with grade VIII students. This emphasises the importance of continued prevention and intervention through middle and high school.

Though the sample reported parental monitoring and supervision, family conflicts were typically high, reported by about one-fourth of the sample. Negative family environments, having high levels of family conflict, have been found to be associated with the development of substance use by adolescents.²⁴ Substance use among both family members and peers was reported to be higher by children using some substance. The percentage of children reporting use of substances among peers is in concordance with earlier reports²⁵ as the higher the perceived use by peers, the higher is the likelihood of adolescents using substances.²⁶

Another substantive finding that emerged was that about one fourth of the sample had high/very high total SDQ scores, probable psychopathology, with past year users having higher scores compared to non-users, with a higher impact on functioning. This difference was not only prominent in the domains of conduct problems and hyperactivity but also in the emotional problems domain. Children with psychological difficulties are vulnerable to substance use. They need to be identified by school teachers and receive psychological intervention by school counsellors through the involvement of parents. This is an important preventive intervention for substance use that is often neglected. Also, children with comorbid psychiatric disorders and substance use may have worse outcomes, hence it becomes even more important. School settings provide a unique platform through which effective prevention and intervention strategies can be put into practice, and study results have been able to provide some directions. Some established school-based drug prevention programmes, modelled as universal programmes, include Project ALERT, Project Life Skills Training, and targeted programmes like SUCCESS, and Project Toward No Drug Abuse.

We propose a prevention and intervention programme for all school students—provide drug education, drug refusal skills, and normative education through interactive sessions. For children at-risk, identify, screen and provide them with psychological support and referral when indicated. The findings of the current study suggest this is very pertinent, given the high rate of psychological difficulties seen among school students and their association with substance use. However, results show that 95% of the children know and believe that drug use is harmful. In spite of that, 15% of them do end up using these substances. The prevention and intervention paradigms should not only focus on ‘Just say no to drugs’ but also need to be supplemented with the care of the psychological health of children. This would include teaching them to cope with negative family and other life situations. It is also important for the teachers to be trained to identify children with psychological or family issues and refer to school counsellors for counselling support. For children using substances, a focus on early intervention and referral for treatment is paramount. The screening and intervention should target the use of other substances besides tobacco and alcohol, such as opioids, especially pharmaceutical opioids, cannabis, inhalants and sedatives. The threshold for intervention should be kept low, and any recent use should be targeted. As study results suggest, consumption is mostly occasional, the students can be managed in the school settings with the involvement of school counsellors and the use of brief interventions.²⁷ Only those with severe substance use problems, or those who would not benefit from a within-school setting, may be referred for specialized intervention. Referral chains or linkages between schools and healthcare settings need to be established.

School policies must facilitate help-seeking with efforts to reduce stigma, as the study showed very little help/treatment seeking. Training of school personnel, including teachers for early identification and counsellors for providing early interventions, is recommended. Also, like elsewhere in the world, periodic surveys need to be conducted at the national level to understand the current substance use situation in school settings.

Some limitations of the study need to be put forth. The sampling was not aimed at generating population-level prevalence data for school students, as 10 centres across the country, as diverse as India, are not sufficient to generalise for the country. The study missed those absent on the survey day, a particular problem since research indicates a higher rate of use among dropouts.¹⁵ Under reporting is evident based on the two questions that were included to find out if it occurred, although data collection was done with self-reported questionnaires with assurance of anonymity and confidentiality. The feasibility of a similar methodology for studying substance use in schools in India had been assessed in a previous study.²⁸