Age at initiation of drug use as an indicator for problematic use

Tags: initiation, tobacco, Madrid, PSYCHOLOGY IN SPAIN, Cochrane Library, illegal drugs, Madrid Salud, la, J Stud Alcohol Drugs, City Council of Madrid, alcohol abuse, Colegio Oficial de Psic�ogos, consumo de tabaco, effects of alcohol, consumo de alcohol, tobacco smoking, risk behaviours, Vander Hoorn, S., REFERENCES Agrawal, Psychol Med, Poor school performance, Shanklin, S., designer drugs, global analysis, Waldron, M., ciudad de Madrid, Westergaard, R., D.J. & Martin, Lemstra, M., Instituto de Adicciones, Giesbrecht, N., Neudorf, C., Estudio de salud de la, Instituto de Salud P�blica, Madrid City Council, Consumo de drogas, Plan Nacional sobre Drogas, Lando, H., Nannapaneni, U., Kunst, A., Can J Public Health
Content: Copyright 2010 by the Colegio Oficial de Psicуlogos. Spain
Psychology in Spain, 2010, Vol. 14. No 1, 22-31
Teresa Hernбndez Lуpez, Jesъs Roldбn Fernбndez, Anunciaciуn Jimйnez Frutos, Carlos Mora Rodrнguez, Dolores Escarpa Sбnchez-Garnica and Marнa Teresa Pйrez Бlvarez Madrid Salud, City Council of Madrid
The aim of our research was to study the relationship between early initiation of tobacco, alcohol and drug use and problematic use in a sample of 6280 young people from Madrid with an age range of 15-24. Early experimentation with tobacco, alcohol (prior to age 14) or cannabis (prior to age 15) is related to higher prevalence of daily tobacco smoking and cannabis use, to daily-average abusive drinking patterns and to either regular polyconsumption or concurrent consumption of 2 or more drugs in the last month. An association was also found with negative consequences of alcohol and drug use for financial, academic and family aspects. This research reveals that the strength of the associations increases as the number of substances with early first use increases. Since this is the case for almost all the associations studied, it would seem relevant in future studies to consider analyzing early initiation of use based on groups of substances. Key words: early initiation of use, tobacco, alcohol, drugs, problematic use, adolescence.
En este trabajo se estudia la relaciуn entre el inicio precoz de consumo de tabaco, alcohol y cannabis y los consumos problemбticos, en una muestra de 6280 jуvenes madrileсos, entre 15 y 24 aсos. La experimentaciуn temprana con tabaco, alcohol (antes de los 14 aсos) o cannabis (antes de los 15 aсos) se asocia a prevalencias mas elevadas de consumo diario de tabaco y de cannabis, a patrones de alcohol abusivo en promedio diario y a policonsumo regular o consumo concurrente de 2 o mбs drogas en el ъltimo mes. Tambiйn se asocia con consecuencias negativas provocadas por el consumo de alcohol o drogas en el бmbito acadйmico, econуmico, familiar y social. Se observa que la fuerza de las asociaciones encontradas aumenta a medida que aumenta el nъmero de sustancias de inicio precoz, resultando esto una constante en la prбctica totalidad de las asociaciones estudiadas, lo que sugiere que seria interesante incorporar en estudios futuros el anбlisis de inicios precoces de consumos agrupados. Palabras clave: Inicio precoz, tabaco, alcohol, drogas, consumo problemбtico, adolescencia.
The use of tobacco, alcohol and illegal drugs is responsible for a considerable burden of general morbimortality (Ezzati et al., 2002). Deaths due to alcohol, tobacco and other drugs account for a substantial component of mortality due to all causes, and especially of premature mortality (Britton et al., 2003; Rehm, Giesbrecht, Patra & Roerecke, 2006; Single, Robson, Rehm & Xie, 1999), with the resulting economic and social costs (Fenoglio, Parel & Kopp, 2003; Rehm et al., 2007). In the USA it is estimated that 70% of deaths in the population aged 10 to 24 are due to accidents, injuries, homicide and suicide (Eaton et al., 2006). Drug use is often related to such causes. The original Spanish version of this paper has been previously published in Intervenciуn Psicosocial, 2009, Vol. 18, No 3, 199-212 ........... Correspondence concerning this article should be addressed to Teresa Hernбndez Lуpez. Departamento de Evaluaciуn y Calidad, Madrid Salud. c/ Juan Esplandiu 11, bajo. 28007 Madrid. Spain. E-mail: [email protected]
Worldwide, an estimated 5% of deaths in adolescents and young adults aged 15 to 29 are attributable to alcohol (Jeringan, 2001). A recent study on health in the city of Madrid concluded that the mortality attributable to alcohol in the year 2003 was 3%, with substantial differences by age, so that those aged 20 to 34 presented the greatest mortality attributable to alcohol, with a rate of 16%. Accidents were the first direct cause of death associated with alcohol use in this group, followed by murder and suicide (Madrid Salud, 2005). The use of drugs in western societies is a phenomenon that is particularly widespread among young people, and especially males. However, a tendency has been observed, consistently and in various countries, toward a reduction of the classic gender-based discrepancy in drug use in the youngest cohorts, which also present higher levels of the use of illegal drugs (OED, 2005; Madrid Salud, 2006; Degenhardt et al., 2008). In general, the risk period for the initiation of drug use is mid- to late-adolescence, beginning with experimentation with legal drugs, moving
on to illegal substances and with a high incidence of transition to regular use patterns in the first three years after initial experimentation (Wittchen et al., 2008). A study which looked at cannabis use in six European countries found that age at initiation of cannabis use is lower in countries with the highest prevalence of its use in the adolescent population (Kokkevi, Nic Gabhainn & Spyropoulou, 2006). Age at initiation of various drugs is a variable classically explored in population-based studies on use, basically involving adolescent and young adult populations, since it directly indicates target ages in which effective preventive intervention should take place, including both universal primary preventive programmes and those aimed more specifically at the prevention of abuse- and dependencerelated disorders. Today, more evidence is available about the effectiveness of school-based programmes for the prevention of alcohol, tobacco and illegal drug use (Fernбndez, Nebot & Janй, 2002; Faggiano, VignaTaglianti, Versino, Zambon, Borraccino & Lemma, 2007; Thomas & Perera 2007), as well as of preventive interventions in the family and community contexts (Foxcroft, Ireland, Lister-Sharp, Lowe & Breen, 2007; Grimshaw & Stanton, 2007; Otead & Lancaster, 2007), which facilitates the planning of effective and timely responses. Likewise, research has identified numerous risk factors related to the initiation of the use of legal substances and cannabis. Prospective research, twin studies and a wide range of reviews have identified individual (sex, age, school performance) and family factors (use by parents or siblings, family problems, parents' vigilance and relationship with one's parents) as associated with the initiation of use, in addition to factors related to social influence and environment, such as use by peers and substance availability (Hayatbakhsh, Mamun, Najman, O'Callaghan, Bor & Alati, 2008; Kendler, Schmitt, Aggen, & Prescott, 2008; Khuder, Price, Jordan, Khuder & Silvestri, 2008; Orwin, 2009). Further aspects found to be related to initiation of use include stressful events in childhood (Andersen & Teicher, 2008) and lower socioeconomic class in childhood and adolescence, though the influence of this latter factor is somewhat more controversial (Degenhardt et al., 2008; Lemstra et al., 2008; Daniel et al., 2009). Fowler et al. (2007) carried out a study with pairs of twins exploring the relationship between the initiation of use and the progression to problematic use of tobacco, alcohol and cannabis and the influence of environmental and genetic factors. They found a higher incidence of
progression to more intensive or regular use in tobacco and cannabis than in the case of alcohol. They highlighted the greater weight of environmental factors than genetic factors in the initiation of alcohol use, while genetic factors would explain a large part of intensive use. In tobacco and cannabis, genetic and environmental factors account for similar proportions of initiation and the transition to problematic use, and though cautiously, these authors conclude that interventions aimed at the avoidance of early initiation would be indicated in tobacco and cannabis, whilst in the case of alcohol, research and intervention should focus on identifying and acting on the factors that underlie more intensive or problematic use. Early initiation of drug use is associated with problematic use and other risk behaviours. Early use of tobacco (smoking) has been found to be linked to habitual use in adulthood and to less interest in quitting or in one's confidence about being able to do so; moreover, it has been associated with the initiation of alcohol use and problematic drinking (Lando et al., 1999; Mathers, Toumbourou, Catalano, Williams & Patton, 2006). A study which analyzed age at first tobacco use in Pregnant women and giving up smoking in pregnancy found that initiation prior to age 15 was associated with a lower tendency for abstinence during pregnancy (Chen, Stanton, Shankaran & Li, 2006). Early initiation of alcohol use has also been associated with more intensive drinking, greater frequency of drunkenness, more prevalent use of other drugs (Vieira, Ribeiro & Laranjeira, 2007) and alcohol abuse/dependence disorders in adulthood (Grant et al., 2006; Warner, White & Johnson, 2007). A longitudinal study concluded that early initiation of tobacco, alcohol and cannabis use is related to higher rates of transition to abuse and dependence disorders, especially in tobacco, though the most rapid transition to abuse was observed for cannabis (Behrendt, Wittchen, Hцfler, Lieb & Beesdo, 2009). DuRant et al. (1999) analyzed the relationship between early initiation (age 11 or under) of drug use and health risk behaviours in adolescents (including indicators of violence and suicide, travelling with a driver under the effects of alcohol and riding a motorcycle without a helmet), finding the strongest correlation with problematic behaviours for early initiation of smoking, though early use of alcohol, cannabis and cocaine were also linked to a set of risk behaviours. A recent review on cannabis concluded that early initiation of its use and its regular use in adolescence are
associated with problematic use of cannabis and of other drugs, with poorer school performance, deterioration of mental health, sexual risk behaviours and delinquency (Copeland & Swift, 2009). Furthermore, studies with twins have found early first use of cannabis to be associated with higher risk of illegal drug use and problems of abuse and/or dependence (Lynskey et al., 2003; Agrawal, Neale, Prescott & Kendler, 2004), whilst other research on the early use of this drug have found it to be linked to poor school performance (Hall, 2006). Cannabis use constitutes a risk factor for the development of psychosis, with a time-based and doseresponse relationship; moreover, various studies have shown the substantial influence of early first use for the development of Psychotic Symptoms (Arseneault, Cannon, Poulton, Murray, Caspi & Moffitt, 2002; Hall, 2006; Roncero, Collazos, Valero & Casas, 2007; Stefanis, Delespaul, Herquet, Bakoula, Stefanis & van Os, 2004). Research on the initiation of other illegal drug use has found associations similar to those described so far; one in particular on inhalants (the substances typically first used by adolescents in certain social contexts) found an association between their use prior to age 14 and subsequent heroin use (Storr, Westergaard & Anthony, 2005). As research has shown, then, early first use of substances is considered one of the best predictors of abuse or dependency disorders. Nevertheless, few studies have analyzed early use of the mostly widely used drugs (alcohol, tobacco and cannabis) as a group, and the implications of that grouping. In one of these few studies, Agrawal (2006), in research with a sample of women, found an association between early first use of tobacco, alcohol and cannabis and experimentation with other illegal drugs, suggesting that early initiation of the use of more than one substance contributes to increasing the risk of experimenting with other drugs. The actual situation in particular contexts ­ which will depend on the extent of drug use in adolescence, age of its initiation and factors such as social permissiveness with regard to certain substance use ­ may differ considerably. Hence, there is a need for local studies that provide the necessary information for better preventive planning. The aim of the present work is to explore the relationship between early initiation of alcohol, tobacco and cannabis use and problematic use in the adolescent and young adult population of the city of Madrid. The 2005 Madrid City Council survey database on drug use
in the population aged 12 to 24 permits an approach to these aspects from the perspective of gender and age. OBJECTIVE To identify age at first use of different substances and its association with problematic use. MATERIAL AND METHOD Type of design Cross-sectional study. Study context Universe: Population aged 12 to 24 in the municipal district of Madrid. Sample: We carried out multi-stage sampling with disproportionate stratification by age and district, so as to lend representativeness to each of Madrid's 21 districts. A total of 7500 interviews took place, with a margin of error of ±1.13%, at a confidence level of 95.5% p=q=0.5. Variables: Sociodemographic: age and sex. Drug use: Substances: Tobacco, alcohol, cannabis, cocaine, ecstasy and designer drugs, amphetamines, hallucinogens, inhalants, heroin and tranquillizers (either prescription or non-prescription). For all substances, participants were asked whether or not they had ever used them; for the illegal substances, they were asked about their use in the last 12 months; and for all substances, their use and its frequency in the last month. Age at first use for each drug. Consequences of alcohol or drug use: Skipping school (truancy), poorer school performance, family conflict, problems at work, financial problems, conflicts with friends, illness, and others. Being absent from work applies only to those aged 18 and over. Circumstances related to alcohol and/or drug use: Having accidents after using alcohol or drugs, getting involved in fights or arguments after using alcohol or drugs, and driving after having drunk alcohol or taken drugs (only for those aged 18 and over). Early initiation of tobacco, alcohol and cannabis use: To define the cut-off point for "early age at initiation of use" we considered the age at first use situated in percentile 30-35 for each substance. Thus, for tobacco and alcohol early initiation is that which takes
place before age 14, and for cannabis, that which occurs prior to age 15. Abusive or risk drinker: average alcohol use 50cc per day in males and 30cc in females. Regular polyconsumption in the last month. The criteria were set at the concurrent use of two or more substances in the 30 days prior to the survey, "use" in this context being considered as daily in the case of tobacco, abusive drinking pattern in the case of alcohol, and a frequency of 2 or more days per week in the cases of illegal drugs and tranquillizers. data collection and analysis Data were obtained from the database of the 2005 survey of the young and adolescent population (aged 1224) of the city of Madrid. For the present study we used the population aged 15 to 24 (n: 6280). The mean and standard deviation are indicated for the quantitative variables. For the qualitative variables we present the score estimation and the interval, with a confidence level of 95%. The analyses were carried out using the SPSS statistics package. RESULTS Drug use is widespread among adolescents and young adults living in Madrid. Legal substances, such as alcohol and tobacco, present higher prevalence: 92.5% of this population report experimentation with alcohol,
and 63.7% with tobacco. Cannabis is the illegal substance most widely used among the young people of the city, 59% having used it on at least one occasion. In total, 94% of the young people in the sample had tried one or more of these substances. Initiation of legal drug use in Madrid is currently early. Tobacco (smoking) and alcohol present the earliest ages of first use, tobacco with a mean of 14.1 years (Sx=2.39) and alcohol with a mean of 14.3 (Sx=2.08). Inhalants and cannabis are the illegal drugs first taken by most young inhabitants of Madrid ­ at a mean age of 15.4 years (Sx=2.68) in the case of inhalants and 15.6 years (Sx=2.15) in that of cannabis. For the remainder of Graph 1 Mean age at initiation of use of various drugs by gender Tranquillizers Heroin Hallucinogens Ecstasy Cocaine Amphetamines Cannabis Inhalants Alcohol Tobacco Age Male Female
Table 1 Percentage distribution of initiation (early and non-early) of one, two and three substances* by age and sex
Age 15-16 Age 17-19
Male 357
Female 387
Non-early initiation
Male 41.2 (±5.1)** 49.9 (±3.3)
Female 41.6 (±4.9) 56.9 (±3.3)
Early initiation 1 drug
26.1 (±4.6)
27.6 (±4.5)
24.1 (±2.8)
20.8 (±2.7)
Early initiation 2 drugs
16.5 (±3.9)
15.2 (±3.6)
12.2 (±2.1)
11.0 (±2.1)
Early initiation 3 drugs
Male Female
16.2 (±3.8)
15.5 (±3.6)
13.8 (±2.3)
11.3 (±2.1)
Age 20-22
(±1.8) (±1.7)
Age 23-24
62.8 (±3.6)
73.8 (±3.2)
18.8 (±2.9)
16.1 (±2.7)
10.7 (±2.3)
6.3 (±1.8)
*Substances with early initiation of use: tobacco and alcohol prior to age 14 and cannabis prior to age 15 ** Confidence level 95% *** The population selected for this analysis is young people who have used tobacco, alcohol or cannabis at some time
drugs the mean age at first use is around 17. No differences are observed by gender in the mean age at first use of the different substances (see Graph 1). Forty-two percent of the population that have tried tobacco, alcohol or cannabis at least once present "early initiation" of use of one or more of these substances, according to the criteria employed in this study. Early first use occurs in a higher proportion in males than in females (45.1% for males and 38.7% for females). Significant differences by gender are found in the early initiation of alcohol use (32.3% males; 26.4% females) and cannabis use (22.8% males and 15% females), with
Table 2 Prevalences of drug use in the last year, last month and daily, and of abusive drinking according to first use (early or non-early) of one, two and three substances*
Early initiation Early initiation Early initiation
Non-early of one
of two
of three
initiation substance
substances substances
Daily tobacco
30.9 (±1.5)**
41.7 (±2.8)
53.8 (±3.8)
68.3 (±3.7)
Abusive drinking
Cannabis in last year 34.4 (±1.6)
54.1 (±2.8)
69.9 (±3.5)
87.8 (±2.6)
Daily cannabis
27.1 (±3.4)
38.1 (±3.9)
Cocaine in last year 8.2
26.8 (±3.4)
33.9 (±3.8)
Cocaine in last month 4.1 (±0.7)
7.2 (±1.4)
13.2 (±2.6)
18.2 (±3.1)
Ecstasy in last year 3.4 (±0.6)
8.7 (±1.6)
15 (±2.7)
15.3 (±2.9)
Amphetamines in last 1.9
5.1 (±1.7)
10 (±2.4)
Hallucinogens in last 2.8
7.4 (±1.5)
13.8 (±2.6)
15 (±2.9)
Inhalants in last year 0.8 (±0.3)
1.8 (±0.8)
1.9 (±1.1)
5 (±1.7)
Tranquillizers in last 4.6
5.7 (±1.3)
5.6 (±1.8)
11.7 (±2.6)
Heroin in last year 0.0
Regular polyconsumption in last month
21.3 (±1.4)
38.3 (±2.7)
54.5 (±3.8)
71.4 (±3.6)
*Substances with early initiation of use: tobacco and alcohol prior to age 14 and cannabis prior to age 15 ** Confidence level 95% *** The population selected for this analysis is young people who have used tobacco, alcohol or cannabis at some time
no differences being observed in the case of tobacco (smoking). Early initiation of the use of tobacco, alcohol and cannabis are associated with age. The youngest members of the sample present a higher proportion of early initiation than the older ones, and both in the case of males and in that of females early first use of one or more substances decreases significantly with age (see Graph 2 and Table 1). The patterns of early first use of one, two and three drugs in the youngest participants are the same for both sexes, but as age increases the patterns diverge, with significant differences between the men and women aged 23 to 24 in early use of two and of three drugs (see Table 1). Having experimented at an early age with tobacco, alcohol or cannabis is associated with higher prevalence of recent use (last 12 months) of all illegal drugs, with the exception of heroin (see Graphs 3 and 4 and Table 2). It is also related to higher prevalence of daily use of tobacco and cannabis and to abusive drinking patterns, daily on average. The association becomes stronger as the number of substances first used at an early age increases (see Graph 3 and Table 2). Regular polyconsumption or the concurrent use of 2 or more drugs in the last month (daily tobacco use, abusive drinking and use on 2 or more days per week in the remaining substances) is also associated significantly with having first used any of these three drugs at an early age; moreover, the strength of this association increases as the number of drugs first used at an early age rises, so that it is present in over half (55.7%) of the early experimenters with the three drugs (see Table 2). Graph 2 Percentage distribution of early first use of one, two and three drugs, by gender and age
Male Female Age 15-16
Male Female Age 17-19
Male Female Male Female
Age 20-22
Age 23-24
Early 1 drug
Early 2 drugs
Early 3 drugs
The associations mentioned above between early initiation of drug use and higher prevalence of use are observed in both males and females. The prevalences observed in young people with some early drug initiation differ by gender in their relationship with daily cannabis use, regular polyconsumption in the last month and recent use (last 12 months) of cocaine, cannabis, ecstasy and hallucinogens, the stronger relationship being found in males; in the case of recent use of tranquillizers, however, the stronger relationship is found in females. No differences by gender are observed in early users for the prevalence of daily smoking, daily (on average) abusive drinking or recent use of inhalants, amphetamines and heroin. If we compare the intergender differences in the population without early initiation we find that they are similar to those of the population who do start drug use early, except in the cases of recent use of ecstasy and tranquillizers, in which no differences are found between males and females in the latter group (see Table 3). Graph 3 Prevalences of use of different drugs according to first use (early or non-early) of one, two and three substances
Daily tobacco
Abusive Cannabis
drinking in last year cannabis in last year in last month
Non-early first use Early 1 drug
Early 2 drugs
Early 3 drugs
Graph 4 Prevalences of use in the last year according to first use (early or non-early) of one, two and three drugs
Non-early first use Early 1 drug
Early 2 drugs
Early 3 drugs
Likewise, early initiation of use is associated with greater frequency of negative consequences of alcohol or drug use, consequences in the academic, financial, family and social contexts. Also, the association of such consequences with early first use is stronger as the number of substances with early initiation of use increases (see Table 4). No differences are observed as regards consequences in the work context, except in the case of those who began use of all three substances at an early age. Also, the young people of Madrid present very low rates of illnesses caused by drug use, whether or not they started use of the studied substances early, with no differences were found among the two groups (see Table 4).
Table 3 Prevalences of drug use in the last year, last month and daily , and of abusive drinking according to first use (early or non-early) of some substance* and sex.
Non-early initiation Early initiation
Male Female Male Female
Regular polyconsumption in last month
16.3 11.2 (±1.8)** (±1.5)
40.4 32.7 (±2.6) (±2.7)
Daily cannabis
(±1.5) (±1)
(±2.5) (±2.2)
Cannabis in last year
39.6 29.8 (±2.4) (±2.1)
70.2 61.9 (±2.4) (±2.2)
Cocaine in last year
11.4 5.4 (±1.2) (±0.8)
26.3 18.1 (±1.9) (±2.2)
Ecstasy in last year
(±1.2) (±0.8)
(±1.9) (±1.6)
Hallucinogens in last year
(±0.9) (±0.6)
(±1.8) (±1.5)
Tranquillizers in last year
(±0.9) (±1)
(±1.1) (±1.7)
Daily tobacco
29.9 32 (±2.2) (±2.2)
49.2 53.9 (±2.7) (±2.9)
Abusive drinking. daily on average
17.4 14.8 (±0.7) (±0.6)
32.3 32.2 (±2.5) (±2.7)
Amphetamines in last year
(±0.7) (±0.6)
(±1.2) (±1.3)
Inhalants in last year
(±0.6) (±0.3)
(±0.9) (±0.9)
Heroin in last year
(±0.2) (±0.0)
(±0.5) (±0.4)
1.628 1.802 1.340 1.141
*Substances with early initiation of use: tobacco and alcohol prior to age 14 and cannabis prior to age 15 ** Confidence level 95% *** The population selected for this analysis is young people who have used tobacco, alcohol or cannabis at some time
Those who started drug use early present higher proportions of problematic situations or circumstances related to drug use, such as being involved in accidents (road accidents or more minor accidents) following use, getting involved in arguments or fights and driving under the effects of alcohol or drugs (see Table 5). CONCLUSIONS While it must be borne in mind that the associations observed in this study do not imply causality, they are undoubtedly of relevance to our understanding and decision-making in this field, and suggest the need for increasing research on these matters. There is an evident need to study the coexistence of psychosocial risk factors or variables for the initiation of use and the progression to problematic use, which will permit the detailed analysis of such factors; to this end, it would certainly be more appropriate to use prospective designs of cohorts than cross-sectional studies such as the present one.
Table 4 Consequences occurring on several occasions following alcohol or drug use. Percentage distribution according to first use (early or non-early) of one, two and three substances*
Non-early initiation of 1 initiation of 2 initiation of 3
Playing truant
from school
Poor school performance
3.9 (±0.7)
7.7 (±1.6)
13.7 (±2.7)
23 (±3.4)
Family conflict
2.3 (±0.6)
5 (±1.3)
Conflicts with friends 1.8 (±0.5)
3.3 (±1.1)
6.1 (±1.9)
8.8 (±2.3)
Financial problems 2.2 (±0.5)
4.6 (±1.2)
9.2 (±2.3)
15.8 (±2.9)
Missing work**** 0.8 (±0.3)
0.4 (±0.4)
2.1 (±1.1)
4 (±1.6)
Problems at work****
0.5 (±0.3)
0 (±0.0)
0.8 (±0.7)
1.2 (±0.9)
0.3 (±0.2)
0.9 (±0.6)
1.1 (±0.8)
1.3 (±0.9)
*Substances with early initiation of use: tobacco and alcohol prior to age 14 and cannabis prior to age 15 ** Confidence level 95% *** The population selected for this analysis is young people who have used tobacco, alcohol or cannabis at some time ****Only age 18 and over, and having been in work. Percentages refer to the population selected for the global analysis
Another limitation of the present work resides in the impossibility of exploring the prevalence of disorders induced by substance use, since the survey does not include a screening test (presumptive diagnosis of abuse or dependence) for alcohol, tobacco and cannabis, so that we studied the association of early initiation with daily use in tobacco and cannabis. It is difficult to explore risk use of alcohol in population-based studies, though research usually employs, in addition to alcohol abuse daily on average, variables such as frequency of drunkenness and binge drinking and other alcoholrelated risk behaviours. Furthermore, "problematic use" is a broad term in this context. The consensual definition used in Europe does not include either alcohol or tobacco, and is out of step with the types of polyconsumption that constitutes the reality among today's adolescents. Indeed, another term in need of clarification is polyconsumption itself. In spite of these considerations, however, in the present study the variable "regular polyconsumption in the last month" (concurrent use of two or more drugs according to the criteria: daily for tobacco, daily on average for abusive drinking, and 2 or more days per week for the remaining substances) constitutes the best approximation to problematic use, given the limitations. Neither the study of age at first use nor the identification of a starting age considered as "early" can take place without taking into account geographical and sociocultural context and local tendencies for drug and alcohol use. The differences observed in the reviewed
Table 5 Percentage distribution of problematic circumstances related to alcohol or drug use, according to first use (early or non-early) of one, two and three substances*
Non-early initiation of 1 initiation of 2 initiation of 3
Accidents following use
7.6 (±0.9)**
11.1 (±1.8)
17 (±2.9)
26.7 (±3.5)
Driving under the 5.8
effects of alcohol or (±0.9)
Involved in arguments/fights
144.7 (±1.2)
19.9 (±2.2)
22.3 (±3.2)
33.5 (±3.8)
*Substances with early initiation of use: tobacco and alcohol prior to age 14 and cannabis prior to age 15 ** Confidence level 95% *** The population selected for this analysis is young people who have used tobacco, alcohol or cannabis at some time ****Only age 18 and over. N: 4676
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