Cannabis use in Tunisian adolescents: Alarming trends from 2013 to 2021

Abstract Background Cannabis is the most widely used illicit psychoactive substance worldwide. In Tunisia, the prevalence of cannabis use and its association with other risky behaviours were reported in several publications interesting mainly early adolescence. However, no publications exploring trends based on national epidemiological data are available yet. Our purpose was to determine cannabis prevalence in Tunisian high school adolescents and assess significant trends from 2013 to 2021. Methods Pooled data from Mediterranean school surveys on alcohol and other drugs conducted in 2013, 2017, and 2021, were used. Based on three-stage stratification sampling method, first and second grade secondary education students were enrolled. Were not included students enrolled in vocational training centers and out-of-school adolescents. Self-administered standardized questionnaire was used in data collection. We studied weighted lifetime prevalence of cannabis use and chi square test for trend was used for global, by gender and by sector (private/public) trends assessement. STATA software was used for statistical analysis. Results A total of 14.723 students were enrolled with sex ratio (M/F) equal to 0.61 and mean age of 16.2±0.8 years. The prevalence of cannabis use increased from 1.4%, to 3.8% then to 7.9% for 2013, 2017 and 2021 respectively. Trend assessement concludes to significant increase in overall cannabis use (p < 10-3). Besides, there was a significant increase in both public and private schools, and among both boys and girls. However, the greatest increase was among male students (3.5% in 2013, 9.2% in 2017 and 16.1% in 2021) (p < 10-3). Conclusions Despite the reinforcement of restrictive legislative measures, the prevalence of cannabis use among Tunisian high school adolescents is significantly increasing. Moreover, it’s important to further investigate problematic cannabis use and its effects on adolescents’ physical and mental health. Key messages • Trend assessement confirmed the significant increase in lifetime cannabis use in high school adolescents in Tunisia, for both sexes and for both private and public sector. • This alarming public health issue requires urgent legislation review and close multisectoral collaboration to control supply and demand.


Background:
Despite a decrease in mortality rates CVD remains the leading cause of morbidity and mortality in Europe. Health behavioural risk factors, low socioeconomic status and cohabitation status are all associated with CVD. However, little is known about social inequality in health behaviour among cohabitating individuals with CVD. Thus, the aim of this study was to examine social inequality in health behaviour among cohabitating individuals with CVD.

Methods:
Register data on CVD were linked with self-reported health behaviour from the Danish 2017 population-based health survey 'How are you?'. In total, 2,443 survey participants aged 45 years and above were registered with CVD. Daily smoking was assessed using a single question about smoking habits.
Physical inactivity was categorised as less than 30 minutes of physical activity at least six days per week. Respondents with a BMI ! 30 were considered obese. Unhealthy diet was assessed using the Diet Quality Score. Moderate risk alcohol consumption was categorised as exceeding the Danish Health Authority's recommendations. Self-reported educational attainment was used as a marker of social position and was categorised as low (0-10 years), medium (11-15 years) or high (! 15 years). Sociodemographic differences in health behaviour were compared using adjusted logistic regression models with health behaviours as dependent variables and adjusted for sex, age, ethnic background, time since initial CVD diagnosis and multimorbidity.

Results:
Cohabitating individuals with CVD and low educational attainment had higher adjusted odds for daily smoking (3.31), physical inactivity (2.10), unhealthy diet (6.37) and obesity (2.55) than cohabitating individuals with CVD and high educational attainment. However, they also had lower adjusted odds for moderate risk alcohol intake (0.35).

Conclusions:
Social inequality in daily smoking, physical inactivity, unhealthy diet and obesity was found among cohabitating individuals with CVD.

Key messages:
Social inequality in health behaviour was found among cohabitating individuals with CVD. Thus, low educational attainment affects CVD risk profile regardless of cohabitation status. Social inequality in health behaviour among cohabitating individuals with CVD should be addressed in public health strategies, targeted secondary prevention, treatment and rehabilitation.

Background:
Cannabis is the most widely used illicit psychoactive substance worldwide. In Tunisia, the prevalence of cannabis use and its association with other risky behaviours were reported in several publications interesting mainly early adolescence. However, no publications exploring trends based on national epidemiological data are available yet. Our purpose was to determine cannabis prevalence in Tunisian high school adolescents and assess significant trends from 2013 to 2021.

Methods:
Pooled data from Mediterranean school surveys on alcohol and other drugs conducted in 2013, 2017, and 2021, were used. Based on three-stage stratification sampling method, first and second grade secondary education students were enrolled.
Were not included students enrolled in vocational training centers and out-of-school adolescents. Self-administered standardized questionnaire was used in data collection. We studied weighted lifetime prevalence of cannabis use and chi square test for trend was used for global, by gender and by sector (private/public) trends assessement. STATA software was used for statistical analysis.

Results:
A total of 14.723 students were enrolled with sex ratio (M/F) equal to 0.61 and mean age of 16.2AE0.8 years. The prevalence 15th European Public Health Conference 2022 of cannabis use increased from 1.4%, to 3.8% then to 7.9% for 2013, 2017 and 2021 respectively. Trend assessement concludes to significant increase in overall cannabis use (p < 10-3).
Besides, there was a significant increase in both public and private schools, and among both boys and girls. However, the greatest increase was among male students (3.5% in 2013, 9.2% in 2017 and 16.1% in 2021) (p < 10-3).

Conclusions:
Despite the reinforcement of restrictive legislative measures, the prevalence of cannabis use among Tunisian high school adolescents is significantly increasing. Moreover, it's important to further investigate problematic cannabis use and its effects on adolescents' physical and mental health.

Key messages:
Trend assessement confirmed the significant increase in lifetime cannabis use in high school adolescents in Tunisia, for both sexes and for both private and public sector. This alarming public health issue requires urgent legislation review and close multisectoral collaboration to control supply and demand.

DJ Ethics and Law
Abstract

Background:
Public involvement in research has potential to transform public health research processes and outcomes, as well as contribute to sustainable collaborations between academia and the civil society. However, this all relies on public involvement being conducted in an ethical and inclusive way, especially when involving representatives from vulnerable populations.

Methods:
In this empirically informed theoretical reflection, ethical perspectives on involvement of vulnerable populations in health research were explored using data collected within a public involvement evaluation project. By analysing observational and longitudinal qualitative data from research projects involving public representatives from vulnerable groups, ethical aspects were identified.

Results:
Responsibility and decision-making appeared as important ethical aspects, where laws and regulations conflicted with involvement ideals. Similarly, reimbursement and recognition for public contributors became an ethical issue when facing legislation and bureaucracy, especially when involving children or refugees. Another ethical aspect concerned researchers' concerns in balancing involvement and protection of vulnerable groups, especially when involving contributors living under unstable circumstances. Finally, effectively communicating around research and involvement in an accessible way, for contributors to be involved but not burdened, was a challenge for researchers.

Conclusions:
Public involvement of vulnerable populations led to ethical challenges related to conflicting ideals and practical realities, including balancing involvement and protection of contributors. This highlighted a need for ethical guidance to support ethical decision-making and practice. The findings are used to guide the development of an ethical framework for decisionmaking in public involvement.

Key messages:
Researchers involving public contributors from vulnerable groups face ethical challenges which causes barriers to involvement.
There is need for guidance on ethical decision-making for researchers involving representatives from vulnerable groups in research. Like most of western countries France has been severely hit by the first wave of covid during Spring 2020. France managed to get through it thanks to a confinement, full dedication of health and << first line >> workers and of course the excellency of its bureaucracy. France is now famous for its digitalized self-made one-hour-walk certificate. It is however less-known for its MARSes, acronym for << message d'alerte rapide sanitaire >> or quick sanitary warning messages that got usually sent to hospitals and nursing homes... on Friday nights or weekends. Some lawyers saluted the method as an innovative and modern process that adapted quickly the response to the evolution of the situation shifting from hard rules written in the due process of law to an era of properly crafted regulations. Professionnals were less enthusiastic regarding this matter. It was less an issue of professional curtesy expected form a central state towards civil servants than one related to the content of the messages. Quality varied depending on the news. Some messages imposed very clear and strict rules such as: << no visit under any circumstances in nursing homes >> or later when tests were available, << should any cluster appear, all residents must be tested. >> However, all messages ended the same and ritual way: << Provisions included in this message must be performed and adapted under direction supervision and adapted to the context of the institution >>. Interestingly enough the way the text was written rose questions: If the rule is clear, why should it be adapted? The rule enters in conflict with other preexisting rules. Which one should apply? Classical legal and political theory are of great help sorting formal issues. Hume's non ethical cognitivism and Kant's categorical imperative were used redesigning the working frame. Since accountability was for direction to bear, so was it for it to draw fair and acceptable solutions in due respect of democratic principles. Key messages: Limit cases prove that rules are unsufficient in decision making.