THE USE OF ALCOHOL AND TOBACCO BY ADOLESCENTS IN THE MUNICIPALITY OF EMBU, SÃO PAULO, BRAZIL EL DE ALCOHOL Y TABACO EN ADOLESCENTES EN EL MUNICIPIO DE EMBU, SÃO PAULO, BRASIL

The objective of this study is to identify the use of alcohol and tobacco among adolescents. It is a descriptive study that was developed with 1533 adolescents, both male and female, based on the following inclusion criteria: aged between 10 and 20 years old, registered and regularly attending elementary or high school at state schools in the morning period, in the regions of Santo Eduardo and Santa Emília, in the municipality of Embu. Results showed that 4.8% smoked and 58.3% tried an alcoholic drink. The age mean for the initiation in the use of alcohol was 13.1 years old (s=1.9) and the age mean for the initiation in the use of tobacco was 12.6 years old (s=1.5). The conclusion was that the study population presented a low consumption of tobacco and a high consumption of alcohol, an early initiation in the use of alcohol and tobacco, the alcoholic ingestion took place, mainly, in parties, with friends, and even at home, with relatives. It was also observed that wine is the favorite drink of these adolescents.


INTRODUCTION
The indiscriminate use of drugs by the population is currently treated as a serious public health problem as it affects both men and women of any age, economic and social class (1) .
In relation to tobacco use in the world, it is estimated that there are currently about one billion and 200 million active smokers, 960 million of whom are addicted to nicotine. In view of this pandemic of modern society, if the current pattern of tobacco consumption continues, by 2010 the statistical projections point to the emergence of 400 million new smokers (2) .
Alcohol use is even more alarming considering that more than 80% of the adult population uses or has had at least one drink, and only about 20% can be considered completely abstinent (3) .
In Brazil, data from the 1 st Household Survey in 2001, which interviewed 41.3% of the national population, it was found that 11.2% were dependent on alcohol and 9% on tobacco (1) . In addition to this prevalence, it was found that, respectively, 41.1% and 68.7% of Brazilians consumed tobacco and alcohol on a daily basis (1) . The 2 nd Household Survey in 2005 found that, in the interviewed population, the daily use of alcohol and tobacco increased to 74.6% to 44%, respectively (4) .
The involvement with licit as well as illicit drugs during adolescence is extremely important as an issue for discussion, as several studies show that it is during this stage of development that adolescents and young people become more susceptible to having the first contact with drugs, especially with those considered licit, among which alcohol and tobacco stand out because of their prevalence (5) .
According to the latest survey conducted by the Brazilian Center for Information on Psychotropic Drugs (CEBBRID -Centro Brasileiro de Informação sobre Drogas Psicotrópicas) among students in primary and secondary education in 27 Brazilian capitals, alcohol and tobacco are drugs that have an earlier onset of use among adolescents and young people; around 12.5 and 12.8 years respectively. Moreover, the same survey compared the data with recent surveys (1987, 1989, 1993 and 1997), and found that the daily use of alcohol did not increase, which agrees with other studies. There was, however, an increase in daily use of tobacco by adolescents (5) .
Regarding the fact that it is easy for young people to obtain and consume alcoholic beverages and tobacco, the current literature reports the following as the major causes: conducive family environment (1,(3)(4) or liberal parents (3) , low price of cigarettes (6) , accessibility (bars, restaurants, bakeries) (7) , influence from peers (8) and advertisements (3) .
Thus when adolescents are referred to as a group at greater risk in terms of the risk of drug use and initiation, it is necessary to clarify that adolescents experience a unique existential moment due to the changes regarding the natural process of development, changing from a child's body to that of an adult, and from then on the most important thing for them is to be popular and have the feeling of "fitting in," trying to adapt to a peer group, a characteristic that may pose a greater tendency for the onset of alcohol and tobacco use among young people, who do not take into consideration the fact that they may be harming their own bodies (9) .
Such damage may further reflect on developing drug addicts, who experienced health-hazardous events. In the case of excessive alcohol consumption, some of the consequences are: memory loss, alcoholic dementia, hepatitis, pancreatitis, myocardial infarction, arrhythmia, stroke, and alcoholic cardiomyopathy (3) . Furthermore, during adolescence the consequences include: decreased academic performance (10) and car accidents involving young individuals under the influence of alcohol (11) .
Health risks involving tobacco refer to cancers of the lung, mouth, throat and esophagus, atherosclerosis, angiogenesis, neurogenic disorders and even sexual impotence in men, and early menopause and osteoporosis in women (2) .
In this context, a university extension project was developed, called "Corporeality and Health Promotion" in the regions of Santo Eduardo and Santa Emília in Embu, a municipality where the Federal University of São Paulo (UNIFESP) has been in operation in the local health system since 1970, through the Embu Program for the Integration of Teaching and Care (Embu-PIDA), counting with representatives in the Municipal Health Department and partnerships with the community. The program promotes activities for health education with adolescents who attend four public schools for primary and secondary education.

OBJECTIVES
The purpose of this study was to characterize the study population; identify the frequency of licit drugs use (alcohol and tobacco) among adolescents studying in public schools of a municipality in São Paulo, with the primary goal to prevent substance use and promote health education.

Type of study
This is a descriptive study, as it promotes an outline of the reality, through which it is possible to describe, register, analyze and interpret the current nature or processes of the studied phenomena (12) .

Ethics
The project of the present study was evaluated and approved by the UNIFESP Ethics Review Board, under document number 1398/05.

Study population and location
The study population consisted of 1541 adolescents who complied with the following inclusion criteria: either gender, aged between 10 and 20 years, enrolled and regularly attending morning classes of 6 th , 7 th or 8 th grade of primary education or 1 st , 2 nd or 3 rd year of secondary education at the public schools located in the region of Santo Eduardo and Santa Emília in Embu, who agreed to participate in the activities of the university extension program Corporeality and Health Promotion. Eight questionnaires were later excluded from the study because they did not comply with the established criteria, thus resulting in a total population of 1533 adolescents.

Instrument and data collection
A semi-structured self-administered questionnaire was designed for data collection, containing questions regarding the addressed issue. The applicability of the instrument was assessed through a pre-test performed at one of the schools, with 48 students. After making the necessary corrections, the questionnaire presented 25 questions containing the following variables: gender, age, education level, marital status, religion, use of licit drugs (alcohol and tobacco), behavior regarding the consumption of alcoholic beverages (frequency, amount and preferred beverages), besides the disorders caused by alcohol use. The questionnaire was distributed in the classroom, in the final quarter of 2006 and early in the first quarter of 2007, on the days that student were involved in the activities promoted by the Extension group, under the supervision of the researcher and all students agreed to participate.

Data analysis
The study data were presented in a quantitative context, in which the information collected from the questionnaires was stored in databanks using Microsoft Excel (Windows X-P/2000). The data was numbered and grouped by school and education level, creating specific databanks for each school, which allowed for a thorough review and consolidation of data into a general databank. The Pearson's Test was applied an in cases when it was not adequate, the Likelihood Ratio Test was used, with significance at 5%, performed using SPS 12.0 for Windows. The median, mean age, and standard deviation were obtained for the population; regarding illicit drugs: the mean, standard deviation and minimum and maximum age of the first use of alcohol and tobacco, and a confidence interval of 95% was applied.

RESULTS
The study population consisted of 1533 adolescents, 799 (52.1%) of which were male and 734 (47.8%) were female. Regarding the health behaviors concerning the use of licit drugs (alcohol and tobacco), the mean age for their initiation of alcohol consumption was 12.1 years (sd=1.9) / (CI95%: 12.24-12.01); for tobacco use the mean age was 12.6 years (sd=1.5) / (CI95%: 12.98-12.30), and the minimum and maximum age was, respectively, 3 and 20 years for alcohol and 9 and 16 years for tobacco.
Stratifying by gender, it is observed that most girls were between 12 and 14 years old, while most boys were between 14 and 16 (p< 0.05). Considering the variables education level and marital status, it is observed that the rates for boys and girls are similar (p=0.204) and (p=0.383), respectively. Regarding religion, stratifying by gender, there was a statistically significant association (p < 0.001) of the population with the category Atheist, which a higher percentage of male subjects (Table 1).
Regarding the use of licit drugs (alcohol and tobacco) it was observed that 4.8% are smokers, with no statistical correlation between genders (p=0.117), and that 58.3% have consumed alcoholic beverages, an girls presenting a higher rate (61.6%) of exposure to alcohol use (p=0.0013) ( Table 2).
Regarding tobacco use and the daily consumption among adolescent smokers, it was observed that 57.1% of girls and 43.7% of boys consumed up to one pack of cigarettes/day (p= 0.635).
Alcohol use among the adolescents showed a significant correlation with the variables age group and education level. It was observed that the older they were or the higher the education level, the more frequent the use of alcoholic beverages.
Hence, comparing age groups side-to-side it is observed that 75% of adolescents older than 20 years have consumed alcoholic beverages at some point of their lives, showing a prevalence 1.8 times greater than that observed among adolescents of ages between 10 and 12 years. The same tendency was observed for the use of alcohol and education level, as 69.5% of the 3 rd year (secondary education) presented this behavior, showing a frequency 1.57 greater compared to students of the 6 th grade (primary education).
The study also sought to investigate the association between alcohol consumption and religion, and it was observed that alcohol use was lesser among students who reported following more conservative religions, such as Evangelic groups (43.9%).   Regarding the consumption of alcohol over the last 12 months, no differences were observed concerning the con-sumption of alcoholic beverages for adolescents of both genders. (p=0.829) ( Table 3).  Table 4 shows that 88% of adolescents reported drinking sometimes, with no significant difference between the drinking behavior among boys and girls (p=0.456). This fea-ture is also observed regarding the amount of alcohol consumed, which is referred to as low (p=0.368). Among the beverages referred to by the adolescents, 51.5% stated that wine is their preferred beverage, followed by beer (18.8%). Regarding the preference of boys and girls, a statistically significant correlation (p< 0.001) was observed, in which over half the girls drink wine and close to 13% drink beer. Most boys also drink wine and beer. Girls, however, drink more wine, showing a frequency of 57.1%.

Rev Esc Enferm
As for the consumption of beer, it is observed there is a higher prevalence among boys (24.8%) ( Table 4). Table 5 shows that, over the last 12 months, the most frequent disorders experienced by the adolescents following alcohol consumption were: physical sickness (51.1%), fights (20.6%) and general accidents (9.9%). Regarding the situations in which the adolescents usually drink, the highest frequency was at parties (72.3%), also 5.2% reported having the habit of drinking with their relatives, 3.9% with their friends, 1.7% at home and 0.9% in cases they experience a mood swing.
As for reasons reported as responsible for influencing the adolescents' decision to drink, the factors that stood out were their own desire (30.7%) and the curiosity (20.9%) towards drinking. Also regarding this item, the following were reported: influence from peers (11.8%), family environment (5.5%), to socialize better (3.6%), thirst (0.9%), stress (0.3%) and only 0.2% reported being influenced by the media.
When addressing the factors that influenced their decision to smoke, most reported they decided on their own (23%) without any external influence. The other reports, however, showed a significant prevalence of influence from peers (17.6%) and influence from relatives who smoked (12.2%). Other alleged reasons were: curiosity (9.5%), stress (6.8%), influence of the environment (4%), because it is a fad (1.3%), to relax (1.3%), because it is addictive (1.3%) and 1.3% because it is prohibited.
Regarding the places where they obtain alcoholic beverages, a marked frequency of 32.3% of adolescents who consumed alcohol over the last 12 months reported preferring the domestic environment for that consumption. Other places with high frequency rates were: 19.0% at parties, 16.5% at a bar, 11.6% at a market, 1.9% at a bakery, 1.4% at friends' house, 0.5% at a relative's house and 0.3% at school.

DISCUSSION
The present study data were specifically based on adolescents living in Embu, a medium-sized city located in the metropolitan region of São Paulo. Embu has a population of 218,535 of which 40% are 20 years old or younger. The area is strongly affected by high rates of unemployment, violence and social exclusion, which reflects on high rates death by external causes, mostly homicides, among adolescents and young adults.
As previously emphasized, adolescents have a high chance of becoming involved with licit drugs, especially alcohol, which stands out due to its high prevalence and the fact that adolescents initiate alcohol use at a younger age, followed by tobacco.
In the study sample, the tobacco use rates were close to those observed in the 5 th National Survey on the Consumption of Psychotropic Drugs among Students of Public Schools of Primary and Secondary Education in the Southeast, which presented an estimated 4.1% for frequent tobacco use (5) . Regarding the distribution of smokers by gender, the present study found there was no significant difference among male and female smokers. The referred data differ from those of a national study performed in the city of Pelotas in 2002, which found a higher rate for girl smokers (16.2%) (13) .
The fact that both genders have a similar rate for tobacco use make us (re) consider new public health policies aimed specifically at the care to possible health complications in the female population.
International literature presents data regarding the smoking behavior of women also point at an increase in their tobacco use rates, mainly from the 1960's with the emergence of feminist movements in some Latin American countries (14) .
The analysis regarding the fact that the studied adolescents had used alcohol at some point of their lives found lower rates compared to the study performed among students of both genders in São Paulo in the year 2004, which reported that 66.2% of boys had used alcohol at some point of their lives, against 74.1% of the girls (5) . The latest survey by the Home Survey performed by CEBRID (4) , however, found that among individuals in the age group of 12 to 17 years living in the Southeast, 60.8% had used alcohol at some point on their lives, with 55.5% of that total corresponding to males and 60.4% to females, which agrees with the findings of the present study.
It should be emphasized that there is a statistically significant association between gender and having used alcohol at some point of life, with girls showing higher prevalence than boys. This data could be analyzed considering the natural cycle of human development, in which girls reach puberty about 2 years before boys (8,9) , culminating in the adolescents' search for new experiences and social interaction with older individuals, thus allowing them to have an earlier contact with alcohol.
Regarding the average age of initiating their use of licit drugs (alcohol and tobacco) the present study found lower average rates, thus showing an earlier initiation of licit drug use among young people compared to the data from (5) .
An early initiation of illicit drug use, under the age of 5 years for alcohol and ten for tobacco, represents a serious public health problem, as early initiation in alcohol and tobacco use increases the cases of further drug addicts (3,5) .
Alcohol use among adolescent shows a clear relationship with their current age group and education level. Therefore, the older they are the higher the chance of having used alcohol at some point of their lives.
The same fact was observed in an international study, which also found that alcohol use among adolescents increased with age as well as with the school grade they were attending (15) .
The approach about health risks and hazards due to indiscriminate use not only of alcoholic beverages but also tobacco among adolescents must be considered when plan-It should be emphasized that there is a statistically significant association between gender and having used alcohol at some point of life, with girls showing higher prevalence than boys. ning public health policies, with preventive actions starting as early primary school, aiming to avoid further complications to the health of those individuals.

Rev Esc Enferm
The religion of the adolescents is also one of the determining factors for the consumption of alcoholic beverages, with lower use among students belonging to more conservative groups, such as Evangelics. This same pattern of behavior regarding the use of alcohol over the last months related was related with the adolescents' religion, showing that alcohol use had a prevalence of 34% among Spiritualists, 28% among Catholics and 14% among Evangelics, which agrees with the data from the present study (16) .
The consumption of alcohol over the last 12 months revealed similar rates for girls and boys, with no difference in terms of frequency or amount of alcohol consumed in the referred period. Regarding this issue, there are currently several statements by both national and international researchers reporting that the idea that men drink and/or smoke more than women is an outdated concept in today's post-modern society, as the female population is, nowadays, a social group with growing rates for the use of psychotropic substances, especially alcohol and tobacco (17) .
The preference for wine by both girls and boys may be explained by a few of its particular characteristics, such as: its sweet taste, it is an ingredient necessary for preparing various cocktails, it is of easy purchase, can be bought in large amounts and at accessible prices.
Among the disorders that occurred after drinking alcoholic beverages over the last year, the present study found different data from that obtained in the 2 nd Home Survey (4) , which points at discussions (2.9%) as the main complications due to the consumption of alcohol. Specifically for the age group of 12 to 17 years, in the referred survey 1.9% of participants reported falls, 1.5% had hurt someone, 1.7% got hurt, 1.7% had aggressive behavior and 3.4% had discussions under the influence of alcohol (4) .
Among the situations reported by the adolescents as being opportune for alcohol use, the present study findings corroborate with those found for students from Paulínia (18) , as well as for students living at a University of São Paulo student housing facility (19) , which refer to the high prevalence of alcohol use at parties.
Regarding the factors that adolescents report as having an effect on their decision to smoke, one important data is the high prevalence of friends and relatives who smoke, which add up to 29.8%, thus showing that tobacco use among young people has a synergism with those surrounding and interacting with them. Adolescents are extremely vulnerable to the environment they live in, as they are experiencing a period of intense transformation, seeking a new identity. To do this, they absorb and share tendencies, customs and behaviors not only with the group of peers they wish to become a part of, but also by those considered their family, and may thus use licit drugs (alcohol and tobacco) during that period.
Based on the present study findings, it is important to notify the non-compliance with Brazilian legislation (Article 81 of the Child and Adolescent Statute) that forbids selling alcoholic beverages to children and/or adolescents (5) .
The fact that purchasing alcoholic beverages is easy was also reported by researchers of the newspaper Estado de São Paulo, which stated that the chances of a commercial facility not selling alcohol to an adolescent are minimal (7) . Another study on selling alcohol to minors, performed in the interior region of the state of Sao Paulo, reported even more alarming data showing that only 1% of the adolescents who participated in the study were unable to purchase alcoholic beverages (18) .

CONCLUSION
The studied population presented low rates for tobacco use and high rates for alcohol use, with early initiation of both. The referred data show a significant relationship with the age and education level (p<0.001), in which the older they were or the higher the education level, the more frequent the use of alcoholic beverages. We found that the consumption of alcohol is lesser among religions that are more conservative; and there is a high prevalence of alcohol use over the last 12 months among both genders (p>0.05); the frequency of consumption is considered occasional and at small amounts by girls and boys (p>0.05); wine is the adolescents' preferred beverage; the main disorder after drinking is physical sickness for both genders (p>0.05); it is easy for them to obtain and/or buy alcoholic beverages, and consumption occurs mainly at parties with friends or at home with relatives.
The information obtained among primary and secondary school students from the region of Santo Eduardo and Santa Emília, in Embu, will help systemize and implement preventive and educational activities about licit drug use, which will be offered to adolescents living in the areas covered by the University Extension Project Corporeality and Health Promotion.
Hence, we found that actions involving adolescents for health promotion and preventing the use of licit drugs (alcohol and tobacco) should be performed since primary education, thus avoiding further complications and hazards to the health of these individuals, and reducing further public expenses with hospitalizations, rehabilitation and treatments for drug addicts.