The Use of Substances at an Early Age : A Qualitative Study among Young Men Living with Substance Use Disorders in Punjab , India

Substance Use Disorders (SUDs) among young people are a major health problem. The magnitude of the problem is increasing in India, especially in Punjab, where the menace of SUDs is debilitating the physical and mental welfare of young people. This qualitative study therefore aims to explore the reasons for initiating substance use at an early age among young people with SUDs. Individual interviews were conducted with young people. A thematic analysis of the data was performed. The analysis yielded four main themes, including adolescent behaviour, peer group influence, family influence, and social and cultural contextual factors. Peer pressure was reported to be the key factor in early substance use leading to SUDs. This study provides an enhanced understanding of the experiences of young people with SUDs, including reasons for early substance use. Further, these experiences may enhance the knowledge required for an integrated approach to prevent early substance use.


Introduction
Substance use affects all societies around the world [1] and has become a major public health problem as the prevalence of Substance Use Disorders (SUDs) is rising. In 2017, 35 million people were suffering from SUDs and lifetime prevalence of substance use disorders was 5.5%, while only one in seven people receive the treatment [2]. SUDs are associated with health and behavioural problems, disturbed interpersonal relationships, low economic prospects, unsafe communities and political instability. Various burdens and traumas are faced by people who abuse substances. These include health hazards, psychological problems, discrimination and stigmatization. Along with these burdens, scientific evidence of genetic susceptibility, mental health factors and dysfunctional families with child abuse or neglect, adds to the problem of SUDs [2].
SUDs, though substantial, are under-recognized as a significant health problem in India. A recent large study on the patterns, profiles and correlates of substance use in India, conducted among schoolchildren and out-of-school and street children across over 100 cities and towns in different states, reported the lifetime use of tobacco (83.2%), alcohol (67.7%), cannabis (35.4%), inhalants (34.7%), opioids (18.1%) and injectable substances (12.6%). The mean age of onset was lowest for tobacco (12.3 years) followed by inhalants (12.4 years), cannabis (13.4 years), alcohol (13.6 years), proceeding to opioids (14.3-14.9 years) and finally through injecting (15.1 years) [3]. A gradual rise in substance use among younger populations, across all socioeconomic groups, in urban and rural settings in India has been documented, with several socio-cultural factors playing a part in this phenomenon [4]. Furthermore, substance use and associated health consequences are highest among young people who are vulnerable due to poverty, lack of parental involvement and social support, poorly equipped schools and early mental and behavioural health problems [5]. In addition, young people tend to think that the use of substances among their peers is much more common than it actually is. They thus often think that 'everyone is using substances' and are influenced to make decisions and form attitudes in favour of using substances. They assume that whatever is accepted among friends and peers is normal and desirable [6].
Recently, the state of Punjab witnessed a remarkable rise in substance use, claiming epidemic proportions [7]. Punjab has the highest prevalence of SUDs in India [8], especially opioid dependence, at 0.8% [9]. This is attributed to various factors, such as the incorporation of more addictive substances in the group of commonly used substances, more individuals shifting from traditional to injectable substances [10], and low access to treatment [11]. A recent survey conducted in Punjab reported that 2.2 million people are alcohol dependent, 1.6 million are tobacco dependent and 0.17 million are opioid dependent [7], where total population of Punjab is 27.78 million by population consensus 2011 [12]. Among those dependent on opioids, 76% were in the age group 18-35 years, and of these 90% injected heroin [9]. This latter abuse has also increased the incidence and prevalence of HIV and HCV infection among young people. Even schoolchildren are susceptible to substance use, including a high number of females [13].
Recent years have seen a significant increase in substance use among young people in Punjab and there is an urgent need for knowledge of what is driving this "epidemic". Moreover, there are limited qualitative studies on SUDs and there is no published literature in Punjab that studies the perceptions and attitudes of persons living with SUDs. It is therefore important to explore perceptions of substance use among young people in Punjab in order to enhance insight into the factors associated with SUDs, which may help in preventing the harmful use of substances. Consequently, this qualitative study sought to explore the reasons that lead young people living with SUDs to initiate substance use at an early age.

Methods
An explorative qualitative study design was used to generate knowledge about the perceptions, attitudes and experiences of young people living with SUDs. The study was conducted in Chandigarh, the capital city of Punjab.

Recruitment and participants
A criterion-based purposive sampling method was employed to recruit the participants. The inclusion criteria were male, aged 18 to 25 years, diagnosed with an SUD as per the WHO definition and admitted to the rehabilitation centre for the treatment of the SUD. Recruitment began by contacting various rehabilitation centres across the city by email and telephone. Detailed information about the study was given to these centres. Recruitment was challenging due to the limited study time, and therefore a private rehabilitation centre was conveniently chosen which met the inclusion criteria for the participants.
Ten participants who met the criteria were included in the study. Nine of the ten were polysubstance users. They used substances such as opium, heroin, cannabis, cocaine and tobacco. In addition, two of the participants had also used benzodiazepines and cough syrups containing codeine. Most of the participants reported having consumed an excess of alcohol to compensate for the periodic unavailability of other substances. However, one of the participants was using only cannabis. The age of first-time use of substances among the participants ranged from 16 to 23 years. Most of the participants were from a high socio-economic class across the state of Punjab, and three out of ten were married.

Data collection
The data were collected through in-depth, semi-structured individual interviews between September 2014 and January 2015. The data were considered sufficient after the tenth interview to meet the aim of the study. The concept of "information power" was used, which infers that the more information relevant to the study in the sample, the fewer the number of participants needed [14]. All the ten interviews were conducted in Hindi, Punjabi and English by the first author, using an interview guide. The interview guide consisted of open-ended questions focusing on the experiences of the participants, including their early substance use, reasons and dependency. Seven out of ten interviews were audio recorded with the permission of the participants. The remaining three participants did not consent to their conversations being recorded, and therefore notes were carefully taken in English and Hindi during these three interviews. Interviews lasted from 40 to 60 minutes. Immediately after each interview, notes were written in order to avoid recall bias which may occur while analysing the data.

Data analysis
All the interviews were transcribed and translated into English by the first author. The interview transcripts were analysed using thematic analysis as outlined by Braun and Clarke, involving the six-stage model [15], which is a useful and flexible tool to analyse rich and detailed data. The analysis was inductive and an attempt was made to put aside the authors' preunderstanding, while complete bracketing was not attainable [16]. The first author read and reread the material several times to become familiar with and understand the content in the study context. Through systematic reading of the data, potential constructs were identified to create the initial codes. The authors then discussed these different codes and grouped them into potential themes and sub-themes [17].

Ethical considerations
Generally accepted research ethics principles were followed, including informed consent, where the participant can refuse or withdraw from the study. Written consent was obtained from each participant. In addition, anonymity and confidentiality of the study participants was maintained. The participants were given the contact details of the first author in case they had any concerns after the interviews. Ethical clearance by the Regional Committees for Medical and Health Research Ethics (2014/1267) in Norway was obtained and the study was also cleared by the ethical committee of the de-addiction centre in India where the study was conducted.

Results
Four main themes emerged from the data, and each theme had various sub-themes. These themes and sub-themes represented the reasons for early substance use as perceived by the participants. The main themes that emerged were: adolescent behaviour, peer group influence, family influence, and social and cultural contextual factors. A thematic network ( Figure 1) of the themes and sub-themes was created to illustrate the factors associated with SUD.

Adolescent behaviour
A majority of the participants mentioned that they started using substances as teenagers, except for two who started at 23 and 22 years of age. Further, behaviour patterns were found during adolescence that were divided into sub-themes: experimentation, curiosity, impulsiveness, boredom, depression and stress.

Experimentation
During adolescence, participants had experimented with substances. They reported that they used substances in order to taste them, feel high and to experience how it felt after taking the substances. They mentioned being curious and impulsive and were not scared of trying anything. Furthermore, they never gave this much thought, making instant decisions most of the time, not worrying about the outcome.
"I started experimenting with substances when I was in college and justified it to myself like that, this isn't that bad. I'm still doing my studying. I haven't stolen anything." (P-5) "At 18, I tried it (substances) because I was fearless. I wasn't scared of trying anything. I was willing to try anything. I should have been scared..." (P-8)

Boredom
Some of the participants indicated that they tried substances out of boredom. They mentioned that taking substances kept them busy and thus helped them to cope with boredom. Moreover, they also reported that after taking substances, they felt that they had a pleasant time.
"Once I had nothing to do, I was getting so bored. I was at my grandparents' house in a village.I came out to the street and suddenly saw a group of people taking bhang (cannabis). I thought I should try that and get rid of this boring time…" (P-2)

Stressful situations
A few participants reported that they used substances to relieve all kinds of stress. They also mentioned that they became aggressive and irritable when they were unable to handle stressful situations and to deal with that they used substances. Some participants also reported that there was growing competition and limited job opportunities, resulting in unemployment which either led to SUD or suicidal tendencies.
"I'm a computer science diploma holder and I didn't have anything to do…no work...it gave me stress…I'm literally running from everything and there's nothing I can think of doing with my life…I take substances to get relief from this feeling…" (P-5)

Peer group influence
The influence of the peer group in substance use, followed by SUDs, was reported to be the key common factor, as all the participants in the study mentioned peer group pressure. They were all introduced to substances by their respective peer groups, initially meant for fun and entertainment and to experiment but gradually this led to dependence. Most participants also reported that they started using substances in order to maintain social relationships among their peers, implying that they had fears of rejection. In addition, the peer group was the source of obtaining the substances for the participants.
"I started taking opium when I joined college under the influence of my circle of friends. They even taught me the way to inject intravenously." (P-7) "I had a friend who was taking substances, I was 18 when he first told me about his substance use. He told me to try opium, so that I could also contribute to the money for buying it." (P-8)

Family influence
In this study, the family's contribution to the individual's substance use was evident. Most of the participants were the only male child in their families, with one or two sisters. They reported that being the male child they were given preferential treatment by their parents. They were not monitored, especially with regard to excessive spending. When asked about their childhood, most of the participants mentioned that male superiority made them stubborn and aggressive, as all of their demands were fulfilled.
"I had enough money, enough food, enough clothes, books, toys, etc. Whatever I demanded was fulfilled, I was stubborn because being the only son…was pampered a lot… nobody asked me anything about how I was spending the money…" (P-1) Some participants mentioned that one of the reasons that led them into substances was a communication gap between them and their parents. Their daily routine and activities were not monitored.
"…my parents are busy, my father is working and mother is busy with parties…they don't have time for me… I never talk to them besides asking for money…they never asked about my grades… not even what I do and what I don't do…I started using substances at the age of 16 but my parents didn't find out until just a month ago… "(P-7) There is evidence of substance use in the families of some of the participants. These participants reported that they had learned the use of substances from their family members. Substance abuse thus also emerges as a learned behaviour from the families.
"…most of my maternal family, they drink alcohol and smoke cigarettes with cannabis…I've seen them taking alcohol since my childhood. All the males… mostly… drink alcohol and smoke cannabis…" (P-2)

Social and cultural contextual factors
All the participants in this study were affected by the social and cultural norms of the Punjabi society. All the participants reported that their associations and experiences of substance use, followed by SUD, were related to the changing social and cultural settings which have reinforced substance use habits as part of their social behaviour. From the major factors associated with substance use reported by the participants, sub-themes such as availability of substances and urbanization emerged.

Availability of substances
All participants stated that substances were easily available in the community. When asked about the source, it was mentioned by all the participants that their circle of friends was the major avenue to obtain substances. Some reported that they had channels in the community that made the delivery of substances to them very easy and accessible. One of the participants also mentioned that he used to buy substances from local pharmacies without any prescription. Substances were within reach of the participants as they were affordable.
"…easily available… you just need to know the circle and places from where you can get…it's kind of social now... and it wasn't difficult for me to get opium or heroin because most of my friends were using it. And in rare cases when I didn't get it, I used to get heavily drunk and you know alcohol is everywhere in Punjab… so many liquor shops…." (P-1)

Urbanization
In our study, most participants mentioned that changing trends and growing urbanization had a great impact on their behaviour. They mentioned that social and cultural acceptability had reduced individual ability to determine responsible behaviour. They also reported that due to urbanization, young people from rural areas were sent to study in Chandigarh for higher education in colleges and thus came into contact with the substances.
"After Year 12 at school my parents sent me to study in Chandigarh as most of the young people in my village were doing the same… then there in college, I came across substances and since then I've been using the substances regularly… using them mostly in a friend's apartment…" (P-5)

Discussion
In our study we explored the reasons that led to the initiation of substance use at an early age among young men living with SUD. From the participants' experiences, four main themes emerged, each containing sub-themes, which we considered as factors associated with early start of substance use, ultimately leading to SUDs. These themes included adolescent behaviour, peer group influence, family influence, and social and cultural contextual factors. Peer pressure was reported to be the key common factor in early substance use leading to SUDs, as all the participants were introduced to substances and pressured to start using them by their peers.
Our study supports the notion of substance use initiation among young men in adolescence. The study found the age of initiation among the participants to be between 16 and 23 years of age. This finding was crucial to the study as the current scenario suggests that the prevalence of substance use among young people is increasing in Punjab. This is consistent with a study conducted in a village of Sangrur district in Punjab by Mahi et al., which showed that the average age of onset of substance use was 15-24 years [18]. Adolescence is a developmental age when most teenagers come in contact with substances. It was evident from the findings of our study that the participants started using substances during this period described as the period of risky behaviour and explorations [19]. Most of the participants stated that they began experimenting with substances to 'feel high', similar to descriptions in psychological theory [20]. This could be understood as adolescence being a transition period involving typical behaviours like the desire to do something new or risky, which increases the tendency of teens to experiment with substances. Often their still-developing judgement and decision-making skills do not assess the risks accurately and they make poor decisions about using the substances [21]. Further, our participants mentioned curiosity to try the things that they found interesting and appealing. This could be related to the fact that physical and biological maturation occurs during adolescence and adolescents are exposed to a range of different behaviours and lifestyles including experimentation [22]. A clinically-based observation study in North India showed that the most common reason for starting to use substances among adolescents was curiosity, which aligns with our findings [23]. In addition, boredom was also mentioned as one of the factors for initiating substance use in order to keep oneself occupied, which is in line with a previous study concluding that boredom has a strong association with increased risk of substance use in teenage years [24]. Furthermore, participants stated that taking heroin and opium kept them alert and they could work and study with more concentration all day long when they started using substances. All of these behavioural factors contributed to the use of substances in adolescence.
Further, stressful situations were also found to be associated with early substance use and SUDs. There is a huge and increasing amount of competition for jobs in comparison to the availability of vacancies in Punjab, leading to unemployment. Young people, despite a good education, are unable to find a secure job for themselves and often end up using substances in order to cope with stress. It was stated by one of the study participants that despite being a diploma holder, he had no work and took substances in order to cope with this stressful situation. Furthermore, participants suggested that peers played a key role in decision making about substance use and they were first introduced to substances by their peers. Peers have considerable influence during adolescence and substance-using peers can even influence those without other risk factors to try substances for the first time [21]. The participants felt the need to do this because of social pressure. Further, learning theories argue that substance-using peers become role models for those who use substances [25]. This role modelling affects the emotions and thoughts that shape the behaviour of the individual towards using substances [26,27]. The role of peer pressure is evident in the prevailing literature. Peer pressure can have both negative and positive effects on the individual's choices and practices. A significant association is well established between the use of substances and peer pressure [28]. Carey and Borsari reported that the peer environment involves a highrisk of alcohol use by direct influences, modelling and perceived norms [29]. A study from Kashmir [28] reported that peer pressure was the most common reason for starting to use substances. In addition, peers were the source of substances. Our participants mentioned that it was easy to get the substances whenever needed because of their peer circle. In addition, they also stated that once a person had SUD, that person tended to find a group that was already using substances. Regarding the social aspect of availability, drugs are more commonly used in certain social groups and this leads to high availability in these groups [30], which holds true for the participants of our study. This ensures the availability of substances around them all the time and the social groups are channels for obtaining substances [24].
Another factor that led to substance use among the participants was the influence of their family. The environment and genetic factors contribute to the individual's substance use [31]. Genetic factors are inherited within families, and therefore the presence of substance users in the family increases the risk of developing substance use among the young family members [25,27]. It was also evident that the style of parenting affected the participants' substance use. The lack of monitoring, lack of control, lack of guidance and increased communication gap were risk factors contributing to such behaviour. Nace and Tinsley found that absent parents led to less authoritative guidance than in previous generations, poor parental monitoring, lack of daily structure and rules, which increased the risk of adolescent substance use [32]. The other risk factor in the substance use of the participants was learned behaviour. It was observed in our study that the participants with a family background of substance use were quite unafraid to try substances. Parental substance use puts the adolescent at greater risk of substance use [33], which was also evident in our study.
In contrast to a previous study conducted in Bengal [34], where poverty was linked to substance use, the substance use in our study was associated with affluence. Most participants were from affluent families and reported their behaviour as stubborn and aggressive during childhood. They were given excessive money to fulfill their demands and were not monitored sufficiently. Therefore, affluence and lack of monitoring by parents were risk factors for substance use. However, this finding could be contextual as the study was conducted at a private rehabilitation centre, charging high fees compared to a government hospital, so it was more likely that the participants were from affluent families.
The findings of our study also suggest that male gender itself is a risk factor for substance use in Punjab. This was revealed when the participants described their behaviour at the time of interviewing. They stated that they had sisters but some of them were the only male child in their families. Similar findings have been reported by previous studies [23,34], showing that being a male is a risk factor for substance use. The state of Punjab has a patriarchal culture, which implies that young men have a great degree of freedom to control their lives and make independent decisions, which may lead to involvement in activities like substance use without the knowledge of their parents [35]. Advani also argues that Punjab's masculinity model makes the Punjabi male more susceptible to substance use, as males have a desire to enhance the capability of their body through using substances [35]. In addition, drinking alcohol is culturally acceptable and represents Punjabi masculinity [36]. To some extent, the culture endorses the use of alcohol as a part of Punjabi masculinity, which is often observed in the lyrics of Punjabi folk music and the dance bhangra, equating manhood with heavy alcohol use. This attitude plays an influential role in the socialization of Punjabi men, subjecting them to culturally believe that alcohol consumption is part of their masculinity [36]. This concurs with our study findings, where the participants believed that masculinity and alcohol consumption went hand in hand in Punjab.
The other important risk factor that contributed to the substance use in this study was urbanization. The changing trends and increased urbanization have a great impact on the behaviour that has become acceptable in the community. It was evident from the findings that young people are moving towards cities like Chandigarh in Punjab for higher education. In order to fit into the trend of the urbanized society, they fell prey to substances. They used substances in colleges and other meeting places without being monitored by their families back in their villages. On the other hand, in most cases, both the parents in the cities are working and adolescents therefore lack supervision. This, in turn, leads to risk of exposure to substances. The effects of urbanization were also reported in a previous study, which stated that urbanization was found to be significantly associated with substance use [37]. Moreover, there is a substantial impact of the rapidly urbanizing world on health, economic and social aspects. Young people are more affected by this impact and are caught between their own personal development and the development of the environment. This has both positive and negative consequences. One negative consequence is substance use and related harm, which takes hold of young people because they are vulnerable [38].

Strengths and Limitations
Our study provides insights into the experiences of persons living with SUDs initiated at an early age, which to our knowledge has not been previously explored in Punjab. The results are based on participants' experiences and while they cannot be generalized to the entire population, we believe that these insights may be relevant for public health preventive measures and future research. Furthermore, the internal validity was enhanced by triangulation which included interviewing, a literature review and peer debriefing sessions among all the authors. However, the recruitment of participants was from only one rehabilitation centre, which was private, and therefore selection was limited to people from families with high socioeconomic status. As participants were from affluent families and male, we cannot comment on females or persons with lower socioeconomic status, which might have influenced the findings of our study.

Conclusion
Young men living with SUD shared their experiences of substance use initiation at an early age and the consequences of developing SUDs. Our study shows that young people can be introduced to substance use by family, peer and socio-cultural influence. Adolescent behaviour makes them vulnerable to changes occurring during these formative years. Studying the perceptions and attitudes of young people can be beneficial in order to understand their needs and to introduce comprehensive measures and strategies to prevent and deal with the growing substance use and SUDs. Hence we argue that the insights from the participants are timely and can broaden the perspectives of practitioners in understanding the holistic picture of substance use among young people in Punjab. Further, the implications for health may include workshops with persons with SUDs provided by public health and social care workers in order to design suitable interventions to meet their needs. Close collaboration between parents, teachers, health and social care workers, and community leaders is required to collectively support, guide and monitor young people in order to prevent them from using substances. In addition, as music is very popular in Punjab among all age groups especially young people and they are highly influenced by Punjabi singers, singers should be involved in anti-drug campaigns. Future research among both male and female substance users at community level, including health professionals' experiences, is recommended.