Pattern of psychoactive substance use by students – Ribeirão Preto

The aim was to analyze the use of psychoactive substances among students in their final year of middle school and high school in Ribeirão Preto and reflect on the pattern of psychoactive drug use based on epidemiological studies conducted over the last century. This is a crosssectional study using a self-administered questionnaire in 29 municipal schools in Ribeirão Preto – SP with 3,955 students. We realized the need to implement specific public policies, provide alternative spaces for leisure, train teachers to motivate students to remain at school, and provide programs and activities that meet their social reality and that are applicable.


Introduction
The youth concept can be understood as a phase of human life preparation in which people prepare to enter the multiple dimensions that make up their social context, such as the entry into marriage and employment and the exercise of their rights and responsibilities as citizens.Clearly, achieving this requires building lasting identities, and contents and attribution of meanings that vary according to the culture, the society and the historical period (ABRAMO, 2005).
Youth includes the age groups between 15 to 24 years, although in some countries it includes older age groups, indicating that despite being a significant condition for all groups in society, youth has some singularities as there are many ways in which it can be lived or experienced (ABRAMO, 2005).
Therefore, one must consider the multiplicity of the profile of youth condition based on differences and social inequalities that permeate those involved (social status, income, gender, ethnicity, territory).Hence, speaking of youths in the plural provides a more adequate view to reveal the current and nonlinear complexities of this generational experience (ABRAMO, 2005).
The licit and illicit drugs are part of the social scenario in which young people are included as products that are offered to them, some strongly rooted in the culture (alcohol and tobacco), for the purpose of leisure, socialization, and relief from physical and emotional pain.Following the logic of economic globalization, the production of both legal and illegal psychoactive substances is in the hands of large transnational corporations that use sophisticated production strategies and distribution to ensure consumption among the population, starting with the preadolescents (CARLINI-MARLATTI, 2001, 2005;PINSKY;JUNDI, 2008).
Ribeirão Preto city, like any other city, experiences this situation.There, epidemiological studies have been conducted on the consumption of psychoactive substances among students in the adolescent age group and they were developed within three historical moments: in the 70s, the 90s and in the 2000s.This study considered the data from two articles published in scientific journals and one original research as means of reflective analysis sought to characterize the peculiarities of the consumption profile of this population in the above-mentioned decades.
The aim of this study was to analyze the use of psychoactive substances among students in their final year of middle school and high school in Ribeirão Preto and reflect on the pattern of psychoactive drugs use based on epidemiological studies conducted over the last two decades of the 20th century.

Methods
This is a cross-sectional study based on the application of an anonymous selfadministered questionnaire that was developed to raise students' characteristics and their environment, to propose prevention strategies, which have been discussed in extension courses.
Of the existing 69 (100%) schools at that time in the city of Ribeirão Preto (state, municipal and private), 29 (42%) were included according to the criteria of consent to participate and offering middle and high school education.Forty schools (57%) that only offered high or middle school programs and adult education were excluded.Of the 29 schools, 12 were selected taking into consideration the five areas of the city -North, South, East, West, Central -according to the zone map of the Department of Health (2004), following the inclusion criteria: authorization from principals, location in the region and school size (largest number of enrolled students).The evening period was excluded since the courses are designed for teaching young adults aged above 18 years.A total of 10 public and two private schools located downtown participated in the study.
In 2005, it is estimated that the population of students enrolled in middle schools was 75,635 and in high schools 25,838, according to the education census data.The twelve schools participating in the study had a total of 9,038 (100%) students enrolled.The sampling technique was accessibility, resulting in a total of 3,955 (44%) students, 28% of these were in the eighth grade, 30.5% in the first year of high school, 23% in the second year and 18.5% in the third year of high school.It was found that the number of students reduced as the courses advanced.Of these students, 941 (24%) came from the central region, 897 (23%) from the Eastern, 816 (21%) from the Western, 690 (17%) from the Northern, and 611 (15%) from the Southern region of the city.
The process of data collection was initiated after approval of the Meetings with school principals and teachers were arranged to explain the project and obtain their cooperation.A schedule was established including information and guidance to students and for the parents or guardians and students to sign the Term of Informed Consent.
After the students were informed about the project and were aware that their participation was voluntary and anonymous and without the presence of the teacher in class, the signed informed consent was collected and the questionnaires were distributed.
Data collection occurred during the second half of 2005 and first half of 2006, with the application of the self-completion questionnaire.An hour and a half per classroom was needed to provide the instructions and to fill out the questionnaire.Next, the student would fold and place the questionnaire in a ballot box.
The instrument consisted of a part about demographic data, one on personal familiarity with substance use, and an evaluation of the frequency of substance use of the students themselves using the categories reported in other similar studies (GALDUROZ ET AL., 2005;MUSA ET AL., 1997).The students were also asked about their closeness or intimacy with people who used psychoactive substances.
Substance use was investigated based on the categories of use in life (use sometime in life), monthly use (use at least once in the last month), frequent use (six or more times in the last 30 days), and daily use.These categories were used in 'V National Survey on psychotropic drug use among students in middle and high school, 2004' conducted by Galduroz et al. (2005).The students reported other forms of use as: whenever it happens and at weekends.The first was grouped as casual use, as it occurred when there was availability of the substance and the second as a frequent use, consumption fell within the definition of this category since there are four to five weekends each month (two days suitable for use).
To detect possible typos in the material, the questionnaires were manually checked, drawing them in batches, according to the schools.Errors reached a maximum of 2% of the total.The data were also referred to qualitative critique, as recommended by Carlini-Cotrim and Barbosa (1993).Since there were questions composed of several items, it allowed internal consistency to be evaluated.
For the analysis of data obtained through the instrument (questionnaire), a database using SPSS (Statistical Package for Social Science) version 16.0 was developed to enter and process the data.

Results
The sample was composed of students of both genders: 1,822 (46%) boys and 2,133 (54%) girls.
In terms of age, the minimum age was 13 years and maximum 21 years with a mean age of 15 years (SD 1.33).The majority of students (2,180: 50.1%) were between the ages of 13 to 15 years, followed by 16 to 17 year-olds (1,578: 40%) with a few students aged 18 years or more (196: 5%).
The pattern of use in life of alcohol was 66.9%, tobacco 26.1%, medications 5.1%, and other drugs 10%.
With regard to the consumption sometime in life, it was perceived that alcohol consumption was higher in females, which should be considered a significant increase since culturally it is thought that Fonte: Elaboração própria men consume more alcohol.Use remains slightly higher for smoking and psychoactive drugs.
Table 1 shows the distribution of patterns of substance use in the student sample, in which occasional use shows that drugs and all 'other drugs' exceed the others, regardless of gender, but particularly for girls.
Alcohol is the most consumed drug in the pattern of monthly use, particularly for girls (887: 41.58%), and boys' consumption of frequent alcohol use is outstanding (192: 10.5%).Tobacco stands out in daily use for both genders.As for the psychoactive drugs, voluntary occasional use exceeds the values of all other psychoactive substances regardless of gender.This finding may indicate that use is related to recreational activities for young people and serves as an alert to the availability and access to drugs obtained illegally.
These data show the vulnerability of students at this stage of life regarding the consumption of psychoactive substances.It is also worth noting that the 16-year-olds were the ones who consumed more alcohol and cigarettes while other drugs may also be included in this sample of adolescents.There was also a reduction of all these substances as they got closer to adulthood.
In the district regions of Ribeirão Preto, it was found that experimental use (once in life) of psychoactive substances among students in the sample was as follows: in the Eastern region, more students have tried alcohol (x2 = 25.86 p. 000) and drugs (x2 = 17.19 p. 002); in the Southern region more students tried cigarettes (x2 = 21.01 p. 000) than in the other regions, the latter region also had a larger number of students who had tried drugs than in the Eastern region.The other outstanding regions were the Central for the use of alcohol and the West for cigarettes and drugs.The East was particularly vulnerable in the year of the survey.
Another finding was related to the socialization of students with people who use psychoactive substances, as shown in tables 2 and 3.

Yes
No Note that drugs related to socialization are alcohol and tobacco, although the number of students (30.7%) in contact with other (illicit) drugs is concerning.
In this respect, it is important to observe the relationship between the user of psychoactive substances and the students, as shown below: In table 3, alcohol use by relatives, particularly by the father or uncle/aunt, is significant.As for cigarettes, the mothers smoke more frequently; the use of other drugs, predominantly by a friend, reveals the influence of peers.As for the psychoactive drugs, the influence comes from the mother or grandfather/mother.This finding raises the question of the possible access of young people to psychoactive drugs prescribed for two community groups, the women and the elderly.As for the use of more than two substances, the friend frequently consumes alcohol, tobacco and other drugs, while the father predominantly consumes alcohol.
These data show the elements that compose the network of people who are significant consumers of psychoactive substances and perhaps may become potential abusers.

Discussion
The results from the original survey were not intended to identify the prevalence of substance use by middle and high school students from the city of Ribeirão Preto because the sample is not representative of all schools in the city, which impedes the extrapolation of the data.
Note also that the type of questionnaire used in this study measures the report of consumption and not consumption itself, hence the need to be cautious when interpreting the data (CARLINI-COTRIM; BARBOSA, 1993).
The study provided an overview of the profile of psychoactive substance use in Ribeirão Preto in the early years of the 21st century (2005 and 2006), particularly in relation to alcohol and tobacco, since other drugs were grouped into a single category without discrimination except for psychotropic medications.
Using existing epidemiological studies in the above-mentioned populations in Ribeirão Preto, two research publications obtained through bibliographic survey and private collection from the printed media were needed.Although these different measuring instruments were used, some of the results are comparable and have the potential to identify similarities and differences in sociodemographic data (age, gender, population) and changes in the types of psychoactive substance, pattern of use, and issues related to the family at different historical moments.
A comparison between studies regarding the pattern of drinking in the age groups proves to be a difficult task due to nonhomogeneity of the data.This was felt during local research, but it also occurs in international research, as in a study by Ahlström andÖsterberg (2004-2005) with adolescents and young adults, because population surveys conducted in different countries generally use different age groups and different measurements to measure the levels of alcohol consumption.
The first epidemiological study focusing on the topic held in Ribeirão Preto was conducted by B. J. G Simões and M. J. S. Simões (1976)(1977) in 1975 with a sample of 2,268 high school students from public and private schools, which at the time represented 30% of the students enrolled in the city, and data were collected through specific questionnaires developed by the researchers.
The second research was a survey conducted by Musa and colleagues (1997) in 1990 with 1,025 students in their last year of middle and high school from 21 schools, 61.6% from public and 38.4% from private schools.The data collection used an adaptation of the "self-administered questionnaire" from the WHO (SMART ET AL., 1980).
When comparing the results of this study with those in the original epidemiological studies in former times in Ribeirão Preto, table 4 was created to show and summarize some information about the characterization and consumption profile in life of psychoactive substances among the students surveyed.
From the results of the study conducted in 1975, 1,539 students reported they did not smoke; of these, 753 consumed no alcoholic beverages, 725 consumed it socially, and 53 consumed it daily (SIMÕES;SIMÕES, 1976SIMÕES, -1977)).

Categories
First  The predominant age group in the second study (MUSA ET AL., 1997) was 16 and 17 years (44.5%),followed by 13-15 (35.8%) and 18-19-year-olds (19.7%).This is corroborated by the results of the original study as it seems that schools seem to be receiving younger students or, as noted on the occasion of the questionnaires in the 2005 study, the older students are dropping out of school.
Given the prevalence of drug use by age in this study, the study in the late 90s (MUSA ET AL, 1997) found an increase with age in the use of psychoactive substances, since the use of alcoholic beverages in the age group between 13-15 years was 86.1%, 89.6% between 16-17-year-olds and it increased to 93.6% between 18-19-year-olds.Regarding the use of tobacco, the same was found (13-15 years, 24.6%; 16-17 years, 43.1%; and 18-19 years, 50.2%).As for the use of other drugs, including medications, consumption also increased with age (13-15 years, 25.3%; 16-17 years, 39.8%; and 18-19 years, 44.8%).
These results differ in part from those observed in the current study, in which the consumption of psychoactive substances generally decreases after the age of sixteen.
A study conducted by CEBRID (GALDUROZ ET AL., 2005) shows that in São Paulo the consumption of alcohol also dominated in the age group between 13-15 years (37.2%), but with a lower rate.As for use in life with regard to data from the city of São Paulo, this survey found similar rates for Ribeirão Preto in 2005.Still considering alcoholic beverages, the mentioned study indicated a higher monthly and a frequent use (47.5% and 12.2%, respectively).The rate of tobacco use in life was similar in both studies and daily use was slightly higher than in the original study.For the other drugs, but not a specific one, only relative data were obtained for use in general without discrimination of the substance, which makes comparison impossible.
The study conducted in the 90s (MUSA ET AL., 1997) indicates a slightly higher consumption of alcohol and tobacco in life (88.9% and 37.7%, respectively), as well as daily use (8.5% and 4.1% respectively).As for alcohol, it appears that there was a change in the current study of the pattern of daily use (1.8%) to frequent use (9.2%), which did not exist (or was not measured in previous studies).Perhaps this is because the sample of the current study has a greater number of young people between 13 and 15 years who have not yet established daily consumption.
Anyhow, the rate presented in the category of frequent use is worrisome.
For tobacco, based on the research data from the 90s (MUSA ET AL., 1997), the rate for daily use has remained high (3.1% in 1997, and 3.1% in 2005).The same can be extended to the use of drugs that presented a lower rate (from 10.5 to 6.4%) of use in 2005, but the daily use increased (from 0.7 to 1.2%) with the appearance of occasional use (79.1%).
The results of this study show that the participants in the sample are experimenting psychoactive substances at higher rates and at earlier ages.As for gender, the presence of girls in all use categories shows their vulnerability and suggests a tendency to match or surpass boys.During adolescence, drinking patterns are not so different, so much so that women can drink more than men, a fact found in this investigation.However, research conducted in the late 90s (MUSA ET AL., 1997) in this city showed higher prevalence of consumption rates for boys, except for medications, which were mostly used by female students.
Regarding the presence of girls in all the categories, this could be due to the faster development of girls in relation to boys and the absence, at this period of life, of the burden of family responsibilities that women have later in life.However, this pattern convergence between genders is not a uniform phenomenon in all countries and the reasons for this may be subjected to changes in the social and cultural background (AHLSTRÖM; ÖSTERBERG, 2004ÖSTERBERG, -2005)).
This study revealed the importance of evaluating the use of psychotropic drugs according to their different forms as it provides indicators of contact and frequency of consumption of substances.The use in life is important because it often occurs in the home environment itself (as in the case of alcohol and tobacco), since use in the year and month denote recent contact and it would be interesting to pursue further epidemiological studies.In the case of frequent use, its importance lies in the fact that it can be an indicator of the establishment of subsequent dependence (GALDUROZ ET AL., 2005).It must be mentioned, however, that the use in life does not reflect the real magnitude of consumption since this category includes those who experiment and other users (CARLINI-COTRIM;BARBOSA, 1993;GALDUROZ ET AL., 2005).
In the assessment of substance use by age, 13-year-old students showed a high frequency of alcohol use, which might indicate that experimentation may be occurring in the previous grades.This finding is in accordance with the 'V National Survey of psychoactive drug use', which alerts to the fact that alcohol consumption may be starting at earlier ages (GALDUROZ ET AL., 2005).
In relation to socialization in the 2005 study, the information recorded in the questionnaire showed that young people are close and in frequent contact with psychoactive substances either through experience or by living with the user, either by access to the drug at places they frequent when meeting colleagues or during leisure activities.
The family behavior and belief system they hold regarding the use of psychoactive drugs can influence the habits of children working as a protective factor, such as the presence of the father/mother at home, or as a risk factor, when tobacco or illicit drugs are used by the parents (HORTA ET AL., 2006), as well as endangering safety and emotional protection and affect the identity construction of the teenager (ROEHRS ET AL., 2008).The existence of a user at home may be clue of family dysfunction that might motivate use.Furthermore, the presence of other users (perhaps an addict) in the same family group is suggestive of possible genetic vulnerability to addiction (TAVARES ET AL., 2004).
A study conducted on alcohol consumption in Mexico at educational centers of middle and high school education pointed out that having relatives and friends who drink is an important risk factor for consumption; it also points out that consumption habits among relatives and people close to adolescents influence the onset, frequency and intensity of use (VILARREAL-GONZALEZ ET AL., 2010).
In the light of the results, the researchers in this study returned to some of the schools that participated in this study to develop extension activities aimed at preventing psychoactive drug use by means of focus groups.Students reported having contact with drug use, including the selling of licit and illicit drugs, in their family and surroundings.Situations of great vulnerability of adolescents were recorded by the researchers, of which the local teachers are aware, but they state that it is difficult to approach the issue because of the lack of public policies, strategies, and institutional support.

Conclusion
Adolescence, as a plural phenomenon, originates and reproduces the objective and symbolic structures of the environment to which the adolescents belong based on the different categories (physical, social class, educational level, etc.) and the historical moment they experience.It was found in this study that psychoactive substances are present in the everyday life of the participants as other significant people around them use these substances.
The findings showed a history of psychoactive substance use by middle and high school students in Ribeirão Preto, and in samples of students collected at different times (1975,1990,2005), in which the first two refer to published studies and the third one is an original study.Furthermore, these studies show a scenario of the pattern of psychoactive substance use by middle and high school students, particularly from public schools, and the more comparable results between the studies refer to alcohol and tobacco.
Taking into consideration students that reported use of psychoactive medications, it would be relevant if programs on primary care could monitor prescriptions to mothers and grandmothers/grandfathers in order to evaluate adolescents' access to these substances.
In view of the results, it was found that specific public policies must be implemented to provide alternative spaces for leisure, to train teachers to motivate students to remain in school (so they know how to handle situations involving legal and illegal drugs), to protect and support students, and provide programs and activities that meet their social reality and that are applicable.Finally, investment of resources in the young population of Ribeirão Preto -SP is needed to prevent them from becoming more vulnerable to social exclusion.
Researchers can contribute by focusing on regional studies in the search for characteristic patterns of this population group and factors that affect the behavior of alcohol and other drug use by young people in general, particularly students.Lastly, longitudinal studies are also necessary to expand the knowledge provided by single cross-sectional studies.
The limitations of this study were the lack of statistical tests due to nonprobability sample, as the objective of this research was to focus on obtaining descriptive data that pointed to the characteristics of this population to guide the development of prevention programs in schools in Ribeirão Preto -SP, which has already been happening through extension projects involving faculty members and graduate students of the School of Nursing of Ribeirão Preto/USP.s

Table 1 .
Distribution of students according to the pattern of use of psychoactive substances and gender.Ribeirão Preto -SP, 2005SP,  -2006

Table 2 .
Number and percentage of people related to the socialization of students in high school and in the eighth year of middle school who use psychoactive substances in Ribeirão Preto (n = 3,955).Ribeirão Preto -SP, 2005-2006 Fonte: Elaboração própria

Table 4 .
Characterization of studies and distribution of psychoactive substance use in life