Prevalence and patterns of tobacco, alcohol, and drug ...

Children and Youth Services Review 60 (2016) 68–79

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Prevalence and patterns of tobacco, alcohol, and drug use among Iranian adolescents: A meta-analysis of 58 studies Alireza Ansari-Moghaddam a, Fatemeh Rakhshani a,b, Fariba Shahraki-Sanavi a,⁎, Mahdi Mohammadi a, Mahmodreza Miri-Bonjar a, Nour-Mohammad Bakhshani a a b

Health Promotion Research Center, Epidemiology & Biostatistics Department, Zahedan University of Medical Sciences, Doctor Hesabi Square, Zahedan 9817667993, Iran Shahid Beheshti University of Medical Sciences, District 1, Daneshjou Blvd., Tehran 1983963113, Iran

a r t i c l e

i n f o

Article history: Received 31 May 2015 Received in revised form 22 November 2015 Accepted 22 November 2015 Available online xxxx Keywords: Smoking Drinking Drug use Adolescents Iran

a b s t r a c t Adolescence is the critical age when adopting high-risk and health-threatening behaviors including smoking, drug and alcohol use is at its peak. Accordingly, this meta-analysis aimed to provide comprehensive nationwide estimates of tobacco, alcohol, and drug use among Iranian adolescents; and to compare their habits with other societies. Electronic databases, including PubMed, Medline, Embase, Google scholar and National Persian databases of SID, Magiran, and IranMedex were utilized in identifying relevant articles. The included studies were those having publications of quantitative estimates and standard errors of the prevalence of cigarette and drug use among 14–19-year-old high school students in Iran from 2000 to 2014. Random-effects meta-analyses were done including a total of 80,588 high school students. The most common drugs among adolescents in Iran were hallucinogens [25.3% (95% CI: 23.9–26.8)], sleeping pills and tranquilizers [25% (95% CI: 24–26.1)], hookah [23.1% (95% CI: 22.2–23.9)], opiates [22% (95% CI: 21.3– 22.7)] and central nervous system (CNS) stimulants [20.1% (95% CI: 19.1–21.1)]. Furthermore, overall estimates for cigarette smoking, alcohol and chewing tobacco/Pan/Nas in the participants were 16.8% (95% CI: 16.4–17.2), 14.7% (95% CI: 14.2–15.3) and 10.0% (95% CI: 8.7–11.4), respectively. However, there was some heterogeneity in the pattern of drug use across the country (P b 0.01). Additionally, the risk of smoking, drinking and drug use by boys was considerably greater than girls. Moreover, data showed a varying trend of drug use over three studied periods of time. In conclusion, a diverse pattern and trend of tobacco smoking, alcohol drinking and drug use among adolescents in Iran was verified. Therefore, preventive and control measures (i.e. education) provided in schools should be compatible with age groups, with emphasis being laid on pattern of use in different parts of the country. © 2016 Elsevier Ltd. All rights reserved.

1. Introduction The abusive use of drugs, tobacco, cigarette, alcohol and other traditional and newly emerging addictive products has become a major public health concern around the world(Aarons et al., 1999; Bauman & Phongsavan, 1999; Cuijpers, 2002; Faggiano et al., 2010; Hong, Lee, Grogan-Kaylor, & Huang, 2011). Currently, about one billion people (about one-seventh of the world's population) smoke cigarettes, and this number is anticipated to rise to 1.5–1.9 billion by 2025 (Guindon & Boisclair, 2003). Furthermore, a recent report by the United Nations Office of Drugs and Crime (UNODC) showed that 5% of the world's population used illicit drugs in 2010. This office also estimated global

⁎ Corresponding author. E-mail addresses: [email protected] (A. Ansari-Moghaddam), [email protected] (F. Rakhshani), [email protected] (F. Shahraki-Sanavi), [email protected] (M. Mohammadi), [email protected] (M. Miri-Bonjar), [email protected] (N.-M. Bakhshani).

http://dx.doi.org/10.1016/j.childyouth.2015.11.018 0190-7409/© 2016 Elsevier Ltd. All rights reserved.

cost of drug abuse at 0.3%–0.4% of the worlds' gross domestic product (GDP) (Chakravarthy, Shah, & Lotfipour, 2013). Cigarettes, tobacco and alcohol are among the most common drugs used across the word, and their usage varies across different regions of the world. Interestingly, although drug abuse and smoking show a fairly stable or reducing trend in many developed countries, they are rapidly increasing in developing countries. Thus, in the next few years, the major burden of drug abuse and smoking will be imposed on these countries, which are less equipped to cope with these challenges (Hickman et al., 2014; Melotti et al., 2011; Mesic et al., 2013; Moeini, Poorolajal, & Gharghani, 2012; Rajabizadeh et al., 2011). On the contrary, studies suggest that the habits and eventually the addiction to smoking by many adults begin in adolescence. Consequently, the age range of 10–20 years is very crucial and plays a determinant role in adopting high-risk and health-threatening behaviors. Generally, the first adolescence years is characterized with biological, cognitive, social and emotional changes which affect the choice of behavior. During this stage, more time is spent outside academic setting and home with

A. Ansari-Moghaddam et al. / Children and Youth Services Review 60 (2016) 68–79

peers. Therefore, they are at an increased risk of indulging in cigarettes, tobacco and alcohol, as well as partaking in drug usage (Bauman & Phongsavan, 1999; Beyers, Toumbourou, Catalano, Arthur, & Hawkins, 2004; Brown et al., 2008; Hale & Viner, 2013; Rhee, Yun, & Khang, 2007; Skara & Sussman, 2003). Importantly, the pattern of drug use among adolescents in developed countries is different from that of developing countries. For example, several studies on high-school students showed that daily smoking is most common in Bulgaria and Croatia (Kokkevi, Richardson, Florescu, Kuzman, & Stergar, 2007). The prevalence rate of cigarette smoking has also been reported variously from 7% in Nigeria to 30% in Hong Kong; while approximately 19% of Iranian adolescents have demonstrated to smoke cigarette. (Degenhardt et al., 2008; Mohammadpoorasl, Nedjat, Fakhari, Yazdani, & Fotiou, 2014). In comparison with other countries, 99% of students in Zimbabwe and 32% in Wales indulge in alcohol consumption(Smart & Ogborne, 2000). Similarly, in Iran, alcohol consumption among juveniles varied from 4.3% in Shiraz, 2003 to 37.7% in Kerman, 2010 (Ahmadi & Hasani, 2003; Ziaaddini, Sharifi, Nakhaee, & Ziaaddini, 2010). Marijuana usage (Delva et al., 2005; Ferigolo et al., 2004; Stronski, Ireland, Michaud, Narring, & Resnick, 2000) also ranged from 2% in Greece to 69.2% in Southern Brazil across the world. Similarly, its usage ranged from 0.8% in the city of Shiraz in 2003 to 3.3% in Sarakhs in 2014 among Iranian students (Ahmadi & Hasani, 2003; Khajehdaluee, Zavar, Alidoust, & Pourandi, 2014). Throughout the world, the lowest to highest consumption rates of central nervous system stimulants by the youth (hashish, marijuana, grass, and cannabis) (Degenhardt et al., 2008; Swadi, 1999) ranged from 1.6% in the US to 27% in New Zealand. Similar records have shown a 0.3% usage of Hashish among Iranian adolescents. Furthermore, according to the available data, a portion of about 0.6% to 22% of the world students reported stimulants use (amphetamine, methamphetamine, ecstasy, and Ritalin) compared to a small fraction (1.1%) of students in Iran, who reported ecstasy consumption (Botvin, 2000; Mohammadkhani, 2012; Smart & Ogborne, 2000). Additionally, 4% to 28.3% of the world adolescents reported usage of tranquilizers/sedatives drugs (T/S) (Kokkevi, Fotiou, Arapaki, & Richardson, 2008), of whom about 0.1% to 21% are addicted to cocaine and psychotropic drugs (Ferigolo et al., 2004; Minozzi, Amato, Bellisario, & Davoli, 2014). There has been some evidence showing that about 0.1% to 5.4%, of the students have stated LSD consumption globally (Minozzi et al., 2014). In comparison, addiction to tramadol was reported among 4.7% to 36% of students in Iran (Nazarzadeh et al., 2013; Nazarzadeh, Bidel, & Carson, 2014). Importantly, over the past decade, there has been a dramatic increase in consumption of opioids and other addictive drugs. Significantly, most opium and its derivatives users are reported from Asia, including Iran which serves as a transit route of the drugs from the producing country of Afghanistan to other parts of the world (Ansari-Moghaddam et al., 2012; Minozzi et al., 2014). Another important point to note is the indulgence of the adolescents in several high-risk behaviors simultaneously. It has been reported that alcohol consumption or drug abuse by adolescents does not occur alone; alcohol consumption may be accompanied by other high-risk behaviors like smoking or drug use. Consequently, some adolescents below 18 years of age have experienced two or more high-risk behaviors, simultaneously. Evidence suggests that in some cases, people have turned to other substances to quit the one they already used, which predisposed them to multiple high-risk behaviors. For example, smokers are more likely to use alcohol, and vice versa. It is also believed that cannabis users are more likely to use other drugs and vice versa (Aarons et al., 1999; Bojorquez, Fernandez-Varela, Gorab, & Solis, 2010; Brener & Collins, 1998; Brown et al., 2008; Hale & Viner, 2013; Melotti et al., 2011). The data indicate that prevalence of simultaneous tobacco and alcohol usage among adolescents varies from 4% to 17% in different places.

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For instance, in the Democratic Republic of Congo, 15% of 14–19-yearold boys simultaneously used cigarettes and alcohol. Health reports in the United States of America demonstrated multiple drug usage among 17% of young people (Hickman et al., 2014). Accordingly, monitoring pattern of drug and tobacco usage by adolescents in different parts of the world is proposed to be a major health concern. Therefore, several studies have been conducted in various parts of Iran, showing a significant frequency distribution of tobacco, alcohol and drug usage among the youth. However, there has been no comprehensive study to summarize the results from previous studies conducted so far. More importantly, Iran serves as a transit route for drug trafficking from the main drug producing country (Afghanistan) to Europe. These geographical and social locations make Iran suitable and convenient for the consumption and tendency toward addictive substances among teenagers. Thus, the primary purpose of the current review was to provide comprehensive nationwide estimates of the overall prevalence rate of tobacco, alcohol, and drug use among Iranian adolescents. A secondary objective was to further estimate the prevalence of tobacco, alcohol, and drug use in Iran by region, gender, and across three time periods. Additionally, the study compared these estimates with other societies descriptively. 2. Material and methods 2.1. Data sources and search strategy Relevant articles were identified through searches of the electronic databases including PubMed, Medline, Embase, Google Scholar and National Persian Databases of SID, Magiran, Iran Medex and also from citations in the selected papers. The search was conducted using the following medical subject heading terms and/or text words: “cigarette”, “medication abuse”, “drug abuse”, “adolescent”, “high school”, and “Iran”. Furthermore, exploration of related studies continued using the name of every single substance under study, including “cigarette”, “alcohol”, “opium”, “tobacco”, etc. Other relevant studies were identified by scanning through reference lists of selected articles and reviews. 2.2. Inclusion and exclusion criteria The studies containing already published quantitative estimates and standard errors of the prevalence of cigarettes and drugs consumption among 14–19-year-old high school students in Iran, in Persian or English language from 2000 to 2014 were included in the study. Also, the studies which reported prevalence of smoking and drug use in the last 30 days or 12 months, or in the lifetime as current, regular, permanent, often, daily, every day, continually, or regularly were examined. However, the studies that provided only frequency of smoking or drug use, with no means to calculate the standard error and consequently confidence interval were excluded. Some authors have multiple identical publications on one subject. For example, they first published the findings of their research project partially and then completely in Persian or in English. Consequently, information from the most recent publications or manuscript with full details was used for the present review to avoid duplication. 2.3. Data extraction The following data were extracted for each eligible study independently by two authors (F.S.S. & A.A.M.): Family name of the first author, year of publication, region, study design, sample size, study setting, data collection setting, age, sex and reported prevalence, and their confidence intervals regarding use of smoking as well as different drugs. The confidence intervals, however, were not available in some reports. Therefore, the following equation was used to

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estimate corresponding confidence intervals for each point estimate (Woodward, 2004): ∝

Pþ

Z 2 =2 Z 2n

rhffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffii ∝ ∝ P ð1−P Þ þ Z 2 =2 =4n = 1 þ Z 2 =2 =n

combined with respect to particular characteristics such as region, sex and publication year. In addition, studies were classified into three time categories (e.g. 200–2005, 2006–2010, and 2011–2014) and then pooled separately to examine the trend of smoking and drug use in these three spans of time by using Meta regression analysis. All analyses were performed using STATA, SE-11.0 (STATA Corp LP, College Station, Texas).

2.4. Data analysis and synthesis 3. Results Pooled estimates of the prevalence rates were obtained using reported prevalence rates for cross-sectional surveys by means of a randomeffects approach which incorporated between-study variability. Studies were weighed according to an estimate of their “statistical size,” which is defined as the inverse of the variance. Heterogeneity of the results was tested using the Q statistic (Woodward, 2004). Possible sources of heterogeneity were examined by comparing the results of studies

The preliminary search identified 1186 studies, of which 63 were potentially related and qualified for the final analysis (Fig. 1). Articles with relevant information on the prevalence of smoking and drugs among a total of 80,588 high school students were eligible enough to be included in these analyses. Table 1 shows the summary information of included studies in meta-analysis. In the present work, substances were

Fig. 1. Flowchart of the literature search.

Table 1 Studies reporting prevalence of smoking, alcohol and substance use in adolescents. Prevalence (95% CI) Region

City

N

Gender

Age

Najafi (2005)

N

Rasht

1474

NA

Mohtasham–Amiri (2005)

N

Lahijan

2345

Mohtasham–Amiri (2008) Najafi (2009)

N N

Rasht Guilan

1297 1927

M: 751 F: 723 M: 1327 F: 970 M M:1041 F: 886

Khajehdaluee (2013 & 2014)

N

Sarakhs

943

M: 507 F: 436

14–19 16.4 ± 1.10

Fakhri (2014) Shariat–Zadeh (2001) Hamidzadeh (2001) Pasharavesh (2003) Mohammadpoo -Asl (2007 & 2007)

N NW & W NW & W NW & W NW & W

North of Iran Oromieh Khalkhal Kermanshah Tabriz

5197 1096 260 3150 1785

NA M: 1096 M: 260 F: 3150 M: NA F: NA

NA NA NA NA 15–19 16.30 ± 0.87

Rahmanian (2010)

NW & W

Jahrom

1145

NA

Kashi (2010)

NW & W

Khoda–Bandeh

240

M: 689 F: 456 M: 120 F: 120

Moeini (2011) Bashirian (2012 & 2012)

NW & W NW & W

Malayer Hamadan

900 650

M: 900 M: 650

NA 14–17

Moeini (2012)

NW & W

Hamedan

1161

Mohammadpoor–Asl (2012 & 2012)

NW & W

Tabriz

4801

Nazarzadeh (2013)

NW & W

Zanjan

1035

M: 588 F: 573 M: 2091 F: 2799 M: 1035

Porkord (2013)

NW & W

Ardabil

616

M: 616

15.37 ± 0.87

Nazarzadeh (2014)

NW & W

Ilam

1894

M: NA F: NA

16.30 ± 0.70

Male (%)

Female (%)

Total (%)

Cigarette: 11.30 (9.29–13.82)

Cigarette: 2.50 (22.11–28.42)

Cigarette: 6.98 (5.81–8.41)

NA 14–18 NA

Alcohol: 16.60 (14.53–19.04) Hookah: 25.90 (23.43–28.74) Opium: 3.30 (2.39–4.58) Heroin: 0.50 (0.22–1.15) Cannabis: 3.60 (2.64–4.93) Ecstasy: 3.00 (2.14–4.23) Cigarette: 23.86 (20.54–27.94)

Alcohol: 3.40 (2.41–4.82) Hookah: 13.00 (11.00–15.43) Opium: 1.50 (0.89–2.54) Heroin: 0.10 (0.02–0.62) Cannabis: 0.20 (0.05–0.78) Ecstasy: 1.10 (0.60–2.03) Cigarette: 13.76 (10.97–17.44)

Cigarette: 30.00 (23.51–39.70) substance use: 11.67 (7.49–19.05) Psychotropic drug: 10.00 (6.17–17.03)

Cigarette: 8.33 (4.89–14.97) substance use: 0.83 (0.22–4.64) Psychotropic drug: 0.83 (0.22–4.64)

NA

Cigarette: 13.40 (10.97–16.48)

Cigarette: 6.80 (5.06–9.21)

14–19 15.70 ± 0.70 17.20 ± 1.30

Cigarette: 9.20 (8.05–10.53) substance use: 2.40 (1.83–3.15)

Cigarette: 0.50 (0.30–0.84) substance use: 0.60 (0.37–0.96)

NA

Cigarette: 14.90 (13.54–16.42) Ecstasy: 1.02 (0.69–1.52) Cigarette: 15.00 (13.20–17.09) Alcohol: 10.50 (9.23–11.97) Hookah: 20.00 (18.31–21.88) Opium: 2.40 (1.81–3.19) Heroin: 0.30 (0.14–0.66) Cannabis: 2.00 (1.47–2.73) Ecstasy: 2.10 (1.55–2.85) Cigarette: 19.20 )16.89–21.92) Alcohol: 6.60 (5.21–8.39) Nas: 4.60 (3.46–6.15) Opium: 4.20 (3.11–5.69) Heroin: 0.20 (0.05–0.75) Marijuana: 3.30 (2.35–4.66) Pill: 1.60 (0.98–2.63) Hookah: 1.50 (1.20–1.87) Cigarette: 12.10 (10.34–14.21) Cigarette: 17.30 (13.45–22.63) Cigarette: 1.10 (0.79–1.53) Cigarette: 4.40 (3.55–5.46) Alcohol: 12.70 (11.26–14.35) Opium: 0.33 (0.15–0.72) Cannabis: 0.44 (0.22–0.87) Ecstasy: 0.84 (0.51–1.38) Drug use: 0.39 (0.19–0.81) Cigarette: 10.13 (8.55–12.05) Cigarette: 19.16 (15.00–24.92) substance use: 6.25 (3.93–10.17) Psychotropic Drug: 5.41 (3.29–9.14) Cigarette: 14.00 (11.95–16.48) Cigarette: 11.10 (8.98–13.81) substance use: 3.40 (2.28–5.11) Cigarette: 10.20 (8.62–12.11)


First Author (Y)

Cigarette: 4.20 (3.67–4.81) substance use: 1.40 (1.11–1.77) Cigarette: 10.80 (9.09–12.88) Ritalin: 4.80 (3.67–6.30) Tramadol: 36.00 (33.27–39.10) Cigarette: 71.70 (68.46–75.56) Alcohol: 20.10 (17.25–23.57) Ecstasy: 3.10 (2.02–4.81) substance use: 4.70 (3.32–6.70) Alcohol: 11.10 (9.79–12.62) Opium: 2.80 (2.15–3.65) Cannabis: 3.30 (2.59–4.21) Ecstasy: 2.70 (2.07–3.54) Tramadol: 4.70 (3.84–5.76) 71

(continued on next page)

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Table 1 (continued) Prevalence (95% CI) First Author (Y)

Region

City

N

Gender

M: 764 F: 760 M: 2005 F: 2018 NA

Age Female (%)

Total (%)

Cigarette: 13.10 (10.96–15.75) Hookah: 6.40 (4.91–8.40) Cigarette: 7.20 (6.16–8.43)

Cigarette: 13.70 (11.51–16.40) Hookah: 7.10 (5.52–9.19) Cigarette: 1.00 (0.65–1.54)

Methamphetamine: 2.10 (1.55–2.85) Cigarette: 9.50 (8.15–11.10) Hookah: 10.40 (8.99–12.06) Cigarette: 4.10 (3.53–4.76)

Mohammad–Alizadeh–Charandabi (2014)

NW & W

Sanandaj

1524

Ziaeei (2000)

T&C

Tehran

4023

Mosavi (2003)

T&C

Isfahan

176

Kelishady (2004)

T&C

1254

M: NA F: NA

NA

Heydari (2004)

T&C

Isfahan, Najafabad & Arak Tehran

1119

14–20

Cigarette: 6.06 (4.57–8.08)

Cigarette: 1.50 (0.71–3.25)

Cigarette: 4.40 (3.36–5.78)

Heydari (2007)

T&C

Tehran

1095

14–18

Cigarette: 6.00 (4.51–8.03)

Cigarette: 2.00 (1.03–3.98)

Cigarette: 5.00 (3.88–6.47)

Momenan (2007)

T&C

Tehran

1635

Barikani (2008)

T&C

Tehran

298

M: 718 F: 401 M: 712 F: 381 M: 837 F: 798 M: NA F: NA

Kazemi (2008)

T&C

Isfahan

351

Ramezankhani (2010)

T&C

Tehran

1725

Khooshabi (2010)

T&C

Tehran

1124

Shamshiri Milani (2011)

T&C

Tehran

2313

F: 2313

Alaei–Kharayem (2011)

T&C

Karaj

447

Tavossi (2012)

T&C

Tehran

Habib (2012)

T&C

Tehran

Ghavidel (2012)

T&C

Nazarabad

Baheiraei (2013, 2013 & 2013)

T&C

Tehran

NA

Cigarette: 14.20 (10.13–20.45) substance use: 5.70 (3.27–10.31) Cigarette: 9.33 (7.87–11.10)

NA

Hookah: 27.70 (25.65–29.98)

14.80 ± 1.40

Cigarette: 16.77 (13.18–21.65) Alcohol: 13.42 (10.19–17.94) Hookah: 41.27 (36.36–47.47) Heroin: 3.69 (2.13–6.54) Cigarette: 10.30 (7.66–14.04)

14–19 16.00 ± 0.77 NA

Cigarette: 4.60 (3.40–6.26)

Cigarette: 1.40 (0.82–2.42)

Cigarette: 2.95 (2.26–3.87)

M: 16.10 ± 1.00 F: 15.90 ± 1.00 NA

Substance use: 10.10 (7.96–12.91)

Substance use: 6.40 (4.69–8.81)

Substance use: 8.27 (6.83–10.06)

M: 208 F: 239

16.50 ± 1.29

Cigarette: 31.20 (25.87–38.38) Alcohol: 24.40 (19.52–31.13) Hookah: 64.90 (59.39–72.26) Opium: 2.10 (0.91–5.14) Heroin: 0.50 (0.12–2.73) Hashish: 2.50 (1.15–5.70) Glass: 1.10 (0.36–3.69) Crack: 0.50 (0.12–2.73) Tablet: 3.90 (2.09–7.61)

Cigarette: 19.20 (15.02–24.98) Alcohol: 4.20 (2.38–7.63) Hookah: 43.10 (37.67–50.14) Opium: 2.10 (0.95–4.86) Crack: 0.40 (0.07–2.34) Tablet: 0.40 (0.09–2.32)

433

M: 433

15–19

4591

M: 2092 F: 2499 M: 196 F: 204

17.53 ± 0.59

Cigarette: 12.10 (10.79–13.59)

Cigarette: 5.30 (4.50–6.26)

Cigarette: 12.71 (11.44–14.15) Alcohol: 8.25 (7.21–9.46) Ecstasy: 2.30 (1.77–3.00) substance use: 1.64 (1.20–2.25) Cigarette: 24.80 (21.24–29.22) Alcohol: 13.80 (11.03–17.43) Hookah: 53.20 (49.02–58.24) Opium: 2.00 (1.07–3.79) Heroin: 0.20 (0.04–1.17) Hashish: 1.10 (0.48–2.58) Glass: 0.40 (0.11–1.55) Crack: 0.40 (0.11–1.49) Tablet: 2.00 (1.07–3.79) Cigarette: 5.50 (3.77–8.12) Hookah: 6.50 (4.60–9.29) Cigarette: 8.40 (7.64–9.24)

Cigarette: 22.20 (19.22–25.81)

Cigarette: 7.80 (5.63–10.93) Opium: 1.30 (0.58–2.98) Heroin: 0.50 (0.15–1.81) Hashish: 0.30 (0.07–1.49) Amphetamine & X tablet: 0.80 (0.29–2.27) Crack: 0.50 (0.14–1.80) Cocaine: 0.30 (0.07–1.49) LSD: 0.50 (0.15–1.81) Cigarette: 26.20 (23.88–28.84)

400

1201

M: 837 F: 888 M: 573 F: 551

17.80

M: 592

15–20

16.74 ± 1.09

Cigarette: 30.20 (26.84–34.21)


NA

14–18

Male (%)

F: 609

Baheiraei (2013, 2013 & 2013)

SE & E

Zabol

900

M: 450 F: 450 M: 216 F: 259 M: 1945 F: 1373

15.50

Mojahed (2004)

SE & E

Zahedan

475

Ziaadini (2006)

SE & E

Kerman

3318

Namakin (2008) Ziaadini (2008)

SE & E SE & E

Birjand Kerman

1233 860

M: 1233 M: 346 F: 514 M: 256 F: 396

16.30 ± 1.30 NA

Nakhaei (2009)

SE & E

Kerman

652

Farhad–Molashahi (2009)

SE & E

Zahedan

292

M: 292

16.75

Ziaadini (2010)

SE & E

Kerman

610

NA

17.90 ± 0.55

Rakhshani (2010) Karimi (2012)

SE & E SE & E

Zahedan Zarandieh

380 215

M: 380 NA

15.90 ± 0.70 14–19

15.90 ± 1.00 NA

NA

Alcohol: 8.40 (6.50–10.93) Hookah: 21.40 (18.46–24.97) Heroin: 1.50 (0.81–2.82) Methamphetamine: 2.20 (1.32–3.71) Ecstasy: 5.00 (3.57–7.06) Ritalin: 3.50 (2.33–5.30) Glass & Crack: 1.00 (0.47–2.16) Steroid Tablet: 4.00 (2.74–5.89) substance use: 2.90 (1.85–4.58)

Alcohol: 15.10 (13.24–17.28) Hookah: 28.00 (25.62–30.70) Heroin: 1.60 (1.03–2.49) Methamphetamine: 2.70 (1.93–3.79) Ecstasy: 5.60 (4.45–7.07) Ritalin: 3.40 (2.53–4.59) Glass & Crack: 1.30 (0.80–2.12) Steroid Tablet: 5.00 (3.92–6.40) substance use: 3.10 (2.27–4.25) Cigarette: 0.70 (0.33–1.50)

Cigarette: 2.30 (1.04–5.34) Drug use: 8.00 (5.23–12.55) Alcohol: 25.60 (23.76–27.64) Opium: 25.10 (23.27–27.13) Opium Concentrate: 26.00 (24.15–28.05) Heroin: 39.30 (37.23–41.57) Hashish: 37.00 (34.95–39.24) Sedative drug: 39.70 (37.63–41.97) LSD: 37.20 (35.15–39.45) Doping: 22.60 (20.84–24.56)

Cigarette: 0.40 (0.09–2.19) Drug use: 1.60 (0.67–4.02) Alcohol: 19.40 (17.45–21.63) Opium: 34.30 (31.93–36.95) Opium Concentrate: 8.30 (6.98–9.90) Heroin: 21.40 (19.37–23.71) Hashish: 15.40 (13.63–17.45) Sedative drug: 10.00 (8.55–11.73) LSD: 10.70 (9.20–12.48) Doping: 23.10 (21.01–25.47)

Cigarette: 2.30 (1.20–4.51)

Cigarette: 0.40 (0.12–1.43)

Cigarette: 1.20 (0.55–2.66) Drug use: 4.42 (2.95–6.70) Alcohol: 23.02 (21.65–24.51) Opium: 28.90 (27.42–30.50) Opium Concentrate: 18.68 (17.41–20.06) Heroin: 31.88 (30.35–33.52) Hashish: 28.05 (26.58–29.64) Sedative drug: 27.39 (25.93–28.97) LSD: 26.25 (26.31–24.81) Doping: 22.81 (21.44–24.30) Cigarette: 3.90 (2.97–5.14) Cigarette: 1.20 (0.67–2.18)

Alcohol: 11.40 (8.24–16.06) Opium: 3.20 (1.70–6.20) Opium Concentrate: 0.800 (5.39–12.11) Heroin: 0.40 (0.09–2.21) Hashish: 1.60 (0.67–4.04) Sedative drug: 5.50 (3.40–9.10) LSD: 0.80 (0.25–2.86) Doping: 2.00 (0.91–4.59)

Alcohol: 8.90 (6.57–12.20) Opium: 6.60 (4.62–9.55) Opium Concentrate: 3.90 (2.44–6.33) Heroin: 2.30 (1.25–4.32) Hashish: 2.60 (1.46–4.71) Sedative drug: 12.20 (9.46–15.91) LSD: 1.60 (0.77–3.40) Doping: 4.40 (2.83–6.94)

Alcohol: 9.80 (7.81–12.38) Opium: 5.20 (3.78–7.21) Opium Concentrate: 2.60 (1.65–4.14) Heroin: 1.50 (0.82–2.77) Hashish: 1.20 (0.61–2.38) Sedative drug: 9.50 (7.54–12.05) LSD: 1.20 (0.61–2.38) Doping: 3.30 (2.20–4.99) Cigarette: 17.20 (13.54–22.18) Pan: 19.90 (15.99–25.12) Cigarette: 34.60 (31.15–38.68) Alcohol: 37.70 (34.18–41.85) Hookah: 51.50 (47.86–55.77) Pan or Chewing Tobacco: 9.70 (7.66–12.37) Opium: 8.70 (6.77–11.26) Heroin: 4.90 (3.48–6.95) Hashish, Marijuana & Bang: 6.70 (4.97–8.97) Ecstasy: 6.60 (4.93–8.90) Strong Painkiller: 10.20 (8.11–12.92) Tranquilizers: 40.70 (37.13–44.90) Cigarette: 2.10 (1.09–4.12) Cigarette: 14.41 (10.61–20.00)

73

(continued on next page)


Godarzei (2002)

Alcohol: 21.90 (18.90–25.55) Hookah: 34.80 (31.30–38.95) Heroin: 1.70 (0.94–3.11) Methamphetamine: 3.30 (2.16–5.09) Ecstasy: 6.20 (4.57–8.48) Ritalin: 3.30 (2.16–5.09) Glass & Crack: 1.60 (0.87–2.98) Steroid Tablet: 6.00 (4.40–8.26) substance use: 3.30 (2.16–5.09) Cigarette: 1.30 (0.61–2.85)

74

Table 1 (continued) Prevalence (95% CI) First Author (Y)

Region

City

N

Gender

Age Male (%)

SE & E SE & E

Zarandieh Zarandieh

365 380

NA NA

Karimi (2013)

SE & E

Zarandieh

150

M: 150

Karimi (2013) Miri (2014) Bakhshani (2014)

SE & E SE & E SE & E

Zarandieh South Khorasan Zahedan

280 2371 1000

NA M: 2371 M: 585 F: 415

14–18 17.02 ± 0.89 14–19

Ahmadi (2002)

S

Shiraz

355

M: 355

15–17

Ahmadi (2003)

S

Shiraz

397

M: 197 F: 200

16.56

Ayatollahi (2004 & 2005)

S

Shiraz

1132

M: 1132

Kelishadi (2006)

Iran

6312

Moghimbegi (2009)

Iran

M: 3142 F: 3170 M: 809

Madadkhani (2011)

Iran

20 provinces in Iran Azarbayejan (E & W), Kurdestan, Kermanshah, Ilam, Ardabil, Hamadan, Zanjan & Gilan South Azarbayejan, Kerman, Isfahan, Ghazvin, Tehran, Chaharmahal Bakhteyari, Khorasan, Zanjan & Mazandaran

1541

M: NA F: NA

Total (%) Cigarette: 15.10 (11.95–19.30) Cigarette: 13.60 (10.66–17.55) Hookah: 17.30 (14.01–21.60) Cigarette: 18.66 (13.73–26.15) Hookah: 28.66 (22.78–37.11) Cigarette: 12.50 (9.31–17.07) Cigarette: 12.30 (11.06–13.70) Cigarette: 11.40 (9.62–13.56) Alcohol: 9.70 (8.05–11.73) Hookah: 35.00 (32.24–38.14) Chewing Tobacco: 8.40 (6.87–10.32) Opioid: 7.90 (6.42–9.77) Tramadol: 8.00 (6.51–9.88) Cigarette: 18.00 (14.55–22.53) Alcohol: 13.50 (10.48–17.60) Opium: 2.30 (1.21–4.48) Morphine: 0.30 (0.06–1.62) Heroin: 0.80 (0.28–2.40) Hashish: 1.70 (0.81–3.68) Marijuana: 2.00 (1.00–4.08) Cocaine: 0.50 (0.14–1.94) Psychedelic: 0.30 (0.06–1.62) Cigarette: 8.30 (6.05–11.51) Alcohol: 4.30 (2.75–6.82) Opium: 0.80 (0.29–2.28) Morphine: 0.30 (0.07–1.50) Heroin: 1.00 (0.01–1.15) Hashish: 0.80 (0.29–2.28) Marijuana: 0.80 (0.29–2.28) Cocaine: 0.50 (0.15–1.82) LSD: 0.30 (0.07–1.50) Cigarette: 2.50 (1.75–3.59)

Cigarette: 9.10 (7.09–11.77) Alcohol: 9.40 (7.36–12.10) Hookah: 40.20 (36.57–44.49) Chewing Tobacco: 8.80 (6.82–11.43) Opioid: 6.90 (5.16–9.29) Tramadol: 6.80 (5.08–9.18)

Cigarette: 12.10 (9.42–15.71) Alcohol: 10.00 (7.57–13.36) Hookah: 27.50 (23.68–32.24) Chewing Tobacco: 7.90 (5.75–10.97) Opioid: 9.30 (6.96–12.57) Tramadol: 9.80 (7.39–13.13)

Cigarette: 15.20 (11.17–21.18) Alcohol: 7.60 (4.82–12.33) Opium: 1.50 (0.55–4.40) Morphine: 0.50 (0.12–2.83) Heroin: 2.00 (0.83–5.12) Hashish: 1.50 (0.55–4.40) Marijuana: 1.50 (0.55–4.40) Cocaine: 1.00 (0.31–3.64) LSD: 0.50 (0.12–2.83)

Cigarette: 1.50 (0.56–4.36) Alcohol: 1.00 (0.31–3.61)

14–19 16.00 ± 0.77 NA

Cigarette: 22.80 (21.39–24.33)

Cigarette: 11.90 (10.83–13.09)

Cigarette: 17.39 (16.49–18.36)

15–20

Cigarette: 12.30 (10.27–14.80)

Cigarette: 4.90 (3.71–6.50)

Cigarette: 10.20 (8.89–11.73)

15–18

Cigarette: 18.92 (17.09–21.00) Alcohol: 12.60 (11.07–14.38) Opium: 1.97 (1.39–2.80) Heroin: 0.42 (0.20–0.89) Hashish: 0.87 (0.52–1.47) Ecstasy: 1.10 (0.69–1.76) Cocaine: 0.40 (0.19–0.86) Glass: 0.25 (0.10–0.65)


Karimi (2013) Karimi (2013)

1745

Female (%)

16.40 ± 1.11 16.49 ± 1.11 15–19 16.70 ± 1.30 15.98 ± 1.48

0.001 0.001 0.001 0.001 0.001 0.50 (0.20–1.20) 3.00 (1.00–1.40) NA NA 0.30 (0.10–1.50) NA 25.70 (24.30–27.20) 21.80 (20.50–23.20) 4.40 (2.90–6.70) NA NR: number report, P: pooled prevalence, NA: not available.

0.70 (0.50–0.90) 25.30 (23.90–26.80) 19.30 (18.10–20.40) 3.50 (3.20–3.90) 4.20 (2.60–6.80) 7 4 4 10 2

NA NA 1 NA NA

NA NA 1.60 (1.00–2.60) NA NA

NA NA NA 5 1

NA NA NA 2.30 (2.00–2.70) 5.40 (3.20–9.00)

3 1 1 4 NA

0.10 (0.70–1.60) 0.50 (0.10–1.80) 5.00 (3.90–6.40) 4.80 (4.10–5.50) NA

NA 2 2 1 NA

2 1 NA NA 1

0.011 NA NA 24.10 (22.80–25.40) 3 NA NA 27.20 (25.20–29.30) 2 NA NA 25.00 (24.00–26.10) 5

(P% value)

0.001 0.001 0.001 0.001 0.001 0.001 0.001 9.90 (8.50–11.70) 10.20 (8.10–12.80) NA NA 1.00 (0.70–1.60) 1.40 (0.90–2.10) NA

P (95% CI) NR

3 2 NA NA 6 4 NA 11.20 (10.50–12.00) 20.20 (19.00–21.40) 27.50 (25.60–29.40) 12.40 (10.60–14.40) 25.80 (25.00–26.70) 27.50 (26.00–29.00) NA

P (95% CI) NR

13 3 4 2 7 2 NA 10.70 (10.30–11.20) 11.40 (10.40–12.50) 28.70 (27.20–30.20) NA 1.90 (1.40–2.50) 0.30 (0.10–1.40) 3.40 (3.00–3.90)

PP (95% CI) NR

13 3 4 NA 4 1 5 27.00 (26.10–28.00) 13.50 (12.50–14.60) 10.40 (9.00–12.00) NA 2.30 (1.80–2.90) 2.60 (2.10–3.30) 2.80 (2.40–3.20)

P (95% CI) NR

13 3 1 NA 2 2 5 14.50 (13.60–15.50) 9.40 (8.40–10.60) 13.90 (12.80–15.10) 4.60 (3.40–6.10) 2.50 (2.10–3.10) 2.50 (2.00–3.20) 1.60 (1.30–2.00)

P (95% CI) NR

4 2 2 1 4 2 2 16.80 (16.40–17.20) 14.70 (14.20–15.30) 23.10 (22.20–23.90) 10.00 (8.70–11.40) 22.00 (21.30–22.70) 20.10 (19.10–21.10) 2.70 (2.50–3.00)

P (95% CI) NR

Iran

49 14 11 3 25 12 13

South South-East & East Tehran & center North West & West North

Region Area

75

Cigarette Alcohol Hookah Pan, Chewing Tobacco, Nas Opioids, Opium Concentrate, Morphine, Heroin Hashish, marijuana, grass, bang, Cannabis Methamphetamine, Amphetamine, X Tablet (Ecstasy), Ritalin Sedative drugs, Tranquilizers, Tramadol, Strong Painkiller Glass, crack, Cocaine LSD, Psychedelic Steroid tablet, tablet, Pills, Doping, Steroids Substance use, Drug use, inject illegal drug Psychotropic drug

According to the findings, juveniles nationwide were mostly addicted to common drugs like hallucinogens, sleeping pills and tranquilizers, hookah, opiates, and CNS stimulants, and about one-fourth to one-fifth of Iranian students consumed these drugs. There was a variation in the pattern of drug usage in different parts of the country as follow: cigarette and hookah had the highest prevalence rate in the North, sleeping pills, tranquilizers and cigarettes in the West and Northwest, hookah and alcohol in Tehran and central Iran, CNS stimulants, hookah and opiates in the East and Southeast, and alcohol and cigarettes in the South. Importantly, the East and Southeastern parts of the country were characterized by an almost high prevalence rate in all substances. Furthermore, the present study showed that boys were more prone to use all studied substances compared to girls, and there were different patterns of usage between the two sexes. Additionally, the present

Type

4. Discussion

Table 2 Prevalence of smoking, alcohol and substance use in adolescents by region.

categorized and reported in the following groups: cigarette, alcohol, hookah, tobacco (pan, chewing tobacco, and nas), opiates and derivatives (Opioids, Opium Concentrate, Morphine and heroin), CNS stimulants (hashish, marijuana, grass, bang and cannabis), stimulants (methamphetamine, amphetamine, ecstasy and Ritalin), analgesics and sleeping pills (Sedative drugs, Tranquilizers, Tramadol and Strong Painkiller), industrial drugs (Glass, crack, and cocaine), hallucinogens (LSD, psychedelic), corticosteroids and energizers (steroid tablet, tablet, Pills, Doping and Steroids), mixed (Substance use, Drug use and inject illegal drug), and psychotropic drugs. Table 2 demonstrates pooled prevalence estimates for smoking, alcohol, and drug use in terms of the type of substance and region in the country. Generally, the most common drugs used by adolescents in Iran were hallucinogens [25.3% (95% CI: 23.9–26.8)], sleeping pills and tranquilizers [25% (95% CI: 24–26.1)], hookah [23.1% (95% CI: 22.2– 23.9)], opiates [22% (95% CI: 21.3–22.7)] and CNS stimulants [20.1% (95% CI: 19.1–21.1)]. Moreover, the pooled estimates for cigarette smoking, alcohol and chewing tobacco/Pan/Nas in Iranian adolescents were 16.8% (95% CI: 16.4–17.2), 14.7% (95% CI: 14.2–15.3) and 10.0% (95% CI: 8.7–11.4), respectively. However, there is some heterogeneity in the pattern of drug use across the country (P for heterogeneity b 0.01). For example, cigarette use varied from [27% (95% CI: 26.1–28)] in the West and Northwest to [9.9% (95% CI: 8.5–11.7)] in the South of Iran. Similarly, the teenagers in the East and Southeast of the country were two times more likely to consume alcohol compared to the North [20.2% (95% CI: 19–21.4) vs. 9.4% (95% CI: 8.4–10.6)]. Data on Hookah usage was unavailable in a particular area. Nevertheless, one out of 10 adolescents [10.4% (95% CI: 9.00–12.00) used hookah in North West and West compared to three out of 10 [28.7% (95% CI: 27.2–30.2) in central area and capital city of the country. This inconsistency is seen for other studied drugs as well. Importantly, a high prevalence of the consumption rate of the study substances (except cigarette) was seen around the border regions of the East and South-East. The estimated combined prevalence for smoking and other substance usage by gender is displayed in Table 3. In general, boys were considerably more likely to use any one of the 10 categories of drugs than girls. The risk of drug usage by boys was greater than girls from 40% [OR = 1.40 (95% CI: 1.03–1.90)] in methamphetamines to more than 13 times [OR = 13.2 (95% CI: 1.69–103.4)] in psychotropic drugs. To assess the trend of drug usage, the studies were divided and compared in three time spans of 2000–2005, 2006–2010, and 2011–2014. Generally, the trend of drug usage was found inconsistent and nonuniform over these time periods. For example, smoking showed a significantly increasing trend from 9.10% (95% CI: 8.60–9.60) in the first time frame to 22% (95% CI: 21.40–22.70) in last time frame (P for trend = 0.007). Use of other substances (except stimulants) initially increased in 2006–2010, and later decreased, even though the differences were statistically insignificant (Table 4).

Test for Heterogeneity within region


76


Table 3 The pattern of smoking, alcohol and substance use in adolescents by sex. Type

Gender Female

Cigarette Alcohol Hookah Pan, Chewing Tobacco, Nas Opioids, Opium Concentrate, Morphine, Heroin Hashish, marijuana, grass, bang, Cannabis Methamphetamine, Amphetamine, X Tablet (Ecstasy), Ritalin Sedative drugs, Tranquilizers, Tramadol, Strong Painkiller Glass, crack, Cocaine LSD, Psychedelic steroid tablet, tablet, Pills, Doping, Steroids Substance us, Drug use, inject illegal drug Psychotropic drug

Male

Male to Female Ratio

NR

P (95% CI)

NR

P (95% CI)

NR

OR (95% CI)

19 6 5 1 10 3 4 3 2 2 3 5 1

10.90 (10.40–11.50) 13.80 (12.70–15.10) 66.50 (61.20–72.20) 7.90 (5.70–10.99) 21.90 (20.70–23.10) 13.80 (12.20–15.60) 3.20 (2.60–4.00) 10.40 (9.20–11.80) 1.00 (0.50–2.10) 9.90 (8.50–11.50) 19.50 (17.80–21.40) 2.80 (2.30–3.50) 0.80 (0.20–3.80)

31 8 6 2 16 7 6 4 3 3 3 7 2

23.40 (22.80–24.10) 20.50 (19.50–21.70) 29.50 (28.00–31.20) 14.00 (11.80–16.60) 27.90 (26.90–28.90) 32.10 (30.30–33.90) 4.10 (3.60–4.70) 36.40 (34.80–38.10) 1.20 (0.70–2.10) 36.70 (34.60–38.90) 20.30 (18.80–22.00) 5.30 (4.60–6.00) 7.30 (4.50–11.80)

19 6 5 1 10 3 4 3 2 2 3 5 1

2.22 (2.05–2.40) 1.85 (1.63–2.10) 1.99 (1.76–2.25) 1.11 (0.70–1.75) 1.44 (1.32–1.58) 3.19 (2.69–3.79) 1.40 (1.03–1.90) 2.59 (2.21–3.02) 1.64 (0.63–4.28) 4.78 (3.94–5.80) 1.00 (0.86–1.17) 2.17 (1.62–2.89) 13.22 (1.69–103.38)

NR: Number Report, P: Pooled Prevalence, NA: Not Available.

study revealed varying trends of drug usage over the three periods of the studied times. In a review study, Rahim Meagher and Izadian examined status of drug usage among students (junior and senior high school) in Iran between 2000 and 2004. According to their findings, alcohol, opium and hashish were the most commonly used drugs, with an estimated number of 6000 to 10,000 students addicted to opiates. In another study, the prevalence of tobacco usage (cigarettes, hookah, and pipe) among high school students was reported as 21% in their lifetime (Rahimi Movaghar & Sahimi Izadian, 2006). In comparison with previous studies, the present work demonstrated that despite continued and frequent use of some substances as mentioned earlier (i.e. opium, opiates, and hashish), there exist a serious tendency toward hallucinogens, sleeping pills and tranquilizers usage among students as well. There were similarities in data for usage of cigarette and hookah in the present study when compared with data obtained from the previous mentioned reports. Globally, cigarette smoking among youths ranged from 2% in Hong Kong to 64.2% in Peking (19, 20, 30, 34–36). The percentage of adolescents' smokers also differed in the neighboring countries of Iran from 13.7% in Pakistan to 18% in Lebanon(Mohammadpoorasl et al., 2014). In the current study, the prevalence of cigarette smoking among Iranian youths was approximately similar and slightly higher than that of neighboring countries, but different from other areas of the world. Moreover, the present study showed that one out of every four students consumed hookah in different parts of Iran, which was less than the prevalence of tobacco usage among adolescents in south

Brazil (76.8%) (Ferigolo et al., 2004), but higher than that of Colorado (8.6%)(Young et al., 2002). Some studies have confirmed potential changes due to tax policies and control of tobacco in reducing the prevalence of smoking among adolescents. Additionally, several studies demonstrated significant relationships between price and smoking behavior, while others demonstrated the direct effect of behavioral changes in peer groups. Thus, social factors may also cause an increase in frequency of cigarette smoking among students. Moreover, a number of studies have emphasized that the smoking behaviors of employees and staff can also influence adolescents to indulge in one or more of these habits.(Melotti et al., 2011; Powell, Tauras, & Ross, 2005). Based on the experiences and the study results, it can be said that implementing tobacco price and tax increases might also be effective. Alternatively, families, parents and guardians have their roles to play through close control and monitoring over adolescents, their friends and schools. Parents could also play an effective role in deciding the area of residence, neighborhood, and school of their children. Furthermore, strict measures need to be taken against smoking in schools by the staff, teachers, visitors, service personnel, and students. Another emerging concern is alcohol consumption among adolescents. A study conducted by the World Health Organization in 2012, on 15-year-old adolescents, in 36 European countries and Canada revealed that the pattern of alcohol usage among adolescents in those countries was similar to that in the United States (Hingson & White, 2014); however, the rate of consumption was much higher than that

Table 4 The trend of smoking, alcohol and substance use in adolescents. Type

Time (published article) 2000–2005

2006–2010

2011–2014

NR

P (95% CI)

NR

P (95% CI)

NR

P (95% CI)

14 2 NA NA 6 4 1 NA 2 1 NA 2 1

9.10 (8.60–9.60) 10.20 (8.10–12.80) NA NA 1.00 (0.70–1.60) 1.40 (0.90–2.10) 1.00 (0.70–1.50) NA 0.50 (0.20–1.20) 0.30 (0.10–1.40) NA 4.80 (3.50–6.70) 0.30 (0.10–1.50)

14 5 4 1 10 4 2 2 NA 2 2 3 1

13.30 (12.80–13.90) 17.70 (16.90–18.60) 24.60 (23.30–25.90) 19.90 (15.90–24.90) 25.20 (24.40–26.00) 24.80 (23.50–26.20) 1.60 (1.30–210) 25.90 (24.50–27.30) NA 25.70 (24.30–27.20) 21.80 (20.50–23.20) 6.70 (5.60–7.90) 5.40 (3.20–9.00)

21 7 7 2 19 4 10 3 5 1 2 5 NA

22.00 (21.40–22.70) 11.80 (11.20–12.50) 21.70 (20.60–22.80) 6.90 (5.80–8.10) 3.50 (3.10–4.00) 2.70 (2.30–3.30) 3.10 (2.80–3.40) 23.60 (22.00–25.40) 0.70 (0.50–1.00) 0.50 (0.10–1.80) 4.00 (3.20–5.00) 2.30 (2.00–2.60) NA

P value for Trend Cigarette Alcohol Hookah Pan, Chewing Tobacco, Nas Opioids, Opium Concentrate, Morphine, Heroin Hashish, marijuana, grass, bang, Cannabis Methamphetamine, Amphetamine, X Tablet (Ecstasy), Ritalin Sedative drugs, Tranquilizers, Tramadol, Strong Painkiller Glass, crack, Cocaine LSD, Psychedelic steroid tablet, tablet, Pills, Doping, Steroids Substance us, Drug use, inject illegal drug Psychotropic drug NR: Number Report, P: Pooled Prevalence, NA: Not Available.

0.007 0.51 0.28 0.61 0.81 0.77 0.54 0.61 0.85 0.85 0.69 0.38 –


in Africa and the Middle East (Degenhardt et al., 2008). A study conducted in 35 European countries (2007) showed alcohol usage among 44% of adolescents (Caria, Faggiano, Bellocco, & Galanti, 2011), with 19% in Greece and 17% in UK (Kokkevi et al., 2007). In Iran, the prevalence of alcohol usage was found to be lower compared to other countries; meanwhile, the East and Southeast regions of the country showed the highest rate of consumption. Basically, both sale and consumption of alcoholic beverages are strictly forbidden by Iranian Government. Therefore, alcoholic drinks are usually smuggled into the country from neighboring countries. Consequently, drinkers including young people have to buy it from black market with a quite high price. Hence, access to alcohol beverages may not be affordable for many adolescents that might be a reason for lower rate of alcohol usage in Iran compared to other countries(Asadi & Mohebzade, 2013). Results obtained from several studies suggest that social determinants such as culture, social confidence, and responsibility during adolescence are negatively correlated with tendency to use alcohol. Moreover, parental supervision over adolescents, friends, and personal expenditure by them is considered a protective factor against risky usage by adolescents. Extracurricular activities like sports in schools are another effective way in changing attitudes and creating health behaviors among adolescents. Other studies show that children of mothers with higher level of education are less likely to use alcohol, and the education of mothers is also effective on healthy behaviors including reduced alcohol and cigarette usage in children of legal age. There is a significant relationship between alcohol usage and family income level, since higher income increases adolescents' access to alcohol (Lowry, Eaton, Brener, & Kann, 2011; Lundborg, 2006; Melotti et al., 2011; Patrick & Schulenberg, 2013). According to results from other studies, proper personal and social culture planning, participation and access of students to sporting activities, and also parental supervision and lack of alcohol use by family members are highly effective. Owing to the increased usage in border regions, greater attention of policymakers is required in assessing and providing strategies to further control borders and adolescents' access. Adolescents' drug use in terms of features and patterns varies from country to country and from one period of time to another. National assessment of school reported the prevalence of heroin use at 1.4% in Europe, 1% and 1.6% in the United States and higher percentages in Asian countries (Konings, Dubois-Arber, Narring, & Michaud, 1995; Minozzi, Amato, & Davoli, 2009). Opium is one of the oldest addictive drugs widely used in Asia. It is believed that more than half of the world's opium users are in Asia, owing to the fact that it is located along the major drug trafficking route. In line with other studies, the results of the present study revealed a high prevalence of opiate usage in the country (22%). Moreover, comparison of different regions showed a higher prevalence of usage in the East and Southeast areas of the country compared to other regions, due to the fact that they share a border with Afghanistan(Ansari-Moghaddam et al., 2012). Generally, Iran has an extensive border with Afghanistan, which is one of the biggest drug producers in the world. Consequently, it is being used as a transit route for drug trafficking from Afghanistan to Europe so that about 60% of the opium produced in Afghanistan is being transported via Iran to Europe. Then, despite strict border controls by the police, part of the drug is distributed in Iran (Sedaghat, Mirsadoo, Ghorbanloo, & Sedaghat, 2014). As a result, Iran has a convenient location for easy access to illegal drugs particularly at the border areas of the country. Additionally, opium consumption in Iran has cultural roots too and it may be used as a painkiller especially by Iranian males. There have also been some reports of recreational use of opium, heroin and other drugs in the country(Sedaghat et al., 2014). Overall, due to above-mentioned factors, data suggest 8% increase rate of addiction in Iran annually. Notably, the highest percentage of the addicted population in Iran belongs to young age groups; especially students who are under 25 years old (Goodarzi et al., 2011). More importantly, Iran has the highest rate of drug addiction and drug-related

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deaths in the world (Sedaghat et al., 2014). Mesic et al. attributed drug usage to a lack of proper border controls, a lack of communication between police and other judiciary institutions, and dissatisfaction with social, political and especially economical status. Thus, policy-makers should find more practical strategies to control entry of drugs into the country and its distribution along borderlines. In 36 European countries (except Greece and Luxemburg), CNS stimulants (hashish) were the most popular drugs, with a prevalence rate varying from 2% in Greece to 53% in Scotland (Smart & Ogborne, 2000). Based on Europe School Survey, marijuana usage was 19% in Italy, 15% in Spain, 8% in Poland, 6% in Norway and Sweden, 4% in Hungary, 2% in Greece, 41% in England and 37% in Ireland (two countries with the highest prevalence). A 41% and 20.9% prevalence was reported in the United States of America and Latin American countries, respectively (Stronski et al., 2000). Meanwhile, 27% Cannabis usage was reported in New Zealand, 20% in the United States, and hashish usage was 7% in The Netherlands (Degenhardt et al., 2008). The use of these types of drugs in Iran was higher than some other countries, such as Greece, Hungary, Poland, Spain, etc). Studies also demonstrated reduced academic performances in students addicted to CNS stimulants. Also, simultaneous usage of alcohol and marijuana is accompanied by high-risk sexual relationships. Early use of such drugs is associated with increased risk of physical and mental health problems, abuse and dependence on other drugs, psychological problems, and problems in adjustment to puberty. People using marijuana are at a higher risk of using stimulants (Bojorquez et al., 2010; Swadi, 1999). Thus, identifying personal, demographic, and social factors and strategies to prevent usage of these drugs should be considered as a priority. Use of T/S drugs (tranquilizers and sleeping pills) has been reported as 28.3% in 31 European countries, 19% in Australia, 5% in America (Oxycodone and Vicodin) (Kokkevi et al., 2008; Minozzi et al., 2009), and 4% to 20% in 7 European countries. Experience has shown that overuse of analgesics and sleeping pills, and prescription drugs such as tranquilizers, anti-anxiety, and sleeping disorder pills can cause dependence or addiction, and subsequent damages. Painkillers are also a major public health concern because they are often used in suicide attempts. In Iran, about one quarter of high school students use tranquilizers and sleeping pills. It is necessary for the Department of Food and Drug to adopt policies to prohibit the sales of such drugs to adolescents. Furthermore, given the availability of these drugs at home, mothers should be taught to keep these drugs out of reach. On the other hand, given adverse effects of overuse and the wrong attitude regarding nonaddictive properties of these drugs, education and control should be planned across the community. Generally, 5% of Amphetamine usage has been reported in European countries, 22% in Netherlands, and 1.2% in Australia (Minozzi et al., 2014). A study revealed that the usage rate of ecstasy prevalence was 12% in Scotland and 7% in south Brazil (Ferigolo et al., 2004). In American use of psychotropic drugs has been reported at 2.8% prevalence, ecstasy 0.3%, inhalants 0.8%, and hallucinogenic drugs 0.6%. In European countries, constant usage of cocaine, crack, LSD, and other hallucinogens were reported to have a prevalence rate of less than 2%, heroin and Gamma Hydroxy Butyric acid (GHB) less than 1% (Minozzi et al., 2014), inhalants 49.2%, anxiolytics 13.4%, hallucinogens 8.4%, and barbiturates 2.4% (Ferigolo et al., 2004). In Mexico City, 5.2% prevalence rate of drug abuse was reported, psychotropic drugs 4.6% (Bojorquez et al., 2010), inhalants 13%, and anxiolytics 8% (Ferigolo et al., 2004). The usage of these groups of drugs by Iranian students was similar to or less than those in other countries. But in the East and Southeast of the country, it was similar to or higher than other countries, and due to border conditions and availability and low cost of drugs, adolescents are at higher risk of drug abuse. Because of different patterns of drug use in different regions, appropriate educational and prevention programs should be designed and implemented in each region individually.

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Dramatic variations have been identified in the prevalence of illegal drug usage in some countries among gender groups. Although in the past 25 years, the rate of tobacco, alcohol and marijuana use among adolescents has varied, gender differences have remained unchanged. Generally, drug usage is higher in males than in females. Boys are more likely to drink and regularly use dangerous drugs than girls, while girls are more likely to smoke and use less dangerous drugs. Moreover, alcohol and tobacco are mainly linked with boys while drugs are mostly reported with girls (Hale & Viner, 2013; Kokkevi et al., 2007; Wang, Deng, Wang, Wang, & Xu, 2009). According to a study by Rahimi-Movaghar, Hefazi, Amin-Esmaeili, Sahimi-Izadian, and Yousefi-Nooraie (2012) the prevalence rate of tobacco usage was 14% among girls and about 40% among boys in Iran compared to tobacco consumption of 17% in girls and 19% in boys in Australia (Mohammadpoorasl et al., 2014). Generally, the results indicate a higher prevalence rate of smoking in boys than in girls (Kokkevi et al., 2007). A study by Hale and Viner showed a higher prevalence of regular smoking among girls (Hale & Viner, 2013). In Mexico, Porto-Ricco and Latin America, alcohol consumption was reported to be more prevalent among boys than girls (Delva et al., 2005; Isralowitz & Rawson, 2006). Prevalence rate of T/S drugs usage was reported to be 30.4% among girls and 25.9% in boys in 31 European countries (Kokkevi et al., 2008). Another study showed significant differences between gender groups regarding drug usage in Hong Kong, Shanghai, and Asian American and native Hawaiian students, with significantly more high-risk behaviors among male students (Wang et al., 2009). In the present study, tobacco and cigarettes usage in boys was almost similar to that in girls, but when compared with previous studies (Rahimi-Movaghar et al., 2012), the prevalence was much higher in girls (nearly 2.5 times). The use of hookah was much higher in girls and this was almost similar to that in Brazil. Generally, with the exception of hookah, the prevalence of drug usage was higher in boys compared to girls, and the risk of the 10 studied categories of drugs was significantly higher in boys than in girls. There is some evidence showing that addiction among women is less than men in Iran because it might be considered as a social stigma especially for women (Mehrjerdi et al., 2013). Studies showed a higher tendency toward self-destructive behaviors (anxiety, depression, and suicide attempt) in girls, and this pattern of drug usage in girls may be due to earlier puberty and desire to establish relationships with older boys. Generally, reasons for drug usage in girls may be attributed to the emotional nature of their relationships, stress and depression (Karimy, Niknami, Heidarnia, & Hajizadeh, 2013). From experience, in adolescents' relationships, drug use is a means to be accepted by peers; it also causes changes in unpleasant feelings, reduces disturbing feelings, depression and stress, and helps in coping with pressures of life. The majority of adolescents use drugs to feel strong and appear good among their fellow peers (Morrison, 1990). Several factors associated with adolescents' problems in school such as academic failure and non-participation in school activities might be predictors of behavioral problems. Reliance on antisocial peers is also associated with severity of adolescents' problems. Within the family, drug use by parents, family conflicts, and poor family management methods are also important risk factors (Cleveland, Feinberg, Bontempo, & Greenberg, 2008). Given these results, it seems that planning should be in accordance with causative differences of drug abuse in males and females. Educational workshops for parents to solve family conflicts and train parenting methods can also be helpful. Epidemiological studies showed a stable and significant downward trend in the prevalence of smoking, alcohol and drug usage among adolescents during 1970–1980. However, from 1990s onward, there has been an increasing trend in the prevalence in American and European adolescents (Mohammadkhani, 2012; Mohammadpoorasl, Fakhari, Rostami, & Vahidi, 2007). A longitudinal national study on Australian students showed an increase in usage of illicit drugs between 1996 and 1999, followed by a reduction afterwards (Rahimi-Movaghar

et al., 2012). The present study also showed an unstable but increasing trend in recent years and this was higher when compared to other countries. Thus, for greater success and improvement, national drug abuse control and prevention policies should not merely change according to decisions made by authorities only because current approaches fail, but they should be modified and developed according to results from social studies, cultural conditions and causative differences. 4.1. Limitations The limitation to this study was the use of results from self-reporting studies on drug usage. Nevertheless, since this was the maiden nationwide meta-analysis study on drug usage and its time-trend among high school students, results may therefore be highly beneficial to national policy-makers in their future decisions. 5. Conclusion In conclusion, this study provided comprehensive evidence of the prevalence and patterns of tobacco, alcohol, and drug use among Iranian Adolescents to be used by Governmental policy-makers for broad social changes in order to reduce the vulnerability of youths during periods of transition. Given the results of the studies, it seems that education provided in schools should be compatible with age groups, with strong emphasis on pattern of use in different parts of the country. Moreover, mass media should run a campaign for culturing and changing norms and wrong attitudes. Educational workshops should be held for parents to teach parental control, parenting and management with collaboration of universities of Medical Sciences and Education Departments. Future research are also recommended to concentrate on multiple prevention and cessation programs and the social determinants which have a key role in the development of youth behaviors including school based intervention approaches combined with families, worksites, media, and community policies. Acknowledgments This article was part of PhD thesis with code 2772. Therefore the authors would like to express their gratitude to the Zahedan University of Medical Sciences and Health Promotion Research Center. References Aarons, G. A., Brown, S. A., Coe, M. T., Myers, M. G., Garland, A. F., Ezzet-Lofstram, R., & Hough, R. L. (1999). Adolescent alcohol and drug abuse and health. The Journal of Adolescent Health, 24, 412–421. Ahmadi, J., & Hasani, M. (2003). Prevalence of substance use among Iranian high school students. Addictive Behaviors, 28, 375–379. Ansari-Moghaddam, A., Habybabady, R. H., Shakiba, M., Mirzaei, R., Shahriyari, F., & Aghaei, S. (2012). Predictors of initiation, continuation and transition of drug use in south-eastern Iran. The Journal of the Pakistan Medical Association, 62, 698–703. Asadi, A., & Mohebzade, G. (2013). Analysis of alcoholic drinks smuggling in the Iranian law. American Journal of Life Science Researches, 1, 122–128. Bauman, A., & Phongsavan, P. (1999). Epidemiology of substance use in adolescence: Prevalence, trends and policy implications. Drug and Alcohol Dependence, 55, 187–207. http://dx.doi.org/10.1016/S0376-8716(99)00016-2. Beyers, J. M., Toumbourou, J. W., Catalano, R. F., Arthur, M. W., & Hawkins, J. D. (2004). A cross-national comparison of risk and protective factors for adolescent substance use: The United States and Australia. Journal of Adolescent Health, 35, 3–16. http://dx.doi. org/10.1016/j.jadohealth.2003.08.015. Bojorquez, I., Fernandez-Varela, H., Gorab, A., & Solis, C. (2010). Factors associated with illegal substance use initiation among young students in Mexico City. Drug and Alcohol Review, 29, 286–292. http://dx.doi.org/10.1111/j.1465-3362.2009.00150.x. Botvin, G. J. (2000). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors, 25, 887–897. Brener, N. D., & Collins, J. L. (1998). Co-occurrence of health-risk behaviors among adolescents in the United States. The Journal of Adolescent Health, 22, 209–213. http://dx.doi. org/10.1016/s1054-139x (97)00161-4. Brown, S. A., McGue, M., Maggs, J., Schulenberg, J., Hingson, R., Swartzwelder, S., ... Murphy, S. (2008). A developmental perspective on alcohol and youths 16 to 20 years of age. Pediatrics, 121(Suppl. 4), S290–S310. http://dx.doi.org/10.1542/ peds.2007-2243D.

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