Prevalence, Knowledge, and Attitude Toward Substance Abuse, Alcohol Intake, and Smoking Among Male High School Students in Riyadh, Saudi Arabia

Background: The prevalence of smoking, alcohol intake and drug use among young people is increasing worldwide. Aim: The aim is to determine the prevalence, knowledge, and attitudes of male high school students toward substance abuse, alcohol intake, and smoking in Riyadh, Saudi Arabia. Methods: A survey was conducted from March to May 2021 using a self-administered questionnaire distributed to male high school students in grades 10 to 12 from randomly selected eight public and three private schools in Riyadh, Saudi Arabia. Results: A total of 400 male high school students participated in this study. The mean age of participants was 17.5 ± 1.3 years (range: 15 to 21 years old). A total of 281 students (70.2%) attended eight public/government schools and 119 (29.8%) attended three private or international schools. Most students (>70%) had knowledge of the harmful effects of smoking, alcohol, and drugs. Nonetheless, the prevalence of smoking, alcohol intake, and drug abuse was 27.8%, 11.5%, and 9.5%, respectively. Students began smoking before age 15, drinking alcohol before age 20, and using drugs as early as age 14. Most smokers and students that drank alcohol procure these substances by themselves whereas many students that took illegal drugs from friends. These substances markedly affected the students' school performance. Conclusion: The prevalence of smoking, alcohol intake, and drug use were high. Students began smoking, drinking alcohol, and using abused drugs at an early age, which were influenced by friends, peers, or their siblings. Some students purchase these substances by themselves while some got them from friends, especially alcohol. These practices affected their performance at school. Although many students were aware of the harmful effects of smoking, alcohol intake, and substance abuse, some students had opposing perspectives. Therefore, health authorities need to educate these students and institute structural and emotional support for students who are in these vices to mitigate misuse, long-term use, and addiction.


Introduction
Substance abuse (including alcohol and other illicit drugs) and tobacco smoking (including vaping, hookah, and e-cigarettes) usually commence during the teenage years [1]. In recent years, substance abuse and tobacco smoking have become more prevalent among youths; however, this practice is unsafe, particularly for individuals of this age [1,2].
The 2011 to 2014 data from the CDC and the National Food and Drug Administration of the United States indicated that an estimated 4.6 million middle and high school students use a tobacco-based product, of which 2.2 million of these students use more than two tobacco products at one time [2]. In another report published in 2016, the estimated number of tobacco users in US high school students increased to 4.7 million [3]. A survey conducted among high school and middle school students in the US in 2016 revealed that 47.2% of high school and 42.4% of middle school students use more than two tobacco products [4].
A high prevalence of cigarette smoking and shisha use among students aged 13-15 years has been reported by Co-operation Council for the Arab States of the Gulf (GCC) member states [5]. High susceptibility to initiating smoking was reported to be troubling, with boys more likely to smoke than girls (5). A study conducted in 2006 among Saudi medical students revealed a prevalence of 13% active smokers, with shisha being the most commonly smoked product (44.1%), followed by cigarettes (32.2%). Another study conducted among Saudi adolescents in 2010 revealed a tobacco smoking prevalence of 9.72% (12.43% among boys and 6.65% among girls) [6]. In contrast, the reported prevalence of substance abuse among male secondary school students in Saudi Arabia was 8.8%, whereas that of male secondary students that drank alcohol was 9.3% (7). The most common illicit drug used by students was cannabis (51.4%), followed by glue/solvents (48.6%) and amphetamine (45.7%) [7].
A report from Saudi Arabia showed that students from higher-income families that have larger daily allowances, spend less time studying, skip classes more frequently, are less religious, spend more time at home, and drink more soft drinks were found to be more likely to smoke and use illicit substances [6]. Another significant predictor of smoking and substance abuse among youths is having friends who smoke [8]. A study revealed that 82.4% of students are sufficiently aware of smoking and substance abuse, and this is significantly correlated with having educated parents, family income, and parents that live together [9].
Furthermore, studies conducted among Saudi high school students revealed that drug abuse and smoking are highly prevalent and estimates of existing knowledge and awareness vary [10]. However, reports on substance abuse and tobacco use among adolescents in Saudi Arabia have reported mixed results depending on the geographical location [6][7][8][9][10]. With the reported high frequencies of smoking and use of illicit substances among high school students and adolescents, it is imperative to assess their knowledge, attitudes, and practices regarding substance abuse and tobacco smoking to understand the reasons for the high prevalence of such practices. Therefore, this study was carried out to determine the prevalence of substance abuse and smoking among high school students, and their knowledge and attitude toward substance abuse and smoking to address this issue.

Materials And Methods
We conducted a cross-sectional survey in March, April, and May 2021 using a self-administered questionnaire distributed to male high school students in grades 10 to 12 at eight public and three private schools in Riyadh, Saudi Arabia. School selection was performed using a random sampling technique. A random drawing of lots from a list of all male schools in Riyadh, Saudi Arabia, was performed via a random selection of 11 high schools in Riyadh, Saudi Arabia. The necessary permits were secured from each selected school.
The sample size was calculated using the formula: n = Z 2p (1 -p)/d 2, where n is the sample size, z is the level of confidence (95% or 1.96), p is the expected proportion in the population (60%), and d is the absolute error or precision (5%). Assuming that the prevalence of smoking and substance abuse was approximately 15%, the calculated required sample size was 369 students. We collected data from up to 400 male students to account for non-participation and low or incomplete responses.
The self-administered questionnaire was developed using constructs from previous related literature [5][6][7][8][9] in the English language that were translated into Arabic. The questionnaire included the demographic characteristics of the students, social influences, attitudes, and knowledge. A pilot study was conducted among 20 students to verify the validity of the questionnaire. This pilot study included one male class from public high schools in Riyadh that was not part of the study sample. The questionnaire was modified following a thorough review of the results of the pilot study. Cronbach's alpha for the pilot study was 0.86. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0 (SPSS Inc., IBM, Armonk, NY, USA). Descriptive statistics of the survey variables were computed as means and frequencies.
Chi-square and t-tests were performed to determine the significant differences between categorical variables. A Pearson correlation test was performed to determine the bivariate relationship between the two variables. Statistical significance was set at p < 0.05.
To ensure the confidentiality and anonymity of our participants, the data collection tool did not include the participants' identifiers (name and address) or telephone numbers. Participation was voluntary, and there were no remuneration or payments for participation in the survey. Students were informed of the study objectives, and their participation was voluntary. Ethical approval to conduct the study was obtained from the Institutional Review Board of the Ministry of Health (Cluster 2), Riyadh, Saudi Arabia (IRB00018774), and the Ministry of Education, Saudi Arabia (transaction number 22421).

Results
A total of 400 male high school students participated in this study. The mean age was 17.5 ± 1.3 years (range: 15 to 21 years old). A total of 281 students (70.2%) attended a public/government school and 119 (29.8%) attended a private or international school. Table 1 shows the demographic profiles of the participants.

Demographic variables
Mean ± SD (range) n (%)   There were no significant differences in the age between students that consume alcohol and those that do not consume alcohol (17.5 ± 1.5 years versus 17.5 ± 1.3 years, p=0.701). There were significantly more students who belonged to those with family income of more than 15,000 SAR a month who drank alcohol compared to those with family income of <15,000 SAR a month (p=0.008). A few students who drank alcohol had excellent grades (p=0.029). Alcohol drinking was significantly negatively correlated with grades in the previous year (r=-0.109, p=0.029) and positively correlated with higher family income (r=0134, p=0.008) ( Table 3).  There were significantly more students who belonged to families with higher monthly income who had attempted the use of drugs and illicit substances than students in lower family income brackets (p=0.050). Furthermore, there were more students who had less than five siblings attempted use of illicit substances than those who had more than five siblings (p<0.001). Few students who used illicit substances achieved excellent grades (*p=0.049). The use of illegal drugs and illicit substances was significantly positively correlated with higher monthly family income (r=0.094, p=0.050) and significantly negatively correlated with number of siblings (r=-0.191, p<0.001) and grades (r=-0.098, p=0.050) (

Knowledge and opinions of smoking, drinking alcohol, and substance abuse
Most students believed that a person who smoked, drank alcohol, and took drugs always had unsatisfactory health (73.8%), developed respiratory disease (64.3%), developed heart disease (65.0%), spent more money (75.0%), dropped out of school (60.8%), and always ran out of money (66.7%). Furthermore, a large proportion of students believed that smoking, alcohol, and drug abuse were against the norms of society (76.0%). They also believed that people do not like the company of people who smoke, drink alcohol, use illicit substances (69.0%), and these people are a burden to society (69.8%). Seventy-two percent of the students believed that smoking, alcohol, and substance abuse are dangerous to their health. However, there were divided views on whether the family of a person who smoked, drank alcohol, and took drugs always experienced poverty, where 154 (38.5%) were undecided. Students do not easily trust a person that uses illicit drugs compared to people who drink alcohol and those who smoke (79.3% versus 68.3% versus 37.8%, respectively) ( Table 5).

Discussion
This study aimed to determine the prevalence rates of smoking, alcohol consumption, and use of illicit substances among high school students. Smoking, alcohol consumption, and the use of illicit substances have long been reported; however, worldwide reports still show a high prevalence of such practices in more than 40% of high school students [2][3][4][5]. Since its inclusion in the WHO Framework Convention on Tobacco Control in 2005, Saudi Arabia has legislated strict laws on advertising, promotion, and sponsorship to restrict sales through the Royal Decree No. 56 or the so-called "Anti-Smoking Law" [10]. Similarly, alcohol, illegal drugs, and the use of illicit substances remain taboo.

Smoking
The prevalence of smoking in this study was 27.8%. This prevalence is lower than the 37.1% found among male secondary students in Jeddah, as reported by Fida and Abdelmoneim in 2013, and 40.8% reported by Albangy et al. in 2019; however, it is higher than the 15.17% prevalence found among intermediate and secondary school students in Madina, Saudi Arabia in 2013 [11][12][13]. Similar to previous studies, having friends and peers who smoke has a significant influence on the smoking status of students [11][12][13]. One of the highlights of this study is the ability of 76.1% of the students who smoke to purchase cigarettes from nearby stores. This occurrence is despite the strict implementation of cigarette sales among students in Saudi Arabia. The magnitude of smoking is reflected by the number of respondents who smoked daily (89.6%). Further, 58.9% of these students began smoking before the age 15 years old. Such a finding is alarming as smoking at an early age is correlated with lifelong smoking, which makes it more difficult for them to quit when they are older [14]. Several other studies on smoking among students conducted in Saudi Arabia had comparable prevalence rates: AlHassa (28.1%) [15], and 28.6% from the National Guard study in 2009 [16].
This study revealed no significant correlation between smoking and school level, age, grades, parents' educational level, parents' employment, number of siblings, and income. The significant effects of the parent's level of education, parent employment, and monthly family income were not found in this study as most parents were educated and had a high monthly income. Students who had better-educated parents and with good family income were better and more effective at school, as these factors markedly influenced student behavior [17]. The strong effect of friends who smoke, parents who smoke, and siblings who smoke were revealed in previous studies. Early smoking, particularly among teenagers and adolescents, was explained by the presence of siblings and peer smoking [18]. A study showed that the prevalence of teenage and adolescent smoking increased from 18% (where no parent or sibling smokes) to 31% when at least one sibling smoke, and to as much as 41% when a parent and a sibling smoke [17,18].

Drinking alcohol
The prevalence of alcohol consumption among the respondents was 11.5%. This prevalence is higher than that of previous studies where 9.3% of male secondary school students drank alcohol [7]. In a study conducted in Jeddah in 2015, 2.6% of students drank alcohol [19]. More than half of the 46 students who consumed alcohol began drinking before age 20. The age at onset of alcohol consumption was reported to have a significant negative correlation with the severity of alcoholism in adulthood and postponing the use of alcohol until age 25 may be a good strategy to prevent severe alcoholism in adulthood [20].
A positive association was found between alcohol intake and higher family income. Further, students who drank alcohol had a significantly lower performance at school. Whether these students had siblings and parents who drank alcohol was not investigated. Studies have shown that alcohol intake among parents and siblings predisposes their son or younger brothers to alcoholism, besides the heightened genetic risk for the development of alcohol abuse [21].

Use of drugs and illicit substances
The prevalence of drug abuse and use of illicit substances in this study was 9.5%. This percentage is slightly higher than the 8.8% reported by Musa in 2016 [7]. Although both studies revealed the use of cannabis (marijuana), this study revealed many other more dangerous substances, including cocaine and heroin. Our findings also confirm those of previous studies that young men abuse drugs and take illicit substances because of peer pressure [22], where 47.4% of our respondents could obtain these drugs and substances from friends, in contrast to smoking products and alcohol. Similar to other studies, 14 to 16 years were identified as the most volatile ages. A study on drug abuse and drug dependents admitted to a health institution in Riyadh showed an age range of 11-21 years old, with predominantly (53.3%) male high school graduates [22]. Similar to findings regarding smoking and alcohol intake, the use of drugs and illicit substances was associated with poor school performance, higher monthly income families and a lesser number of siblings. Such finding might be due to the fact that drug users and substance abusers have a capacity to buy and procure these substances and greater tendency to hide their vices from their parents and siblings, but usually carry out these vices with friends and peers and also may be due to the lower sample size of people who take these illicit substances.

Reasons for smoking, alcohol intake, and drug abuse
Loneliness and wanting to be happy and curiosity were the main reasons for smoking, drinking alcohol, and abusing drugs in this survey. Such finding is not surprising, as many reports have suggested that loneliness is particularly familiar among adolescents and young adults that turn to these vices [23]. Adolescents and young adults face peer pressure and experience a feeling of connection and social acceptance. Teenagers, who usually connect with peers who smoke, drink alcohol and use illicit substances, are lured not just by peer pressure or sense of belongingness but also by curiosity. These in turn make these vices easily accessible to them. Thus, during these years, they require social support as they are experiencing social changes and coping with social stress, including romantic relationships and relationships with family and friends [24]. Very few adolescents can control their emotions to cope with stress, anxiety, and depression, which may lead to drug use that can be heightened by the influence of peers who are also drug users [25].

Knowledge, opinions, and attitudes toward smoking, drinking alcohol, and substance abuse
Despite the high prevalence of smoking, alcohol, and drug use among our respondents, seven of 10 believed that smoking, drinking alcohol, and drug abuse are not good for their health. Most students perceived that smoking, drinking alcohol, and drug abuse were a burden to society. These perception and knowledge echo those of previous studies where adolescents were knowledgeable about the aspects of smoking and alcoholism, but less knowledgeable about substance abuse [26,27]. Despite their high knowledge and negative perception of smoking, drinking alcohol, and drug abuse, there is still a high prevalence of smokers, alcohol drinkers, and drug users, similar to other reports [28]. Further, despite their knowledge, healthy behaviors are not practiced, and unhealthy vices are not curbed.
Approximately 20%-25% of our respondents believed that these unhealthy vices are not harmful to their health. In fact, only seven of 10 will resist taking or using these substances. A study revealed that knowledge of the hazards of smoking, and even alcohol and illicit substances, does not influence smoking and the use of illicit substance [29]. Although some studies have implicated indicators for the use of these drugs, tobacco, and alcohol, which include family income, wealth, and parental education, these factors were not observed in this study [30].
The nature of the survey served as a limitation. The responses were self-reported by students; thus, the possibility of underreporting must be considered. We also failed to extract information on the family structure of smoking, alcoholism, and drug use by other family members to determine its association with the use of these substances by students. On the lighter side, we demonstrated the prevalence of smoking, alcohol intake, and substance abuse that can be employed as a basis by our group as well as other researchers for further studies on this subject matter.

Conclusions
Among the male high school population evaluated herein, the prevalence of smoking was quite high (27.8%). Further, the prevalence of alcohol intake was 11.5%, while that of drug abuse or use of illicit substances was 9.5%. Students began smoking, drinking alcohol, and abusing drugs at an early age, which may be influenced by friends and peers or siblings. These students procure these substances by themselves while some receive help from friends, particularly for alcohol. These practices affect the performance of students at school. Although many students know the harmful effects of smoking, alcohol intake, and substance abuse, some students had an opposing perspective. Health authorities need to educate these students and institute structural and emotional support for students who are in these vices to mitigate misuse, long-term use, and addiction.

Additional Information
Disclosures