Early Substance Use Initiation And Psychological Distress Among Adolescents In Five ASEAN Countries: A Cross-Sectional Study

Introduction

During adolescence substance use, such as alcohol, tobacco, and illicit drugs, e.g., cannabis, is often initiated and a pattern of its use may become established.¹ Studies mainly in high-income countries found that early substance use initiation is associated with substance use disorders, polysubstance use, and/or mental disorders,^1–4 including suicidal behaviour.⁵ Therefore, the study aimed at investigating the association between early substance use initiation, polysubstance use and psychological distress among adolescents in five middle-income countries in ASEAN. The prevalence of current tobacco use among adolescents in ASEAN countries was 11–15% in Brunei, Indonesia, Malaysia, Thailand, and the Philippines, and the prevalence of current alcohol use was 16% to 24% in Thailand, Vietnam, and the Philippines.⁶ While the prevalence of lifetime cannabis and amphetamine use was 0.9% and 1.0%, respectively, in Malaysia, and 0.6% and 0.2%, respectively, in Vietnam.⁷

Methods

Sample And Procedure

Cross-sectional data from the 2015 “Global School-Based Student Health Survey (GSHS)” of five ASEAN countries were analyzed. The GSHS uses a “cluster sampling design in two stages (schools and classrooms) in order to produce nationally representative samples of school children in middle schools.”⁸ “Students completed a self-administered questionnaire under the supervision of trained survey administrators.”⁸ “Country level ethics review boards approved the GSHS, and informed consent was obtained from the students, parents and/or school officials.”⁸

Measures

The GSHS measure questions that were used in this study are detailed in Table 1.⁸ “Early cigarette smoking, early drinking alcohol, and early drug use initiation were trichotomized into never, prior to 12 years, and 12 or more years.”⁵

The psychological distress items (no close friends, loneliness, anxiety, suicidal ideation and suicide attempt) were summed, and grouped into 0=0 low, 1=1 medium and 2–5=2 high. The four items on parental or guardian support were summed, and classified into three groups, 0–1 low, 2 medium and 3–4 high support.⁹

Table 1 Variable Description

Data Analysis

Descriptive statistics were applied in order to present tabulations. Multinomial logistic regression was utilized to estimate the relative risk ratios (with 95% confidence interval=CI) for medium and high psychological distress. Missing data were not included in the analysis. All statistical procedures were performed using “STATA software version 15.0 (Stata Corporation, College Station, TX, USA)”, which took into account the complex survey design.

Results

Characteristics Of The Sample

The study sample included 33,184 middle school children, with a median age of 14 years (interquartile range= 2 years) from Indonesia, Laos, Philippines, Thailand and Timor-Leste; the overall response rates ranged from 72% in Laos to 94% in Indonesia.⁶ The overall prevalence of pre-adolescent (<12 years) cigarette use was 10.6%, 8.1% pre-adolescent current alcohol use, and 4.2% pre-adolescent drug use initiation. There were country variations in the prevalence of pre-adolescent cigarette use, ranging from 3.3% in Laos to 11.0% in Indonesia and the Philippines, in the prevalence of pre-adolescent alcohol use, ranging from 3.9% in Indonesia to 14.1% in Timor-Leste, and in the prevalence of pre-adolescent drug use, ranging from 0.6% in Laos to 7.4% in the Philippines (see Table 2).

Table 2 Descriptive Characteristics Of Substance Use Initiation

Associations Of Substance Use Initiation With Medium And High Psychological Distress

In adjusted multinomial logistic regression analysis, pre-adolescent initiation of cigarette smoking, pre-adolescent initiation of alcohol use, pre-adolescent initiation of drug use and multi-substance pre-adolescent initiation were highly associated with medium and high psychological distress. Late initiation of cigarette use and late initiation of drug use were not associated with medium and/or high psychological distress (see Table 3).

Table 3 Adjusted Prevalence Ratios For The Associations Of The Initiation Of Substance Use With Medium And High Psychological Distress

Discussion

The study found prevalences of pre-adolescent initiation of substance use, which seem lower than in previous studies, e.g., in four Pacific Island countries (15.7% smoking; 13.8% alcohol use, and 12.9% drug use),⁵ France (pre-teen cigarette initiation 24.1%, pre-teen alcohol initiation 65.1% and pre-teen cannabis initiation 3.9%), and the United States (pre-teen cigarette initiation 18.1%, pre-teen alcohol initiation 27.7% and pre-teen cannabis initiation 9.7%).¹⁰ The World Health Organziation¹¹ notes that alcohol consumption in Southeast Asia is lower than in other regions of the world, and in particular, in Indonesia, a predominantly Muslim country, alcohol use may be lower because Islam prohibits the consumption of alcoholic beverages.¹²

The study confirmed previous findings,^1–5 showing an association between early substance use initiation and psychological distress in this adolescent population in Southeast Asia. The correlations between psychological distress, illicit and licit use of drugs, such as alcohol and tobacco, may develop, because psychological problems and illicit and licit drug users may have common risk factors.^13,14

Study Limitations

The study was cross-sectional, which precludes causal inferences. Drug use was measured by self-reporting and may have been underreported. Several study indicators were assessed with single items, and future studies should employ more comprehensive measures. The study did also not assess urban–rural residence, which should be included in future studies.

Conclusion

The study confirmed previous findings, showing an association between early substance use initiation and psychological distress in this adolescent population in Southeast Asia. Early prevention programmes should target concurrent early substance use initiation in order to prevent possible subsequent psychological distress.