Psychiatry Research 237 (2016) 290–295

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Factors associated with illicit drugs' lifetime and frequent/heavy use

among students results from a population survey
Tânia Bitancourt a,n, Maria Cristina Ribeiro Grilli Tissot b, Thiago Marques Fidalgo c,
José Carlos Fernandes Galduróz d, Dartiu Xavier da Silveira Filho a
a
Department of Psychiatry and Medical Psychology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
b
Department of Psychiatry, Universidade de São Paulo, São Paulo, SP, Brazil
c
Department of Psychiatry, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
d
Department of Psychobiology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil

art ic l e i nf o a b s t r a c t

Article history: Substance use among teenage students and factors associated were investigated through a survey using a
Received 17 April 2015 questionnaire adapted from the WHO's Program on Research and Reporting on the Epidemiology of Drug
Received in revised form Dependence, additional questions on family factors and personal risks, and the Coopersmith Self-Esteem
21 November 2015
Inventory, adapted to Brazil. The target population consisted of 3891 10–22-year-old students from the
Accepted 13 January 2016
Available online 14 January 2016
city of Embu das Artes, São Paulo, Brazil. The prevalence of lifetime substance use was 26.7%. Most
commonly used substances were energy drinks combined with alcohol (19%), solvents (11.2%) and
Keywords: marijuana (4.8%). Almost 60% of the students had already tried alcohol and 18.2% had tried tobacco.
Psychoactive drugs Factors associated to lifetime substance use were: lower self-esteem, going to nightclubs at least twice a
Epidemiology
week, use of alcohol, trying tobacco, bad relationship with the mother, permissive mothers, practicing
Survey
sports as an obligation, working, and higher socioeconomic level. Concerning frequent/heavy substance
Self-esteem
Risk and protective factors use, chances were found to be higher among students who had use tobacco and alcohol, going to
Family relationships nightclubs at least twice a week, and those with lower self-esteem. Preventive actions concerning drug
Students use should focus on avoiding the first experimentation, approaching family relationships, and improving
students' self-esteem.
& 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Studying the environmental background is essential for health
promotion and prevention of mental diseases. Several studies have
already described the importance of trauma, neighborhood con-
ditions and maltreatment on the development of mental disorders
in general and substance use related problems in particular
(Adams et al., 2015; Culpin et al., 2015; Daigre et al., 2015; Chap-
man et al., 2004). Concerning the use of psychoactive substances
among adolescents, epidemiologic researches allow us not only to
map the problem, revealing data on the incidence, prevalence,
identification of new drugs and consumption trends over time, but
also to search for use-associated factors.
Previous trials have identified as risk factors: early use, avail-
ability of drugs, violence in the community, anti-social friends,
drug use by parents, parents' lenient attitude concerning the child
n relationship with coworkers (De Micheli and Formigoni, 2004;
Correspondence to: Rua Cel. Palimércio de Rezende, 150, São Paulo 05505-010,
SP, Brazil.
E-mail address: taniabitancourt@amplitudeclinica.com.br (T.M. Fidalgo).
use of drugs, lack of dialog on the matter, and poor family com-
munication (Cava et al., 2008; Hofler et al., 1999; Kaplow et al.,
2002; Mares et al., 2011). On the other hand, good relationship
with parents, being monitored, religion, awareness of drug effects,
and fear of the effects concerning drug use have been considered
protective factors (Cleveland et al., 2008; Kliewer and Murrelle,
2007). Studies analyzing cumulative effects among several risk
factors and their interrelationship with protective factors have
found out that risk factors are more important in predicting the
use of drugs than protective factors (i.e., the harm caused by a risk
situation outweighs the benefits of the protective factors) (Os-
taszewski and Zimmerman, 2006; Zufferey et al., 2007).
In prevalence studies conducted in Brazil with adolescent stu-
dents, the following were identified as risk factors: low-commit-
ment to school, anti-social behavior, loneliness, suicidal ideas,
friends using drugs, bad relationship with or between parents; use
of drugs by family members, working over 4 h, and unsatisfactory
Galduróz et al., 2004; de Souza, 2006; Vieira et al., 2008). Among
the protective factors, the importance of family, such as good

http://dx.doi.org/10.1016/j.psychres.2016.01.026
0165-1781/& 2016 Elsevier Ireland Ltd. All rights reserved.
 T. Bitancourt et al. / Psychiatry Research 237 (2016) 290–295
relationship with and between parents and judicious attitude
stand out. Practicing a religion was also observed to be directly
associated with lower alcohol and other drugs use (Galduróz et al.,
2004).
Regarding personal factors that may influence drug use, there is
no study developed in Brazil assessing self-esteem. Self-esteem is
considered by many a value judgment, resulting from a self-eva-
luation that expresses an attitude of approval or disapproval and
indicates how much the subject considers himself/herself capable,
important and valuable (Coopersmith, 1967; Rosenberg, 1965). It is
known that, among those trying some substances, most of them
do not become dependent. The theoretical assumption to explain
such finding is that dependency occurs more often in weakened
adolescents with lower self-esteem.
The main purposes of this study were (i) to assess the pre-
valence of substance use in a representative sample of adolescent
students; and (ii) to assess whether there is an association be-
tween self-esteem and substance use. Our hypothesis is that the
lower the self-esteem, the higher the substance use.
2. Method
2.1. Sample selection, procedures and sample descriptive
characteristics
A cross-sectional, population-based epidemiologic study was
conducted. The target population were students in public schools
(6–12th grades) of the city of Embu das Artes SP. Located in the
Southwest region of Brazil, with a population of 248,722 people
and a 0.772 Human Development Index (HDI) (IBGE, 2009), Embu
das Artes is part of the third most populated metropolitan region
in the world, the so called “Grande São Paulo” [Greater São Paulo].
A two-step probability selection was used. First, 20% of all 793
classes of 6–12th grades of all 35 public schools at Embu das Artes
were randomly drawn. Second, the sample was cluster rando-
mized (grades and school term morning, afternoon and evening).
All students in sampled classrooms were invited to participate.
There was a loss of 12 classes among the 157 selected, resulting in
a final sample of 145 classes. These 12 classes were lost due to the
refusal of the responsible teacher to allow the research team to
assess the students.
2.2. Measures
Questions on substance use were based on the World Health
Organization's (WHO's) research instrument adapted to Brazil
(Carlini-Cotrim et al., 1989; Smart et al., 1980), which includes
questions on the use of alcohol, tobacco, energy drinks in asso-
ciation with alcohol and illicit drugs. This instrument divides
substance use indexes into: lifetime use (experimentation), past
year use (12 months prior to the research), past month use (30
days prior to the research). Past month use is categorized in 1–5
days (low-use), 6–19 days (frequent use), and 20 days or more
(heavy use).
Questions on socioeconomic level adopted the scale of the
Brazilian Association of Market Survey Institutes (ABEP1), which
classifies socioeconomic levels from A (the highest) to E (the
lowest). Due to the inequality of distribution of Brazilian income,
we defined three ranks of SES: A (A1 and A2), B–C (B1, B2, C1 and
1
ABEP provides eight different social economic strata (A1, A2, B1, B2, C, D and
E, where A1 is the highest). When data was collected annual family income ranges
were as follows (average income): A1: U$ 3692,00 or higher; A2: U$ 2404,00; B1: U
$ 1262,00; B2: 732,00; C1: U$ 440,00; C2: U$ 292,00; D: U$ 203,00; E: U$ 135,00
(quoting rate: U$ 100¼ R$ 350).
291
C2), DE (D and E). It was important to analyze classes B and C, and
D and E together to have enough cases to run the regressions.
Students were also questioned on personal factors (religion;
sports, work, and frequency of visits to nightclubs) and their
perception on family relationships (good, regular or bad), such as
relationship with the father, mother, relationship between parents,
and parenting style (authoritarian, moderate or permissive).
The Multidimensional Scale of Self-Esteem adapted to Brazil by
Gobita (2004) from Coopersmith “Self-Esteem Inventory (SEI)
School Form”, was used to assess self-esteem. (Gobita, 2004). This
is a 50-item scale, developed to assess students' self-esteem. It
comprises questions such as ‘I am pretty sure of myself’ ‘I can
make up my mind without too much trouble’ and ‘I am a lot of fun
to be with’. Answers can be: ‘like me’ or ‘unlike me’. The inventory
Cronbach's alpha was of 0.88 in the original validation study
(Gobita, 2004). In order display data in a more comprehensive
way, the scale score, which varies from 56 to 280, was converted
into a 0–100 scale, in which 0 indicates the lowest possible self-
esteem, and 100 indicates the highest possible self-esteem.
A computer program was developed for this research, using the
ASP.NET development platform for acquiring data via web, and
data processing and consistency of answers were made using the
SQL SERVER 2000.
2.3. Procedures
Data was collected through a classroom survey performed in
May/June 2009. All principals of the schools were contacted re-
ceived a letter explaining research goals and procedures. A consent
form, which should be signed. Afterwards, a trained team of field
researchers gathered anonymous standardized self-reported
questionnaire data. This team explained research objectives for
students. Anonymity, confidentiality and volunteering were re-
assured to the students before distributing questionnaires. The
survey was conducted in the teacher's absence. In average, stu-
dents took 45 min to complete the questionnaire, and 3891 valid
questionnaires were collected.
2.4. Data analysis
First, exploratory analyses through basic contingency tables
with Chi-square tests (po 0,10) were performed. Analyses were
conducted on data weighted to correct for unequal probabilities of
selection into the sample. The complex survey design took into
account the stratum (schools), primary sampling unit (classes),
clusters (school period), the expansion weight, and the probability
of drawing the student who answered the questionnaire.
Then, to estimate the association of self-esteem with lifetime
and frequent/heavy substance use, logistic regression for complex
samples survey design was performed. Two key response variables
were used in two different regression models: (i) lifetime illicit
substance use and (ii) frequent/heavy illicit substance use. The
suspected covariate of central interest was SEI total score. Gender,
age, SES, school term, alcohol use (lifetime and frequent/heavy
use), tobacco use (lifetime and frequent/heavy use), family re-
lationships and personal factors (religious and leisure's activities,
as described above) were included in all models, to control pos-
sible influences of these variables in the results.
Analyzes were performed using SPSS 20.0, with the complex
sample procedures to address variance estimation under the
complex sample design in these regression models and in esti-
mation of all 95% confidence intervals (CI). Results are presented
via weighted proportions (wgt%), adjusted Odds Ratios (ORs) and
95% confidence interval (po 0.05).
292 T. Bitancourt et al. / Psychiatry Research 237 (2016) 290–295

2.5. Ethical aspects
The protocol was reviewed and approved by the Universidade
Federal de São Paulo Research Ethics Committee (IEC 1371/07). An
informed consent form was signed by the schools principals, au-
thorizing the research team to get in contact with students'
caregivers. Students' caregivers were asked to sign a consent form,
authorizing the student to participate of the study. Participation
was voluntary, anonymous, and students were allowed to decline
to participate, leave questions unanswered, and interrupt their
participation at any time, without any consequence of that.
3. Results
Of the 3891 students, 2474 (63.6%) were in Middle School (6–
9th grade), and 1417 (36.4%) were in High School (10–12th grade).
The sample was balanced concerning gender, with 1802 (46.3%)
male and 1959 (50.3%) female adolescents. Students were 13.8
years old on average, ranging from 10 to 22 years old. Concerning
SES, over 70% of them was from BC class. Over 60% of students
stated having a religion. Most of them were catholic (35.5%) and
protestants (16.4%). Most students did not work (83.1%) and over
80% of them practiced sport. The most commonly played ones
were: soccer (56.5%), volleyball (34.5%), and basketball (12.3%).
Almost half of the students (46.4%) practiced sports as a hobby, not
as some kind of commitment or obligation, and 18.7% practiced no
sports. Concerning nightlife, 11.6% stated they went out more than
twice a week. Regarding family relationships, almost 90% stated
having a good relationship with their mother and 68.5% with their
father. Relationship between parents was considered good by
65.2% of the students. Overall, students' self-esteem was con-
sidered high (mean of 73 in the 0–100 scale, with a 13.6 standard
deviation).
Lifetime substance use was of almost 58.1% for alcohol, 18.2%
for tobacco and 26.8% for illicit drugs. Most commonly used sub-
stances were energy drinks with alcohol (19.0%), inhalants (11.6%),
and marijuana (4.8%) (Table 1). Mean age of the first used was 12.1
years old for alcohol, 12.7 for tobacco, 12.8 for inhalants, and 14.0
for marijuana.
Lower self-esteem was significantly associated with lifetime
illicit drug use (p ¼0.001) and with frequent/heavy illicit drug use
(p ¼0.002). Higher SES, lifetime alcohol and tobacco use, frequent/
heavy alcohol use, bad relationship with the mother, being raised
by permissive mothers; playing sports as an obligation, going to
nightclubs at least twice a week and having a paid work were also
associated to lifetime illicit drug use. Adjusted odds ratio are
presented in Table 2. Having tried illicit drug use, frequent/heavy
use of tobacco and of alcohol, going to nightclubs at least twice a
week, and having low self-esteem were significantly associated
with frequent/heavy illicit drug use. Adjusted odds ratios are
presented in Table 3.
According to the logistic regression models, a 1-point increase
in SEI's score reduces by 1% the odds of lifetime illicit substance
use (Table 2) and by 3% the odds of frequent/heavy illicit substance
use (Table 3). Interclass comparison of self-esteem, both for life-
time use and for frequent/heavy use, confirmed that the lower the
self-esteem, the more frequent the use of illicit drugs (Table 4).
4. Discussion
Two substantive findings emerge from our analyses: (1) both
lifetime and frequent/heavy substance use in the city of Embu das
Artes was similar to reported data for Brazil; (2) having a lower
score on the SEI increases the odd of lifetime and frequent/heavy
illicit substance use.
Previous studies have already discussed the influence of low
self-esteem on delinquent behavior, sexual risk behavior and
substance use risk behavior (Wild et al., 2004; Hofler et al., 1999;
Rouse et al., 1998). Although no causality relationship between
low-self-esteem and substance use can be established, due to our
study design, it seems reasonable, based on the available litera-
ture, to hypothesize that the pleasure resulting from the substance
use would relieve the low-value feeling of adolescents with low-
self-esteem.

Table 1
Alcohol, tobacco and illicit drugs use patterns by 6–12th grade students in public schools in the city of Embu das Artes, SP, 2009 (n¼ 3891).

Drugs Use pattern

Lifetime Past year Past month Frequent use Heavy use

n wgt% n wgt% n wgt% n wgt% n wgt%

Illicit Drugs – total* 1.037 (26.7) 398 (10.2) 248 (6.4) 92 (2.4) 67 (1.7)
Marijuana 185 (4.8) 96 (2.5) 70 (1.8) 27 (0.7) 22 (0.6)
Cocaine 89 (2.3) 58 (1.5) 39 (1.0) 13 (0.3) 6 (0.2)
Crack 21 (0.5) 16 (0.4) 12 (0.3) 3 (0.1) 3 (0.1)
Amphetamines 74 (1.9) 56 (1.4) 38 (1.0) 9 (0.2) 7 (0.2)
Solvents 453 (11.6) 270 (6.9) 155 (4.0) 45 (1.2) 30 (0.8)
Anxiolytics 85 (2.2) 54 (1.4) 36 (0.9) 10 (0.3) 8 (0.2)
Anticholinergic 21 (0.5) 18 (0.5) 14 (0.4) 9 (0.2) 5 (0.1)
Barbiturate 15 (0.4) 12 (0.3) 8 (0.2) 5 (0.1) 5 (0.1)
Opioids 9 (0.2) – – – –
Sirups 8 (0.2) – – – –
Hallucinogens 21 (0.5) – – – –
Orexygen 6 (0.2) – – – –
Energy drinks with alcohol 738 (19.0) – – – –
Steroids/performance-enhancers 12 (0.3) – – – –
Tobacco 707 (18.2) 382 (9.8) 231 (5.9) 96 (2.5) 68 (1.7)
Alcohol 2.261 (58.1) 1.800 (46.3) 1.155 (29.7) 414 (10.6) 258 (6.6)

Data presented as simple frequencies and weighted proportions (wgt%) from 3.891 students. Basis (100%).
The dash (–) indicates data not gathered.
Note. Although energy drinks are not classified as psychotropic substances. it is here listed because its use was in association with alcohol. Steroids/performance enhancing
substances, even though they are not psychotropic substances, have been reported by several studies for its increasing use.
*
Overall excludes steroids/performance enhancers. Tobacco and alcohol.
 T. Bitancourt et al. / Psychiatry Research 237 (2016) 290–295 293

Table 2
Factors related to lifetime illicit drug use multivariate analysis results from adolescent students in primary and secondary school in public schools in the city of Embu das
Artes, SP, 2009 (n¼ 3891).

Lifetime illicit drug use

OR CI (95%) p-Value

Demographic characteristics Age (years) 1.02 (0.95; 1.10) p 40.05

SES A 2.28 (1.40; 3.70) 0.001
BC 1.65 (1.06; 2.56) 0.027
DE Ref.

School shift Morning 0.93 (0.70; 1.24) p 40.05

Afternoon Ref.
Evening 1.12 (0.78; 1.63) p 40.05

Tobacco use Lifetime 4.18 (3.30; 5.29) p o 0.001

Frequent/heavy 1.90 (0.96; 3.74) 0.064

Alcohol use Lifetime 9.04 (6.57; 12.43) p o 0.001

Frequent/heavy 2.35 (1.81; 3.05) p o 0.001

Poor or bad relationship With the father 1.12 (0.86; 1.48) p 40.05
With the mother 1.54 (1.08; 2.18) 0.016
Between parents 1.04 (0.79; 1.36) p 40.05

Type of father Authoritarian (bossy) 0.91 (0.67; 1.24) p 40.05

Moderate 1.00 (0.74; 1.36) p 40.05
Liberal Ref.

Type of mother Authoritarian (bossy) 0.73 (0.54; 0.01) 0.05

Moderate 0.76 (0.57; 0.01) p 40.05
Liberal Ref.

Personal factors Sports (importance) Hobby only 1.24 (0.95; 1.63) p 40.05
Individual commitment 1.20 (0.84; 1.70) p 40.05
Group commitment 1.35 (0.95; 1.92) p 40.05
Obligation 2.20 (1.40; 3.46) 0.001
Not practicing Ref.
Nightclubs Twice a week or more 1.69 (1.27; 2.25) p o 0.001
Work Formal or informal 1.55 (1.21; 2.00) 0.001

Self-esteem Overall SEI score 0–100 0.99 (0.98; 1.00) 0.001

Ref ¼ reference category; OR ¼odds ratio; CI ¼Confidence interval.

Table 3
Factors related to frequent/heavy use of illicit drugs multivariate analysis results from adolescent students in primary and secondary education in public schools in the city of
Embu das Artes, SP, 2009 (n ¼3891).

Independent variables Frequent/heavy use

OR CI (95%) p-Value

Demographic characteristics Age (years) 0.95 (0.8; 1.13) p 40.05

SES A 1.31 (0.44; 3.92) p 40.05
BC 0.77 (0.28; 2.16) p 40.05
DE Ref.

School shift Morning 0.91 (0.42; 2.00) p 40.05

Afternoon Ref.
Evening 1.11 (0.43; 2.87) p 40.05

Tobacco use Lifetime 2.43 (1.35; 4.35) 0.003

Frequent/heavy 3.01 (1.47; 6.15) 0.003

Alcohol use Lifetime 4.28 (1.43; 12.80) 0.009

Frequent/heavy 2.92 (1.72; 4.96) p o 0.001

Poor or bad relationship With the father 1.49 (0.83; 2.70) p 40.05
With the mother 1.66 (0.86; 3.20) p 40.05
Between parents 0.77 (0.41; 1.45) p 40.05

Personal factors Nightclubs (twice a week or more) 2.64 (1.54; 4.54) p o 0.001
Work (formal or informal) 1.30 (0.73; 2.31) p 40.05

Self-esteem Overall SEI score 0–100 0.97 (0.95; 0.99) 0.002

Ref. ¼ Reference category; OR ¼odds ratio; CI ¼Confidence interval.

In addition to that, parenting style seems to be related to et al., 2008; Cleveland et al., 2010; Gutman et al., 2011; Kuntsche
adolescents' substance use. Several studies have found good family et al., 2009). Aligned with that, some studies consider the un-
relationship as a protective factor for lifetime substance use (Cava satisfactory family relationships as a risk factor for substance use
294 T. Bitancourt et al. / Psychiatry Research 237 (2016) 290–295
Table 4
Lifetime and frequent/heavy illicit drug use according to self-esteem classification
from primary and secondary school students in public schools in the city of Embu
das Artes, SP, 2009 (n ¼3358).
Self-esteem classes
Lower Medium Higher
(n¼ 1116) (n¼ 1098) (n ¼1144)
Illicit Lifetime 349 (31.3%) 320 (29.1%) 243 (21.2%)
drug Frequent/ 42 (3.8%) 23 (2.1%) 14 (1.2%)
use heavy
(Brière et al., 2011; De Micheli and Formigoni, 2004; Galduróz
et al., 2010; Gutman et al., 2011; Kliewer and Murrelle, 2007;
Kokkevi et al., 2007). An authoritarian parenting style has already
been related to a lower chance of using substances than a per-
missive parenting style. For substance use initiation, the existence
of limits seems to be better than their absence. In addition, a ju-
dicious attitude by parents has been considered a protective factor
for substances use, as it relates to lower experimentation rates.
Supporting such findings, a positive relationship with parents,
opportunities to take decisions, feelings of support and care have
been found to have lower protective impact than controlling and
monitoring (Cleveland et al., 2008; Gutman et al., 2011; Horner
et al., 2011; Kliewer and Murrelle, 2007; Kokkevi et al., 2007;
Kuntsche et al., 2009).
Another interesting finding was the association between going
to nightclubs (over twice a week) and illicit drugs use, both for
experimentation and frequent/heavy use. Similar findings were
found in several studies (Sañudo et al., 2015; Santos et al., 2015;
Kokkevi et al., 2007). Nightclubs gather several risk factors (Sa-
ñudo et al., 2015; Santos et al., 2015). As they focus on offering
pleasure, fun and social interaction, alcohol and tobacco use by
adolescents usually is tolerated.
In the present study no association was found between higher
frequency of sports practice and sports as a group commitment
and psychotropic drug use. Similarly, there was no association
when considering sports as an individual commitment or hobby.
However, when sports were considered as a mandatory activity,
the chances of trying drugs increased. In Brazil, it is common to
perceive sport activities as potential preventive practice. This is
supported by NIDA Monitoring the future research (Johnston et al.,
2012), in which high-levels of exercise have been related to lower
alcohol, tobacco and marijuana use. On the other hand, a Chinese
study found association between the high-frequency of physical
activities and higher alcohol and cigarette use (Tao et al., 2007). A
hypothesis raised by the authors was that students being a group
to practice sports become very close and share other social activ-
ities, among which drug use is. With such different results in the
literature, further studies are necessary to better understand such
relationship, also addressing cultural differences.
Both going to nightclubs and practicing sports are behaviors in
which peer group is developed. Becoming a member of a group is
an important task of adolescence. In a positive perspective, this
facilitates socialization and increases the sense of belongingness.
However, peer group comes together with peer pressure. Adoles-
cents must adapt themselves to some rules and behaviors that
may not necessarily reflect their own values. This peer pressure
has already been established as a risk factor for drug and alcohol
abuse (Iwamoto and Smiler, 2013; Trucco et al., 2011; Nash et al.,
2004; Santor et al., 2000; Arnett, 2000). Adolescents with low-
self-esteem, willing to be socially accepted, may feel compelled to
use psychotropic substances. The fear of failure, more prevalent
among these adolescents, may also increase vulnerability.
A few limitations should be mentioned. It is important to note
that as this study is based upon a cross sectional survey, associa-
tion does not imply causation. Besides, data is based upon self-
report, thus, the questions were subject to interpretation by the
participants and to a possible information bias. However, the
anonymous nature of the survey and the absence of the teacher in
the classroom should help promoting response validity. Our find-
p-Value
ing are comparable to other Brazilian studies. Lifetime alcohol use
in the city of Embu das Artes was similar to reported data for Brazil
p o 0.001 (58.1% and 60.5%, respectively), so was tobacco lifetime use (18.2%
p o 0.001 and 16.9%, respectively). Lifetime illicit substance use was of 26.7%,
similar to data from Brazilian population (25.5%). Inhalants were
the most used illicit substance, which is similar to what is ob-
served in national surveys (Carlini et al., 2010), although rate in
this study was slightly higher than the national rate (11.6% and
8.7%, respectively). These similar findings reinforce that limitations
stated were not a main concern in our study. Nevertheless, al-
though this is a population representative sample, it is only pos-
sible to extend results to adolescents with similar socio-demo-
graphic and cultural characteristics.
The shortcomings of this study point to some insights. Strate-
gies to improve students' self-esteem may be useful tools for
preventing lifetime and frequent/heavy illicit substance use. Con-
sidering the risk that experimentation of a substance may lead to
frequent/heavy use, it is important to avoid or postpone experi-
mentation. In this sense, focusing on developing satisfactory fa-
mily relationships and on improving students' self-esteem seems
to be promising interventions. Focusing on developing peer pres-
sure resistance training may also be a positive strategy.
Acknowledgment
This research was supported by the Fundação de Amparo a
Pesquisa do Estado de São Paulo (FAPESP) through the Grant no.
08/50955-9.
References
Adams, R.E., Ritter, C., Bonfine, N., 2015. Epidemiology of trauma: childhood ad-
versities, neighborhood problems, discrimination, chronic strains, life events,
and daily hassles among people with a severe mental illness. Psychiatry Res.
230, 609–615.
Arnett, J.J., 2000. Emerging adulthood: a theory of development from the late teens
through the twenties. Am. Psychol. 55 (5), 469–480.
Brière, F.N., Fallu, J.-S., Descheneaux, A., Janosz, M., 2011. Predictors and con-
sequences of simultaneous alcohol and cannabis use in adolescents. Addict.
Behav. 36, 785–788. http://dx.doi.org/10.1016/j.addbeh.2011.02.012.
Carlini-Cotrim, B., Carlini, E.A., Silva-Filho, A.R., Barbosa, M.T.S., 1989. O uso de
drogas psicotrópicas por estudantes de primeiro e segundo graus da rede es-
tadual, em dez capitais brasileiras, 1987. In: Consumo de Drogas Psicotrópicas
no Brasil, em 1987, Série C: Estudos e Projetos 5. Centro de Documentação,
Ministério da Saúde, Brasília, DF.
Carlini, E.A., Noto, A.R., Sanchez, Z. van der M., Carlini, C.M. de A., Locatelli, D.P.,
Abeid, L.R., Amato, T. de C., Opaleye, E.S., Tondowski, C.S., Moura, Y.G. de, 2010.
VI Levantamento nacional sobre o consumo de drogas psicotrópicas entre es-
tudantes do ensino fundamental e médio das redes pública e privada de ensino
nas 27 capitais brasileiras – 2010. CEBRID – Centro Brasileiro de Informações
sobre Drogas Psicotrópicas: UNIFESP – Universidade Federal de São Paulo, São
Paulo, SP.
Cava, M.J., Murgui, S., Musitu, G., 2008. Diferencias en factores de protección del
consumo de sustancias en la adolescencia temprana y media. Psicothema 20,
389–395.
Chapman, D.P., Whitfield, C.L., Felitti, V.J., Dube, S.R., Edwards, V.J., Anda, R.F., 2004.
Adverse childhood experiences and the risk of depressive disorders in adult-
hood. J. Affect. Disord. 82, 217–225. http://dx.doi.org/10.1016/j.jad.2003.12.013.
Cleveland, M.J., Feinberg, M.E., Bontempo, D.E., Greenberg, M.T., 2008. The role of
risk and protective factors in substance use across adolescence. J. Adolesc.
Health 43, 157–164. http://dx.doi.org/10.1016/j.jadohealth.2008.01.015.
Cleveland, M.J., Feinberg, M.E., Greenberg, M.T., 2010. Protective families in high-
and low-risk environments: implications for adolescent substance use. J. Youth
Adolesc. 39, 114–126. http://dx.doi.org/10.1007/s10964-009-9395-y.
Coopersmith, S., 1967. The Antecedents of Self-Esteem. Freeman, San Francisco, CA.
 T. Bitancourt et al. / Psychiatry Research 237 (2016) 290–295
Culpin, I., Stapinski, L., Miles, Ö.B., Araya, R., Joinson, C., 2015. Exposure to socio-
economic adversity in early life and risk of depression at 18 years: the med-
iating role of locus of control. J. Affect. Disord. 1 (183), 269–278.
Daigre, C., Rodríguez-Cintas, L., Tarifa, N., Rodríguez-Martos, L., Grau-López, L.,
Berenguer, M., Casas, M., Roncero, C., 2015. History of sexual, emotional or
physical abuse and psychiatric comorbidity in substance-dependent patients.
Psychiatry Res. 229 (3), 743–749.
De Micheli, D., Formigoni, M.L.O.S., 2004. Drug use by Brazilian students: associa-
tions with family, psychosocial, health, demographic and behavioral char-
acteristics. Addiction 99, 570–578. http://dx.doi.org/10.1111/
j.1360-0443.2003.00671.x.
Galduróz, J.C.F., Noto, A.R., Fonseca, A.M., Carlini, E.A., 2004. V Levantamento na-
cional sobre o consumo de drogas psicotrópicas entre estudantes do ensino
fundamental e médio da rede pública de ensino nas 27 capitais brasileiras-
2004. CEBRID - Centro Brasileiro de Informações sobre Drogas Psicotrópicas,
São Paulo, Brazil.
Galduróz, J.C.F., Sanchez, Z., van der, M., Opaleye, E.S., Noto, A.R., Fonseca, A.M.,
Gomes, P.L.S., Carlini, E.A., 2010. Factors associated with heavy alcohol use
among students in Brazilian capitals. Rev. Saúde Pública 44, 267–273. http://dx.
doi.org/10.1590/S0034-89102010000200006.
Gobita, M., 2004. Escala Multidimensional de Autoestima (EMAE): Construção e
Validação com Crianças e Adolescentes Brasileiros (Dissertação de Doutorado).
Pontifícia Universidade Católica de Campinas, Campinas, Brazil.
Rouse, K.A. Gordon, Ingersoll, G.M., Orr, D.P., 1998. Longitudinal health endangering
behavior risk among resilient and nonresilient early adolescents. J. Adolesc.
Health 23, 297–302. http://dx.doi.org/10.1016/S1054-139X(98)00019-6.
Gutman, L.M., Eccles, J.S., Peck, S., Malanchuk, O., 2011. The influence of family
relations on trajectories of cigarette and alcohol use from early to late adoles-
cence. J. Adolesc. 34, 119–128. http://dx.doi.org/10.1016/j.
adolescence.2010.01.005.
Hofler, M., Lieb, R., Perkonigg, A., Schuster, P., Sonntag, H., Wittchen, H.-U., 1999.
Covariates of cannabis use progression in a representative population sample of
adolescents: a prospective examination of vulnerability and risk factors. Addic-
tion 94, 1679–1694. http://dx.doi.org/10.1046/j.1360-0443.1999.941116796.x.
Horner, P., Grogan-Kaylor, A., Delva, J., Bares, C.B., Andrade, F., Castillo, M., 2011. The
association of family and peer factors with tobacco, alcohol, and marijuana use
among Chilean adolescents in neighborhood context. Subst. Abus. Rehabil. 2,
163–172. http://dx.doi.org/10.2147/SAR.S20507.
IBGE, 2009. Instituto Brasileiro de Geografia e Estatística [WWW Document]. URL:
www.ibge.gov.br/home/estatistica/pesquisa_resultados.
Iwamoto, D.K., Smiler, A.P., 2013. Alcohol makes you macho and helps you make
friends: the role of masculine norms and peer pressure in adolescent boys' and
girls' alcohol use. Subst. Use Misuse 48 (5), 371–378.
Johnston, L.D., O’Malley, P.M., Bachman, J.G., Schulenberg, J.E., 2012. Monitoring the
Future National Survey Results on Drug Use. 1975–2011: Volume I., Secondary
School Students. Institute for Social Research, The University of Michigan, Ann
Arbor, Michigan.
Kaplow, J.B., Curran, P.J., Dodge, K.A., 2002. Child, parent, and peer predictors of
early-onset substance use: a multisite longitudinal study. J. Abnorm. Child
Psychol. 30, 199–216. http://dx.doi.org/10.1023/A:1015183927979.
Kliewer, W., Murrelle, L., 2007. Risk and protective factors for adolescent substance
use: findings from a study in selected Central American countries. J. Adolesc.
Health Publ. Soc. Adolesc. Med. 40, 448–455. http://dx.doi.org/10.1016/j.
jadohealth.2006.11.148.
Kokkevi, A.E., Arapaki, A.A., Richardson, C., Florescu, S., Kuzman, M., Stergar, E.,
295
2007. Further investigation of psychological and environmental correlates of
substance use in adolescence in six European countries. Drug. Alcohol Depend.
88, 308–312. http://dx.doi.org/10.1016/j.drugalcdep.2006.10.004.
Kuntsche, E., van der Vorst, H., Engels, R., 2009. The earlier the more? Differences in
the links between age at first drink and adolescent alcohol use and related
problems according to quality of parent–child relationships. J. Stud. Alcohol
Drugs 70, 346–354.
Mares, S.H.W., van der Vorst, H., Engels, R.C.M.E., Lichtwarck-Aschoff, A., 2011.
Parental alcohol use, alcohol-related problems, and alcohol-specific attitudes,
alcohol-specific communication, and adolescent excessive alcohol use and al-
cohol-related problems: an indirect path model. Addict. Behav. 36, 209–216.
http://dx.doi.org/10.1016/j.addbeh.2010.10.013.
Nash, S.G., McQueen, A., Bray, J.H., 2004. Pathways to adolescent alcohol use: family
environment, peer influence, and parental expectations. J. Adolesc. Health 37,
19–28.
Ostaszewski, K., Zimmerman, M.A., 2006. The effects of cumulative risks and pro-
motive factors on urban adolescent alcohol and other drug use: a longitudinal
study of resiliency. Am. J. Community Psychol. 38, 237–249. http://dx.doi.org/
10.1007/s10464-006-9076-x.
Rosenberg, M., 1965. Society and the Adolescent Self-Image. Princeton University
Press, Princeton, NJ.
Santor, D.A., Messervey, D., Kusumakar, V., 2000. Measuring peer pressure, popu-
larity, and conformity in adolescent boys and girls: predicting school perfor-
mance, sexual attitudes and substance abuse. J. Youth Adolesc. 29, 163–182.
Santos, R., Baldin, Y., Carlini, C.M., Sanchez, Z.M., 2015. Classification of alcohol use
disorders among nightclub patrons: associations between high-risk groups,
sociodemographic factors and illicit drug use. Am. J. Drug. Alcohol Abus. 41 (5),
433–441.
Sañudo, A., Andreoni, S., Sanchez, Z.M., 2015. Polydrug use among nightclub pa-
trons in a megacity: a latent class analysis. Int. J. Drug. Policy 26, 1207–1214.
Smart, R.G., Hughes, P.H., Johnston, L.D., Anumonye, A., Khant, U., Medina Mora, M.
E., Navaratnam, V., Poshyachinda, V., Varma, V.K., Wadud, K.A., 1980. A Meth-
odology for Student Drug-use Surveys. World Health Organization.
de Souza, D.P.O., 2006. Uso de Drogas Psicoativas Entre Estudantes Adolescentes
Trabalhadores e não Trabalhadores da rede Estadual de Ensino de Cuiabá, Mato
Grosso (Doctoral dissertation). Escola Paulista de Medicina, São Paulo, Brazil.
Tao, F.B., Xu, M.L., Kim, S.D., Sun, Y., Su, P.Y., Huang, K., 2007. Physical activity might
not be the protective factor for health risk behaviours and psychopathological
symptoms in adolescents. J. Paediatr. Child Health 43, 762–767. http://dx.doi.
org/10.1111/j.1440-1754.2007.01217.x.
Trucco, E.M., Colder, C.R., Wieczorek, W.F., 2011. Vulnerability to peer influence: a
moderated mediation study of early adolescent alcohol use initiation. Addict.
Behav. 36, 729–736. http://dx.doi.org/10.1016/j.addbeh.2011.02.008.
Vieira, P.C., Aerts, D.R.G., Freddo, S.L., Bittencourt, A., Monteiro, L., 2008. Alcohol,
tobacco, and other drug use by teenage students in a city in Southern Brazil.
Cad. Saúde Pública 24, 2487–2498. http://dx.doi.org/10.1590/
S0102-311X2008001100004.
Wild, L.G., Flisher, A.J., Bhana, A., Lombard, C., 2004. Associations among adolescent
risk behaviours and self-esteem in six domains. J. Child Psychol. Psychiatry 45,
1454–1467. http://dx.doi.org/10.1111/j.1469-7610.2004.00851.x.
Zufferey, A., Michaud, P.-A., Jeannin, A., Berchtold, A., Chossis, I., van Melle, G., Suris,
J. Carles, 2007. Cumulative risk factors for adolescent alcohol misuse and its
perceived consequences among 16 to 20 year old adolescents in Switzerland.
Prev. Med. 45, 233–239. http://dx.doi.org/10.1016/j.ypmed.2007.04.015.