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J. Indian Assoc. Child Adolesc. Ment. Health 2013; 9(3):62-79

Review Article

Substance Abuse in Children and Adolescents in India

Manu Agarwal MD, Anil Nischal MD, Anju Agarwal MD, Jitendra Verma MD,
Saranya Dhanasekaran MBBS
Address for correspondence: Dr. Manu Agarwal, Department of Psychiatry, King
Georges’ Medical University, Chowk, Lucknow, UP (pin-226003). E-mail:
drmanuagarwal7@gmail.com

Abstract

Substance abuse in childhood and adolescence is a major problem defining the future of

the youth in both developed as well as developing nations. Studies in developed nations

have focussed on this issue since long, and the trend is now taking direction towards the

developing nations specially India. Even though a large number of studies are not

available on this topic from India, but a review of these studies can define the future

course of action and help in planning other studies as well as health related strategies.

Key words: substance abuse, children, adolescents, India

Introduction

The problem of substance abuse in adolescence is becoming a global health concern and

is fast assuming alarming proportions in both developed and developing nations. There

has been extensive research on the extent and nature of substance abuse in adolescents in

the West with tobacco, alcohol, cannabis, inhalants and stimulants being the most

common substances of abuse. Of late, research on substance abuse has also been

receiving attention in developing countries like India because of changing trends in the

prevalence of substance use and the rising magnitude of the problem. Many adult
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substance users are found to have initiation of substance use in adolescence. There is

also a progressive decline in the age of initiation of substance use [1]. Early initiation is

often associated with poor prognosis and a lifelong pattern of irresponsible behaviour

[2] .In this paper we have reviewed the extent, pattern and trends of substance abuse in

adolescence in India. Our review was based on published national and international

literature yielded on systematic search using Pubmed, Google scholar and the archives of

the Journal of Indian Association of Child and Adolescent Mental Health. Our search

included the key words ‘substance abuse, India, children, adolescents and preventive

measures’.

Magnitude and demographics of the problem

Substance abuse is one of the pressing problems in most countries and is associated with

several social and economic consequences. This assumes greater relevance in developing

countries like India which are already burdened with healthcare problems like inadequate

health-care facilities [2]. In general, adolescence and late childhood is a time of

experimentation, exploration, and a search for self and risk taking. By the time they reach

adolescence, young people in developing countries like India have been exposed to

various stresses like competition both in the fields of education and employment,

changing roles in the family and society, new found responsibilities and a changing

identity, both physically and emotionally. By adolescence they have also seen their first

exposure to many drugs, especially those easily available – glues and other inhalants,

cannabis, tobacco and alcohol. In a milieu where social and peer pressures are often

difficult to resist youth often fall prey to addictions. The vulnerable groups like street
 64

children, child labourers, those with family history of substance use and those with

emotional and behavioural problems are at particularly higher risk.

In 2002, the use of Alcohol and Illicit drugs was estimated to contribute 4% of the

disease burden in the 15-29 years age group in low and middle income countries by the

WHO [3]. In 2003, United Nations Office on Drug and Crime (UNODC) conducted a

survey titled "Extent, Patterns and Trends of Drug Abuse in India - National Survey" in

which they reported that India has two million opiate-users, 8.7 million cannabis-users

and 62.5 million alcohol users among whom 17 to 20 per cent were dependent users [4].

A clinic based retrospective study on adolescents done at Postgraduate Institute of

Medical Education and Research, Chandigarh by Saluja et al 2007 [5] showed that there

was a consistent increase in adolescents registered in De-addiction OPD, 27 in the first 20

years (1978-1997), 31 over the next four years (1998-2001) and 27 over the final 2 years

(2002-2003). These findings show that the number of adolescent substance users

reporting to treatment centres has increased in the last few years which may be an

indirect indicator of an increase in substance use in adolescents.

A population based cross-sectional study was conducted by Tsering et al 2008 [6], during

June 2003 to May 2004 in two schools in West Bengal on 416 students. The overall

prevalence rates among rural and urban students were 6.14% and 0.6% for illicit drug

use, 8.60% and 11.04% for tobacco, and 7.37% and 5.23% for alcohol consumption,

respectively. Both licit and illicit substance use was associated more with male students.

This study also reported that the use of a substance by family members had a significant

impact on its use by their children. The substance use was significantly high among male
 65

students (45.8%) as compared to female students (7.3%). Male students belonging to

urban area were involved in substance abuse significantly more than the rural male

students. The prevalence of substance use was found to be significantly more in the

students who were living away from their homes.

In a study in Jaipur, students of classes 9-12,aged 13-18 years by Singh et al 2006 [7] ,

2.1%boys and 1.7% girls were current tobacco users. Smoking cigarettes or bidi was

present in 72.8% boys and 50.0% of girls with substance use. Smoking or tobacco use

was present in immediate family of 42.1% boys and 32.4% girls but was significantly

more in the family of children who used tobacco (86.4% boys, 68.8% girls).

A study was carried out by Kushwaha et al, 1992 [8] in the slum areas of Gorakhpur city,

covering a population of 10,187 in the four colleges of Gorakhpur. Five hundred and

eighty children and adolescents in urban slums, and 750 college students between 10-18

years were studied for detection of prevalence rate and various others correlates of abuse

of psychoactive substances. Overall, prevalence of abuse of psychoactive substances was

25% in slum areas and 18% in college students. More abusers were from Hindu families

with low educational status and low family income.

In another study on substance use (tobacco, alcohol, cannabis, arecanut / panmasala,

opium, sedatives and hard drugs) among inter college students by Juyal et al in 2008 [9],

a total of 58.7% students were found to be ever users while 31.3% were regular user of

any substance. The prevalence of regular use of substances was significantly higher

among urban students as compared to rural students (urban - 37.9%, rural -24.4%). The

abuse of substances was significantly more in male students as compared to female

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students (45.8% & 7.3% respectively). Prevalence of substance abuse among various

socioeconomic classes was found to be highest in the middle class. Substance use was

maximum among Hindus (32.0%), followed by Muslims (25.0%) and Sikhs (21.0%).

A clinic based study by Malhotra et al. 2008 [10] at a De-addiction and treatment centre

of Postgraduate Institute of Medical Education and Research, Chandigarh between the

periods 2002- 2006 on 173 subjects of age group 10-19 years, 83% adolescents were in

the 15-19 years age group, Hindu (80%), educated till high school (52%), single (94%),

from nuclear family (69%) and from urban background (69%).

A study of substance use among higher secondary school students from Imphal, Manipur

reported that the prevalence of tobacco and alcohol use was high among students.

Familial use of substances was associated with the behaviour of adolescents. Friends

were the key proximal determinant. The authors also recommended the introduction of a

substance use prevention policy in schools to educate students about various adverse

effects and to impart refusal skills [11].

These studies suggest that substance abuse is fast becoming a public health problem

among the children and adolescents of India. Tobacco and alcohol are the common

substances of use. Substance abuse is commoner in males than in females. Family history

of substance use is a common predisposing factor.

Substances of abuse in children and adolescents in India

Tobacco

Majority of the Indian studies on adolescent substance abuse are based on tobacco use as

tobacco is the most common substance of use in India. Data for other substances are
 67

lacking in comparison. India is the third largest producer and consumer of tobacco in the

world. Adolescents are the most vulnerable population to initiate tobacco use. It is now

well established that most of the adult users of tobacco start tobacco use in childhood or

adolescence [12].

About 20 million children of ages 10-14 are estimated to be tobacco users according to a

survey done by the National Sample Survey Organization of the Indian Government. To

this astounding figure, about 5500 new users are added every day, making two million

new users every year [12]. The Global Youth Tobacco Survey [13] showed that 4.2%

students of age group 13-15 years were smoking cigarettes and 13.6% were using tobacco

products other than cigarettes.

A study done in Noida, Uttar Pradesh by Narain et al 2001 [14] on students aged 11 to 19

years, found that tobacco use was found in 11.2% students, with 8.8% were ‘ever

smokers (including current smokers),’ 4.6% were ‘ever tobacco chewers (including

current chewers),’ 3.7% were ‘exclusive smokers’ and 2.5% were ‘exclusive

tobacco chewers’. The mean age of initiation of tobacco use was around 12.4

years. Nearly 70 per cent of boys and 80 per cent of girls ≤ 15 years initiated the use of

tobacco before the age of 11 yr.

In college based study in Banglore by Bhojani et al 2009 [15], the prevalence of ever use

of tobacco was 15.7%, whereas 5.3% were current tobacco users. Smoking was the

predominant form of tobacco consumption among ever and current tobacco users. For

75% of ever users of tobacco, the mean age for initiation of tobacco use was 14.7 (S.D.

2.05) years. Malhotra et al. 2008 [10] found that smokers constituted the single major
 68

group (60%) of substance abusers, out of which 38% were additionally using smokeless

tobacco. Nicotine users reported peer-pressure as a single most important cause for

initiation.

Alcohol

Earlier studies have found alcohol to be one of the most prevalent substance of use in

children and adolescent. A study shows that the age of first alcoholic beverage was 18.7

among male college students in Punjab, India [16]. A study from NIMHANS on the

Public Health Impact of Alcohol reported a reduction in the age of onset of drinking [17].

Current studies however give conflicting results in the reporting of trends in alcohol

dependence. A relative decrease in the percentage of subjects presenting with alcohol

dependence has been reported [18,19]. These studies report a decrease in the percentage

though an increase in the total number of patients dependent on alcohol. A study on

Andaman school students by Sinha et al 2006 [13] showed onset of regular use of alcohol

in late childhood and early adolescence is associated with the highest rates of alcohol

consumption in adult life as compared to later onset of drinking.

Inhalant use

There is a growing trend of use of inhalants among adolescents especially in the lower

economic groups like street children [20]. Benegal et al, 1998 [21] showed in their study

that, street based children start off with tobacco use when they are 10-11 yrs when they

are little older they graduate to use inhalants. Other studies in special populations like

juvenile delinquents also show that inhalants are one of the commonly used drugs of

abuse [22]. They described as gateway drugs, which supposedly causes its users to move
 69

on to harder drugs. All the gate way drugs like inhalants are easily available to the

children and can cause severe addiction.

Opioids

There has been a significant increase in the percentage of subjects presenting for the

treatment of opioid dependence over the decades [19, 23]. There is also a decrease in the

age at presentation in opioid users [18].

There has also been a change in types of opioid abuse over the years. There has been a

significant decline in the dependence on natural opioids and a concomitant increase in the

use of prescription drugs. Rise in the numbers dependent on buprenorphine and codeine-

containing cough syrups and of dextropropoxyphene dependence have been reported [18,

23, 24].This has been observed in studies from across the globe as well [25,26].

Cannabis

In India, the use of cannabis within the context of religious beliefs and local traditions has

been historically documented leading to early exposure of children and adolescents to

cannabis [12]. Cannabis is a widely used substance of abuse among adolescents, many of

whom perceive little risk from cannabis [27]. Population studies have shown that 3% of

children and adolescents (12-18 years) abused cannabis and that only 4% of the abusers

sought treatment for their problems [28]. Other studies have also found cannabis to be a

common substance of abuse among adolescent populations like school students [11],

college students [29], street children [30] and working children [12]. Cannabis use has

acute effects on the cognitive performance of adolescents and is also associated with high

risk behaviours [27].

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Changing trends in substance use among children and adolescents

Substance use among children and adolescents are on the rise and causes of serious

concern [31]. Amongst the various substances, tobacco and alcohol use among

adolescents have been studied the most. There is an alarming increase in the incidence of

tobacco and alcohol use among young people. Abuse of volatile substances or inhalants

has increased in children and adolescents due to its easy availability. Another trend

which has been noted is the change in the type of opioids use i.e., the increase in the

number of prescription drugs being abused. Poly-substance abuse is also on the rise

among young people.

Impact and burden of substance use

Dependence is a state characterized by emotional and mental preoccupation with the

effects of the substances and a persistent craving for it. In a crucial developmental period

like childhood and adolescence, this could lead to progressive neglect of studies,

extracurricular activities and interpersonal relationships placing these youth many paces

behind their contemporaries.

The financial burden substance use poses on the substance users, their families and the

nation at large is also significant. A recent study by the National Institute of Mental

Health and Neuro Sciences (NIMHANS) in households of rural, urban, town, and slum

populations of 28,500 people in and around the city of Bangalore, Karnataka, found that

the average monthly expenditure on alcohol of patients with alcohol addiction is more

than the average monthly salary. Researchers from NIMHANS have calculated that the
 71

direct and indirect costs attributable to alcohol addiction is more than triple the profits of

alcohol taxation and several times more than the annual health budget of Karnataka [17].

Addiction to substance abuse especially among the vulnerable populations can directly

contribute to high risk behaviours [32]. Activities like gambling, drug peddling, pick

pocketing, stealing, fighting, rape and self harm are common among youth when

intoxicated. They are at a higher risk of depression and suicide. Children and adolescents

at times indulge in or are forced into sex in exchange for drugs. Youth substance abusers

are prone to delinquent behaviour and anti-social activities. They are at risk of

contracting blood borne and sexually transmitted infections like AIDS, when they share

used needles or have unprotected sex under the influence of substance. Younger ages at

the onset of substance use and dependence like that of opioids are associated with a

higher severity of substance use, a higher lifetime use of other substances, higher

sensation seeking and higher global psychopathology [33].

Preventive measures

There is limited evidence on the treatment and preventive strategies of drug abuse in

adolescents, with very few studies from the developing nations and India in particular.

Research shows that rates of tobacco use, harmful alcohol use, and illicit drug use in

adolescents can be reduced by a combination of regulatory, early-intervention, and harm-

reduction approaches [34]. Studies from other low income countries have showed that

community based and school based preventive strategies are effective in reducing drug

and alcohol consumption among adolescents [35-37]. The need of the hour is to
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investigate the efficacy of these interventions in the Indian setting and to formulate

policies based on an evidence base.

In a study on substance abuse among school going male adolescents from Dehradun,

80.2% of adolescent substance abusers expressed their desire to quit the habit [38]. A

similar percentage was reported among substance abusers among the adolescent street

boys in Mumbai city [39]. These statistics further serve to highlight the need for

preventive measures for substance use among these seemingly motivated adolescent

substance users who express desire to quit using/ abusing these substances.

Decreasing the proportion of children using substances and delaying the age of onset of

substance use are important goals that need to be addressed. Therapeutic self-help groups

that function for children with substance use problems in the West, can be initiated in the

Indian setting. Children and adolescents should receive early screening and intervention,

for which the pass through points and intervention venues can be schools, emergency

departments, primary health care settings, and specialized treatment centres. It is

especially important for early screening and intervention in those youth at a high risk of

developing substance use like children whose peer groups are substance abusers or in

whom there is positive family history of substance use [40]. Substance use prevention

programs can involve role plays, campaigns and rallies highlighting the ills of substance

use and can be targeted at school students, college goers and their parents. Parents should

be educated about the warning signs of substance use in their child, the effects of

substance use on children and adolescents, effective parenting styles that could minimise

the risk of initiation and the need for immediate and early preventive strategies.
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In India, children and adolescents manage to obtain psychoactive substances with relative

ease. Although the Indian constitution includes the prohibition of alcohol among its

directive principles, alcohol policy is differs among the individual states and these

policies do little to curb its flow. Tobacco products like ‘ghutkas’, ‘pan-masalas’, other

chewable forms of tobacco and beedis are available in tea stalls and other roadside shops

easily and at a cheap rate. Stricter legislation monitoring the sale of these substances

needs to be put forth. More important is the implementation of these legislative measures

by the concerned authorities. Substance use estimates, however, are liable to change over

time, depending upon diverse factors such as availability and cost of the substances in the

community, existing legislations and their implementation, social perception and attitude

about use of particular substances, peer pressure and other socio-cultural factors [41,42].

Further research to understand current factors involved in influencing and the initiation of

substance use among adolescents, progression in substance use to abuse and dependence,

its impact on the lives of the users and their families and possible interventional and

preventive strategies is essential in the better understanding and management of the

problem of substance use among the youth of our nation.

Conclusion

Substance use among adolescents in India is a major health concern associated with many

co-morbidities and complications. Initiation of substance use in adolescence almost

always ensures continuation of the abuse well into adulthood. Therefore it is important to

plan preventive strategies aimed at this vulnerable population to reduce the burden caused

by substance abuse in a developing nation like India. There are no large scale studies on
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adolescent substance use in the country as of date. Most of the research data available is

from studies like small school based surveys, data from treatment and rehabilitation

centres data or studies on special populations like street children. Further research in

substance abuse in adolescents especially in the avenues of treatment and prevention are

lacking and is the need of the hour.

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Dr. Manu Agarwal, Lecturer, Dr. Anil Nischal, Associate Professor, Dr. Jitendra

Verma, Senior Resident, Dr. Saranya Dhanasekaran, Junior Resident-IIIrd year,

Department of Psychiatry, King Georges’ Medical University, U.P., Lucknow. Dr.

Anju Agarwal, Lecturer, Department of Psychiatry, Era’s Lucknow Medical College,

Lucknow.