| | Tobacco use as a predictor of illicit drug use and drug-related problems in Colombian youthAccepted 4 September 2002. Abstract PurposeTo examine the extent to which personality and peer factors mediate the relationship between early cigarette use and later illicit drug use, as well as associated drug use problems, in a population of Colombian adolescents. MethodsA longitudinal study (2-year interval), using face-to-face structured interviews was begun in 1996 using a community-based sample, randomly selected from census data in three cities in Colombia, South America. The participants were 2837 adolescents with a mean age of 15.0 (SD ± 1.6) years at time 1 (T1). Males comprised 52% of the sample and 65% resided with two parents. Approximately 78% (N = 2226) completed the second structured interview 2 years later (T2). The main outcome measures were marijuana use, other illicit drug use, and associated drug use problems at T2. Three series of logistic regressions were conducted. ResultsThe odds of marijuana use (adjusted odds ratio [AOR] = 1.64–2.01; confidence interval [CI]: 1.11–2.94), other illicit drug use (AOR = 1.77–2.49; CI: 1.03–4.19), and associated drug use problems (AOR = 2.25–3.47; CI: 1.45–5.26) at T2, was increased two- to three-fold among adolescents reporting cigarette use at T1, with control on the demographic, personality, and peer factors, as well as T1 drug use variables. ConclusionsEarlier adolescent cigarette smoking was directly associated with later marijuana use, other illicit drug use, and problems with drug use.
Tobacco use is still considered the chief, single, preventable cause of premature death in the United States, accounting for more than 440,000 deaths each year [1]. Globally, if current trends continue, more than 200 million persons who are currently children and teenagers will die from tobacco-related illness [2]. Smoking has significant health consequences and in adolescence is associated with other problem behaviors 3, 4, 5.
Recent national surveys indicate that 63.9% of high school students have reported lifetime use of cigarettes and 14% are current frequent smokers [6]. The likelihood of having smoked cigarettes daily among Hispanic students (16.2%) was intermediate between white (24.1%) and black students (10.4%). These school-based surveys of adolescents miss the 15% to 20% of students who drop out before graduation and those with poor attendance records who are at highest risk for smoking. To deal with this issue, we have chosen to use a community sample.
A number of cross-sectional 7, 8, as well as longitudinal studies 9, 10, have been conducted to examine the progression of drug use in youth. Their results support the idea of a general pattern of progression from nonuse to tobacco and alcohol use (licit drugs in adults), to marijuana, and finally to the use of other illicit drugs [11]. A similar pattern of drug use has been found in various cultures in cross-sectional studies [12]. Longitudinal studies evaluating the role of cigarettes (as opposed to a general category of licit drugs) in the progression of drug use, using school-based samples of adolescents followed into adulthood, have noted that cigarettes play a prominent role as a gateway to marijuana and other hard drug use 13, 14, 15.
Prior research has examined the association between cigarette smoking and personality factors such as intrapersonal distress (e.g., anxiety) and unconventional and deviant behavior. Three themes have emerged from this research. First, adolescents who smoke are more likely to experience intrapersonal distress such as anxiety and low ego integration 16, 17. Second, they are more likely to report tolerance of deviance and unconventional behavior, such as rebelliousness 16, 18. Third, adolescent smoking behavior is related to peer delinquency and drug use 16, 19, 20. For these psychosocial factors to be mediators, they need to be related to illicit drug use as well as the use of cigarettes. Several investigators have reported that personality attributes such as intrapersonal distress, unconventional behavior, and involvement with drug using/deviant peers are related to the use of illicit drugs cross-sectionally 21, 22 as well as longitudinally [23]. However, the importance of the mediating role of personality attributes and peer factors necessitates its study in conjunction with smoking and the use of illicit drugs.
Colombian adolescents represent a unique population to evaluate smoking behavior and its relationship to future illicit drug use, as the conditions under which the adolescents live are quite different from the conditions existing in the United States. Adolescents living in Colombia are experiencing a great deal of environmental stress. The country has been in a recession for the last several years; unemployment stands at 20% [24]. There is rampant crime and Colombia is currently the world’s leader in kidnappings. Colombia supplies 90% of America’s cocaine and 70% of its heroin. Cocaine also has fueled Colombia’s 40-year war. Nearly 2 million people have fled the war zones for Colombia’s cities, with more than 12 political killings a day last year [25]. The cocaine trade undoubtedly has contributed greatly to the stress experienced by the adolescents living there. Both adolescents and their parents are extremely concerned about their safety. A number of Colombia’s most promising young professionals and business people have reluctantly left the country in search of safety, success, and stability [24]. Since 1996, 1.1 million of Colombia’s 40 million people have migrated to other countries. These conditions have been accompanied by a growing number of conflicts among the leftist guerrilla groups, the less-than-effective military, and an illicit right-wing paramilitary army. In addition, awareness of the health risks of tobacco use is generally low, as reported by the World Health Organization (WHO) [26]. According to their estimates, 40% of men and 21% of women in Latin America and the Caribbean smoke.
In line with Lewinsohn’s note about the importance of cross-country generalizability, this is an ideal population to study. The results of this study have implications for youth in Colombia, as well as youth in the United States. An increased comprehension of the issues surrounding tobacco and other substances is important to prevent their use.
This study extends the research on the relation of cigarette use in middle adolescence to illicit drug use in later adolescence by addressing several significant questions. Four questions will be addressed: (a) Does early cigarette use relate to later use of marijuana, other illicit drugs, and problems with drugs? (b) Assuming a relationship between early cigarette use and later drug use, do personality variables mediate this relationship? (c) Do peer factors mediate the relationship between early cigarette use and later drug use? (d) Does gender moderate the relationship between cigarette and drug use?
Methods  Participants and setting In lieu of sampling throughout the country of Colombia (South America), three cities were chosen for data collection: Bogota, Medellin, and Baranquilla, to both reduce the cost and because the scientific infrastructure was established in these three cities. Bogota is the capital of the country with a population of mixed socioeconomic status and a large concentration of young people with a varying urban experience. Medellin is the second largest Colombian city, with a commercial and industrial center, and is also the center of the drug cartel. Barranquilla is the fourth largest city, on the coast, and has a Caribbean-like culture (costeño). Tobacco and drug use is prevalent in all three cities. Within each city our sample was randomly selected from census data. We moved from census tracts to households to individuals while preserving the random sampling procedures. Households with at least one child between the ages of 12 and 17 years were “qualified” for this study. Address lists were compiled. Our success rate in reinterviewing participants was approximately 78%. Participants received incentives to participate that included American sports apparel ($7 per item). Characteristics of the sample The Time 1 (T1) sample included 2837 Colombian adolescents and the Time 2 (T2) sample included 2226 respondents, or 78% of the T1 sample. The T1 participants who were not interviewed at T2, as compared with those who were interviewed at T2, had higher rates on unconventionality, sibling and peer drug use. The mean age of the participants at T1 was 15 years (SD ± 1.66). Males comprised 52% of the longitudinal sample. Sixty-five percent lived with two parents. Self-reported ethnic identification indicated that the longitudinal sample was composed of the following: Mestizo (i.e., Spanish, Indian, and African-Colombian) (57%), Spanish (32%), and other groups (11%) that included African, Asian, Indian, and European participants. Data on education for both the respondents and their parents were measured on a 5-point scale that ranged from 1 (grade school) to 5 (postcollege). Eighty-four percent of the respondents attended school, with a mean educational achievement level just over the seventh grade. For fathers’ educational level, results indicate that about three-quarters of the fathers had less than a 10th grade education and 23% had between a 10th grade and university degree education. Only 2% had a business/technical or graduate school degree. About 60% of fathers were never employed, unskilled, semiskilled workers, or homemakers. About one-third were skilled, clerical, semi-professional workers, or military personnel. The remaining 7% were professionals. Procedure The data collection took place over a 2-year period beginning in 1996. Each subject was contacted by phone or in person. The study was described to each subject before the request to participate. Parents and adolescents were both required to sign consent forms in order for the subject to participate. Individual interviews, lasting approximately 2 hours, were conducted in private in the adolescents’ homes and administered by Colombian interviewers. The subject and the interviewer were matched in terms of gender. The staff followed a standardized protocol in giving instructions to participants and answered questions about individual items. The Institutional Review Board of the Mount Sinai School of Medicine approved all protocols. Measures The adolescent interviews included demographic, personality, and peer measures, as well as items concerning tobacco and drug use. The percentage of participants in the T1 sample who had “ever smoked” was 90%, and 16.7% reported daily use. Ever smokers were then asked how much they smoked in the last 2 months on a 6-point scale ranging from “never” (0) to “about one and a half packs a day” (6). This measure has been shown to have predictive validity [27]. The dependent measures of frequency of marijuana use and frequency of other illicit drugs were self-report measures, and previous analyses support their validity [28]. The options were “never,” “once or twice,” “3 to 12 times,” “several times a month,” and “several times a week to daily.” The percentage of adolescents in the T1 sample who reported marijuana use was 41.4% and the percentage using other illicit drugs was 11%. Drug problems were measured on a 7-item scale with scores ranging from 7 to 28 (Cronbach alpha of the scale was 0.85). An example of the questions follows: “How often have you had trouble at school or on the job because of your use of alcohol or drugs?” In addition, personality and peer measures were derived from earlier studies and are consistent with a family interaction framework [27], problem behavior theory [29], and social learning theory [30]. The personality and peer measures reported on in this study, their sources, reliabilities, and sample items are shown in Table 1 31, 32, 33, 34, 35, 36. These scales have been validated with youth from different ethnic groups living in the United States and have been found to predict drug use, delinquency, and psychopathologic symptoms 16, 23, 29. A number of the scales were adapted to ensure their linguistic and cultural relevance. Six researchers conversant in both Colombian Spanish and English translated the questions into Spanish, and the questionnaire was then translated back into English. Then two pilot studies were conducted to make certain the psychometric properties of the scales were equivalent to those obtained in the United States. Statistical analysis The analyses involved logistic regression as a way of studying the association of daily tobacco use (independent variable) at time 1 and three different illicit drug outcomes (marijuana use, illicit drug use, and problems with drug use) at time 2. Odds ratios estimated the increase in the odds of Time 2 drug behavior with an increase in Time 1 tobacco use. An odds ratio greater than 1.0 represented a positive relation between tobacco use and illicit drug use. The measure of tobacco use was dichotomized to form a high-risk group (those who smoked cigarettes daily) and a low-risk group (the remaining participants). Marijuana use, other illicit drug use, and problems with drug use were also dichotomized to form high-risk groups (those scoring in the top 25%) and the remainder of the participants. Dichotomizing measures in this way provided us with sufficient numbers in the high- and low-risk groups necessary for analytic purposes. Regression analyses were run in which the interaction between tobacco and the demographic factors were examined. Less than 5% of the interactions of tobacco use with age, parents’ education, gender, and ethnicity were significant, so we did not include these interaction terms in the logistic regression analyses. Because there were significant demographic differences in drug use on some of the drug variables, we controlled for the demographic variables (i.e., gender, age, ethnicity, and parents’ education) in the analyses. The psychosocial variables were treated as continuous variables. Three series of logistic regressions were conducted. In the first series, we examined the relation between tobacco use at Time 1 and marijuana use at Time 2 (while controlling for marijuana use at T1). In the second, we examined the relation between tobacco use at Time 1 and illicit drug use (other than marijuana) at Time 2 (while controlling for illicit drugs other than marijuana at T1). In the third logistic regression we examined the relation between tobacco use at Time 1 and problems with illicit drug use at Time 2, controlling for T1 drug problems. Odds ratios (OR) and 95% confidence intervals (CI) are reported. In each series we first controlled for T1 age, gender, ethnicity, and fathers’ education level. Then, in addition, we controlled for a number of psychosocial (personality and peer) variables. Finally, we controlled for the T2-dependent outcome assessed at T1 as mentioned above. Results Results of the first logistic regression (Table 2) indicate that cigarette smoking at T1 was associated with a more than four-fold increase in marijuana use at T2 with control on the demographic factors (age, gender, ethnicity, and fathers’ education level). The odds of later marijuana use were almost doubled with control on the demographic and psychosocial variables (anxiety, depression, tolerance of deviance, rebelliousness, sensation-seeking, self-deviancy, peer deviance, and peer drug use) as well as T1 marijuana use (Table 2). The next logistic regression (Table 3) indicates that the odds of later illicit drug use other than marijuana use, with control on the psychosocial factors in addition to the demographic factors, was increased almost five times. With control on the psychosocial factors and illicit drug use other than marijuana at T1, the odds of later illicit drug use given earlier smoking behavior was doubled. In the final logistic regression (Table 4) the odds of later drug problems given earlier cigarette use were calculated. The odds ratios indicate that cigarette smoking was strongly related to later problems with drugs, despite all the controls. Of further interest is that the odds ratios (each row) remained strongly significant despite control on the psychosocial variables and on T1 drug problems. We also examined the relation of daily cigarette and marijuana use, other illicit drugs, and problem use of drugs controlling for all of the measures simultaneously. These results reveal a consistent pattern: earlier adolescent cigarette smoking is directly associated with later adolescent marijuana use, illicit drug use other than marijuana, and problems with drug use. Discussion Although many studies note the association of earlier cigarette use in adolescence to later illicit drug use, our study of this association is unique. To our knowledge, we are the first to have controlled for two important factors that are believed to be mediators in the progression from cigarette smoking to further illicit drug use and problems with the use of drugs. These two factors are the broad categories of peer and personality/attitudes/behavior variables that have been found to be related to both cigarette use and illicit drug use 16, 19. We found a strong association between earlier daily cigarette smoking and later marijuana use, other illicit drug use, and problems with drug use despite controls on the personality and peer factors. The odds ratios between the independent and dependent variables still remain significant with control on drug behavior. Our findings indicate that males reported more frequent drug use than females. However, gender does not significantly moderate the association between cigarette smoking and future illicit drug use and problems resulting from the use of drugs. In addition, our results indicate that age, ethnic background, or social disadvantage of the family of origin does not affect this progression. The findings in the present study also extend previous research. First, it has been noted that studies evaluating risk factors for smoking and the progression in drug use have mainly been conducted in white populations [37]. Our sample is unique in having been drawn from a Hispanic country (Colombia, South America), attesting to the generalizability of the relationships studied. Further evidence for such generalizability lies in the fact that within this sample, we do not find differences among the various ethnic groups. Secondly, this is a country where violence is endemic. Related to this, there are no laws regarding smoking behavior, drugs are easily available despite laws banning their use, and there is an economic recession. There is the possibility that the ready availability of drugs and the legal nature of smoking make it easier for the vulnerable among the smokers to assume drug-taking behavior. Third, the sample is large, diverse, and community-based. Fourth, the longitudinal study design confirms the temporal relationship between tobacco use and illicit drug use, lending support to the hypothetical causal relationship. Fifth, we controlled for the earlier use of illicit drugs when examining the association between earlier tobacco use and later illicit drug use. Such control suggests that smoking is related to both drug-taking behavior and an increase in drug use behavior between T1 and T2. Finally, we included in our study not only the use of drugs but also the problems resulting from the use of illicit drugs. This attests to the seriousness of smoking, which is related to later drug taking and problem behavior resulting from the use of drugs. This linkage between earlier cigarette use and later problems with illicit drug use was the strongest and not affected by the mediators. It has been theorized by a number of authors, that a variety of deviant behaviors have similar antecedents [29]. Although the psychological factors we assessed were not mediators, it could be that these factors enter into the relationship earlier on and may be related to the onset of use of cigarettes. These results emphasize the need to further study the association of earlier cigarette use to later problems with illicit drug use in the United States. There are no studies to date that have provided empirical findings of why tobacco users are more likely to use other substances than their non-tobacco-using peers. There have been several hypothetical explanations of why this may occur. One mechanism, which has been postulated, is the social influence of the peer group 16, 19, 20. Thus, tobacco users are more likely to associate with drug-using friends who may pressure them to use or make accessible illicit drugs. The youngsters may serve as models to be emulated. However, when we controlled for the effect of the peer group the findings still suggested that tobacco use had a direct effect on illicit drug use. A second mechanism has to do with personality factors. Thus, tobacco users may experience intrapersonal distress, unconventional and sensation-seeking behavior, which in turn may be related to their use of illicit drugs as a form of self-medication. We found that cigarette smoking was related to illicit drug use with control on significant personality attributes. Therefore, our findings do not lend support to this hypothesis. A third explanation has to do with the pharmacological aspects of the drug. The effects of nicotine (the substance responsible for the addictive nature of tobacco) appear to be mediated by the meso-limbic dopamine system [38]. This system mediates the effects of many addictive drugs [39]. Chronic nicotine treatment, like many drugs of abuse, including ethanol, morphine, and cocaine, has been shown to cause adaptation to take place in this meso-limbic dopamine neuronal system [40]. Perhaps the development of tolerance to the effects of nicotine results in increased craving that may be satisfied by other substances that have similar reward mechanisms. Moreover, another possibility is that the mediators between tobacco use at Time 1 and illicit drug use at Time 2 consist of the interactions between psychosocial and peer factors with genetic and family factors. Future research should shed further light on the mediators between smoking behavior and illicit drug use. These drug use relationships are noteworthy, as both tobacco use and illicit drug use are common in adolescence. Limitations The study has several limitations. All of the measures were based on self-reports of the adolescents. Thus, the correlation between the tobacco variable and illicit drug use could be the result of shared-method variance. Research conducted in the future should obtain information from multiple reporters of the same constructs. Second, no biologic confirmation was obtained to confirm use or nonuse of tobacco and other drugs. Obtaining such confirmation would increase the accuracy of self-reports. Third, the participants who withdrew from the study were on the whole more involved in problem behavior than were the participants. Thus, the longitudinal sample represents a more conventional group than would be anticipated if all the adolescents who participated at Time 1 continued to participate at T2. Had the adolescents who dropped out of the study been included in this research, the independent and dependent measures would have had more variance so that the results might have been even stronger. Finally, the study uses measures of frequency of drug use rather than diagnosable disorders. Nevertheless, the use of drugs does place one at an elevated risk for substance abuse. Although we have controlled for a number of peer and personality factors that have been shown to be related to both tobacco and drug behaviors, there may be others that might act as mediators. Despite these caveats, the present research provides an opportunity to study the longitudinal relationships between two major public health problems: tobacco use and illicit drug use including problems resulting from illicit drug use. The implications of the relationship between cigarette smoking and illicit drug use are that if you reduce early tobacco use there may be an accompanying decrease in later illicit drug use and problems resulting from illicit drug use. The next step is translational research that would demonstrate the utility of these relationships in clinical or prevention settings. Acknowledgements This research was supported by a Research Scientist Award DA 00244 and a Research grant DA 10348 from the National Institute on Drug Abuse, NIH, Bethesda, MD to J.S.B. References 1.
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a Department of Pediatrics, Miami Children’s Hospital, Miami, Florida, USA (L.M.S.) b Department of Community and Preventive Medicine, Mount Sinai Medical Center, New York, New York, USA (J.S.B.)  Address correspondence to: Lorena M. Siqueira, M.D., Miami Children’s Hospital, 3100 S.W. 62nd Avenue, Miami FL 33155-3009,USA.
PII: S1054-139X(02)00534-7 © 2002 Society for Adolescent Medicine. Published by Elsevier Inc. All rights reserved. | |
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