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Demographic and social correlates of tobacco, alcohol and cannabis use among 15-16-year-old students in Albania: Results of the ESPAD survey

Aims Our aim was to assess the demographic and social factors associated with lifetime use of tobacco, alcohol and cannabis among school students aged 15-16 in Albania in order to make information and knowledge available for health promotion specialists working on substance use prevention. Design This cross-sectional study was conducted in March-May 2011 in the framework of the European School Survey Project on Alcohol and Other Drugs (ESPAD). In total, 3189 students born in 1995 participated in the survey. The standardised ESPAD questionnaire was used to collect data about substance use. Results Our multivariable adjustment analysis showed that being a male and having easy access to cigarettes were the only universal factors significantly increasing the likelihood of ever using tobacco, alcohol or cannabis. Own smoking was strongly and significantly associated with alcohol and cannabis use. The associations of own substance use with peer substance consumption were weak to moderate. Conclusions Own smoking seems to be the most important single independent risk factor which strongly and significantly predicted alcohol and cannabis use among Albanian school students. Policy makers need to strengthen the rule of law whereas health promotion professionals should firmly address smoking in adolescence through target interventions.

Substance use has been linked to a number of demographic and social characteristics of individuals. For example, the prevalence of alcohol, tobacco and cannabis use is argued to be higher among males (Bauman & Phongsavan, 1999;SAMHSA, 2012), while reversed gender trends have also been documented.  . In any case, the gender differences in the prevalence of alcohol and tobacco are small, especially in developed countries (Bloomfield, Gmel, Neve, & Mustonen, 2001;Hibell et al., 2012).
It is important to study substance use epidemiology because it is associated with important health and economic consequences for both individuals and society as a whole. The harmful health effects of tobacco and excessive alcohol use are welldocumented beyond doubt: tobacco has been linked to lung cancer and cancers of upper digestive tract, stomach, pancreas, kidney and cervix uteri as well as coronary and heart disease and myocardial infarction (CDC, 2004;Prescott, Hippe, Schnohr, Hein, & Vestbo, 1998) whereas excess use of alcohol is linked with higher risk of mortality and cancers of different types (Gronbaek et al., 1998;Hart, Smith, Hole, & Hawthorne, 1999). Alcohol also contributes to a series of social harms, ranging from violence (Room & Rossow, 2001) to divorce (Leonard & Rothbard, 1999) and child abuse (Barber & Gilbertson, 1999). In addition to the health effects, alcohol and tobacco may jeopardise the financing of national health systems (Single, Robson, Xie, & Rehm, 1998;Fenoglio, Parel, & Kopp, 2003), and the treatment of alcohol-related problems and consequences may increase the costs of social welfare and criminal justice systems (Weisner, 2001). Cannabis is also associated with increased costs to society (Rehm et al., 2007).
There is evidence that tobacco, alcohol and cannabis are interconnected in the sense that, in certain individuals, they may stimulate initiation and further mutual use as well as the use of other illegal drugs. For instance, it is suggested that the initiation of cannabis use is usually preceded by the use of alcohol and tobacco (Valenzuela & Fernández, 2011), whereas cannabis is often regarded as a pathway to using heavier illegal substances (Kenkel, Mathios, & Pacula, 2001;Hall & Lynskey, 2005;Fergusson, Boden, & Horwood 2006;Valenzuela & Fernández, 2011). Furthermore, the earlier the use of a psychoactive substance is initiated the higher the likelihood of continued use and escalation of use toward other illicit drugs later in life (Valenzuela & Fernández, 2011 (Vakeflliu, Argjiri, Peposhi, Agron, & Melani, 2002;Shapo, Gilmore, Coker, McKee, & Shapo, 2003;Bozicevic, Gilmore, & Oreskovic, 2004;Ross, Zaloshnja, Levy, & Tole, 2008;Burazeri & Kark, 2010;ADHS, 2009)

Study population and sampling
The ESPAD survey targets school children turning 16 during the year of data collection or, otherwise, if we refer to the 2011 data collection wave, school children born in 1995 . In Albania, this cohort of children is found in two different which meets the ESPAD sample size requirement. Our report refers to these 3189 students born in 1995.
All the selected schools and classes agreed to participate.

Data collection
The translated version of the ESPAD questionnaire was used to collect data on substance use among school adolescents in Albania.
The data collection process occurred Children were encouraged to freely express their opinion and, in order to ensure anonymity, the completed questionnaires were wrapped in individual envelopes.

Measures
The lifetime prevalence of tobacco and

Results
In total, 3189 students participated in the ESPAD survey in Albania in 2011. More than half of the participants (55%) were females. There were no significant differences in the distribution of gender, school system and type of school by geographic location of school (Tirana versus all other regions) (P>0.05) ( Table 1).
The prevalence of lifetime tobacco, alcohol and cannabis use was 40.8%, 80.6% and 4.4%, respectively. The proportion of lifetime tobacco and alcohol users was significantly higher in Tirana than in the other regions, whereas no regional difference was evident on the prevalence of lifetime cannabis use (Table 1). Significantly more students in Tirana than in other regions found it easy or very easy to get cigarettes.
Also, students in Tirana schools reported significantly more friends who smoke, drink or use cannabis compared to students from other regions ( Table 1).
The prevalence of lifetime tobacco, alcohol and cannabis use according to demographic and social characteristics of participants is shown in Table 2. In general, the lifetime prevalence of tobacco, alcohol and cannabis use was significantly higher among males, urban schools, students who had friends who smoke, drink or use cannabis, those who find it easy to get cigarettes or alcohol and among students with worse average grades.
The univariate analysis of the factors associated with substance use is presented in Table 3. All the independent variables in the table significantly increased the likelihood of lifetime tobacco use. Conversely, some variables such as geographic location and type of school were not significantly associated with lifetime and/or cannabis use (Table 3).
In multivariable adjusted analysis, the factors more strongly correlated with significantly increased likelihood of lifetime tobacco use were being a male (OR=2.6), having friends who smoke (OR=2.3), finding cigarettes easily/very easily (OR=2.1),   . When compared to the more developed European countries (such as France, Germany or Italy), the same pattern is noticed but the cross-country differences are even bigger: the overall prevalence of substance use among Albanian school adolescents is much lower than in most developed countries for any of the substances under study, but the gender differences are larger in Albania except for cannabis . In addition, in some European countries the prevalence of tobacco, alcohol and cannabis use is higher among girls .
The particularly large gender differences in the prevalence of substance use may indicate that Albanian society is still a traditional one where more males than women are involved in substance use. This pattern also seems to apply to youngsters. However, this is changing: the increasing trend in the prevalence of lifetime substance use among adolescents in Albania is accompanied by narrowing gender differences, when more females become involved with the use of psychoactive substances.
Studies suggest that the prevalence of substance use among school girls is increas-  (Table 4).
The association between substance use and school location and type varies from country to country. A study did not find The majority of private schools in Albania are found mainly in Tirana, and the students in these schools are invariably well off. In this regard, the positive association between smoking and private schools (signifying higher SES) is supported by the international literature (Hanson & Chen, 2007b). Also, the lack of significant associations between school location and type with adolescent alcohol and cannabis use is in accordance with previous research (Hanson & Chen, 2007b).
The other significant universal risk factor for substance use among adolescents which emerged in our survey after controlling for a number of confounding effects was tobacco smoking, which highly increased the likelihood of ever alcohol and cannabis use four-and sixfold, respectively, whereas alcohol and cannabis use were not significantly associated. Our results are compatible with those reported in the international literature, which suggests that tobacco is a major independent risk factor for other legal and illegal substance initiation and use through the "gateway" theory (Pierce, Naquin, & Gilpin, 1991;Torabi, Bailey, & Majd-Jabbari, 1993;Lindsay & Rainey, 1997;Biederman et al., 2006;Valenzuela & Fernández, 2011). Also, cannabis use could serve as a gateway toward using other heavier illicit drugs (Fergusson, Boden, & Horwood 2006;Valenzuela & Fernández, 2011). Different studies suggest that the overwhelming majority of substance using adolescents start with tobacco, followed by alcohol consumption, cannabis and potentially escalating toward other illicit drugs (Fergusson et al., 2006;Valenzuela & Fernández, 2011).
However, other reports support the theory that alcohol is the gateway drug (Welte & Barnes, 1985;Kirby & Barry, 2012). In this regard, our results are more supportive of the tobacco gateway theory among Albanian adolescents.
The associations between peers who use substances with own substance use was present in our survey even though they were not strong, except for cannabis use. Our findings suggest that having smoking friends increased one's likeli-hood of using tobacco or alcohol by 2.3 and 1.5 times, respectively, while having cannabis using friends was significantly associated with lifetime tobacco and cannabis use. Our results in general support the well-established international findings regarding substance using among adolescents and their peers (Ennett et al., 2006). However, having alcohol using peers did not appear to be associated with one's substance use in our sample, except for alcohol, a finding which finds some support in the international literature (Andrews, Tildesley, Hops, & Li, 2002). The inconsistent findings between peer and adolescent substance use in our survey, especially as regards peer alcohol use, may be an indication of complex and specific peer contexts, networks and relationships (Ennett et al., 2006) among Albanian adolescents.
This calls for more research in the future.
The negative association between school attainment with tobacco and cannabis use mimics similar findings from the literature which suggest that young students with below average results are significantly more likely to have ever used tobacco, alcohol and cannabis compared to students doing better than average (Leatherdale et al., 2008). Also, substance use is negatively associated with years of school completed (Engberg & Morral, 2006;Chatterji, 2006).
Another independent risk factor for psychoactive substance use among Albanian adolescents is the availability of alcohol and tobacco. Students who find it easy to get cigarettes or alcohol are significantly more likely to have ever used tobacco, alcohol or cannabis. The high availability and easy access of youngsters to psychoactive substance is a common phenomenon (Ogilvie, Gruer, & Haw, 2005). Al-though Albania has an anti-tobacco law and restrictions on underage use of alcohol which prohibit the sales of such substances to those under 18, adolescents find ways of gaining access all the same. This is partly because the state structures are unable to monitor the implementation of legislation. There is therefore an urgent need to ensure the rule of law in order to reduce adolescents' access to these substances -

Study limitations
Our study has several limitations. The cross-sectional design does not permit us to draw conclusions about the temporality of events. The interpretation of results therefore warrants caution. We relied on self-reported information from participating students, which does not allow us to rule out the presence of reporting bias especially regarding sensitive issues such as illegal drug use. Therefore, it is very likely that the prevalence of illegal substance use is underestimated in our survey. Moreover, we collected information about the students present at selected classes on the day of the survey. This leaves out students who were absent on the day. If the missing students should be different with regard to substance use compared to those present then this aspect could have had an Unauthenticated Download Date | 12/16/16 12:10 PM effect on our estimation of prevalence of tobacco, alcohol and cannabis use. However, we think that there is no good reason to believe that this is the case. Also, we estimated the lifetime alcohol prevalence using a proxy question which asked about the age when respondents had first con-

Conclusions
Our study provides new evidence regarding the demographic and social factors associated with the use of psychoactive substances among school adolescents in Albania through using a multivariable adjusting approach. We have demonstrated that the prevalence of lifetime tobacco, al-cohol and cannabis use among 15-16-yearold students in Albania is comparable to that of neighbouring countries but lower than in most Western European countries.
However, the prevalence of substance use is on the rise. Males predominate in substance use but the gender gap is narrowing. This suggests that interesting developments are taking place in the Albanian society. Own smoking emerged as the most important single independent risk factor strongly and significantly correlated with alcohol and cannabis use. The fact that tobacco products are almost freely available to anyone in Albania may facilitate access to and use of such products, leading to increased exposure to smoking peers and ultimately to increased prevalence of tobacco use among Albanian adolescents. Therefore, our main conclusion is that although substance use among adolescents is associated with various demographic and social factors, smoking in young ages may represent the "real" threat and should be the primary target of health behaviour promotion interventions in secondary and high school students of Albania.

Practical implications
The finding that smoking might be the main determinant of substance use among Albanian adolescents leads to important implications for both policy makers and health promotion professionals. With regard to policy implications, evidence suggests that tobacco consumption is sensitive to increasing prices (Ranson & Jha, 2002;Ogilvie et al., 2005;Levy, Ross, Zaloshnja, Shuperka, & Rusta, 2008). In Albania, the price of cigarettes is relatively not high, making tobacco affordable to youngsters. legislation about smoking in public places, is the main political action to be taken, as the advertising ban and the enforcing of clearly visible health warnings on tobacco products do not seem to have had the desired effect. With regard to health promotion, there is room for professionals to get involved in addressing the tobacco challenge during adolescence through comprehensive educative interventions, tailored according to the needs of risk groups identified in this paper.