Inhalant substance abuse among adolescents in Manipur , India : An upcoming

Background: Inhalant use, an important, yet-under recognized form of substance abuse has been reported commonly among adolescents in India but the true extent of the problem is not known due to paucity of data. Aims: To assess the prevalence and determinants of inhalant substance used amongst the adolescents in Manipur. Settings and Design: This cross sectional study was conducted among 1671 adolescent studying in Eighth to Twelfth standard in schools of Imphal-East District Manipur, India during March to June 2013. Materials and Methods: Schools were selected by simple random method and a semi-structured self-administered questionnaire adapted from the ‘UNDCP/WHO Global initiative on Primary Prevention of substance abuse’ was used for data collection. Univariate and Multiple logistic regression analysis were performed for association between ever users and selected variables. Results: Mean (SD) age of the students was 14.5(1.32) years, with males constituting 923(55.2%). Prevalence of ever users was186 (11.1%) and glue/ dendrite was the commonest substance abused 98(52.7%). Being male, belonging to joint family and increase in age were found to have signifi cant higher risk of being a user, whereas higher level of parental education shows a protective effect. Conclusion: An increased effort for prevention, treatment along with sensitization of parents and teachers is a distinct challenge for policy makers.


INTRODUCTION
The term inhalants include a wide range of pharmacologically diverse substances that readily vaporize.Inhalant abusers use these volatile products that are capable of producing a quick and generally pleasurable sensory experience, that quickly dissipates leaving little or minimal "hangover" symptoms.These substances are widely available, inexpensive, easily concealed and legal for specifi c intended uses but are intentionally misused by abusers [1] The effects include slurred speech, light headedness, euphoria, hallucinations, drowsiness etc.Long term consequences including liver, kidney damage and hearing loss has been reported. [2]Inhalants are appealing to adolescents since the "high" achieved with inhalants occurs rapidly and disappears relatively quickly, compared with other drugs.Thus, a user can sniff after school and still return home sober. [3][6][7] Few studies have reported inhalant abuse among street children and it has also been linked to school dropout. [3,8]1][12] Despite long standing awareness of the signifi cant morbidity and mortality associated with inhalant abuse, research and concrete data on its use and effects has been comparatively sparse in India.For these reasons, we took up this study to have a preliminary idea about the prevalence and associated factors of inhalant use among adolescents in our State.June 2013.Study population comprises of all adolescent school children studying in standard Eighth to Twelfth in the sampled schools.Sample size was calculated based on a prevalence of 9.9% among 10 th grade school children [13] by using a precision of 1.5% and at 5% signifi cance level a sample size of 1522 was calculated.Assuming a little more than 10% non-responders, the sample size was increased to 1600.

Sampling design
From the list of high schools and higher secondary schools located in the district the schools were sampled sequentially using lottery method and all eligible students in the selected schools were included.Absentees on the date of visit and refusals to participate were excluded.A total of 12 schools were selected till the required sample size was reached.
Study tool comprises of a self-administered, semi-structured questionnaire which was adapted from the 'UNDCP/WHO Global initiative on Primary Prevention of substance abuse-Overall Evaluation: Baseline Assessment Guidelines and instruments'. [14]The questionnaire contained two parts-the Socio-demographic profi le like age, sex, class, religion, father's and mother's educational qualifi cations and occupations, family type etc. and the KAP questions: based on knowledge, attitude and practice on inhalant substance abuse.

Collection procedure
After giving brief introduction and purpose of our visit, verbal informed consent was obtained from the participants.Students were requested to give the correct and true information without concealing anything as the information obtained will be used for research purpose only maintaining strict confi dentiality.Any unclear question(s) were clarifi ed and participants were informed that any question which they feel uncomfortable to answer may be omitted.
After collecting the questionnaire a short interactive health talk was delivered for about 30 to 40 min with the school teachers in attendance.Basic knowledge like risk factors for abusing inhalants, their side effects and methods to prevent inhalant substance abuse were provided to the students.

Operational defi nitions
Inhalants were defi ned as volatile substances that release chemical vapours that can be inhaled to induce a psychoactive or mind altering effect.Inhalant abuser -Any adolescent who ever abuse inhalant (s) for its psychoactive effects.

Statistical analysis
Data collected was entered into Ms Excel spreadsheet and transferred to SPSS version 11.5.Descriptive statistics like mean, median, percentages and analytical statistics like chi-square test and multiple logistic regression analysis were performed to look for association between ever users and selected variables.A P < 0.05 was taken to be signifi cant.

Ethical issues
Permission from school authorities was obtained prior to visiting the schools.Purpose of study was explained and Verbal informed consent was taken from the participants and strict confi dentiality was maintained.An interactive health talk was given after data collection.

RESULTS
A total of 12 schools were selected, consisting of 4 Govt.schools and 8 private schools.The number of eligible students was 1993, out of which 332 were absent on the day of visit, so 1671 students were included in the study.There were no refusals to participate.
Males constitute 923 (55.2%) and majority of the study population 519 (30.9%) were of 14 years with maximum proportion 521 (30.25%) of students belonging to 9 th Grade.As the 10 th board results were still awaited during the study period there were no eleventh class students enrolled in any of the schools.Almost half 910(54.5%) of the students belong to hindu religion and majority of them 1009(60.4%)belong to nuclear family [Table 1].
Most of the students 1207 (72%) have heard about inhalant substances and 345 (20.6%) of them feels that it will be very easy to obtain such substances if they wanted.Around 682 (40.8%) reported knowing classmates who are users.Majority 620 (37.10%) responded 'peer pressure' being the reason for abuse and almost half of the respondents 691 (41.4%) were not aware about harmful effects of inhalant use.In many of the families 578 (34.6%) the issues of drugs and drug abuse were never discussed [Table 2].
The study recorded a prevalence of 186 (11.1%) of ever users with fi rst time use being highest during 13 to 14 years of age 73 (39.2%).Majority of them 150 (80.6%) reported 'friends' as the one who introduced them to inhalant use and 'glue/dendrite' 98 (52.7%) was the substance most commonly abused followed by 'Correction fl uid/ Eraz-X' 57 (30.6%).A few of the ever users 11 (5.9%) reported use of other oral drugs like 'SP/N10'(Spasmo-proxyvon/ Nitrazepam) besides using inhalants.Majority of them 152 (81.7%) have tried to quit the habit in the past and 68 (36.6%) reported being absent from school or having poor school performance due to the habit [Table 3].
Table 4 shows the crude and adjusted logistic regression analysis with being 'ever users' or not as the dependent variable with selected independent variables.Males showed a signifi cantly higher risk of being a user as compared to females (OR 4.037, 95% CI 2.655 to 6.139).The odds of being a user signifi cantly increase with increasing age (OR 2.355, 95% CI 1.587 to 3.494).The crude analysis showed an increasing risk of exposure with increasing grades from 8 th to 12 th grade but this effect was no longer seen in the adjusted analysis.Higher the father's education, the risk of being a user decreases signifi cantly but no such relationship is observed with mother's educational level.Ever users are signifi cantly more likely to come from joint families (OR 1.633, 95% CI 1.165 to 2.289) as compared to nuclear family and being an user is signifi cantly more likely to know classmates who were also users (OR

DISCUSSION
Though, the overall prevalence of ever user of inhalants in this study was 11.1% this could be an underestimate of the real problem as absentees, school dropouts were not covered and some of the students might not be giving the true response.But the study, do confi rms the general belief of the people of the region that inhalant use among school children is prevalent.However, further studies are necessary to understand the epidemiology and diverse extent of this problem.
In the study, males are signifi cantly more likely to be ever users of inhalants as compared to females.These may relate to their aggressive nature and risk taking behaviour.Moreover as adolescents are in a transitional phase, confusion can make them susceptible to take up the unfavourable habit as an act of rebellion against parents and elders.Initiation of inhalant use started at around 13 to 14 years  for 39.2% of the ever users.In western society also inhalant use tends to start early, with 58% of users reporting fi rst use by the end of ninth grade. [15] increasing trend in the use of inhalants with increasing age is seen in this study which is contrary to fi ndings of studies in western countries. [16]Present confl ict situation in this part of the country, low socio-economic status, poor parental education and awareness about the problem with the added increasing risk taking behaviour of adolescents with increasing age, peer pressures, frustration and emotional problems may be the reason for this difference.However; father's education seems to have a protective role against inhalant abuse thus emphasising the importance of parental education and awareness for prevention and control of the problem.Low level of parental education has been shown to be important risk factor for inhalant use among middle and high school students. [15]The study also shows an increasing trend in prevalence with increasing class with the lowest prevalence among eighth standard (6.1%) and highest among twelfth standard (17.1%.) which is contrast to the trend in prevalence in some studies conducted in western countries which shows decreasing trend with higher grades. [17]Among the adolescents, those who belong to Christianity are signifi cantly more likely to be users.This may be due to their more lenient life styles, availability of more pocket in the State.Interactive Health Talk was given after collection of data that could clear their doubts and misconceptions.The students were provided with basic information about the health effects and long-term consequences of inhalant abuse and its prevention.They were advised to spread our messages to those whom we fail to reach in our study.Absentees could not be covered whose characteristics might differ from rest and the prevalence might be higher among them.A further study, with house to house survey can be taken up to cover the absentees, school dropouts and street children to get a better understanding of the problem.

CONCLUSION
Inhalant abuse offers a distinct challenge to parents as well as the health care provider, who needs to become more aware of the extent of the problem, the substances commonly abused and its health consequences.State Government should take up initiative and incorporate the problem and the adverse health effects of inhalants use in the school curriculum as early as the primary level.
There is also a need to advocate for the replacement of dangerous and psychoactive substances in common products with less harmful alternatives.