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Teenagers’ Awareness of Peers’ Substance and Drug Use in Kuwait
Abstract
Background:
Teenage substance use is a global challenge, and youths residing in Kuwait are not immune from it. Tobacco products are licit; however, alcohol and other mood-altering illicit substance are prohibited with severe penalties including imprisonment. Youths residing in Kuwait are being initiated into the use of mood-altering substances like tobacco at an early age, and it is postulated that, as they grow older, they may progress into using alcohol and other prohibited illicit drugs.
Aims:
The aim of this study was to determine licit and illicit substance use by teenagers residing in Kuwait. The study will also explore their awareness of substance use among their peers.
Design:
A cross-sectional survey using a snowball sampling technique was used to recruit 190 teenagers aged 15-18 years residing in Kuwait. Data were collected using the 130-item questionnaire adapted from 1998 New Jersey Triennial Public High School Survey of Drug and Alcohol Use. Data collection was from September 2012 to June 2013.
Data analysis:
The Statistical Package for Social Sciences Version 22 for Windows was used. Pearson's chi-square, Kruskal-Wallis, and Mann-Whitney U tests were used to test the hypotheses.
Results:
Tobacco was the most commonly used substance by these teenagers; 8.4% were current smokers, and 50% had experimented. Age of initiation for 21% was before 14 years old. Hashish (marijuana) was the most commonly used illicit drug, with 3.7% current users and 5.3% claiming to have used it. More male than female teenagers in Grade 9 were using tobacco products (χ = 27.428, df = 5, p < .001).
Conclusion:
The use and abuse of mood/mind-altering licit and illicit substances appear to be increasing among older teenagers. Intensifying campaigns about the hazards of substance use and drug testing should start from the primary school level.
... Despite the importance of this topic, to our knowledge, the few studies published thus far concerning illicit substances that have been seized or consumed, or the associated-death rates, in the Middle East in general, and more specifically in Kuwait (representing a population of approximately 4 million people), have not been comprehensive [11,12]. Additionally, most studies that have been previously conducted in Kuwait were outdated survey-based studies that did not rely on solid analytical data generated by laboratory-based experiments [13,14]. Moreover, the only previous analyticalbased study is outdated [15]. ...
... A cross-sectional questionnaire conducted on Kuwaiti male students (n = 1587) reported that the most commonly used illicit substances were marijuana (11%), stimulants (7.1%), cocaine (2.2%), and heroin (1.3%) (13). Omu et al. (2017) performed a survey on illicit drug abuse among teenagers (15 to 18 years) between September 2012 and June 2013 [14]. The results showed that the trend of illegal substances abuse is increasing, especially among older teenagers. ...
... A cross-sectional questionnaire conducted on Kuwaiti male students (n = 1587) reported that the most commonly used illicit substances were marijuana (11%), stimulants (7.1%), cocaine (2.2%), and heroin (1.3%) (13). Omu et al. (2017) performed a survey on illicit drug abuse among teenagers (15 to 18 years) between September 2012 and June 2013 [14]. The results showed that the trend of illegal substances abuse is increasing, especially among older teenagers. ...
Background
The misuse of illicit substances is associated with increased morbidity and mortality; thus, substance abuse is a global health concern. The Arabian Gulf region is considered a crossing point and a consumer of illicit drugs. However, a lack of laboratory-based research has limited the scientific assessment of drug misuse in the Arabian Gulf region. Thus, an up-to-date analytical representation of the drug situation is warranted.
Methods
We investigated the type and quantity of detained narcotic drugs and psychotropic substances from 2015 to 2018, representing a population of approximately 4 million people, in addition to the number of abusers and mortality among abusers. In total, 6220 cases from the Narcotic and Psychotropic Laboratory and 17,755 cases from the Forensic Toxicology Laboratory were reviewed and analyzed. Substances were identified and documented using gas chromatography–mass spectrometry and liquid chromatography–mass spectrometry.
Results
Cannabis, including marijuana, was the most seized substance, followed by heroin, opium, and cocaine. Amphetamines, including methamphetamine, in the form of powder or pills, were seized in larger quantities than other psychoactive substances. The most consumed substances were, in order, amphetamines (including methamphetamine), benzodiazepines, cannabis, and heroin. We identify the common drugs in postmortem specimens, according to sex, from suspected drug-related deaths. The most common single drug identified were heroin, benzodiazepines, and methamphetamine. Similarly, the multiple-drug cocktail of heroin–benzodiazepines, cannabis–benzodiazepines, and cannabis–amphetamines, were detected frequently.
Conclusions
The data shows that cannabis is the leading type of illicit substance seized. Deaths resulting from benzodiazepines and heroin abuse were the highest in the single drug category, while heroin-benzodiazepines combination deaths were the highest in the multiple-drug category. Methamphetamine was the most abused illicit drug in Kuwait. These findings revealed the illicit drug abuse situation in the State of Kuwait, in a region that suffers from the scarcity of information regarding illicit substances. Thus, providing valuable information for drug enforcement, forensic analyst, health workers on national and international levels.
... Despite the importance of this topic, to our knowledge, the few studies published thus far concerning illicit substances that have been seized or consumed, or the associated-death rates, in the Middle East in general, and more speci cally in Kuwait (representing a population of approximately 4 million people), have not been comprehensive [11,12]. Additionally, most studies that have been previously conducted in Kuwait were outdated survey-based studies that did not rely on solid analytical data generated by laboratory-based experiments [13,14]. Moreover, the only previous analytical-based study is outdated [15]. ...
... A cross-sectional questionnaire conducted on Kuwaiti male students (n = 1587) reported that the most commonly used illicit substances were marijuana (11%), stimulants (7.1%), cocaine (2.2%), and heroin (1.3%) (13). Omu et al. (2017) performed a survey on illicit drug abuse among teenagers (15 to 18 years) between September 2012 and June 2013 [14]. The results showed that the trend of illegal substances abuse is increasing, especially among older teenagers. ...
... The results showed that the trend of illegal substances abuse is increasing, especially among older teenagers. Hashish (marijuana) was the most commonly used illicit substance among both current users and previous users, 3.7% and 5.3%, respectively [14]. A Kuwaiti pilot study con rmed the association between levels of self-esteem and anxiety with drug user behavior [16]. ...
Background: The misuse of illicit substances is associated with increased morbidity and mortality; thus, substance abuse is a global health concern. However, a lack of laboratory-based research has limited the scientific assessment of drug misuse in the Arabian Gulf region. Thus, the primary aim of this study was to assess the problem of illicit drugs in Kuwait using laboratory-based analyses.
Methods: We investigated the type and quantity of detained narcotic drugs and psychotropic substances from 2015 to 2018, number of abusers, and mortality among abusers. In total, 6220 cases from the Narcotic and Psychotropic Laboratory and 17,755 cases from the Forensic Toxicology Laboratory were reviewed and analyzed. Substances were identified and documented using gas chromatography–mass spectrometry and liquid chromatography–mass spectrometry.
Results: Cannabis, including marijuana, was the most seized substance, followed by heroin, opium, and cocaine. Amphetamines, including methamphetamine, in the form of powder or pills, were seized in larger quantities than other psychoactive substances. Benzodiazepines, tramadol, Khat, synthetic cannabinoids, and psilocin were also seized. The most consumed substances were, in order, amphetamines (including methamphetamine), benzodiazepines, cannabis, and heroin. Drug misuse was considerably higher among men than among women. We report the death rate associated with the abuse of various illegal drugs according to sex. The mortality rate associated with single-drug use was the highest among abusers of heroin, benzodiazepines, and methamphetamine. The mortality rate asscoaited with multiple-drug use was the highest among abusers of heroin–benzodiazepines, cannabis–benzodiazepines, and cannabis–amphetamines.
Conclusions: Our study shows the changing trends in quantity and variety of substances illegally abused and marketed in Kuwait. Additionally, we report a direct gender-based association between mortality and consumption of certain substances. These findings suggest that there is a growing need to conduct larger scale studies to implement new strategies, policies, and interventions in populations affected by illicit drugs.
... generated by laboratory-based experiments [13,14]. Moreover, the only previous analytical-based study is outdated [15]. ...
... A cross-sectional questionnaire conducted on Kuwaiti male students (n = 1587) reported that the most commonly used illicit substances were marijuana (11%), stimulants (7.1%), cocaine (2.2%), and heroin (1.3%) (13). Omu et al. (2017) performed a survey on illicit drug abuse among teenagers (15 to 18 years) between September 2012 and June 2013 [14]. The results showed that the trend of illegal substances abuse is increasing, especially among older teenagers. ...
... The results showed that the trend of illegal substances abuse is increasing, especially among older teenagers. Hashish (marijuana) was the most commonly used illicit substance among both current users and previous users, 3.7% and 5.3%, respectively [14]. A Kuwaiti pilot study con rmed the association between levels of self-esteem and anxiety with drug user behavior [16]. ...
Background
The misuse of illicit substances is associated with increased morbidity and mortality; thus, substance abuse is a global health concern. However, a lack of laboratory-based research has limited the scientific assessment of drug misuse in the Arabian Gulf region. Thus, the primary aim of this study was to assess the problem of illicit drugs in Kuwait using laboratory-based analyses.
Methods
We investigated the type and quantity of detained narcotic drugs and psychotropic substances from 2015 to 2018, number of abusers, and mortality among abusers. In total, 6220 cases from the Narcotic and Psychotropic Laboratory and 17,755 cases from the Forensic Toxicology Laboratory were reviewed and analyzed. Substances were identified and documented using gas chromatography–mass spectrometry and liquid chromatography–mass spectrometry.
Results
Cannabis, including marijuana, was the most seized substance, followed by heroin, opium, and cocaine. Amphetamines, including methamphetamine, in the form of powder or pills, were seized in larger quantities than other psychoactive substances. Benzodiazepines, tramadol, Khat, synthetic cannabinoids, and psilocin were also seized. The most consumed substances were, in order, amphetamines (including methamphetamine), benzodiazepines, cannabis, and heroin. Drug misuse was considerably higher among men than among women. We report the death rate associated with the abuse of various illegal drugs according to sex. The mortality rate associated with single-drug use was the highest among abusers of heroin, benzodiazepines, and methamphetamine. The mortality rate asscoaited with multiple-drug use was the highest among abusers of heroin–benzodiazepines, cannabis–benzodiazepines, and cannabis–amphetamines.
Conclusions
Our study shows the changing trends in quantity and variety of substances illegally abused and marketed in Kuwait. Additionally, we report a direct gender-based association between mortality and consumption of certain substances. These findings suggest that there is a growing need to conduct larger scale studies to implement new strategies, policies, and interventions in populations affected by illicit drugs.
... The male sex was, unsurprisingly, a recurrent associated risk factor with tobacco use. This sex disparity was common with other studies' findings both in Arab countries 40,41,43,47,67,68 and even elsewhere, 45,69-72 that indicates a significantly higher prevalence of tobacco use among males. But it is noteworthy that in Morocco, as in other Arab-Muslim countries, tobacco use is more disapproved among women than men. ...
Introduction
Tobacco use is the major preventable cause of premature death worldwide, responsible for about 8 million deaths per year, mostly in low- and middle-income countries, such as Morocco. Adolescents’ tobacco use is a matter of concern, because early initiation increases the risk of becoming a lifelong user. There exists a notable gap in the synthesis of evidence concerning tobacco use among Moroccan adolescents. Thus, the purpose of this study was to provide a comprehensive view of the prevalence of tobacco products’ use and associated factors among adolescents in Morocco.
Methods
We systematically searched PubMed, Scopus, Web of Science and ScienceDirect for relevant studies reporting prevalence rates of tobacco products’ use among Moroccan adolescents, published until June 2024, using inclusion and exclusion criteria in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Additional searches were completed on other sources to reach unpublished reports. The Joanna Briggs Institute Critical Appraisal Checklist was used to assess the quality of included studies.
Results
After the final screening, 22 papers met the inclusion criteria. Life-time prevalence of tobacco use ranged from 7.8% to 20.4% for cigarettes smoking, from 10.6% to 21.9% for waterpipe, from 7.9% to 9.1% for chewing tobacco and from 9.2% to 12.4% for snuff. The last 12-month prevalence of cigarette smoking was comprised between 6.9% and 10.8%. As for the prevalence of current use, ranges of (1.8%-16.4%) and (4.9%-8.4%) were noted for cigarettes and waterpipe, respectively. The most commonly highlighted risk factors for tobacco use included male sex, older age, having friends or family members who use tobacco and low perception of risk associated with tobacco use.
Conclusion
Our findings reveal an alarming situation of tobacco use among Moroccan adolescents. Therefore, it is crucial that all stakeholders engage in concerted efforts to develop and implement evidence-based preventive interventions among early adolescents.
... Earlier studies endorsed that smoking is generally the first step towards drug addiction because smoking is very common in the society with lesser restrictions (e.g., Quigley, 2014;Omu et al., 2017). Students then start taking drugs, usually charas (cannabis), through the cigarette. ...
A rapid increase in drug addiction among students of academic institutions has emerged as a serious social problem confronting the contemporary Pakistani society that constitutes one of the highest proportions of young people in the world. This study was designed to explore the processes that lead to drug addiction among students of higher education institutions and how it affects their everyday activities. To gain insights to the phenomenon, the study deployed the qualitative research approach involving in-depth interviews with drug addict students from three public-sector universities in Pakistan. The data were analysed through narrations and thematic analysis. The results unveil that students consume drugs in the universities without much restriction and risks as the academic institutions have not taken serious steps to address the issue in their premises. There is an urgent need for Pakistan to develop a comprehensive strategy to address the alarming problem of drug addiction in academic institutions involving all the stakeholders to interrupt the supply chain and punish those who are involved in the heinous crime of trading illicit drugs.
... This theory acts as if their drug use is supposed to be a one-time occurrence, which ignores the fact that this special occasion can turn into a daily habit and possibly drug dependence. According to Omu et al. (2017), adolescents are the population who is most likely to use drugs. So health concerns are raised when looking at young populations and their risk of drug use. ...
A third of Hispanic youth live below the poverty line, making them vulnerable for exposure to gangs, substances, and violence, all of which have been associated with substance use. The aim of the present study was to test the link between these variables, using a multiple mediation model. Results suggest that the relationship between gang exposure and adolescent substance use was mediated by both access to substances and exposure to violence. Findings provide insight into how gang exposure impacts outcomes for low-income youth. Implications for prevention and policy are discussed.
Conceptualizing aetiology underpinning an individual's substance use disorder (SUD) not only facilitates insight and understanding, but also serves to identify targets for treatment and aid practitioners in selecting the most appropriate interventions. There is now a wealth of literature on aetiology and treatment approaches, and in more recent years, also literature to support the concept of 'recovery' from a condition which was previously thought of as a chronic, relapsing condition. The burgeoning literature around research into recovery is revealing how recovery can best be defined and what factors might be associated with recovery from SUD. To add further to this growing body of literature, a new six-domain, explanatory biopsychosocial model of substance dependence and recovery, the Lifestyle Balance Model (LBM) is proposed. Based on research findings and theory reported in the literature, the LBM is a generic model depicting six domains of biopsychosocial functioning and includes within it the role of lifestyle. The LBM has been constructed as a domain model, allowing conceptualisation of the relationships between the six domain areas that perpetuate dependence and may also be associated with recovery from SUD, providing service users and clinicians with a tool for the delivery of case formulation and identification of target areas for intervention.
THE USE OF NATURALLY OCCURRING MOOD-
altering substances is deeply rooted in the traditions and cultures of many communities worldwide. As documented in other societies and historical records,1,2 various compounds have been employed for altering consciousness and for their curative effects.3 Two substances traditionally used in the Middle East include hashish and khat.4 Hashish, as cannabis, has been known in the region since ancient times.5 Khat, also known as chat, derived from the leaves and young shoots of the khat plant (Catha edulis), is used for its stimulant effect.6 Technological advances that enable high purification of drugs and transporting them fast, and increasing urbanisation, have caused these mood altering substances to be taken out of their traditional role in societies and have come to pose new, complex and challenging threats.7 These threats have been manifested in two important ways: () wider use of drugs, and (2) a shift from natural drugs to the more potent purer forms. Globally, illegal money derived from illicit drug transactions amounts to 400 billion dollars annually, and is second only to the arms trade.8,9 The countries of the Arabian Gulf Co-operation Council (GCC) offers an interesting study area because their diverse cultures have experienced rapid acculturation, a phenomenon often equated with a rise in psychosocial stress.10 Psychosocial stress has often been associated with vulnerability to self poisoning11 and substance abuse.12 Although there are no adequate statistical studies to indicate the incidence of substance dependency in the GCC, it is clear that substance abuse is not a minor problem considering the number of reported drug seizures by the authorities.13 In real terms, the drugs seized by law enforcement authorities constitute only 5–0 percent of the actual quantity.14 Comprehensive data on the pattern of substance dependency is hampered by the criminal and moral stigma associated with substance dependency. Whatever the real number of people afflicted with addiction, substance dependency is a severe problem when considered in terms of personal distress, family disruption and interference with productivity and economic growth. Efforts have been undertaken in GCC countries to reduce the demand for drugs and to prevent drug abuse before it occurs. These efforts are coordinated through the Demand Reduction Committee, created in 200 with members from all countries of the GCC. The committee provides leadership in coordinating and facilitating strategies in this area including law enforcement, rehabilitation and leading and assisting the community in the task of education and prevention of substance abuse. Some studies have suggested that substance dependency occurs in adolescents in all strata of the society.14–16 However, these studies are limited to self-report questionnaires based on secondary school students. Although peer pressure is likely to play a significant part in the initiation of substance abuse,16 the subsequent heavy abuse is often associated with various psychosocial factors. It has been suggested that of all the social factors that predispose individuals to substance abuse, boredom is the most significant.14,17 The recent affluence and modernisation of the GCC societies have led many people to have a lot of spare time, as household chores are carried out by expatriate servants.14 The detrimental effects of such a lifestyle, including substance dependency, have been speculated in the literature.13,18–21 In a study cited by Al-Harthi14 of personality profiles and descriptive analyses of typical substance users enrolled in a treatment centre in Riyadh, Saudi Arabia, the most frequently stated reason for indulging in drugs was to escape boredom. This view, though substantiated by other studies in the region,22,23 has not taken into account the relationship of individual temperament to substance abuse. Recent studies have suggested that phenotypical “risk takers” or “sensation seekers” are often not inhibited from yielding to various illicit practices including substance abuse.24 Future studies in the region should examine the association between personality types, risk taking behaviour and boredom. The premise that the rise in substance dependency might be precipitated by erosion of traditional family networks and skewed social expectations might be relevant to GCC countries. Al-Hashmi18 has suggested that modernisation has resulted in the Omani family becoming nuclear at the cost of the traditional extended family. Concurrently, domestic servants brought from overseas, often illiterate in the dominant language, are providing much of the socialisation to children. Reinforced by frequent international travelling, satellite televisions and the Internet, acculturation appears to have occurred too quickly in GCC societies. Smith has remarked that these changes have brought these communities development that took a thousand years in Europe in less than 20 years.25 Studies from other parts of the world that have experienced similar rapid pace of modernisation have shown disintegration of native culture and identity as well as dissolution of the social network, to which individuals had previously turned for help when in trouble.26 In addition, the spread of education have resulted in higher levels of expectations. In the new social order, individuals in the region tend to regard employment opportunities, guaranteed higher levels of income, and especially, higher social standing, as acquired rights. Frustration of the desire to climb the social ladder leads to social insecurity.14 The present situation of society in transition fits with the classical sociological observations of Ibn Khaldun and Emile Durkheim: rapid transformation leads to breakdown of traditional social cohesion.14As a result, the sense of belonging becomes a luxury, leading to social drift, alienation, and the proliferation of social misfits. The society itself may become anomic. The relationship between acculturation, anomie and drug taking has received empirical support.27 The present tendency is to view substance abuse in its psychosocial context rather than on moral terms. While more studies that are comprehensive are needed to examine the pattern of use and misuse of drugs in the GCC countries, there are various reasons to assume that substance dependency is likely to continue to pose a problem in the region. First, the geography helps both trafficking and consumption. GCC countries are located close to the “Golden Triangle” or “Drug Belt”, a part of Asia where underdevelopment and political instability have fuelled drug driven economies. Second, being on a major route for international airlines and sea routes by virtue of being in the middle of the world, GCC countries are at constant risk of being used as trans-shipment points for drug trafficking. The Arabian Peninsula has a vast coastline with its horizon overlooking major sea routes to different continents. Even if vigilance to guard its borders is heightened, such a long coastline would remain porous. Moreover, effective surveillance would require more allocation of resources and work force, drawing vital resources away from establishing essential remedial and rehabilitation services for the victims of substance abuse. Thirdly, the increasing number of visitors and the presence of foreign labour in the GCC also help make the “Gulf route” a crossroad for trans-world drug supplies. Some individuals may fall prey to the fallouts from these passing illegal shipments even though they may be destined elsewhere. It is also possible that an increase in consumption of illicit substances among the local population has in itself escalated the demand. In support of the latter view are the rising statistics on the mortality related to drug abuse and the number of clients seeking treatment in rehabilitation centres in the GCC states.15,28 Dispensing accurate information on issues related to substance abuse is a key component to fighting drug abuse. Studies are needed to illuminate the effect of substance dependency in the GGC countries as the mass media often tends to downplay the risks of drug use, or sometimes even glamorises it. Evidence is emerging on the personal consequences of substance dependency. Okasha, in the context of Egypt, has demonstrated that substance dependency is likely to lead to underachievement at school or work and exacerbate family stress, financial burdens and exposure to criminal activity.29 However, literature does not discern whether these social problems are the cause or the effect of the substance dependency. Substance dependency is often associated with psychiatric morbidity30 but it is not clear whether this is cause or effect. Karam et al in their report from Lebanon suggest a strong relationship between addiction to substances of abuse and psychiatric diagnoses.31 These authors further suggest that certain personality types often abuse specific substances. However, such a simplistic view appears to be merely reiterating the chicken-or-the-egg argument. Some authors have suggested that substance dependency is a form of self-medication, which implies that individuals with substance dependency have high levels of psychosocial distress and use illicit drugs in an attempt to alleviate their distress. This is relevant to the suggestion that some psychiatric symptoms may mimic withdrawal effects of chronic substance dependency and withdrawal symptomatology co-varies with cognitive and psychological functioning.32 In addition to psychiatric illness, substance dependency has been seen to increase the risk of adverse drug reactions. A well-known complication of substance dependency is the risk of transmission of human immunodeficiency virus and other infections.33
VISIBLE PATTERNS IN THE GCC The discovery of oil in the GCC has brought rapid modernisation as well as unprecedented material progress and economic security.34 Although GCC nationals, like other cultural groups in developing countries, are thought to have beliefs that protect them against developing substance dependency, such beliefs appear to be eroding with the rising tide of acculturation and economic restructuring. Demographic factors such as the preponderance of adolescents in the population will continue to elude those advocating demand reduction policies even if harsher penalties are decreed for traffickers and users. Approximately 60% of the population in the region are less than 20 years old.35 As reported elsewhere, 36 adolescents are prone to risk taking behaviour, a temperament that has been associated with developmental milestones including the underdevelopment of the orbital-frontal cortex.34 In GCC countries, the rate of juvenile delinquency has, in a span of 0 years, increased approximately by 400%. Unless the needs of such a large and important segment of society as its young people are addressed, this may present a demographic time-bomb with unpredictable social consequences. With a fast growing population, competitions for social and occupational roles are likely to be more intense, leaving many failed individuals behind. With such a demographic trend, it is likely that many individuals carry a greater risk of developing various adjustment difficulties including substance dependency.37 Data emanating from other developing countries suggest that drug peddlers tend to target the poor and the unemployed. Whereas substance dependency in other parts of the world is often associated with economic and social breakdown,38 no study has examined whether substance dependency in the GCC countries follows the same pattern.39 Preliminary observations in Oman suggest that there is relationship between unemployment and propensity for substance abuse.14 Interestingly, the study suggests that addiction to illicit drugs is likely to interfere with employment, often rendering some individuals to lose their jobs. In the midst of such conflicting views, further studies are needed to ascertain the conditions that trigger drug dependency in the community.40 While more information is needed in order to make an informed policy on substance dependency, there is some evidence pointing to which substances are widely abused in GCC countries. First, clinical reports suggest that solvent misuse is extensive although no formal studies have been conducted. Hafeiz41 has suggested that abuse of solvents often occurs in order to overcome the boredom of modern living. There is also increasing evidence to suggest that some of these agents cause mental disorders42 as well as neurological complications.43 The chemicals in question include glues, liquid shoe polish, deodoriser, petrol, cologne and insecticides.44,45 A special pattern of substance dependency associated with social deviancy and delinquency also involves a home-made mixture of dates and ointments as well as inhalation of intoxicating fumes derived from burning the wings of cockroaches and ants with volatile substances. Habitual inhaling of these substances is often associated with a failure to thrive.42 Secondly, inhaling smoke derived from nicotine based substances is now common in many GCC countries.46,47 Tobacco is often chewed, snuffed or smoked either in cigarettes or in sheesha. The latter (also known as hookah) is a smoking device, widely used in some communities of the Arabian Peninsula, to smoke jurak, a cooked tobacco-fruit mixture, and burnt by an electrical device or by charcoal. The produced smoke passes through the water at the base of the sheesha and then a long-tube before it is inhaled. Though most smokers consider sheesha less harmful to health than cigarette smoking,48 this has not been substantiated in regional studies.48,49 Experimental and clinical studies have found that nicotine, an active ingredient of both sheesha and cigarettes, not only triggers cardiovascular diseases, but also predisposes frequent users to various neuropsychiatric disorders.50 The question remains whether smoking triggers mental illness or people with mental illness are more likely to smoke.51 Pharmacological studies have unequivocally shown that nicotine is as addictive as other well-known psychoactive drugs such as cocaine and amphetamines.52 However, GCC countries have given a low priority to this a public health issue. Demand for nicotine has been falling in industrialised nations, 53 but a similar picture is not emerging from middle and low income countries. Cigarette companies are now targeting the developing world.53 Moreover, cigarette companies are manufacturing products of differing quality for sale in different markets. It has been shown that cigarettes of the same brand sold in developing countries have higher tar content than in the country of origin.54 Some studies have suggested that certain cigarettes are made from more potent, hence, more addictive, nicotine.53,55 As there is no known effective program to educate people about the dangers of smoking, prevention and smoking cessation appear to an unattainable goals. To compound the problem, some proponents of the “gateway phenomenon” suggest that smoking is a springboard to hard drugs such as cocaine and heroin, 56 though there is also evidence to contradict this view.57
The social problems precipitated by alcoholism have not yet been reported in the GCC countries though some reports suggest that drinking problems are proliferating.13,44,58 The World Health Organisation59 estimates that more then 5 million people are disabled because of alcohol use, making it the fourth leading cause of worldwide disability. Theobald has suggested that approximately 0% of alcohol consumers will at some time experience serious health problems related to their drinking habit.60 As many individuals are now facing the daily challenges of modern living and the pressures of modern life, alcohol abuse is thought to be one of the elusive antidotes to modern insecurity.17 Some recent findings suggest that individuals who have a high subjective level of insecurity in their lives are likely to abuse alcohol to ward of their psychosocial stress. Interestingly, people with such attributes have been seen to have refractory types of alcoholism.61 Alcohol syndromes such as delirium tremens and Korsakoff’s psychosis are known to occur among people who consume it regularly.50 Persons at risk of drinking problems cannot be reliably identified in the population; therefore the pattern of drinking and its psychosocial correlates are indicated for the GCC countries. The bulk of the studies21,45,58 have focused solely on exploring the validity of research instruments on cross-cultural application of drinking attitude and behaviour. Little is known on the effect of alcohol repackaged as “cologne” available in some GCC countries.62,63 Colognes or ethyl alcohol-containing perfume and after-shave are sometimes ingested as an alcohol substitute.64 Relevant to this, it would be important to determine whether the availability of alcohol and other soft drugs deters people from going into narcotics that are more dangerous. One suggestion is that in those societies of GCC where there is a relaxed attitude towards alcohol, there are fewer propensities towards heroin and other dangerous drugs.14 It also not clear how such information would be helpful in planning intervention programs in GCC countries, as the experiences from other societies suggest a complex relationship between alcohol and substance abuse. The “gateway theory” would suggest that using alcohol leads people to use harder drugs like cocaine and heroin.65 There is also scant information on the pattern and psychosocial correlates of over-the-counter medications in the GCC countries. Though generally viewed as harmless, many of them have the potential for abuse, particular those that are considered to be amphetamine-like stimulants.66 These includes nasal decongestants, bronchodilators, appetite suppressants and energy pills and drinks.
While there is no evidence to suggest that cocaine and hallucinogens are widely consumed in the GCC countries, 13 the story of opiate use is somewhat different. Historical documents suggest that opium was considered as a medicinal substance in the Middle East. It was recommended by various towering Arab figures such as Ibn Sina.1 More recently, however, its semi-synthetic counterpart, heroin, far removed from its cultural context, is becoming the drug of choice for addicts in the GCC countries. Being close to heroin producing regions of the world, GCC appears to be the trafficker’s place of choice. Being capable of causing compulsive dependency within a short time, heroin has a devastating effect on the user and society in general. To those who are addicted to heroin, it appears the habit leaves them little time for meaningful life. To compound the problem, as 90% of GCC heroin addicts use it intravenously, sharing of contaminated needles causes infections of human immune deficiency virus and a high incidence of other infections.33 Similarly, the number of cases of heroin addiction is often directly related to the number of crimes.27 Despite stringent regulations to reduce the supply and demand, the habit proliferates. Judging from the quantities of drugs seized by the authorities, the last decade has witnessed a dramatic increase in the number of cases of heroin addiction, the number of addicts seeking rehabilitation, and death due to heroin overdose.
PROSPECTS FOR THE FUTURE
Rehabilitation for addiction is often in the hands of psychiatric or penitentiary services though some specialised centres have emerged in some GCC countries.16 Culturally sensitive interventions seem to be often relegated to fringe importance. Medical interventions are likely to grow considering the many claims about new pharmacological tools that take advantage of the chemical properties of alcohol and other drugs. However, drug treatment for substance dependency should not hold up the search for psychosocial predisposing factors, which, in turn, could be a springboard for educational strategies to reduce demand. Indeed, blind adherence to pharmacological intervention not only seems similar to drug peddling, but also may be counterproductive in the long term. A biomedical explanatory model of substance dependency may lead to stigma, and lessen the individual and societal accountability in tackling compulsive dependency. Stressing personal responsibility, on the other hand, motivates one to change, as well as help one understand the challenges ahead and evolve coping mechanisms.67
As distress and stress are experienced in a socio-cultural context, rehabilitation services should avoid committing what Kleinman has called a “category fallacy”, where a view of human nature developed for one cultural group is uncritically applied to members of another group for whom its validity has not been established.68 According to Kleinman, this results in a “distortion of pathology” rather than a critical understanding of the ways in which the members of a different cultural group perceive, experience and communicates beliefs and distress. One of the essential grounds for formulating enlightened policies toward drug dependency is to consider the society’s outlook towards mood altering substances. Despite the documented frequency of substance abuse in GCC countries, a review of the literature reveals no objective studies on knowledge, attitude and perception. Opinion towards substance dependency among citizens of GCC countries is likely to have a wide-ranging influence, affecting issues as diverse as personal consequences of substance dependency, prevention, care and management of people with substance abuse. Historical and cross-cultural studies have suggested that individuals with substance dependence are likely to encounter active discrimination and harassment which, in turn, exacerbates their psychosocial predicament and perpetuates their relapse into drug taking.37 Similarly, it has been suggested that social attitudes can be more devastating than the addiction itself, and the addict’s family suffers as well.69 Although many victims of substance dependency could benefit from treatment, attitudes of society towards them is likely to hamper their seeking rehabilitation. As a result, many are likely to stay underground until addiction has reached an advanced stage of irreversible pathology. This not only increases pessimism of the victims and those around them but also shatters the prospect of recovery. Therefore, more research in GCC countries should be conducted in order to shed light on socio-cultural factors that precipitate individuals to succumb to substance abuse. This would open the door for contemplating strategies to achieve a reasonable level of prevention as well as to prioritise which aspects of services are pertinent to the region. Grinspoon and Bakalar have suggested that of all the mistakes repeated, the most serious is trying to free society of drugs via legislation and regulation.70 Indeed, many studies1 suggest that no punitive measure deters availability and abuse of drugs.14 It appears that financial gain is one of the strongest determining factors. Globally, though consensus from the experts in the field suggests that substance dependency is a disease, public opinion often considers it a form of moral degeneracy that can destroy social values. As a result, victims of substance dependency are sent to the prison. Many countries have pursued the idea of creating a national consensus towards zero tolerance for substance abuse and death penalty for drug traffickers. The policies fluctuate between curbing trafficking, reducing demand and decriminalisation of certain classes of drugs.71 Some countries have considered decriminalizing soft drugs and the debate continues on the rationale of dispensing heroin to heroin-addicts.72 Although more time is needed to assess the long-term outcome of these new programs, history has shown that none of the previous campaigns to curb the spread of substance misuse has worked. Instead, the situation appears to be summed up in Bob Marley’s lyric, “So you think you have found the solution; But it’s just another illusion”.
CONCLUSION
The problem of drug abuse in the GCC is a multi-dimensional one without easy solutions. This paper has touched upon several of these issues. Even though for zero tolerance to substance dependency is advocated, no program has been found to be universally successful in reducing drug dependence. Historically, many societies have tried both criminalisation and decriminalisation but to no avail. Despite all the technologies to monitor and legal authority to bring the drug traffickers to justice,including the threat of death penalty, dealing with substances that cause addiction is becoming a global challenge of ever increasing magnitude. More discouraging, the problem has even affected societies where one would expect cultural factors to protect them from the attraction of drugs. The purpose of this paper, thus, is to “point a finger to the moon”, the moon symbolising the complexity of substance dependency. One should not confuse the moon with the finger that points to it.
This article examines differences and similarities in adolescent tobacco use among Member States of the Health Ministers' Council for the Gulf Cooperation Council (HMC/GCC) using Global Youth Tobacco Survey (GYTS) data.
Nationally representative samples of students in grades associated with ages 13-15 in Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates, and Yemen. Schools were selected proportional to enrollment size, classes were randomly selected within participating schools, and all students in selected classes were eligible to participate.
GYTS results confirmed that boys are significantly more likely than girls to smoke cigarettes or use shisha (water pipe). Students had higher rates of tobacco use than adults in Bahrain, Oman, and United Arab Emirates. For boys and girls, shisha use was higher than cigarette smoking in almost all countries. Susceptibility to initiate smoking among never smokers was higher than current cigarette smoking in all countries. Exposure to secondhand smoke in public places was greater than 30%, direct protobacco advertising exposure was greater than 70% on billboards and in newspapers, and more than 10% of students were influenced by indirect advertising. Finally, less than half of the students were taught in school about the dangers of tobacco use in the past year.
For boys and girls, high prevalence of cigarette smoking, high prevalence of shisha use, and high susceptibility of never smokers to initiate smoking in the next year are troubling indicators for the future of chronic disease and tobacco-related mortality in the Member States of the HMC/GCC.