Dual alcohol and cannabis use in male and female adolescents: Relationships with family variables

Abstract

Family dynamics influence adolescents’ use of alcohol and other substances, such as cannabis. The aim of this study was to understand the relationship between family variables and alcohol use, dual use of alcohol and cannabis, and non-use in adolescents according to sex. A cross-sectional study was conducted. The sample comprised 879 adolescents (56.4% boys; M(SD)age = 14.25 (1.88) years). Multinomial regression analysis showed that for boys, the presence of family conflict increased the likelihood of being an alcohol (OR = 1.19) and dual (OR = 1.22) user rather than a non-user. For girls, communication reduced the probability of being an alcohol user (OR = 0.89), and the presence of consequences for breaking rules reduced the probability of being a dual user rather than a non-user (OR = 0.83) or an alcohol user (OR = 0.83). These findings highlight the importance of family prevention of adolescents’ substance use, bearing in mind the participants’ sex.

Full text

Addictive Behaviors 146 (2023) 107798
Available online 1 July 2023
0306-4603/© 2023 Published by Elsevier Ltd.
Dual alcohol and cannabis use in male and female adolescents:
Relationships with family variables
Dalila Eslava
a
, Carmela Martínez-Vispo
b
, Víctor Jos´
e Villanueva-Blasco
c
,
*
,
Jos´
e Manuel Errasti
a
, Susana Al-Halabí
a
a
Department of Psychology, Faculty of Psychology, University of Oviedo, Plaza de Feijoo, 33003 Oviedo, Spain
b
Departament of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Santiago de Compostela, Calle Xos´
e María Su´
arez Nú˜
nez, s/n, 15782
Santiago de Compostela, Spain
c
Faculty of Health Sciences, Valencian International University, C. del Pintor Sorolla, 21, 46002 Valencia, Spain
ARTICLE INFO
Keywords:
Alcohol
Cannabis
Dual use
Family variables
Adolescents
ABSTRACT
Family dynamics inuence adolescents’ use of alcohol and other substances, such as cannabis. The aim of this
study was to understand the relationship between family variables and alcohol use, dual use of alcohol and
cannabis, and non-use in adolescents according to sex. A cross-sectional study was conducted. The sample
comprised 879 adolescents (56.4 % boys; M(SD)age =14.25 (1.88) years). Multinomial regression analysis
showed that for boys, the presence of family conict increased the likelihood of being an alcohol (OR =1.19) and
dual (OR =1.23) user rather than a non-user. For girls, communication reduced the probability of being an
alcohol user (OR =0.88), and the presence of consequences for breaking rules reduced the probability of being a
dual user rather than a non-user (OR =0.83) or an alcohol user (OR =0.84). These ndings highlight the
importance of family prevention of adolescents’ substance use, bearing in mind the participants’ sex.
1. Introduction
Substance use in adolescence is an important public health issue due
to its negative consequences (World Health Organization, 2018).
Alcohol use is particularly important at this age, not least because of its
association with the early use of other substances such as cannabis
(Stamates et al., 2021) and an increased likelihood of risky alcohol use in
adulthood (Elsayed et al., 2018). The most recent prevalence data about
substance use in Spain indicate that alcohol is the most-used legal sub-
stance in adolescence, while cannabis is the most-used illegal substance
(Espa˜
nol, 2021). Previous studies have indicated that adolescence is a
period in which experimentation and use of various substances is routine
(Moss et al., 2014), with the dual use of alcohol and cannabis being
common (Lees et al., 2021; Yurasek et al., 2017), especially by boys
(Patrick et al., 2018; Subbaraman & Kerr, 2015; Thompson et al., 2021).
In Spain, 75.2 % of adolescents with problematic cannabis use also re-
ported having binged on alcohol during the previous month (Espa˜
nol,
2021).
The literature shows that dual alcohol and cannabis use is related to a
higher frequency and quantity of use of the two substances than when
either is used alone (Patrick et al., 2018), increased likelihood of driving
under the inuence of drugs (Kelley-Baker et al., 2021), risky sexual
behaviors (Green et al., 2017), mental disorders (Yurasek et al., 2017),
and long term alcohol dependency (Wardell et al., 2020). In addition,
Banks et al. (2019), found that adolescents who were polyconsumers of
cannabis and other substances, including alcohol, demonstrated worse
perceptive reasoning, more internalizing problems, and more compli-
cations related to substance use than those who only used cannabis.
Social factors have been shown to be relevant variables related to
adolescent substance use, including siblings and family members. In this
vein, Thomas et al. (2022) found that siblings exert an inuence on each
other’s participation in risky behaviors, including alcohol and cannabis
co-use. Similarly, the association between family variables and sub-
stance use in adolescence is well-established in the literature (Xia et al.,
2019). Family conict is one of the most widely-studied aspects (Best
et al., 2014; Eslava et al., 2022), and high scores in this variable predict
more prolonged, problematic alcohol and cannabis use (Best et al., 2014;
Elam et al., 2018; Hern´
andez-Serrano et al., 2021). Other family vari-
ables, such as parental support and communication, also signicantly
inuence adolescents’ development of healthy behaviors (ˇ
Sumskas &
* Corresponding author at: Valencian International University, C/ Pintor Sorolla, 21, 46002 Valencia, Spain.
E-mail address: vjvillanueva@universidadviu.com (V.J. Villanueva-Blasco).
Contents lists available at ScienceDirect
Addictive Behaviors
journal homepage: www.elsevier.com/locate/addictbeh
https://doi.org/10.1016/j.addbeh.2023.107798
Received 12 April 2023; Received in revised form 27 June 2023; Accepted 1 July 2023

Addictive Behaviors 146 (2023) 107798
2
Zaborskis, 2017). Adolescents have been found to be at less risk of
alcohol and cannabis use where they have more family support (Moore
et al., 2018) and better communication between family members
(Cambron et al., 2018; Moore et al., 2018; Ryan et al., 2010). Moreover,
Zuckermann et al. (2020) indicated that family support reduced the risk
of substance use.
Another family factor that has been examined in relation to drug use
is the rules about substance use. Heerde et al. (2019) noted that when
adolescents did not have rules about substance use or where the rules
were not clear, the frequency of alcohol and cannabis use in the previous
twelve months was higher. Hummer et al. (2022) found that adolescents
who felt that their parents approved their alcohol and cannabis use
demonstrated greater use of both substances in adulthood. Looking at
the consequences of rule-breaking, Miller et al. (2017) found that ex-
pectations of being punished for cannabis use could be a protective
factor, as the presence of such expectations was negatively related to
use. However, Cox et al. (2018) found no signicant results regarding
the consequences of alcohol use, highlighting the importance of
continuing to study this relationship given the scarcity of research.
Despite that family variables have been extensively studied in substance
use, the literature about the relationship between family variables and
dual use of alcohol and cannabis in adolescence is scant. Bri`
ere et al.
(2011) indicated that the use of these two substances in the previous
twelve months was related to poor communication and the presence of
conict with parents, as well as with the absence of parental rules.
According to the literature, it seems that the prevalence of dual
alcohol and cannabis use is greater in boys (Bri`
ere et al., 2011;
Thompson et al., 2021), as is the probability of consuming various
substances (Zuckermann et al., 2020), and developing use problems
(Fern´
andez-Artamendi et al., 2021). As far as we are aware, no studies
have examined the association between family variables and dual
alcohol and cannabis use by sex. This analysis may be interesting, as
parents seem to encourage different behaviors in their sons and
daughters (Naldini et al., 2018), and adolescents, depending on their
sex, seem to have different interpretations of the family context (Guo
et al., 2018). Furthermore, most studies about dual alcohol and cannabis
use have used medium-term use data (previous 12 months). Using short-
term measures of use (e.g., previous 30 days) would give more reliable
ndings about the relationship with family variables at the current time.
In addition, existing studies have tended to limit themselves to exploring
the dynamics with parents, without considering other members of the
family who may also inuence substance use (Howe et al., 2020).
Additionally, in Europe, between 77.2 and 90.9 % of people that use
cannabis mix this substance with tobacco (spliff), compared to 4.4–16.0
% of Americans (Hindocha et al., 2016). Although most of the literature
examining cannabis focuses merely on that substance, it would be
interesting to consider this phenomenon in European samples. For
instance, in Spain, 86.4 % of boys and 89.2 % of girls between 14 and 18
that use cannabis mix this substance with tobacco (Espa˜
nol, 2021). To
our knowledge, no studies have examined dual alcohol and cannabis use
with this conceptualization which has been pointed as a relevant ques-
tion when investigating cannabis use (Hern´
andez-Serrano et al., 2021).
Based on the reviewed literature and the relevance of understanding
the social and contextual variables involved in adolescent substance use
in order to intervene in this problem, as highlight Zuckermann et al.
(2020), this study aimed to examine the relationship between family
variables and only alcohol use, dual use of cannabis and alcohol, or non-
use according to sex in a sample of Spanish adolescents. Due to the
scarcity of studies analyzing this question, the present research may
offer novel and notable ndings with implications for designing and
tailoring preventive strategies.
2. Method
The study design was approved by the Ethical Research Committee of
Aragon (Spain) and Research Ethics Committee of the Valencian
International University (Spain). The study was conducted in accor-
dance with the Declaration of Helsinki and complied with the ethical
standards established in the Spanish Data Protection and Guarantee of
Digital Rights Law 3/2018.
This was a cross-sectional study; the STROBE checklist can be found
in the Supplementary material.
2.1. Participants
The target population was 912 Spanish adolescents from two sec-
ondary schools in the east of Spain selected by convenience sampling.
The inclusion criteria for participating in the study were (1) providing
parents’ or legal guardian’s written informed consent and (2) being
willing to participate. Most of the target population agreed to participate
(96 %). The nal study sample consisted of 879 participants (56.4 %
boys, Mage =14.25; SD =1.88, range =11–19).
2.2. Measures
2.2.1. Sociodemographics
An ad hoc questionnaire was administered to collect sociodemo-
graphic information (age, sex, ethnicity, school year).
2.2.1.1. Alcohol and cannabis use. The scales for alcohol and cannabis
use were from the ESTUDES 2012 survey (Espa˜
nol, 2014). Alcohol use
was measured using the question “How many days have you used
alcohol in the last 30 days?”. Cannabis use was measured using two
questions, “Indicate if you have used cannabis and tobacco combined
(spliff) in the last 30 days” and “Indicate if you have used cannabis
(joint) in the last 30 days”. Both questions were included since cannabis
is frequently used mixed with tobacco in Spain.
2.2.2. Family-related variables
The Evaluaci´
on Familiar Estrat´
egica [Strategic Family Evaluation]
(EFE) (Morell-Gomis et al., 2011) was use to measure family-related
variables. This consists of a self-report instrument assessing ve con-
structs about family dynamics (communication, social support, conict,
rules and consequences). It consists of 18 items, and they are rated on a
ve-point Likert scale (1 =never; 5 =always). The original instrument
assesses each dimension for each family member. In the present study,
only the adolescents lled out the questionnaire.
2.3. Procedure
Prior to the administration of the questionnaires, the school sent a
letter to the students’ legal guardians requesting their consent. The letter
informed them of the voluntary nature of the children’s participation
and the condentiality of the data by means of an alphanumeric code.
We protocolized the administration of the instrument battery. At the
beginning, we asked the students’ teacher to conrm the guardians’
authorizations. Next, we presented the study to the students, briey
explaining the research and requesting their collaboration. The ques-
tionnaires were completed in the students’ regular classrooms during
school hours (approximately 30–40 min), under the researcher’s
supervision.
2.4. Analytical strategy
First, descriptive statistics for the total sample were calculated as
mean ±standard deviation for continuous variables and as frequency
(percentage) for categorical variables. Second, substance use and family-
related variables according to sex were assessed using the chi-squared
test and t-test. Then, a one-way analysis of variance (ANCOVA) was
used to compare differences in continuous family-related variables by
substance use, including sex and age as covariates. For this purpose,
D. Eslava et al.

Addictive Behaviors 146 (2023) 107798
3
three categories were created: non-use, only alcohol use, or both alcohol
and cannabis use. A group for cannabis-only users was not created since
only 1.2 % participants reported using cannabis and not alcohol. Bon-
ferroni tests were used for multiple comparisons. Where the assumption
of homogeneity of variances was violated, the Brown-Forsythe test and
Games-Howell tests for multiple comparisons were used.
Finally, multinomial logistic regression analyses were conducted
separately for male and female participants, including family-related
variables as independent variables (Communication, Social Support,
Conict, Rules, Consequences), age as a covariate, and substance use as
the dependent variable (three levels: non-use, only alcohol use, and both
alcohol and cannabis use). Overall model t (R
2
,
χ
2
) along with the
unstandardized parameter (B), standard error, odds ratio (OR), and 95 %
condence interval (CI) were calculated for the models. To illustrate
these results, ORs and Lower and Upper CI are represented with forest-
plot graphs. A p-value of <0.05 was considered statistically signicant.
Data analysis was done using IBM SPSS Statistics for Windows, Version
26.0 (IBM Corp., Armonk, New York, USA).
3. Results
3.1. Demographics, substance use and differences according to sex
A little over half of the total sample (56.4 %) were male and 43.6 %
were female. The ages of the sample ranged between 11 and 19 years (M
=14.25; SD =1.88). Less than a quarter (23.9 %) of the male and 29.2 %
of the female participants had used only alcohol during the previous 30
days (26.2 % of the total sample). Of the total sample, 10.1 % used
cannabis in the last 30 days (10.7 % males and 9.4 % females).
Regarding modality of use, 52.8 % only used cannabis mixed with to-
bacco (spliff) (n =47), 10.1 % only used cannabis joints (n =9), and
37.1 % (n =33) used both modalities (spliff and joint). When examining
alcohol and cannabis use, 9.9 % of the male participants and 7.6 % of the
female participants reported dual use during the previous 30 days (8.9 %
of the total sample).
Non-signicant differences were found in substance use according to
sex (Table 1). However, in family-related variables, female participants
reported signicantly higher communication and social support scores.
3.2. Differences in family-related variables according to substance use
Statistically signicant differences were found in family-related
variables between participants who had not used alcohol or cannabis
and those who had (alcohol only, or both alcohol and cannabis)
(Table 2). The post-hoc test showed that non-users’ family communica-
tion, social support, rules, and consequences were signicantly higher
than those who had used alcohol or alcohol and cannabis during the
previous 30 days (Table 3). These tests also showed that family conict
scores were signicantly higher for those using alcohol or alcohol and
cannabis than non-users.
3.3. Multinomial regression analysis for family-related variables and
substance use
Multinomial logistic regression analyses (adjusted by age) examining
family-related variables and substance use during the previous 30 days
are presented in Fig. 1, and Table 4 for male participants and in Table 5
for female participants. The results indicated that male participants with
higher scores in family conict had a higher probability of being alcohol
users (OR =1.19) or dual alcohol and cannabis users (OR =1.23) than
being non-users. Only non-signicant associations were found between
participants using alcohol and cannabis and alcohol-only users.
The results from female participants showed that higher scores in
communication were associated with a decreased probability (OR =
0.88) of being an alcohol-only user compared to non-use (Table 5).
Moreover, higher scores in consequences were associated with a lower
probability of dual-use compared to non-use (OR =0.83) or alcohol use
(OR =0.84).
4. Discussion
The aim of this study was to examine the relationship of family
variables and dual alcohol and cannabis use in comparison to alcohol
use alone and non-use according to participants’ sex. Overall, the nd-
ings indicate that the family variables inuenced the probability of ad-
olescents’ use of alcohol and dual use of alcohol and cannabis, albeit
with some differences between the sexes and for each type of use. These
ndings not only broaden our understanding of alcohol use, but also
contribute to the scant evidence available about dual alcohol and
cannabis use considering sex differences.
We did not nd any differences in the percentages of dual alcohol
and cannabis use according to sex, in contrast to other studies which
found that girls used alcohol more frequently (Kyrrestad et al., 2022)
Table 1
Differences in last-30 days substance use and family-related variables according
to sex.
Total
sample
(N =868)
Male
(n =
492)
Female
(n =376)
χ
2
p
% (n) % (n) % (n)
Substance use 1.120 0.290
Non use 63.8
(561)
66.1
(325)
62.8
(236)
Only alcohol use 26.1
(229)
24.0
(118)
29.5
(111)
Alcohol and
cannabis use
8.9 (78) 10.0 (49) 7.7 (29)
Mean
(SD)
Mean
(SD)
Mean
(SD)
t p
Communication 18.7
(4.16)
18.45
(4.17)
19.03
(4.15)
−2.070* 0.039
Social Support 17.29
(3.05)
17.06
(3.15)
17.58
(2.89)
−2.541* 0.011
Conict 9.37
(3.14)
9.30
(3.25)
9.46
(2.99)
−0.757 0.449
Rules 6.7 (2.3) 6.57
(2.28)
6.86
(2.33)
−1.833 0.067
Consequences 10.86
(3.12)
10.73
(3.11)
11.03
(3.12)
−1.412 0.158
Note. Scale ranges: Communication (5–25), social support (4–20), conict
(4–20), rules (2–810) and consequences (3–15).
*p <0.05.
Table 2
Differences in family-related variables for non-use, only alcohol use, and alcohol
and cannabis use for last-30 days use.
Non-use Only
alcohol
use
Both alcohol
and cannabis
use
F p
Mean
(SD)
Mean (SD) Mean (SD)
Communication 19.22
(4.19)
17.96
(3.92)
a
17.41 (4.06)
a
12.611 <0.001
Social Support 17.65
(2.93)
16.87
(2.99)
a
16.05 (3.55)
a
10.980 <0.001
Conict 8.82
(2.96)
10.21
(2.99)
a
10.79 (3.83)
a
21.341 <0.001
Rules 6.93
(2.35)
6.28
(2.12)
a
6.37 (2.34) 7.464 <0.001
Consequences 11.24
(3.16)
10.36
(2.99)
a
9.76 (2.88)
a
13.217 <0.001
Note. Including sex and age as covariates.
a
Signicantly different from Non-use, p <0.05.
D. Eslava et al.

Addictive Behaviors 146 (2023) 107798
4
and boys exhibited more dual alcohol and cannabis use (Thompson
et al., 2021). In the family variables, we did nd that girls indicated that
there was more communication and support in their families than boys,
which is in line with the literature (Bireda & Pillay, 2018; Chen et al.,
2019). Our results are consistent with previous research conducted in
Spanish samples that found no signicant differences in substance use
according to sex but did nd signicant differences in family variables
(Cutrín et al., 2017). In addition, we looked at the differences in the
family variables between the participants who did not use either alcohol
or cannabis, those who used only alcohol, and those who used both. The
ndings indicated signicant differences between the groups. Non-users
exhibited higher scores in communication and social support, less con-
ict, and more consequences for rule-breaking than alcohol users or dual
users. The presence of rules was statistically greater in non-users than
alcohol-only users. These results are consistent with ndings of previous
studies that have found an association between dual use in the last 12
months and poor communication, conict, less support and lack of rules
(Bri`
ere et al., 2011; Zuckermann et al., 2020).
With regard to the inuence of family variables on the probability of
boys consuming alcohol and cannabis, the results show that higher
scores in family conict were associated with a greater likelihood of
being alcohol-user and dual-user than non-user. This is in line with
previous studies that have found a robust relationship between family
conict and substance use (Best et al., 2014; Yap et al., 2017). In a
longitudinal study, Heerde et al. (2019) found that adolescents who had
used alcohol and cannabis in the previous year reported greater family
conict, relating that to problematic use of both substances in adult-
hood. In addition, Bri`
ere et al. (2011) noted a positive relationship be-
tween family conict and dual alcohol and cannabis use. In the present
study, we only saw this relationship in the male participants. One
possible explanation for this result might be that family conict is more
common with boys, as girls tend to distance themselves less from their
parents during adolescence, and reach more agreements with them (Hou
et al., 2020). Substance use may also be a regulation strategy for the
unease or discomfort family conict causes (Trujillo et al., 2016), a
strategy that is more likely in boys/men (Turner et al., 2018; V´
azquez-
Reyes et al., 2021). Nonetheless, our results differ from those presented
by Nelson et al. (2017), who found that girls with higher scores in family
conict tended to be more likely to consume cannabis. They did not nd
signicant results in boys, which they attributed to sex differences, with
the possibility that parents supervised girls more and this produced
more conict.
For the girls in our study, higher scores in family communication
were associated with a lower probability of consuming alcohol. Ohan-
nessian et al. (2016) also found this relationship only in women. Xia
et al. (2016) indicated that adolescent girls’ proper communication with
their parents is more strongly related to psychosocial wellbeing than in
boys, which is why this may act as a protective factor for alcohol use. We
did not nd any differences with dual alcohol and cannabis use, possibly
because the numbers of girls reporting this kind of use was very small.
The size and number of studies need to be increased. On the other hand,
girls who reported greater consequences for breaking the rules were
associated with a lower likelihood of being dual users than non-users or
only alcohol users. In this regard, Cox et al. (2018) found no relationship
between the presence of family rules and alcohol use, whereas Miller
et al. (2017) found a negative relationship between cannabis use and the
family applying consequences in relation to that use, which might
explain why these results appear only for dual use.
Finally, another of our study’s notable ndings was that the inu-
ence of the family variables we looked at did not demonstrate signi-
cance with regard to the probability of being a dual user or an alcohol-
only user, with the exception of differences in consequences for rule-
breaking in girls. This is a new nding, because, as far as we know, no
studies have examined the differential relationships of family variables
concerning alcohol-only use compared to dual-use. One hypothesis that
may, at least in part, explain this result is the normalization and
increasing acceptance of cannabis use (Kilwein et al., 2022). It is
important to note that the current study does not specically explore the
concurrent use of alcohol, cannabis, and tobacco, as tobacco smoking
was not examined. Research investigating cannabis use in European
samples usually report that tobacco and cannabis are frequently used
together. This form of use leads to various implications, such as an
increased likelihood of developing cannabis dependence (Agrawal et al.,
2009) and the association of exposure to nicotine to a higher probability
of future tobacco use among non-tobacco users (Belanger et al., 2013).
Therefore, it is crucial to continue investigating this approach in future
studies. It is essential to continue studying how family variables affect
the different patterns of use through longitudinal studies that examine
progression over time because adolescence is a critical period when it
comes to experimenting with substance use (Moore et al., 2018), bearing
in mind the sex of the participants. Looking at the broader picture, the
quality of family relationships has a signicant inuence on the social
and emotional well-being of adolescents (Weymouth et al., 2016).
Furthermore, Fern´
andez-Artamendi et al. (2021) highlighted the
Table 3
Games-Howell post hoc multiple comparison analyses of the analysis of variance (ANCOVA).
(I) (J) Mean Difference (I-J) Std. Error Sig. 95 % CI
LB UB
Communication Non-Use Only alcohol 1.268* 0.322 <0.001 0.50 2.04
Alcohol and cannabis use 1.814* 0.496 0.001 0.62 3.01
Only alcohol Non-Use −1.268* 0.322 <0.001 −2.04 −0.50
Alcohol and cannabis use 0.546 0.539 0.933 −0.75 1.84
Social Support Non-Use Only alcohol 0.775* 0.236 0.003 0.21 1.34
Alcohol and cannabis use 1.598* 0.363 <0.001 0.73 2.47
Only alcohol Non-Use −0.775* 0.236 0.003 −1.34 −0.21
Alcohol and cannabis use 0.822 0.394 0.112 −0.12 1.77
Conict Non-Use Only alcohol −1.394* 0.240 <0.001 −1.97 −0.82
Alcohol and cannabis use −1.975* 0.369 <0.001 −2.86 −1.09
Only alcohol Non-Use 1.394* 0.240 <0.001 0.82 1.97
Alcohol and cannabis use −0.581 0.401 0.443 −1.54 0.38
Rules Non-Use Only alcohol 0.641* 0.180 0.001 0.21 1.07
Alcohol and cannabis use 0.553 0.277 0.138 −0.11 1.22
Only alcohol Non-Use −0.641* 0.180 0.001 −1.07 −0.21
Alcohol and cannabis use −0.088 0.300 1.00 −0.81 0.63
Consequences Non-Use Only alcohol 0.878* 0.242 0.001 0.30 1.46
Alcohol and cannabis use 1.484* 0.373 <0.001 0.59 2.38
Only alcohol Non-Use −0.878* 0.242 0.001 −1.46 −0.30
Alcohol and cannabis use 0.606 0.405 0.404 −0.37 1.58
Note. CI: Condence Interval; LB: Lower Bound; UB:Upper Bound.
D. Eslava et al.

Addictive Behaviors 146 (2023) 107798
5
relevance of addressing mental health in adolescents to reduce sub-
stance use-related problems, particularly among girls, as a stronger as-
sociation has been observed in this group.
These results show how it is not just family involvement that is
needed in prevention and intervention for substance use in adolescence
(Al-Halabí Díaz & P´
erez, 2009; Errasti P´
erez et al., 2009; Fonseca-
Pedrero et al., 2021). As various authors have emphasized (Ballester
et al., 2021; Díaz-Mesa et al., 2016), sex differences also need to be
considered. Prevention programs such as “Familias que funcionan” or
interventions such as “Functional Family Suppport Therapy” that
include families present effective results for reducing both substance use
and family risk factors (Errasti P´
erez et al., 2009; Fern´
andez-Artamendi
et al., 2022). However, a gender-based approach is still a pending task.
4.1. Limitations and strengths
The current study has some limitations to be considered in inter-
preting the results. First, causal and temporal interpretations could not
be established due to the cross-sectional nature of our data. Future
research should examine longitudinal associations between family var-
iables and different patterns of substance use. Second, due to the limited
number of participants who exclusively used cannabis in the past 30
days, we could not investigate the relationship between family variables
and only cannabis use. Furthermore, the small sample size prevented us
from separately analyzing cannabis users who consumed only joints
versus those who mixed it with tobacco. Third, we did not examine
substance use quantity nor frequency but only use (vs. non use). In
addition, we have no information on whether it was a rst-time or
regular use. Future studies with greater sample sizes and gathering
complete information about forms of use and quantity are warranted to
examine family variables and cannabis use further. Fourth, other social-
related factors, such as the specic inuence of siblings, have not been
examined. Future studies should consider the role of siblings concerning
substance use. Fifth, the self-reported and retrospective nature of the
data collected may have inherent biases such as report bias, social
desirability, stigma and participant’s ability to recall information. To
Fig. 1. Forest plots for alcohol and cannabis use during the last 30 days according to sex. Note. OR =odds ratio; LLCI =lower limit condence interval; ULCI =upper
limit condence interval.
D. Eslava et al.

Addictive Behaviors 146 (2023) 107798
6
mitigate the impact of this, we used a short and recent time period for
substance use assessment (last 30 days use) in line with previous
research (Kalmijn, 2022; Pedersen et al., 2019). Finally, we only gath-
ered information adolescents provided and did not include parent report
measures concerning family variables. Future studies should also
include parent-reported data in order to prevent possible bias.
Our study does have some strengths. Methodologically, it focuses on
a sample of adolescents between 11 and 19 years old (n =879), whereas
other studies have looked at young adults (17–25 years old) (Green
et al., 2017; Hern´
andez-Serrano et al., 2021; Stevens et al., 2021). This is
important in the design of prevention policies (Gonz´
alez-Roz et al.,
2023). Patterns of use established during adolescence are likely to be
maintained over time (Terry-McElrath et al., 2017; Tomczyk et al.,
2016), and the number of different substances being used may grow
(Merrin et al., 2018). In addition, our analysis considered the inuence
of age, reducing the possibility of bias. The analysis differentiated by sex
also produced more specic results and was more sensitive to sex dif-
ferences, unlike other studies which referenced samples in general
(Bri`
ere et al., 2011; Zuckerman et al., 2020). Moreover, a novel
approach is provided by considering the pattern of cannabis use in
Europe, thus supporting cross-cultural studies. Finally, another novel
aspect of our study was the inclusion of analysis of dual alcohol and
cannabis use in the previous 30 days, compared to previous studies
which looked that the previous 12 months. This methodological
approach gave added information to the study in terms of family dy-
namics, as that can vary less over short time periods than over longer
periods.
5. Conclusions
This study contributes to the information in the literature about how
family variables inuence the probability of adolescents being users of
alcohol, dual users of alcohol and cannabis, or non-users according to
sex. The study conrms that various family variables inuence that
probability. However, there were family variables that were common to
both types of use, whereas others only exhibited relationships with one
type, and some variables were different for boys and girls. More spe-
cically, in boys, family conict was related to a greater probability of
being a user of alcohol alone or a dual user of alcohol and cannabis. In
girls, communication reduced the probability of both types of use, and
the presence of consequences for breaking family rules reduced the
probability of dual use rather than alcohol-only use.
CRediT authorship contribution statement
Dalila Eslava: Conceptualization, Methodology, Investigation, Re-
sources, Data curation, Writing – original draft. Carmela Martínez-
Vispo: Conceptualization, Methodology, Formal analysis, Data cura-
tion, Writing – original draft. Víctor Jos´
e Villanueva-Blasco:
Conceptualization, Methodology, Investigation, Resources, Writing –
review & editing, Supervision, Funding acquisition. Jos´
e Manuel
Errasti: Writing – review & editing, Visualization. Susana Al-Halabí:
Conceptualization, Methodology, Writing – review & editing, Visuali-
zation, Supervision.
Declaration of Competing Interest
The authors declare that they have no known competing nancial
interests or personal relationships that could have appeared to inuence
the work reported in this paper.
Data availability
Data will be made available on request.
Appendix A. Supplementary material
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.addbeh.2023.107798.
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