Use of tobacco, alcohol, and other substances is a worldwide problem and affects many children and adolescents.\[[@ref1]\] Early initiation of substance use is usually associated with a poor prognosis and a lifelong pattern of deceit and irresponsible behavior.\[[@ref2]\] The hope that simple information given through educational programs will be sufficient to prevent drug dependence is frequently expressed, however, there is no evidence to support it and there are many reasons to doubt it.\[[@ref3]\] Knowledge with regard to the consequences of substance use among adolescents enough to prevent them from initiating and continuing its use is a question that needs to be clarified further. Shaping the attitude of children and promotion of a healthy lifestyle, including constructive behavior is essential in the formative years of life.Therefore, keeping in focus the research question --- What is the level of knowledge and attitude held by the users with regard to the harm of substance use? --- we have formulated the objective of our study, which is, to assess the knowledge regarding harm of use and to obtain information about the attitude among high school students, and also to discover the opinion on substance use held by the users.

Materials and Methods {#sec1-1}
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This study was a population-based, cross-sectional study, conducted on 416 students in classes VIII, IX, and X, in two high schools, selected by multistage random sampling, in West Bengal, India, with no interventions. A self-administered anonymous questionnaire was administered. From the experience of the researchers in this field, we concluded that:

a)The understanding level of the students of class VIII onward, allows the administration of a self-administered questionnaire, young students might not understand the questionnaire, which could give rise to false responses and low response rates.b)Initiation of substance use usually begins at the age of 13- or 14 years.c)Students of these age groups are usually present in class VIII, IX, and X.d)Similar studies on student population have been carried out from class VIII onward.

Therefore the classes chosen represent an ideal population for this study.

Main outcome measures were substance use: knowledge regarding the harm, attitude, and opinion.

Content validity and reliability of study instruments {#sec2-1}
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The survey module was developed using an anonymous self-administered questionnaire, designed by adopting the questionnaire suggested by the World Health Organization\'s (WHO) (1980) study team,\[[@ref4]\] prior to the study, for ensuring feasibility, acceptability, time management, validity, and reliability. A pilot study was carried out at the Seventh Day Adventist Day School, Kolkata, among students in class VIII, IX, and X, following which, some of the questions from the interview schedule were modified.

Study instrument {#sec2-2}
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The pre-tested, close-ended questionnaire contained questions relating to addiction and the attitude towards it. These were related to the socio-demographic situation prevailing in India. By initial translation, back-translation, and re-translation, followed by a pilot study, the questionnaire was custom-made for the new study. The data collection tool used for the study was an interview schedule that was developed at the institute with the assistance of the faculty members and other experts. The interview schedule included the demographic variables that covered their personal characteristics such as age and gender, as well as educational level and socioeconomic status. All aspects of substance use were queried including frequency, associated factors, knowledge, attitude, and their opinion regarding substance use.

Data collection procedure {#sec2-3}
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Out of the entire list of Urban and Rural High schools in West Bengal, one school in each category was chosen randomly. Subsequently, all the 478 students in class VIII, IX, and X, in both schools (210 students in the urban area and 268 in the rural area) were initially taken as the study population. Out of the 478 students, 462 (205 students in urban area and 257 in the rural area) could be covered. They were given anonymous self-administered questionnaires. The ultimate response rate was 87.02% and 416 students could be covered in our study.

The permission to conduct the study in these two schools was taken from the Heads of the schools well ahead of the data collection. The school teachers actively co-operated during the whole period of the study. All the participants were explained the purpose of the study and were ensured strict confidentiality. Next verbal informed consent was taken from each of them before the interview. The participants were given the choice of not participating in the study if they did not want to. The collection of the data was from the 1 June, 2003 -to 31 May, 2004, and the completed ones were collected on the same day. Details of the questionnaire can be provided, if required.

Principal investigator collected the data and disseminated information on substance use in health education sessions to complement the findings of the study.

Limitation of the study {#sec2-4}
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Magnitude of substance abuse in a specified geographic area was not attempted; instead it describes the types and characteristics of a specified population group.The findings of the present study cannot be generalized to the entire population, it is specific to school children.In order to keep the anonymity, the reasons for incompleteness of responses could not be sorted out.Even after repeated visits, few absentees could not be covered.Follow up of the users could not be done.

Statistical analysis {#sec2-5}
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The data collected were thoroughly cleaned and entered into Excel spread sheets and analysis was carried out. The procedures involved were transcription, preliminary data inspection, content analysis, and interpretation. Proportions and Chi-square test were used in this study.

Indicators {#sec2-6}
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*Ever users (lifetime users):* All the users who used or abused drugs irrespective of time and frequency in his/her life.*Current users:* All the users who used or abused drugs at least once during the past 30 days.*Regular users:* All the users who used or abused drugs for 20 or more days during the past 30 days.

Results {#sec1-2}
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In our study population, the overall prevalence of substance use among high school students was 12.5 percent with 15.1 and 10.7 percent among urban and rural responders, respectively \[[Table 1](#T1){ref-type="table"}\].

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Prevalence of substance use among urban and rural students

![](JPBS-2-137-g001)

Prevalence of substance use was associated more with males than with females, as also current and regular use, which was more common among males, both among urban and rural students \[[Table 2](#T2){ref-type="table"}\].

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Distribution of urban and rural users according to gender and frequency of substance use

![](JPBS-2-137-g002)

Nearly half of the urban and rural users (urban - 69.2% and rural - 46.2%) had communicated that they had tried to quit the habit and around 15 percent of the responders expressed a desire to quit. Of the remaining, 50 percent wanted to continue the habit and others were uncertain about their decision regarding continuation of use \[[Table 3](#T3){ref-type="table"}\].

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Prevalence of substance use among urban and rural students

![](JPBS-2-137-g003)

With respect to the reasons for continuation and quitting, there were mixed responses among the urban and rural users. The urban users stated 'easy availability' (11.5%) as the most frequent reason for continuation, whereas, 'relief from tension' (19.2%) was reported by the rural users. The other reasons such as 'acceptance by peers' remained common among the respondents. 'Moral sense' (urban - 42.4% and rural - 15.4%) and 'fear of health problems' (urban - 15.4% and rural - 15.4%) were the most frequent reasons for quitting both among the urban as well as rural users. \[[Table 4](#T4){ref-type="table"}\]

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Distribution of urban and rural users according to reasons for continuation and quitting of substance use (multiple response)

![](JPBS-2-137-g004)

A majority of the respondents reported having knowledge about the harm of substance use, especially the licit ones, with almost two-thirds (urban - 84.6% and rural - 61.5%) having knowledge about tobacco and around 50 percent knowing about alcohol (urban - 61.5% and rural - 30.8%) and cannabis which was higher among the rural users (urban - 11.5% and rural - 57.7%) \[[Table 5](#T5){ref-type="table"}\].

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Distribution of urban and rural users according to knowledge regarding harm of substance use (Multiple response)

![](JPBS-2-137-g005)

Other substances for which there was no response were not included in [Table 5](#T5){ref-type="table"}.

'Media' accounted for the most common source of knowledge regarding harm of substance use (urban - 61.5% and rural - 34.6%). Family members (urban - 46.2% and rural - 34.6%) and teachers (urban - 42.3% and rural - 15.4%) also had an important role to play in imparting knowledge about the harmful effects of use. \[[Table 6](#T6){ref-type="table"}\]

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Distribution of urban and rural users according to source of knowledge regarding harm of substance use (Multiple response)

![](JPBS-2-137-g006)

Almost one-third (26.9%) of the rural users had influenced their peers into taking up the habit. Although it was less among the urban users, still 11.5 percent influenced their friends into doing the same. \[[Table 7](#T7){ref-type="table"}\]

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Distribution of urban and rural users according to attempt of users to influence others for substance use

![](JPBS-2-137-g007)

DISCUSSION {#sec1-3}
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In the present study, ever use of substance as well as distribution among the males and females, were comparable to the findings of studies by other authors, where we noted similar results with that of other studies.\[[@ref5]--[@ref7]\]

A majority of the users reported trying to end the habit and most of the users expressed a desire to quit the habit. These views were also expressed in other studies,\[[@ref8]--[@ref10]\] which revealed that all users did not want to continue the habit and they held a positive attitude toward quitting, therefore, motivation on the part of family, friends, and close ones could help the user to come out of this habit.

Easy availability of substances, especially the licit ones, has been the most common reason for continuation, followed by relief from stress, and acceptability among friends. These reasons have been cited even by other authors.\[[@ref11]--[@ref17]\] This shows that home and neighborhoods furnish the adolescents with ways to procure and continue using substances. Moreover, as adolescents are in a transitional phase, confusion can sometimes make them susceptible to taking up unfavorable habits. In contrast to this, factors leading to quitting substance use also exist in and around adolescents, as the major reasons stated were moral sense and fear of health problems, which clearly suggests that attitude shaping by parents and knowledge of harmfulness of use can indirectly motivate the user to give up the habit. These findings have also been seen in studies from related areas.\[[@ref8][@ref10][@ref16][@ref18][@ref19]\] Knowledge regarding the harmful effects of substance use is considerably high among the users, particularly for licit ones such as tobacco, alcohol, and cannabis. Researchers in related studies have found similar results\[[@ref15][@ref16][@ref20]--[@ref23]\] where the users are not deprived of the knowledge regarding the consequences of consumption of substances. Particularly disturbing is the fact that they continue their use despite knowing the effects. This information has been provided primarily through the media, principally the television and hoardings. A small percentage also reported being taught about it in school and by family members. Therefore, media and close contacts are primarily responsible for imparting knowledge, whether it be pro- or anti-substance use, and these findings are common anywhere, as is seen in other studies.\[[@ref8][@ref15][@ref21][@ref22][@ref24]\] Users are mainly responsible for influencing their peers and close contacts into taking up the habit, as is seen in the present study as well as in other studies. Influence of peers and close contacts who use substances are usually responsible for initiating their use in others and this is evident in the present study as well as in related studies\[[@ref8][@ref15][@ref16][@ref21][@ref25]\] where users have been accountable for instigating the habit.

Conclusion {#sec1-4}
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Awareness of the harmful effects of substance use is high. A disturbing aspect that has been noticed is that despite having knowledge of substance use, adolescents initiate and continue its use. Efforts to control the problem in this age-group should also target their parents and other family members, by means of the media. The school being an essential part in a student\'s life can include and promote an effective and healthy life-style. Interventions that enhance parental self-efficacy in conveying and enforcing attitude shaping for their children could reduce adolescent substance use. Healthy substance use control programs, focusing on youth, are essential, to reduce the burden of related diseases. Repeat surveys would help in monitoring the tobacco epidemic in schools and in evaluating the efficacy of state level tobacco control programs.

**Source of Support:** Nil

**Conflict of Interest:** None declared.
