substance abuse poses a major political , social and health challenge worldwide . besides being a personal risk , addiction is a social problem and imposes harmful and permanent effects on society . at present ,
3.6%6.9% of adults ( 1564-years - old individuals ) are under the influence of illicit substances . according to the world drug report 2013 , since 2008
, the number of illicit drug users has shown 18% increase ; rise in population and ease of availability appears to be the two common reasons .
substance abuse in iran , one of the middle east countries , has a historical origin . during world war
i , among 250,000 individuals of the tehran municipality , 25,000 were reported to be addicted to opium . in recent centuries
these traditions are stronger among rural populations owing to a lack of access to trained physicians .
the usage of opium had been so common in rural areas that mothers often exposed babies to opium in an effort to calm them and sleep better .
the past two centuries have seen several changes with respect to handling illicit substances in iran , from open access to death penalty for carrying illicit drugs . at present , iran policy against illicit drugs is considered to be a combination of war on drugs and harm reduction strategies . with regards to opium use , iran ranks among the top three countries in the world .
therefore , epidemiological studies in iran can provide better understanding for national policy makers as well as for other researchers in the world .
although several studies on the prevalence of substance abuse in iran have been reported , the majority have been limited to urban areas [ 5 , 6 ] ; studies in rural areas were limited or often included small sample size .
approximate one third of the iran population lives in rural areas ; hence , it is critical to evaluate the substance abuse pattern in rural areas .
in addition , the majority of epidemiological studies focussed on the trends of substance abuse because drug use behaviours are often dynamic , and with time are affected by various factors such as drug availability .
the present study aimed to investigate the trends of substance abuse among the rural communities of the kerman province , the largest province in iran , during a 12-year period by comparing data for the years 2000 and 2012 .
first , kerman as an eastern province , due to neighborhood with afghanistan , the largest oipioid producing country in the world , is at higher risk of substance use , especially in youth group .
a previous study reported that the usage of waterpipe , cigarette and alcohol , among high school boys , in this area was 51.5% , 34.6% and 7.27% , respectively .
historically , kerman had highest of opium usage in iran ; second , accessibility of data from earlier years from this region   makes it easy to compare and analyse the changes with time . to the best of our knowledge ,
a household survey was conducted in 2012 in dashtkhak , a northeastern village of kerman province with a total population of 4416 .
the research was conducted under the approval of the ethical committee of kerman university of medical sciences ( approval code : k/90/516 ) . following a brief meeting with the village council , details regarding the aim of the study , protocols and information regarding the questionnaire
confidentiality agreement and informed consent form were provided before the study . a researcher along with community health workers distributed the questionnaires to each house .
one participant above 12 years of age per household was chosen to complete the questionnaire . upon completion of the questionnaire
community health workers are employed by the ministry of health and provide primary health care in rural areas . because of their acquaintance with the residents , their involvement in this research provided a great benefit to acquire data in a timely manner .
the validity and reliability of the questionnaire used in this study has been confirmed in previous studies .
it focussed primarily on three areas : the demographic features , details on substance abuse and the availability of substance . for details on substance abuse ,
substance abused throughout the lifetime , the last 30 days and every day were accounted .
considering the pattern of substance abuse in iran [ 5 , 10 ] , the questionnaire included the following substances : cigarette , waterpipe , opium , shireh ( opium residues ) , heroin , cannabis , shisheh , alcohol and sedatives . substance availability was counted using a four - degree likert scale .
shireh comprises opium residue obtained after opium consumption that is boiled and concentrated ; this is more potent than opium .
the chi - square test was used to compare the frequency of substances abused between the two time points .
two separate multivariate logistic regression models for tobacco and the other drugs were included to assess the association between baseline characteristics and substance abuse .
among the 1200 distributed questionnaires , 900 participants responded and completed the questionnaires ( response rate = 75.0% ) .
the average age and sex of non - respondents did not differ from those of respondents .
the majority of respondents ( 61.8% ) were below 30 years of age , and 54.4% among them were male ( table 1 ) .
majority of the substances were consumed high among men compared with women ( table 2 ) .
cigarette , opium and sedative usage was higher among the participants above 30 years compared with younger groups , whereas waterpipe consumption revealed a reverse pattern ( table 3 ) . from the participant point of view , cigarette , opium and waterpipe were easily accessible compared with other substances ( table 4 ) .
moreover , cigarette , opiates , heroin and sedatives consumption increased significantly in 2012 ( table 5 ) .
tobacco smoking was prevalent among male ( or = 10.8 , ci 95% : 6.218.6 ) and unemployed participants ( or = 2.4 , ci 95% : 1.44.3 ) .
other drugs such as opium , heroin , cannabis , sedatives , alcohol and amphetamines were common among males ( or = 2.7 , ci 95% : 1.94.0 ) and married ( or = 4.5 , ci 95% : 2.48.5 ) and unemployed ( or = 2.4 , ci 95% :
detailed analysis on the trend and pattern of substance abuse is necessary to develop preventive measures .
the present study illustrates a substantial increase in substance abuse in a rural area over a 12-year period .
our study evaluates two different time periods in the same area using similar method , with a gap of 12 years ; this offers the additional advantage for comparing the effect of substance abuse over time .
household surveys are considered as the gold standard for estimating the number of substance abusers , provided the participants are ensured of privacy and that they trust those collecting their information .
such mutual trust between village inhabitants and community health workers governs the rural regions in iran .
the primary drawback of this study was its limitation to a single rural area , which requires caution in generalizing results .
in addition , although response rates less than 70% were considered acceptable , non - participation of 25% of subjects in our study may limit data interpretation .
kerman province , because of its borders with afghanistan , is in the transit path for opium and heroin from eastern borders to other parts of the country .
since the early 19th century , heavy opium use among the natives has been connected to its easy access .
the participant population in the year 2000 was younger compared with that in 2012 ( p < 0.05 ) .
this is probably because of an increase in average life span in iran in recent years .
the lifetime substance abuse pattern showed a minor difference compared with that of the near - daily pattern .
opium , waterpipe and cigarette had highest prevalence of substance abuse throughout life and opium , shireh and cigarette among the daily abused substances ( table 2 ) .
this study reveals that opium abuse is endemic in this region   with lifetime prevalence higher than that of cigarette smoking ( table 2 ) . in comparison with the data from 2000 showed that , in 2012 , except for cannabis and alcohol , abuse of all other substances increased significantly .
shireh and heroin abuse enhanced 7 - 8 times . based on anecdotal data , one of the reasons for
the consumption of substances , such as waterpipe and shisheh , was not investigated in 2000 ; these substance gained popularity during the last few years and are now considered as re - emerging drugs [ 11 , 12 , 17 ] . although methamphetamine consumption was low compared with that of opiates , in urban areas , a gradual switch from traditional substances such as opium to synthetic substances such as methamphetamine is observed . however , according to the current study , substance abuse patterns in rural areas differ from those in urban areas .
sedative consumption increased 6-fold , which is probably caused by easy availability of prescription drugs .
an earlier study conducted in one of the rural regions of northern iran reported that 13.5% of the participants abused opium almost daily and 28.1% smoked cigarette daily . in another study , which analysed urine samples through anonymous unlinked testing ,
14.5% showed opioid consumption , that is , similar to the rate of daily abuse of opium in our study ( 15.7% ) .
a comparison of substance abuse among urban and rural population showed that opioid abuse is higher among rural population , whereas other substances such as alcohol waterpipe and cannabis were prevalent among urban population .
substance consumption , except waterpipe , was higher among participants above 30 years of age compared with the younger age groups , indicating that waterpipe is regaining popularity among youth . in united states , it has been reported that except ecstasy and amphetamines , drug usage in the past year is relatively similar among adolescents in rural and urban regions .
although new studies are in favour of higher usage of tobacco , cannabis and alcohol in u.s .
the substance abuse was also much higher among men compared with that among women ( table 3 ) ; the most obvious difference was observed for cigarette , suggesting the social stigma associated with cigarette smoking in women in iranian culture , while the stigma associated with waterpipe consumption is significantly less .
sedative consumption was similar among both men and women probably because of similar and easy access to prescription drugs and the prevalence of anxiety and insomnia in general population .
approximately three quarters of rural population had easy access to cigarette and water pipe , and half of them had easy access to opium .
despite the law against usage of tobacco , sale of cigarette and waterpipe tobacco in public places is common in iran .
waterpipe usage is common among youth and has increased in recent years , which can be often observed in coffee shops , parks and college dormitories .
because alcohol was prohibited by religion , it was expected that access to alcohol be most difficult .
the logistic regression analysis showed that higher the difficulty towards access to tobacco , the less the probability of tobacco smoking ( table 6 ) . in iran
, there is no close monitoring on tobacco sales to youth and cigarette smoking is socially well accepted in metropolitan areas than rural areas . in rural areas , cultural barrier appears to play a role than geographical barrier , and the difficulty in access may be related to factors such as family supervision and cultural taboo on smoking by youth and women .
the higher probability of tobacco smoking among men was in - line with the earlier results from both the urban [ 20 , 21 ] and rural   areas of iran .
the differences among men and women regarding drug abuse ( or = 2.7 ) were less prominent than tobacco smoking ( or = 10.8 ) ( table 6 ) .
it may be because of the fact that except for tobacco all other substance abuse is illegal in iran ; while drug abuse is considered a taboo among men and women , usage of tobacco is socially accepted among men , whereas it is stigmatized among women [ 20 , 21 ] .
in contrast to drug abuse , age had no effect on tobacco smoking , perhaps because of the higher age at onset of drug abuse comparing with that of tobacco abuse [ 10 , 21 ] .
drug abuse was more common among unemployed ; a finding that may not imply causation because of an ambiguous order of variables ( i.e. unemployment and drug abuse ) .
in conclusion , the present study shows increased prevalence of substance abuse among rural population in iran .
the results of the present study emphasize the necessity of immediate multi - dimensional preventive measures to regulate substance abuse among rural communities .
 
 introduction and aim . 
 substance abuse imposes hazards on human health in all biopsychosocial aspects . 
 limited studies exist on epidemiology of substance abuse and its trend in rural areas . 
 the present study aimed to compare substance abuse in one of the rural areas of southeast iran , in a 12-year period ( 2000 and 2012 ) . 
 design and methods . in a household survey conducted in 2012 
 , in dashtkhak / kerman , 1200 individuals above 12 years of age completed a questionnaire to determine their frequency of substance abuse . 
 the questionnaire included the following three areas : demographic characteristics , frequency of substance abuse and ease of access to various drugs . results . among 900 completed questionnaires , 
 majority of the participants ( 61.8% ) were below 30 years of age and among them 54.4% were male . 
 cigarette ( 17.0% ) , opium ( 15.7% ) and opium residue ( 9.0% ) were the most frequent substances abused on a daily basis . 
 based on the participant 's opinion , we conclude that the ease of access to cigarette , waterpipe and opium contributed to their increase in consumption compared with earlier years . 
 discussion and conclusion . 
 the steady rise in substance abuse in rural communities demands immediate attention and emergency preventive measures from policy makers . 
1. Introduction
2. Methods
3. Results
4. Discussion
5. Conclusions