The significance of information variables in polydrug use by adolescents: insights from a cross-sectional study in Tarragona (Spain)

Introduction

Adolescence is a pivotal phase in human development, and substance consumption is a prominent concern among teenagers (Leal-López et al., 2021). This period involves engaging in risky behaviors and making impulsive choices, often exposing adolescents to psychoactive substances. In this early stage of life, substance use can influence brain development and potentially increase the risk of long-term addiction (Whyte et al., 2018). The three most widely used substances among adolescents are alcohol, tobacco, and cannabis (Gray & Squeglia, 2018; OEDA (Spanish Observatory on Drugs and Addictions), 2022).

These substances have neurotoxic effects on both cognitive and mental functions. These disorders contribute to the development of personality disturbances (Magallon-Neri et al., 2015), mental disorders, depression, and attentional deficits. There is some evidence, especially in the case of cannabis, that its use might increase the likelihood of its future use due to a gateway effect (Hamidullah et al., 2020; Shapira et al., 2020). Furthermore, substance use often results in decreased academic performance, risky behaviors, accidents, and undesirable behaviors, such as sexual harassment (Francis et al., 2019; Livingston et al., 2022). When discussing polysubstance use, we refer to the consumption of two or more drugs, whether legal or illegal, within the same period of time (Brière et al., 2011). Alcohol is the most frequently used substance in simultaneous polysubstance use patterns and is often accompanied by tobacco and cannabis (Brière et al., 2011; Jongenelis et al., 2019; OEDA (Spanish Observatory on Drugs and Addictions), 2022). Mixing substances are considered to be a particular risk to the safety and well-being of young people, especially because of their potentially unpredictable additive or interactive effects (Brière et al., 2011).

Multiple variables often influence substance use through complex interactions. These factors can encompass genetic predisposition, personality traits, parental style, levels of school engagement, peer influences, cultural factors, etc. (Cross, Lotfipour & Leslie, 2017; Trucco, 2020; Nawi et al., 2021). In this context, although several studies have noted the importance of health literacy in promoting healthier lifestyles (Jayasinghe et al., 2016; Bröder et al., 2017), one of the less explored factors is the influence of adolescents’ information regarding substance use (Belzunegui-Eraso et al., 2020).

Several authors have reported that health literacy protects against substance use in young people and teenagers (Fleary, Joseph & Pappagianopoulos, 2018; Sadeghi et al., 2019; Rolova, Gavurova & Petruzelka, 2021). However, neither the information campaigns carried out in educational centres nor those carried out in the mass media necessarily have a significant effect (Mélard et al., 2020). Dermota et al. (2013) in Switzerland and Belzunegui-Eraso et al. (2020) in Spain reported that more information about substance use among adolescents was associated with increased tobacco and cannabis consumption. Belzunegui-Eraso et al. (2020) call this the “information paradox” of substance use. One reasonable argument supporting this finding is that health literacy depends on the trustworthiness of information sources (Chen et al., 2018; Buawangpong et al., 2022). For this reason, Belzunegui-Eraso et al. (2020) suggested further analysis of the influence of information sources on adolescent substance use.

In this study, we considered six sources of information that are commonly regarded as influential on health literacy, specifically among young people: schools, parents, media, peers, siblings, and the Internet (Manganello, 2008; Dermota et al., 2013; Bujnowska-Fedak, 2015; Chen et al., 2018; Buawangpong et al., 2022). The reliability of each item can be differentiated by the level of regulation provided by public bodies and professional associations regarding the information they provide to young people.

In Spain, the information provided by schools, parents, and the media is subject to strong regulations and monitoring. This information usually discourages substance use and emphasizes the harm associated with consumption. While there is limited assessment of the effectiveness of many drug supply control policies and, as a result, their actual impact is often not measured (Strang et al., 2012), there is some evidence suggesting that the perception of the potential harm of drug use may deter certain adolescents from using them (Zimmerman & Farrell, 2017).

First, educational institutions, particularly schools, are paramount for imparting knowledge to young people. They serve as the foundational pillar of health literacy, which is a crucial aspect of youth education (Manganello, 2008). The primary goal of education, as emphasized by UNICEF (2021), is to foster the health and well-being of youth, with health literacy being a key contributor (Fleary, Joseph & Pappagianopoulos, 2018; Sadeghi et al., 2019). In Tarragona, public institutions and healthcare professionals closely monitor substance abuse prevention programmes in schools.

Second, parents bear a significant responsibility for their children’s welfare, as mandated by international and national laws (United Nations, 1989; Spanish Civil Code, 1889). Fulfilling this obligation includes providing reliable information regarding the adverse effects of substance use. Spanish law even sanctions against the loss of custody when parental behavior endangers a child’s well-being due to issues such as substance abuse (Odériz-Echevarria, 2023).

Finally, conventional media channels, which are tightly regulated by legislation and ethical codes, serve as a means of disseminating information about drug risks. Stringent bans on tobacco and alcohol advertising and sponsorship exist at both the European and national levels (European Union Directives, 1989, 2003; Feliu et al., 2019). Similarly, marijuana and hashish are illegal drugs; therefore, no advertisements are allowed. While these outlets are used by public health authorities to warn about tobacco dangers, their content is subject to scrutiny for its accuracy (Dermota et al., 2013). Furthermore, while the ethical code of the Spanish College of Journalists safeguards, among other issues, the accuracy of information provided in the media (Federation of Associations of Journalists of Spain, 2017) and the content offered by television during protected hours for children are subject to special oversight in Spain by the National Commission of Markets and Competition (2015).

Certain sources of information have limited control over their influence on adolescents, potentially encouraging substance consumption. Peer-, sibling-, and Internet-based information channels lack effective oversight from both legislative and administrative perspectives.

Peers and siblings often embrace a perspective that prioritizes immediate gratification and hedonism over long-term risks and may focus on themes such as enhancing social enjoyment, relaxing, or associating substance use with status and glamour (Megías et al., 2006; Eisenberg et al., 2014; Montgomery et al., 2020; Gupte, D’Costa & Chaudhuri, 2020; Henneberger, Mushonga & Preston, 2021). This can lead to adolescents underestimating the potential harm associated with substance use. To understand the trends in adolescents’ risk-taking attitudes, it can be helpful to consider the justification of the so-called dual-system model. According to this framework, risk-taking is attributed to the activation of an early maturing socioemotional incentive processing system, which intensifies adolescents’ attraction to exciting, pleasurable, and novel activities. This occurs concurrently with an immature cognitive control system that has not yet been sufficiently developed to consistently inhibit potentially hazardous impulses (Shulman et al., 2016).

The Internet has the potential to provide valuable health-related information and support networks. It allows access to substance-use prevention information (Parissi-Poumian et al., 2023) and facilitates online interventions involving professionals, peers, or a combination of both (Ahmad et al., 2022). However, this information often lacks control (Tonsaker, Bartlett & Trpkov, 2014), which can have a negative impact on health literacy (Chen et al., 2018). Furthermore, alcohol use serves as a source of health misinformation, with one of the primary areas of concern being drug and tobacco consumption (Suarez-Lledo & Alvarez-Galvez, 2021), which may also stimulate risky behaviors (Vannucci et al., 2020). Adolescents may encounter content that glamorizes substance use by peers or influencers (Gateway Foundation, 2023), stumble upon scientifically unfounded information, or even gain access to legal substances without proper regulation (Gateway Foundation, 2023).

The reflections presented in the previous paragraphs motivate the current study, which should be contextualized in the most common polysubstance use, namely, the combination of alcohol, tobacco, and cannabis. Specifically, we address the following research question (RQ): What are the protective and facilitating factors of polysubstance use, and what influence do information factors have? In this regard, we tested the relevance of the level of information that adolescents perceived and the number of sources of information consulted monitored versus unregulated on the prevalence of polysubstance use. Therefore, whereas we expect that monitored sources have a protective effect on polysubstance use, nonmonitored sources can stimulate this practice.

Materials and Methods

Results

Descriptive statistics

As shown in Table 2, 502 teenagers (38.41%) were admitted to having consumed alcohol, 196 (15%) had consumed tobacco, and 88 (7.28%) had consumed cannabis in the last 30 days. Likewise, Table 2 shows that while 51.10% of the sample stated that they had not consumed any of the studied substances in the last 30 days, 380 (29.07%) acknowledged consuming one substance, 117 (8.95%) admitted to consuming two, and 57 (7.80%) had consumed three.

In terms of information variables, Table 2 shows that nearly 80% of the respondents mostly agreed or completely agreed that they were well informed about the consequences of substance use. Concerning sources of information, the most relevant ones, in order of decreasing relevance, were schools (866, 66.26%), the Internet (861, 65.88%), and parents or legal guardians (815, 62.36%). The three least common sources, from least to most reported, were siblings (305, 23.41%), peers (584, 44.68%), and the mass media (720, 55%).

Similarly, within the pattern of information source usage, while the most common practice regarding monitored sources was obtaining information from all three monitored sources (451 responses), the least common practice was not recognizing any supervised source (121 responses). In terms of nonmonitored sources, the most common was recognizing one source (449 responses), and the least frequent was recognizing information from all three analysed sources (183 responses).

Figure 1 shows that among the adolescents who consumed only one substance, the majority consumed alcohol (26.01%), while the majority consumed tobacco (2.60%) or cannabis (0.46%). Within the group of adolescents who used two substances, the majority combined alcohol and tobacco (7.04%), those combining alcohol and cannabis (0.92%), and those combining tobacco and cannabis (0.99%) were notably lower. Notably, cannabis consumption was more common when cannabis was combined with tobacco and alcohol (4.36%) than when cannabis was used alone or in combination with either tobacco or alcohol.

Discussion

This study examined the primary patterns of polydrug use among adolescents and their key drivers. Although alcohol is the most commonly used single substance, tobacco tends to be used in conjunction with alcohol, and cannabis users often use both alcohol and cigarettes.

When assessing the explanatory factors of polydrug use, this study placed significant emphasis on the quality and quantity of information perceived by adolescents, as well as the number of information sources. It distinguishes between controlled and uncontrolled sources. The influence of these factors is controlled for variables related to the individual characteristics of the adolescent, such as age, sex, or temperament, as well as the primary variables associated with their microsystem (school, family, and peers).

Although the examined individual and environmental variables are well established in the literature, investigations into the impact of variables related to the level of information and available sources among adolescents are groundbreaking. Our findings indicate that the inclusion of additional variables enhances the explanatory power of multiple drug consumption patterns.

We should differentiate the findings related to the control variables (individual and environmental) from those that are subject to special analysis, which are related to the information available to teenagers and their sources. The utilization of multinomial regression instead of Poisson-type count regression has enabled us to quantify not only the significance and direction of the relationship between the number of substances consumed and the explanatory variables but also the varying intensity of their impact and significance based on the number of substances consumed by the adolescent.

The most relevant factor for the individual control variables was the age of the teenagers. We observed that age was positively related to all the substances consumed (one, two, or three substances), and its influence increased as the number of substances consumed increased. The results, in any case, are logical, as we observed that the number of teenagers initiating the use of all substances increased with age. Thus, the probability of a teenager being a polydrug user increases with age. Therefore, our findings align with those of Libuy, Ibáñez & Mundt (2020) and Andres-Sanchez & Belzunegui-Eraso (2022), who demonstrated that the probability of consuming cannabis increases with age, and with those of Brière et al. (2011) and Jongenelis et al. (2019), who observed a greater prevalence of the use of more than one drug as youth age.

The fact that being male significantly facilitates the consumption of three substances, but not fewer, is consistent with the variability of the sex variable in studies of the prevalence of substance use by adolescents (McHugh et al., 2018). On the one hand, there are physiological differences between men and women in their reactions to any substance (National Institute on Drug Abuse, 2022), and men typically tend to be heavier substance users (McHugh et al., 2018). However, the latter assertion depends on the culture of the society being analysed; the more similar the gender roles are, the fewer differences in substance use tend to be (McHugh et al., 2018). In some cases, women may even consume more tobacco than males, as shown in studies by Eisenberg et al. (2014) and Andres-Sanchez, Belzunegui-Eraso & Fernández-Aliseda (2021). On the other hand, men may have greater engagement with cannabis (Francis et al., 2019; Andres-Sanchez & Belzunegui-Eraso, 2022), tend more toward polydrug use (Brière et al., 2011) and are more likely to develop disorders associated with such practices (McHugh et al., 2018).

We found that while the aggressiveness of teenagers is relevant to their substance use, this finding is in line with the reports of various authors that higher levels of irritability are an enabler of substance use (Picciotto et al., 2015; Kivimäki et al., 2014; Turner et al., 2018; Francis et al., 2019; Nawi et al., 2021). Similarly, rebelliousness has a significant positive impact on strict polydrug use (two or three substances), which is supported by the findings of Boddington & McDermott (2013), Kwon et al. (2018), and Nawi et al. (2021) but not on the use of a single drug.

Among the control variables in the microsystem of the teenagers’ environment, the most relevant factor in the consumption of multiple substances was peer influence. In fact, this factor progressively increases in impact, as teenagers tend to consume more substances. These results are consistent with the literature reviewed in this study (Cengelli et al., 2012; Brière et al., 2011; Burk et al., 2012; Eisenberg et al., 2014; Gupte, D’Costa & Chaudhuri, 2020; Cavazos-Rehg et al., 2021; Henneberger, Mushonga & Preston, 2021; Soriano-Sánchez & Jiménez-Vázquez, 2022).

The main contribution of this study is the assessment of the effects of information variables on the consequences of substance use on behaviors related to the number of substances used in the last 30 days. Our findings reveal that an overwhelming majority of adolescents (approximately 80%) tend to either agree or fully agree with the statement “Do you consider yourself adequately informed about the repercussions of substance consumption?” However, it is crucial to note that the lack of statistical significance concerning the level of information on substance use implies that this information does not serve as a distinguishing element capable of elucidating the varying degrees of substance use among adolescents. These findings contrast with those of Dermota et al. (2013) and Belzunegui-Eraso et al. (2020), who indicated that greater amounts of information lead to a greater tendency toward drug use, as well as with the findings of Fleary, Joseph & Pappagianopoulos (2018) and Sadeghi et al. (2019), which indicated that greater health literacy inhibits smoking habits. However, we understand that this does not contradict the analysis conducted, as it reconciles both positions.

However, obtaining information from sources that are presumably more reliable, such as schools, parents, and mass media, which highlight the risks associated with drug consumption, can positively impact health literacy and potentially safeguard adolescents against polydrug use. These channels often emphasize the dangers of substance use, which is a significant factor in protecting against drug use (Zimmerman & Farrell, 2017). This protective effect may increase with the number of substances consumed. In contrast, information acquired from sources that are less reliable and controllable, such as peers, the Internet, and siblings (Chen et al., 2018), has the potential to negatively affect health literacy and facilitate polydrug use. This enabling effect may be amplified by the number of substances used.

The findings of this study have valuable implications for health authorities and organizations responsible for designing preventive interventions for substance use among young people. While greater information about substance use may not necessarily lead to a lower prevalence of polydrug use habits, it is crucial for health authorities to monitor sources of information about substance use and ensure that reliable information is provided. Authorities should also establish interventions that enable teenagers to access useful resources for their health while protecting them from harmful and unreliable information, particularly on platforms such as the Internet. These interventions should also protect them from influences, such as peers or siblings, whose testimonies may emphasize issues related to pleasure or prestige rather than the more relevant ones, which are the harmful effects outlined in the introduction of the study.

However, caution must be exercised when generalizing our results to other places because our study was conducted in a specific geographical location with its own unique sociodemographic characteristics. Tarragona, a city with approximately 150,000 residents, has a distinct economic landscape characterized by industry and services. It is also home to a significant number of migrants from South America and North Africa. Therefore, while our findings provide valuable insights applicable to European regions with similar social and regulatory settings and population demographics, they may not directly apply to areas with different characteristics. For example, regions with fewer migrant populations or economies, primarily based on the primary sector, may exhibit different dynamics regarding adolescent smoking habits and sources of information.

It should also be understood as a limitation of the study that the outcome reflects the number of substances consumed by adolescents in the last 30 days, but it does not capture the intensity with which they were consumed. Subsequent analyses could be differentiated not only by whether a substance is consumed but also by the degree to which it is consumed in combination with others, which can also be used sporadically or habitually.

Furthermore, as we consider the future implications of our study, we must remain vigilant about the ever-evolving landscape of information dissemination. The digital age has brought new challenges and opportunities, especially as the Internet has become a major information source. As regulations regarding online information evolve and the behaviors of adolescents continue to adapt, our study serves as a crucial snapshot in time. Therefore, the insights gained from our research are invaluable but should be interpreted with caution.

Conclusions

In this study, we conducted a cross-sectional survey in Tarragona, Spain, to investigate the relationships between information sources and the consequences of substance and polydrug use among adolescents. Our research revealed a notable pattern: An increased number of monitored information sources had a substantial impact on discouraging substance use among adolescents. Conversely, a higher prevalence of unsupervised sources appears to facilitate the development of such habits. This phenomenon led us to speculate on the potential implications for public health and educational strategies. Monitored sources of information, which are subject to regulation by laws and public authorities, have emerged as trustworthy sources of knowledge about the harmful consequences of drug use. However, unmonitored sources operating beyond regulatory oversight represent a worrisome contrast. These sources have the potential to undermine health literacy, as they may disseminate inaccurate or misleading information, making it difficult for adolescents to discern the true risks associated with drug use.

Supplemental Information