CHAPTER I: INTRODUCTION
Adolescence is a period of transition from childhood into adulthood, a period of physical, psychological and social maturation. This is a crucial period of life when an individual is no longer a child but not yet an adult. The term adolescent refers to individuals between 10-19 years of age (early adolescence 10-14 years and late adolescence 15-19 years). In this period they are usually very energetic, enthusiastic, and anxious and become more autonomous in their decision taking.1 To show that they are capable of handling themselves the risk taking behavior among them is very high which, as a consequence, may bring different kinds of problems. Substance abuse is common and one of the most disturbing problems among the youths. In Nepal adolescents comprise about one fourth (24%) of the total population.2 Substance abuse refers to the harmful or hazardous use of psychoactive substances, including tobacco, alcohol and illicit drugs.3 Substance abuse is the use of any substance(s) for non-therapeutic purposes or use of medication for the purposes other than those for which it is prescribed. It refers to the over-indulgence in and dependence of a drug or other chemicals leading to effects that are detrimental to the individualâ€Ÿs physical and mental health, or the welfare of the others. Substance abuse has complex roots; in biological predisposition, personal development, and social context. Specific social correlates such as parent-child conflict, child physical and sexual abuse, family breakdown etc has also great role4. The transition from adolescence to young adulthood is a crucial period in which experimentation with illicit drugs in many cases begins. Because of their innate curiosity and thirst for new experiences, peer pressures, their resistance to authority, sometimes low self-esteem and problems in establishing positive interpersonal relationships, young people are particularly susceptible to the allure of drugs. However, all youth around the world do not have the same reason for abusing drugs.5 Substance abuse also predicts affiliation with network of deviant peers who introduce these adolescents to other substances.4 
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Adolescent substance use usually starts with alcohol and cigarette which are referred to as gateway substances. They are the initial substances used before others are tried out and later progress to more dangerous ones such as cannabis and cocaine.4 In most societies cigarette smoking, alcohol drinking and using drugs are more or less perceived by young people as something alluring. Many also see it as a status symbol, a way to telling their peers and contemporaries that they have come of age. In Nepal, alcohol use has not been taken seriously either by the community or by any social organization.6 There is no age restriction on buying cigarettes. Cannabis and alcohol were traditionally used in Nepal for centuries. A cannabis derivative such as marijuana and bhang is often justified in connection with religious festivals because of the presumed prediction by one principal figure of the Hindu pantheon, the lord Shiva for the drug.7 With time, risky behavior such as gluing, sniffing and injecting the drugs has been introduced. Though drug use is strictly illegal in Nepal, the easy access and availability of drugs has created a conducive environment for the people to start taking such substances, especially among young people and children. Substance abuse is one of the main risk factors for numbers of heart and lung diseases, oral, lung and stomach cancer, psychiatric problems and even death. Poor social coping skills, broken homes, disturbed relationships and risky behaviors is its social consequences.3 A number of measures, both on supply reduction and demand reduction, have been taken by the government and non-governmental organizations. However, the number of drug users is in the increasing trend.6 Substance abuse, therefore, is still a major public health problem and there’s a need of more extensive awareness and rehabilitation programmes.
1.2. Problem statement
Substance use poses a significant health, social and economic threat to families, communities and nations. The extent of worldwide psychoactive substance use, according to World Health Organization (WHO) 2002, is estimated at 2 billion alcohol users, 1.3 billion smokers and 185 million drug users. Similarly, there are 150 million adolescent tobacco users. In an initial estimate of factors responsible for the global burden of disease, tobacco, alcohol and illicit drugs contributed together 12.4% of all deaths worldwide in the year 2000.8 
Tobacco alone contributes 8.8%, alcohol- 3.2% and illicit drugs-0.4% of all the death worldwide. Injecting drug use has been reported in 136 countries, of which 93 countries report HIV infection among this population. Tobacco is the largest burden in Europe and South-East Asia while alcohol poses the largest burden in Africa, the Americas, and Western Pacific. Worldwide alcohol causes 2.5 million deaths (3.8 % of total) and 69.4 million (4.5% of total) of Disability-Adjusted Life Years (DALYs).8 According to Nepal Demographic Health Survey (NDHS) 2006, one-third of men smoke cigarettes and two-fifth consumed other forms of tobacco, whereas 15% of women smoke cigarettes and 5% consumed other forms of tobacco.2 According to Non Communicable Disease Risk Factors Survey 2008 in Nepal, 37.1% were tobacco users. Of them, 26.2% (35.5% men and 15.9% women) were found to be currently smoking among which 23.8% were daily smokers. Mean age of the initiation of smoking was 18.8 years for men and 12.9 years for women. Similarly, 28.5% were found to be currently consuming alcoholic drinks wherein almost one and half times more men (39.3%) than the women counter parts (16.5%).9 The report published by United Nations Economic and Social Council (UNESC) showed that the younger the age of first use of illicit drugs, the higher the severity of drug problem later. The age of first experience with drugs has been falling in many regions of the world. Adolescent substance use is increasingly prevalent throughout the world.10 According to the Nepal Adolescent and Young Adult (NAYA) Survey 2000, about one-quarter of the young boys and one in ten girls have experienced smoking.11 Study conducted in Nepal by Ministry of Health and Population (MOHP), New ERA and orc Macro, 2002 have revealed that 47.4% of the adolescents aged 15-19 has consumed alcohol. Study conducted among teenagers in seven districts of the country stated that more than one in ten teenagers admitted to taking drugs. Of these teenagers, 56% took drugs by smoking, a quarter by inhaling (26%) and 5.4% admitted to injecting drugs.11 
Substance abuse has been a rising social, economic and public health problem and the hazards associated with it are undeniable. It is one of the forms of behavior most damaging to the health in the long term and is associated with other risky behavior such as engaging in unprotected sex which may result in HIV/AIDS.7 Adolescence period is the major age of initiation of substance abuse.6 Substance abuse among adolescents seems to be alarmingly pace around the world and Nepal is no exception. Though there are organizations working for adolescents, very fewer studies are conducted regarding this issue. Awareness programs are insufficient due to the scarce of information of the real scenario. Since majority of substance abuse among youths starts in the school, the school population is the best place for early detection and prevention of substance abuse in the adolescent population. As a result of lack of sufficient and reliable data from which generalization can be derived for Nepal, there is a definite need for additional school surveys on substance abuse in the country. This study provides the base information on the use of various substances among school adolescents. It is intended to describe the magnitude of substance abuse among school children, the factor motivating them to abuse and knowledge and perception regarding substance abuse so that the possible intervention could be taken.
1.4.1. General objective
To find out the magnitude and associated factors of substance abuse among adolescent students in secondary schools of Vyas municipality, Tanahun. 
1.4.2. Specific objectives
To identify the prevalence of substance abuse among the adolescent students of Vyas municipality. To determine the age of initiation of substance abuse. To find out the factors influencing the initiation of substance abuse. To explore the students’ desire for quitting abuse of substance. To determine the students’ knowledge and perception regarding substance abuse. To determine patterns of substance abuse in terms of sex and type of school.
1.5. Research questions
What is the prevalence of substance abuse among the adolescent students? What is the knowledge and perception of adolescents towards substance abuse? Do sex and type of school influence the use of substance?
ï€ Substance abuse
ï€ Peer influence
ï€ Types of school
ï€ Knowledge and perception regarding substance abuse
1.7. Conceptual framework
Substance abuse among school adolescents
Type of school
Knowledge and Perception regarding substance abuse
Types of substance
Figure 1: Conceptual framework
1.8. Operational definitions
Substance: Any psychoactive material which when consumed affects the way people feel, think, see, taste, smell, hear or behave. Cigarette, chewing tobacco, alcoholic products and drugs (drug tablets, cannabis, heroin, opium, glue/gum, tidigesic, tranquilizers) are included as a substance in this study. Substance abuse: Substance abuse is the non-medical use of substances in order to achieve alterations in psychological functioning. Use of any of the substances mentioned above for two or more times in a lifetime is included under substance abuse. Adolescent students: Secondary school students of grade 8, 9 & 10 of both community and institutional schools within the age of 10-19 years are considered adolescent students. School: Government-aided community schools and institutional schools are studied. 
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Knowledge level regarding harmful effects of substance abuse: Those who could list at least one or more harmful effects of substance abuse are considered as having “good knowledge” and those who couldnâ€Ÿt list any are regarded as having “poor knowledge”. Perception towards substance abuse: The perception of the students was measured in 3 points scale: „agreeâ€Ÿ, „disagreeâ€Ÿ and „canâ€Ÿt sayâ€Ÿ. Statements for measuring perceptions are:
ï€ One who abuses substance has more friends.
ï€ One who abuses substance has negative image in the society.
ï€ It is difficult to quit the substance after getting into it.
CHAPTER II: LITERATURE REVIEW
Substance abuse is rising public health as well as social problem throughout the world. It poses a significant threat to the health, social and economic foundation of families, communities and nations. It is one of the major preventable causes of death and disability. There are about 2 billion alcohol users, 1.3 billion smokers and 185 million drug users worldwide.8 Consumption of substances has increased all over the world and the age of initiation of substance abuse is progressively falling. There has been increase in social and economic factors which make young more vulnerable and likely to engage in drug use and drug-related risk-taking behavior.10 A study carried out on “Socio-Demographic Correlates of Psychoactive Substance Abuse among Secondary School Students in Enugu, Nigeria” showed that 33.7% of the adolescents were substance abusers. Alcohol was most commonly abused (31.6%). Prevalence of the cigarette smoking was 14.3%, inhalants 9%, tranquilizers 7.4% and cannabis 4.15%. Males consumed most psychoactive substances more frequently than the females. Cigarette and cannabis were the exclusive preserve of the males. Older students were more involved in multiple substance use compared to younger ones. Among the users, 75% of the respondents were using more than one substance whereas 24.8% used only one substance.4 In a study carried out on “Drug use among adolescents in Asturias (Spain)” among the school students, 29.1% were drug user among which 55% were male. The average age of initiation of drugs was 15.4 years for males and 15.5 years for females. Cannabis was the most frequent drug used ever i.e. 20.8% of the total respondents became involved with this drug at sometime of their lives. Tranquilizers was second (10.3%), followed by amphetamine-like substance (7.9%) and inhalants (2.3%). The mean age at first drug use was 15.4 years for males and 15.5 years for females.12
A study carried out on “Licit and illicit substance use by adolescent students in eastern India: Prevalence and associated risk factors” among 416 students of classes VIII, IX and X in rural and urban settings gave the prevalence of 6.14% and 0.6%. The mean age of initiation of substance abuse was 12.6 and 13.9 years among rural and urban students respectively. Tobacco followed by alcohol was most commonly used in both setting. Prevalence was higher in males. Use of a substance by family 
members had a significant impact on its use by their children. Enjoyment and Curiosity were found to have the major influence in their decision to use a substance.13 Another study carried out on “Substance use among secondary school students in an urban setting in Nigeria: prevalence and associated factors” revealed that the life time use prevalence rates of alcohol and tobacco were 9.25 and 5.2%. The commonest substance used by the students was caffeine (85.7%). In terms of gender, the prevalence rate for male was higher than for their female counterparts except for antibiotics, analgesics, heroin and cocaine. Major Reason for using substances included relief from stress- 43.5%. About three quarters of the respondents (70%) were unaware of problems or complications that could arise from substance use while 10.5% believed poor physical health could arise.14 Department of Narcotic Control in Bangladesh, in June 2008, reported about 5 million drug addicts in the country among which young and adolescent population comprised 91%. Heroin is the most widely abused drug in Bangladesh.15 A study of adolescent smoking and drinking carried out among adolescent students in 2007 in Korea have shown that the prevalence of smoking was 29.2% while drinking was 48.2%. The mean age at the first instance of smoking and drinking was 13.8 and 14.1 years respectively. Among drinking adolescents, 30.1% were offered a drink by their parents, although most adolescents were encouraged to smoke or drink by their friends.16
The Global Youth Tobacco Survey (GYTS) of school-going adolescents of class 8-10 conducted by WHO in the South-East Asia Region revealed that one in 10 school-going adolescents in Nepal use some form of tobacco. The smoking rate for girls was significantly lower than that for boys. Exposure to smoke was both at home and in public places. Despite a substantial proportion of adolescents using tobacco, a large proportion of current smokers wanted to stop smoking. Regular presence of smokers in the family and easy accessibility of tobacco products were the major contributing factors to the prevalence of the smoking habit among adolescents in Nepal. It was also observed that almost one in ten smoking students smoke at home, revealing that there is no parental pressure on them to stop.11 
United Nations International Children’s’ Fund (UNICEF) 2001 survey in Nepal reported that more than one in ten teenagers admitted to taking drugs. Of these, 56% took drugs by smoking, 26% by inhaling and 5% by the injecting route. Majority (76.7%) of the adolescents was introduced to the drugs by their friends and 12% started taking on their own while 7% were encouraged by their father and uncles.11 According to a study done in school students of Grade 8, 9 and 10 in Pokhara sub- metropolitan city, nearly half 47.1% of the students ever used tobacco products. One in seven (13.2%) were current users, one in four (22.7%) were experimental users and one in ten were the past users of any tobacco product. The mean age of initiating tobacco was about 13 years and nearly one fifth (18.9%) initiated before 10 years of age. Boys were more likely to use tobacco than girls and adolescents of institutional schools were more likely to use tobacco products as compared to community school students. Regarding the knowledge of students about tobacco use nearly one third (31%) of the adolescent students were having good knowledge and less than half (42.7%) were having some knowledge about the hazards of tobacco use. Significant proportions of the adolescents have wrong perceptions about the use of tobacco i.e.47% thought that tobacco users have more friends and 27.3% thought that tobacco users are more attractive.17 
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