The age of adolescence is a challenging time. During these ages, youths are making a series of cognitive, biological, psychological, and physiological transitions. Some say that adolescents are “wired” for to seek new experiences and risk-taking. They are in a period where they are trying to find their own identity, looking for peer acceptance, and deal with problems or perform well in school [18]. This makes them more prone to experiment with substances and engage in other harmful behaviors [19]; thus, a plan for prevention should take the adolescents into consideration. Furthermore, the population of the school students is a “well-defined well-delineated” community to an extent. In a Third World country, it is a clearly organized population, in terms of geographical distribution, registration, documentation, and caregiver consent. These reasons helped the authors to focus on secondary school students as a target population for the present research.
Generally, the prevalence studies require high standards of representativeness. The sample of the current study was selected and calculated using a multi-stage sampling procedure to ensure proportionate representativeness of different school types and students’ gender. Being a sensitive stigmatizing issue, the declaration of using a substance of abuse was encouraged by the structure, the design of the questionnaire, the variable ways of asking repeated questions about substance use in a clear but sensitive manner, and the highest possible confidentiality measures.
The actual sample of the study is 10,648 students (4385 males, 6263 females); their ages are ranging mostly between 13 and 18 years old. In the absence of selection bias, the female preponderance in the sample (58.8%) challenges the common attitude towards Egyptian female education; UNICEF reports describe higher engagement into education systems in males than in females. Otherwise, a higher representation of female students in the sample may be attributed to the tendency of the male students to absenteeism from school whether for work or for leisure activities. Males are more frequently involved in child labor activities than their female colleagues. The findings point to a percentage of 17.3% of the students working besides their studies (32% of the male students, 6.8% of the female students). The gender differences in child labor may be explained in light of the financial difficulties facing a multitude of Egyptian families, coupled with the universal gender role deeply adopted by many cultures, in addition to an inadequate financial support from the large families, noticed by the low percentage of extended families in comparison with the nuclear family atmosphere (1:4), and the percentage of “single-parent” families, whether due to traveling, death of a parent, or parental separation and divorce.
In spite of having a higher family history of nicotine, cannabis, and benzodiazepine use, female students are still less indulged than their male colleagues in poly-substance use (M = 74.46%, F = 25.54%) and less fulfilling the criteria of dependence syndrome (M = 62.1%, F = 37.9%). This may invite more research about the attitude towards addiction, the perceived dangerousness of substance use, and their relations to the gender and the family history.
In the current study, less rates of dependence are detected in Upper Egypt than in Cairo and Delta. Other studies give conflicting results about the regional distribution of substance use: The last national Egyptian map 2015–2017 showed similar results as regards the prevalence of dependence syndrome: Al-menoufiya 9.3%, Cairo 6.4%, and Assiut 3.2%. However, regarding the rates of substance regular use, National Addiction Research Study revealed the prevalence of use to be 33% in Cairo, 22.4% in Upper Egypt, and 9.6% in Delta [20].
Expectedly, the most commonly used substance in the present research among students was nicotine during lifetime (9%), last 12 months (4.9%), and last month (2.4%). According to the Council of Europe report 2017 on the prevalence of alcohol, tobacco, and drug use among adolescents in the Mediterranean region, the lifetime prevalence of tobacco use was as follows: Italy 58%, France 55%, Greece 39%, Portugal 37%, Cyprus 36%, Malta 29%, Tunisia 23%, Algeria 22%, Israel 21%, Morocco 16%, Lebanon 14%, and Egypt 9% [21].
The lifetime prevalence of use of benzodiazepines, e.g., Xanax, apetryl, was the highest among other substances of abuse (5%) after the exclusion of nicotine, declared by the students. The male use was exceeding the female use, dissonant to the literature stating a female tendency to sleeping pill addiction. Interestingly, the last year and the last month prevalence are quite the same (1.7%), highlighting that these substances are well tolerated and used regularly (Fig. 3). These findings may be denoting the high levels of anxiety in this special population. The lifetime prevalence of medications without a prescription use among adolescents in the Mediterranean region is almost the same in all countries except France: France 10%, Italy 5%, Portugal 5%, Morocco 5%, Cyprus 5%, Egypt 5%, Greece 4%, Algeria 3%, and Malta 3% [21]. In the USA, non-medical prescription drug use among youths aged 12–17 is 2.2%, and non-medical pain reliever use is 1.7% [22].
In the current study, the lifetime prevalence of alcohol use among students was 3.3%, with higher estimates among male students than among female students. However, the last month prevalence (1.6%) is markedly lower than the lifetime and last year prevalence (2.9%), which gives the impression that it is not used regularly and hence not one of the preferred substances (Fig. 4). In comparison with other Mediterranean countries, Egypt had the lowest lifetime prevalence of alcohol use: Greece 94%, Cyprus 88%, Malta 86%, Italy 84%, France 84%, Portugal 71%, Israel 50%, Lebanon 35%, Morocco 8%, Algeria 5%, Tunisia 5%, and Egypt 3% [21]. It is obviously observed that other Arab countries had a much lower prevalence of alcohol use than European countries, which can be explained by the cultural and religious differences as alcohol is prohibited by the Islamic religion. In the USA, it was reported that 32% of 12th graders, 18% of 10th graders, and 6% of 8th graders reported being drunk within the last 30 days [3]. Another report showed that approximately 10% of their sample of youths aged 12–17 met the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM-IV) alcohol abuse by self-report, and 3.5% met the criteria for alcohol dependence [23].
Organic solvents are relatively common in the Egyptian market. It was found to be one of the most common substances used by adolescents of the present study during lifetime (3.1%, reaching 4.13% among male students, last 12 months with a prevalence of 2.7%, and the most commonly used in the last 30 days (1.9%). In the USA, inhalant use within the last 30 days was reported to be 1.2% for 12th graders, 2.5% for 10th graders, and 3.9% for 8th graders showing inhalants to be more favored among younger adolescents [24]. These findings can be attributed to the availability, cheap price, and easy accessibility of organic solvents to this age group.
Expectedly, cannabis (natural and synthetic) was one of the most commonly used substances among the students in the last year (2.6%) and the last month (1.6%) prior to the study (Fig. 5). Compared to other Mediterranean countries, the lifetime prevalence of cannabis among Egyptian adolescents was one of the lowest among the region: France 31%, Italy 27%, Portugal 15%, Malta 13%, Morocco 9%, Greece 9%, Israel 8%, Cyprus 7%, Algeria 5%, Lebanon 4%, Egypt 2%, and Tunisia 1% [21]. In the USA, it was reported that 23% of 12th graders, 18% of 10th graders, and 8% of 8th graders reported using marijuana or other illicit drugs within the last 30 days [3].
According to the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM-IV), the prevalence of regular use of any substance (excluding nicotine) among the students of the study was 1.5%, while the prevalence of the dependence syndrome (excluding nicotine dependence) was 0.9%. These rates are lower than those detected in the National Addiction Survey 2015 which was conducted on the Egyptian adult population; most of the sample was from the age group 26–35 years old. In this survey, 6.7% were regular on substance use, while 6.4% were fulfilling the criteria of dependence. It is obvious that the rates of substance abuse increase by age; thus, preventive services should be mainly directed towards youth in order to combat these phenomena.