Doctor P P
Resident in Opthalmology
KEM Hospital,Mumbai

Address for Correspondence:
Dr Priyanka Doctor P
Dept of Opthalmology
KEM Hospital
Mumbai.
E-Mail :priyanka_doctor@hotmail.com 

ABSTRACT
Background:Substance abuse remains a critical problem in most countries,due to their far reaching social and economic repercussions.Socio-economic and health hazards resulting from substance use are enormous and intensified further due to pre-existing overpopulation and low socio-economic development.
Material and Methods:An urban community having a total population of approximately 18,000 was chosen. A sample frame of one-twentieth of the total households was chosen by random sampling method. In-depth personal interview and examination of the subjects was carried out
Results:A total of 376 individuals 21 yrs of age and above were studied : 211 males and 165 females. The following substances were used by the population under study: alcohol (country liquor, beer, whiskey), smoked tobacco (beedi, cigarette)**, smokeless tobacco (paan, masheri, chuna, gutka)* and charas*. 
Conclusions:Substance use among males was higher than that among females and varied according to various socio-economic factors.

KEYWORDS: Substance Abuse, Urban, Youth, Epidemiology

INTRODUCTION

A 'Substance' is defined as i)any drug, chemical or biological entity or ii)any material capable of being self-administered or abused because of its physiologic or psychologic effects (1) This include Alcohol, Amphetamines, Cannabis, Cocaine, Hallucinogens, Inhalants, Nicotine, Opiods, Phencyclidine, Sedatives, hypnotics and anxiolytics and Others (eg digitalis, amyl nitrate). (2) Abuse remain critical problems in most countries, not least because of their far reaching social and economic repercussions (3) . The use of drugs and illicit substances starts during adolescence and young adulthood (4) and hence emphasizes the need for preventive education at this impressionable age. 
The choice of drug used depends on various factors such as sex, social customs, economic status, peer usage and popularity and easy availability.

In 1989 the Ministry of Welfare carried out a study in 33 cities to ascertain the nature and extent of drug abuse. The report showed that drug addiction was prevalent in varying degrees among all religious and caste groups. Most drug abusers were male and literate, and the age group of 16-35 years was worst affected. A significant number of abusers came from the lower strata. Differences in marital status or living alone did not seem to contribute to drug use. Most (individuals, family members) were well aware of ill-effects of drug abuse and many informed persons felt that drug abuse was on the increase.(5)

Socio-economic and health hazards resulting from substance use are enormous and intensified further due to pre-existing overpopulation and low socio-economic development.

It is therefore important to determine the extent of drug use and to ascertain any pattern of use over time. Previous such studies have been carried out but patterns of the type of substance used have been furthur elaborated and compared. Against this background, we investigated substance use in a middle class urban community in Mumbai, India to discover its prevalence. Such information is essential if any education programme intended to discourage people from abusing drugs is to succeed. The present study determined the prevalence of substance use over 3-month period (February-April 2002) and correlated it with epidemiological factors.

MATERIAL AND METHODS

In the year 2002, an urban middle class community located 1 km. from the Teaching Institution and having a total population of approximately 18,000 was chosen. A sample frame of one-twentieth of the total households in 30 chawls (buildings) was chosen by random sampling method. In-depth personal interview and examination of the subjects was carried out. Full community participation was ensured with the help of the community worker. Statistical analyses were performed to compare differences in use of the drugs by sex, age, age of first use of substance, education, income, employment, marital status and morbidity. Analyses using x2 tests determined any significant
differences in the substance use based on these independent variables.

RESULTS

A total of 211 males and 165 females participated in the study.
The present study shows prevalence of alcohol use in males = 18.96 % , in females = 0.61 %. Total tobacco prevalence was : males = 25.12 %, females = 16.36 %, total males + females = 17.02 %. 8.08 % of males smoked (cigarette, beedi) while 17.54 % used smokeless tobacco (pan, masheri, chuna, gutka). None of the females smoked while 16.36 % used smokeless tobacco. Total charas users for males was 0.47 %. No Intravenous Drug Users were reported. Maximum users for most drugs ( cigarette, beedi, country liquor, chuna, pan ) were in the age group 51 - 60 years while it was 31 - 40 years for gutka, masheri & beer and 41 - 50 years for charas and whiskey.
Age of initiation of use was 21 - 30 years for most drugs except whiskey for which it was 31 - 40 years.

All female tobacco users used smokeless tobacco, while prevalence of Alcohol Use in females was 0.61 % as opposed to 18.96 % for males. No Narcotic or Psychotropic Substance users were found to be females, while 0.27 % of males were found to be users.

Income of Smokers above Rs.2000/- was more for cigarette users than beedi users. Amongst smokeless tobacco in decreasing order : chuna, gutka, pan, masheri. Amongst drinkers it was more for beer drinkers than country liquor drinkers and least for whiskey drinkers

A significant co-relation between Substance Use and Morbidity could not be established.
Reasons for initiation of Substance Use was : Family use:41.80%, Peer pressure 27.87%, Social reasons 10.66%, Curiosity 7.38%, Unemployment 6.56% and Other Stressors 5.74%.

Of those who stopped usage, 75 % were due to medical reasons. 25 % users stopped to prevent possible associated morbidity as a social and health measure.

DISCUSSION

Drug use and abuse have grown to such proportions that they have become priority health problems and a serious threat to the stability of social, political and legal institutions in many countries (4). In the USA, drug abuse is critically linked to crime, neglect of children, family violence, incomplete education, homelessness, acquired immunodeficiency syndrome (AIDS), high health costs, urban decay, and decreased economic competitiveness.(6) According to a previous study (Drug Abuse Monitoring System, 1989-91 by the Ministry of Health and Family Welfare), 65 % of users were initiated between the ages 15-25 with an overwhelmingly male predominance.
In the studies carried out in India [(Channabasavanna et al.- 1990 Karnataka (south India, 5 cities), Singh et al. 1992 Manipur (N.E. States, urban & rural), Mohan et al. 1993 3 Cities (north, west, urban), Mohan and Desai, 1993 Delhi (urban)], the prevalence of Drug Use was predominantly male and 92 - 94 per cent of women were non-drug users (lifetime).(5) Among men, the period prevalence showed estimates of various drugs used: heroin 0.2 - 1.3 %, raw opium including other opiates 0.3 - 0.5 %, cannabis 0.4 - 1.7 %. Prevalence of Alcohol Use was 17.2 % for males. No injectable Drug Users (IDU) were reported. 65 % of all men use some form of tobacco ( about 35 % smoking, 22 % smokeless tobacco, 8 % both ).(5) 

Prevalence rates for women differed from 15 % to 67 %. However overall prevalence of bidi and cigarette smoking among women is 3 %. The use of smokeless tobacco is similar among women and men. About 33 % of all women use at least one form of tobacco.(7) A recent study showed that 25 % of women used smokeless tobacco(8) while in a study carried out in Bombay among those above 35 years of age, tobacco use among women was found to be 57.5 % with smokeless forms being the most popular.(8) Differences in tobacco use also vary among other groups - Sikhs do not use tobacco at all. Parsis use very little, while tobacco use is permissible amongst Hindus, Muslims and Christians.(7) 
The present study shows similar results: prevalence of Alcohol use in males = 18.96 % , in females = 0.61 %. Total tobacco prevalence was : males = 25.12 %, females = 16.36 %, total = 17.02 %. 8.08 % of males smoked while 17.54 % used smokeless tobacco. None of the females smoked while 16.36 % used smokeless tobacco. Total charas users for males was 0.47 %. No IDU were reported. No other drugs were reported to have been used. In the present study, statistical significance was found in the age groups of 41 - 50 years and 51 - 60 years between sex and substance use. All female tobacco users used smokeless tobacco, while prevalence of Alcohol Use in females was 0.61 % as opposed to 18.96 % for males. No Narcotic or Psychotropic Substance users were found to be females, while 0.27 % of males were found to be users.

According to a previous study 60 % were in the age group of 21-30 years and about 65 % were initiated to drug use between the age of 15 - 25 though tobacco use started earlier, in the early teens.(5) The present study shows maximum users for most drugs to be of an older age group: ( cigarette, beedi, country liquor, chuna, pan ) were in the age group 51 - 60 years while it was 31 - 40 years for gutka, masheri & beer and 41 - 50 years for charas and whiskey.

However age of initiation was 21 - 30 years for most drugs except whiskey for which it was 31 - 40 years. Whiskey users were of a noticeably older population (most of them retired) and also had an older age of initiation to use as opposed to Beer and Country Liquor drinkers.

A predominant 62 - 68 % of Users were married in a previous study(5). Similarly, 67.46 % of Substance Users in the study were found to be married. How marital status influences Substance Use is not yet clear and needs to be further studied.
Of the total users, 23 - 27 % were illiterate and 3 - 29 % were unemployed at the time of study(5) while in the present study, total no. illiterate were 16.39 %. 9.83 % of Substance Users were unemployed at the time of study. Of those who have completed at least till SSC (Std. X), amongst smokers, it was maximum for Cigarette smokers (66.67%), while for Beedi users it was 50.00%. Amongst smokeless tobaccco the order was : Gutka (100%), Chuna (70.00%), Pan (34.78%) and Masheri (15.38%). Amongst Alcohol drinkers, it was maximum for Whiskey drinkers (100.00%), then Beer (72.22%) and Country Liquor(47.62%). Charas was 0.00%. Income of Smokers above Rs.2000/- was more for cigarette users than beedi users. Amongst smokeless tobacco in decreasing order : chuna, gutka, pan, masheri. Income amongst drinkers it was more for beer drinkers than country liquor drinkers and least for whiskey drinkers, probably due to the highest rate of retired individuals amongst whiskey drinkers. In the present survey, a significant co-relation between Substance Use and Morbidity could not be established either due to use of substance in lesser quantities or due to insufficient sample size even though past research is to the contrary. (9-15) 

Reasons for initiation of Substance Use was : Family use:41.80%, Peer pressure 27.87%, Social reasons 10.66%, Curiosity 7.38%, Unemployment 6.56% and Other Stressors 5.74%.

75 % stopped usage due to medical reasons. 25 % users stopped prior to development of symptoms of any known associated morbidity as a health precaution.
Drug use and abuse affect all cultural and socioeconomic groups, with the type of substance used depending on educational status, income and peer usage as borne out by this study. 

The use of drugs is relatively common and measures to reduce this use should be a priority. Although the problem is multifaceted, prevention by education is important. Among the measures used should be the prevention of primary initiation, as well as secondary progression into adult abuse and to more hazardous drugs.

ACKNOWLEDGEMENTS

I would like to thank Dr. SR Shinde, Prof & Head , Dr. SS Bansode, Assoc Prof., Dr. SR Suryavanshi, Assoc Prof, Dept. of PSM, KEM Hospital and Seth GS Medical College for their invaluable guidance in going about this project.


GLOSSARY OF INDIGENOUS TERMS USED
BEEDI: tobacco rolled in tobacoo leaf to make a rudimentary cigarette, very cheap.
BHANG: Dried leaves, flowering tops of cultivated plants of Cannibis 
PAN: betel leaf Tobacco with betel nut and lime [commonly called as PAAN]
CHARAS: Resinous exudate from the flowering tops of cultivated plants of Cannabis
CHUNA: Raw tobacco leaves chewed either with lime, beetalnut or along with pan and is then spitted out 
GANJA: Small leaves and brackets of inflorescence of highly cultivated plants of Cannabis
GUTKA: Beetle - nut and tobacco mixture
MASHERI: Roasted tobacco leaves taken orally and rubbed onto teeth


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