As far as our knowledge goes, this is the prime nationwide study to determine factors related to alcohol use disorder among adolescents. Our research revealed that tobacco and waterpipe smoking, internet addiction, sexual child abuse, neglected child, bullying and divorce in parents were associated with higher AUD among our Lebanese adolescents sample.
Concerning psychometric properties in our study, we found that the AUDIT score had an outstanding Cronbach’s alpha of 0.978, in agreement with other studies33,35,54. Moreover, the one-factor model of the AUDIT scale that we obtained in the Arabic version was shown to be better than the Portuguese one55 in terms of internal consistency and number of factors, making this tool useful in recognizing risk intake, signs of addiction and unhealthy alcohol use among adolescents in Lebanon. Accordingly, the use of the AUDIT scale for the assessment of alcohol use disorder among Lebanese adolescents is recommended. However, further studies are needed to assess more validation features of the AUDIT (face validity, validation compared to physician’s diagnosis).
A high prevalence (28.0%) of risk of AUD was found among Lebanese adolescents, in line with other studies2,56,57. Besides the correlations with psychological factors identified in this research, this proportion may also be related to the normalization of alcohol use, to its wide availability especially in Beirut and Mount Lebanon, to the government’s inaction and existing indefinite policies toward the unlawful sale of alcohol to minors, to the very low taxes on alcohol excise and low cost, the poor regulatory framework for alcohol publicizing and promoting techniques, the lack of effectively reported adverse effects of alcohol consumption and the impact of friends and cousins on the young population26.
A notably higher mean AUDIT score was found in Beirut and Mount Lebanon compared to the other governorates. As stated in the methods’ section, this might be related to the distribution of the religious area in Lebanon, whereas North, South and Bekaa having most of the Lebanese Muslim rural populations26,29. Alcohol drinking is forbidden in the Qur’an as it is proclaimed to be a Satanic act58. Moreover, devout believers in Islam, adhere harshly to the expressions of Muhammad59. Abstention from alcohol use, is thought to be related first to its illegality and also to the feeling of guilt, followers of Islam may experience if they do drink59. In that manner, adolescents raised in families where the Islamic law and faith in forbidding alcohol is practiced, may encounter little or no alcohol drinking or misuse. This distribution further corroborates the validity of the AUDIT scale.
Cigarette and waterpipe dependence and AUD
In the current study, higher cigarette smoking dependence was remarkably associated with higher AUDIT scores in agreement to other studies8,60. We also found that waterpipe smoking is related to higher AUDIT scores, while few previous studies exhibited this association60,61. In fact, waterpipe smoking is addictive and associated with nicotine dependence among adolescents62. In general, it is assumed that youth smokers are at elevated vulnerability to AUD at the equal drinking rates compared to non-smokers8. This was reflected by Kandel and Chen who found elevated levels of AUD at minimal quantity of alcohol drinking for teenage smokers and associated amount of cigarettes with nicotine addiction symptoms63. To clarify this association, Grucza et al., 2006 suggested that a pharmacological influence on response to alcohol may result from smoking by expanding vulnerability to AUD8. There may also be a genetic predisposition or other obscure factors associated with the initiation of youth smoking that may assume a role in the development of AUD8. Adolescents’ nicotine exposure may alter gene expression and brain development, thereby modifying future social reactions to other drugs, expanding susceptibility to alcohol and other substance use disorders and fortifying impacts of multiple drugs of abuse. This was evidenced by an animal study exploring the nicotine effects on the adolescent rats’ central nervous system64 − 68.
Internet addiction and AUD
The current study demonstrated that a higher internet addiction was associated with a higher AUDIT score in harmony with previous results69. Internet addiction is a potentially dangerous condition that results in many negative consequences70,71 such as depression, anxiety isolation, loneliness72, loss of self-esteem and personal, social, academic problems as well, increasing the problematic use of alcohol among adolescents69 − 71. Afterwards, adolescents may diverge to misuse of alcohol in order to deal with the repercussions following dysfunctional use of the internet and to escape from their reality69. Likewise, Problematic Internet Use (PIU) and risky alcohol use may divide similar vulnerability elements alike positive attitudes toward alcohol, family history of alcoholism, and the presence of deviant peers13 raising the probability of appearing together, with the fact that PIU appears to antecede and increase the risky alcohol use among young people69. Similar to other behavioral addictions, adolescents suffering from PIU may use the internet more frequently in order to produce a satisfactory effect73,74. As a compulsion, equivalent to the suggestion of Problem Behavior Therapy75, getting involved in a problem behavior such as Internet addiction will decrease the threshold for other addictions and subsequently increase the alcohol use disorder.
Child sexual abuse, neglect and AUD
In the present study, results illustrated that higher child sexual abuse was correlated with higher AUD. Our findings are steady with other studies documenting this association among adolescents20,76. Several explanatory models are proposed for the association of these two major problems. First, the relationship is likely referred to psychiatric issues, as childhood sexual victimization frequently leads to depression and anxiety77. Youths who lack the appropriate system to manage their past bad experience and the subsequent results, may utilize alcohol to cope or escape from their traumatic childhood, and increase the requirement of alcohol trying to fix their issues and to make themselves feel much improved, leading to its misuse76,78 at some point.
Moreover, several studies found that antisocial behaviors can also be a consequence of childhood victimization79,80 and so, a strong predictor of AUD. Specialists theorized that youth displaying such delinquent practices may regularly become involved in deviant peer groups likewise advancing AUD78. Besides, a higher neglect abuse is found to be associated with a significantly higher AUDIT scores in line with previous researches81. Unfavorable life experiences during childhood, led to the development of Post-Traumatic Stress Disorder and have had a genuine and inescapable effect on biological stress response mechanisms and mental health driving victims to respond to their previous traumatic experiences by drinking alcohol82. Furthermore, ignored children can’t develop a valuable relationship with their inert primary caregiver and are more prone to build up a sense of vulnerability, poor social skills and companion issues83,84 thusly, degradation of self-confidence and self-control81
leading to more alcohol use.
Bullying and AUD
Our findings showed that higher bullying victimization was significantly associated with more alcohol use disorder, concurring previous research findings25,85. Bullying itself is a major global health problem with serious consequences86,87, long linked to issues with self-worth88,89. Besides, victimized adolescents have a propensity to have loneliness, depression, anxiety or physical symptoms with no known organic cause like headaches, difficulty breathing or abdominal pain90. It is suggested that alcohol use disorder is a way to deal with symptoms of mood disorders developed after being bullied90, to ease the anxiety and escape from reality. Others may use alcohol as a way to emphasize their social image and to improve their previously diminished self-worth90. Additionally, youth tend to seek the peer environment because they can’t solve bullying themselves, which seems to reinforce the susceptibility to engage in this antisocial behavior85.
Separated Parents and AUD
In this framework, more alcohol use disorder was also found in adolescents whose parents are separated, consolidating previous findings91,92, compared to those whose parents live together. Deviant conduct is probably produced by low levels of attachment and loyalty to the family resulting from decrease in infant monitoring and parental involvement that pursue separate usually compatible with social control hypothesis92.
Moreover, these findings may be highlighting the important role parents play in influencing the behavior of their children towards alcohol and actual alcohol consumption26,92. Parental absence, for instance, may result in a reduction in fruitfulness of parenting93 and increased access to alcohol, and increased access to alcohol, thereby increasing the chance of drinking94. In addition, as youth need to have emotional exigency met while experiencing divorce, prominent connection with substance-using peers will be developed95,96. Peers are thought to be potentially important in determining drinking habits26.
Poor parental observation could thus establish a cascade of development that leads to deviant peers, better alcohol exposure and, eventually, quicker drinking initiation92.
Clinical Implications
The findings of this study carry important implications for interventions. As per the nearness of immense gaps in protecting adolescents in the laws leading alcohol control in Lebanon, there is a pressing need to set new and actualized approaches to manage alcohol sale to the young, to decrease the density of alcohol shops, and to incorporate civic messages supporting endorsement of these arrangements28.
In addition, interventions should fundamentally focus on authorizing or boosting the legal minimum drinking age to minimize drinking by young people97, and to reduce morbidity and mortality related to alcohol as it has progressively become the second leading reason of road accidents in Lebanon (as reported by Red Cross Lebanon)2.
Furthermore, a national alcohol harm reduction plan based on evidence should be actualized as it has been shown to be successful in averting and lessening damage from alcohol use2. The World Health Organization (WHO) implemented the Global Strategy to Reduce Harmful Alcohol Use in May 2010, which showed progress in expanding the commitment of successful governments to encourage effective action while combating the harmful use of drug, by targeting one or more regions, including alcohol trading or promoting, costing and accessibility, and drinking and driving initiatives97 − 104.
Also, families, schools, public health and communities have to alert youth about alcohol consumption and focus on its negative aspects105. To begin with, families are one of the main sources that drive adolescents into alcohol consumption via making it accessible2,100,103,106; therefore, their role should be incorporated as part of any national study as they have to be aware and put effort into preventing and restricting the availability of alcohol at home100,103,106. Quite importantly, parent-child communication about alcohol use and its associated harms is also important in preventing alcohol use disorder2.
Second, reinforcing school-based alcohol awareness and its related dangers and incorporation of an available confidential academic-based counseling is essential for the prevention of AUD2.
At the level of community, awareness’ messages are required since they have a huge impact on influencing youth before they reach high school, parents, and larger community on how the interaction with alcohol should be by highlighting the risks of alcohol consumption risks, taking the problem into public conversation and helping to promote effective policy implementation26,104. Suggestions should also call attention to stop or regulate the alcohol advertising and marketing companies targeting the youth population2.
To reduce underage drinking, prevention efforts should involve not only young people and adults in attitudinal dialogs, but also community standards on underage drinking107, including a community based approach would help minimizing, clearing, preventing harms related to alcohol. Indeed, long-term programs and teaching styles that involve interaction with parents and the community concerned are shown to have a long enduring and effective impact on afterward alcohol use108. Finally, implementation of medical and rehabilitation services, in addition to more research related to the matter, are also needed26.
Limitations
This research was not free of limitations. Few potential weaknesses are worth to mention. First, the current study is limited by its cross-sectional design and thus, showed risk factor association with Alcohol Use Disorder but could not establish causality. In addition, as in Lebanon, a small country, eighteen religious communities share their convictions freely, some still perceive alcohol as a taboo, and as a consequence some schools refused to participate in our investigation. Participants were analyzed using a score tool and not through a clinical assessment test, therefore, we couldn’t affirm the precision of responses; a non-differential information bias is thus expected. A selection bias is also possible, related to the refusal of some schools to participate.