The aim of this study was to investigate the prevalence rate of SU and its risk and protective factors among Iranian adolescents in Bam County, Iran. Considering adolescence as the riskiest period of life to start SU, it seems necessary to investigate the determinants of adolescents’ tendency towards SU [16, 19], with the hope to identify the most effective and relevant stratgies for interventional efforts. In the present study, using hookah, alcohol and cigarette were the most commonly reported substances by the participants. These results are consistent with those reported or higher than in several previous studies throughout the world [5, 20–25]. Also, more than 38% of the participants experienced hookah (45.3% in boys and 31% in girls), 20% consumed alcohol (33.7% in boys and 6.3% in girls), and 10% smoked cigarette (14.3% in boys and 5.7% in girls). These results are in line with those of similar studies among adolescents in Kerman province (the setting of our study), and higher than those of previous studies among Iranian adolescents outside the Kerman Province . Comparing our results with those of similar previous studies in this setting [24, 27].
In our study, there was a remarkable difference between the prevalence rates of hookah (38.1%) and cigarette (10%) smoking. Previous studies have shown that adolescents consider hookah smoking as a less risky and less addictive behavior, compared to other modes of tobacco use. Also, in our setting, hookah is much more readily available to adolescents than other forms of tobacco products at restaurants, traditional cafe shops and even the adolescents’ homes. Moreover, there is a lower level of social stigma against hookah use, compared to the other forms of substances. So, it is so easy for the teenagers to do the behavior [26, 28].
Assessing the relationships between the SDM constructs and SU behavior, we found that involvement in pro/anti-social activities and interactions, attachment and commitment (bonding) to prosocial others and activities (family and school), perceived rewards for pro/antisocial interaction/involvement, as well as belief in others’ morals or antisocial values, and skills for interaction/involvement were the most significant predictors of SU. These results are consistent the assumptions of SDM and those reported in previous studies on the risk and protective factors of SU [15, 19].
In the present study, we found that participation in prosocial activities and belief in prosocial values derived from social environments such as family, school and peer groups had a protective role against SU, suggesting them as detrimental factors to be considered while designing SU prevention interventions. SU by one's close friends was found to be a very strong risk factor for tendency towards SU among the participants, which is consistent with those reported in previous similar studies [6, 29–30]. These findings necessitate particular considerations on the strategies applied while designing interventional efforts. We should pay attention that adolescence is a period of age when the impact of parents on the child decreases, gradually, and the impact of peer groups is increased instead. In adolescence, also, having abusive peers can be a risk factor, but if the peers have prosocial behaviors, it can be considered as a protective factor[5, 31–32]. Therefore, strengthening bonding with family, school and prosocial communities may lead to receiving more positive social support and decreasing stress among adolescence .
In several previous studies, having a positive attitude towards hookah, cigarette and alcohol, lack of skills to cope with the other’s recommendations, having friends (peers) who use substances, weakness of parent-child relationships, lack of bonding with school, and incorrect cultural beliefs and mores, weakness of religious beliefs in society are mentioned as the most common reasons for teenager tendency towards SU, which is consistent with those found in our study [11, 30, 33]. Despite Iran's intense struggle with drug trafficking during the last 40 years, and due to the easy access to ATOD in the studied area, an increase in the prevalence rate of SU in Iranian population is undeniable. So, the country requires a careful observation on the prevalence of SU and an overview of the coping methods. We need to pursue indirect coping ways based on scientific frameworks such as SDM. Based on our findings, bonding with family and school and joining prosocial peer groups were the most important protective factors against SU, as an antisocial behavior. Therefore, interventional efforts should be focused on families and schools (particularly preschool and elementary schools) from the ages younger than adolescence. Therefore, life skills training for teachers and parents of children under 12 years of age may be helpful in making better bonding of children to their school and family members, when they will become a teenager in their society.