Investigating The Prevalence of Alcohol Consumption and Its Related Factors in 13 To 17-Year-Old Adolescents: Data Extraction From 55 Eastern Mediterranean Countries

Alcohol consumption has become very common among adolescents in recent years and its prevalence varies in different countries. The aim of this study was to investigate the prevalence of alcohol consumption and related factors in adolescents aged 13 to 17 years living in the Eastern Mediterranean Region (EMR). The present study was a cross-sectional study that was performed on 191228 adolescents (girl, 51.1% of total) aged 13 to 17 years in 55 EMR countries. In this study, the data that were collected by the World Health Organization from students were used. In order to investigate the factors affecting alcohol consumption, univariate and multivariate logistics models with 95% condence limits were used. programs be conducted to raise students’ awareness of the effects of alcohol consumption in schools.

Introduction Adolescents are exposed to many physical and hormonal changes during puberty (1). They face a range of changes in various physical, psychological, social and cultural aspects (2). Many adolescents go through this critical phase safely, but some of them are not able to cope with these conditions and expose themselves to high-risk behaviors such as alcohol consumption (3). Various factors may affect related to alcohol consumption in adolescents in order to develop prevention programs, therefore, the aim of this study was to investigate the prevalence of alcohol consumption and its related factors in adolescents aged 13 to 17 years in Eastern Mediterranean countries.

Materials And Methods
The present cross-sectional study used data from the Global School-based Student Health Survey (GSHS) (obtained from World Health Organization (WHO)). The GSHS is a school-based health survey which is conducted for students who are 13-17 years old, it is performed by the WHO and the Centers for Disease Control and Prevention (CDC) in collaboration with United Nations International Children's Emergency Fund (UNICEF), United Nations Educational, Scienti c and Cultural Organization (UNESCO), and United Nations programme on Human Immunode ciency Virus/ United Nations programme on Acqired Immunode ciency Syndrome (UNAIDS).
The aim of the GSHS is to supply data on health behaviors and protective factors among students in the age group of 13-17. The 10 core questionnaire modules address the main causes of morbidity and mortality among children throughout the world (e.g., alcohol, tobacco and drug use, nourishing behaviors, sexual behaviors contributing to Human Immunode ciency Virus (HIV) infection, other infections which are sexually transmitted, and unexpected pregnancy plus some questionnaires regarding mental health, physical activity, accidental injuries, and violence).
A cluster sampling designed in two stages randomly was performed to choose suitable partakers in each country. At the rst stage, schools were chosen with probability proportional to enrollment size. On the following stage, classes were randomly chosen, all of the students in the classes were included in the survey. The school and student response rates varied from 83-100% and 71-99%, respectively.
Ethical approval was taken according to the instructions related to each country prior to data collection (More details are available at www.who.int/chp/gshs/factsheets/en).

Data collection and de nition of variables
The present study used data from the last accessible GSHS for 55  Lastly, 191228 students were included in this study (Table 1). Variables were classi ed into six generic categories as follows: socio demographic factors (such as age, sex, and educational level); mental health factors (loneliness, insomnia due to anxiety or worry, the number of close friends, and suicide plan); protective factors (parental supervision, parental support, parental awareness, peer support, and physical activity); and other background factors (cigarette, times used marijuana, had sex, eating fruit, truancy, bullied, parental used tobacco). The details of variable description in Table 1.

Prevalence of alcohol consumption
The prevalence of smoking and marijuana use was higher among the students who consumed alcohol than among the students who did not consume alcohol, so that among students who consumed alcohol, (50.9%) and (62.5%) students, respectively, among the students who drank alcohol, (50.9%) and (62.5%) of male and female students had a history of smoking, respectively, 83.6% of the male students who consumed alcohol had at least 10 or more days of marijuana use in 30 days, and among (39.6%) boys and (39.2%) girls, a suicide plan was observed (Table 3).

Discussion
The aim of this study was to investigate the prevalence of alcohol consumption and its related factors in adolescents aged 13 to 17 years living in the Eastern Mediterranean. Analysis of the ndings showed that alcohol consumption is common in adolescents, which was also found in the studies of Benjet et al. (10), Kittipichai et al. (11), and Getachew et al. (12). In a study of Thai adolescents, Luecha et al. (9) found that 31.01% of adolescents aged 10 to 14 had consumed alcohol at least once. In a study by Ting et al. (22) on 11 to 12-year-old Taiwanese adolescents, alcohol consumption was reported at 48% in this group.
Explaining this nding, it can be said that seeking diversity, curiosity, easy access, misconceptions about alcohol, being in uenced by friends and imitating them are among the most important causes of adolescents' tendency to consume alcohol (10)(11)(12). It can also be stated that adolescents are exposed to high-risk behaviors such as alcohol consumption due to special conditions in this age group (23).
Adolescence is a period of changes in physical, sexual, psychological, cognitive development, as well as changes in social needs, lack of appropriate conditions for passing this critical stage can lead to a tendency to consume alcohol (24).
Another nding of the present study was that the prevalence of alcohol consumption in boys is higher than girls, this nding was consistent with the ndings of Alex-Hart et al. can point to the biological differences in alcohol consumption between men and women. Compared to men, women generally have less water in their body, which is why women reach the peak with less consumption, even if they consume the same amount as men, and this causes men to consume more (29,30). We can also point to cultural differences, because in most societies drinking alcohol is masculine, and some men are better accepted by drinking alcohol in the company of their friends and have stronger personal relationships (31,32). Social control is greater for women, and women are concerned that alcohol consumption may affect their family relationships and general behavior or make them sexually vulnerable (33,34).
The study also found that marijuana use in adolescents greatly increases the chances of alcohol consumption. In a study conducted by Sokolovsky et al., (35) 341 young university students were surveyed. In this study, it was found that marijuana and alcohol are often used simultaneously and their simultaneous use has more negative consequences. There is a two-way relationship between alcohol consumption and marijuana use, adolescents who use marijuana may also use more alcohol, and vice versa, usually marijuana and alcohol are consumed simultaneously. In general, it can be said that performing a high-risk behavior in adolescence can lead to different behaviors (36-38).
Another nding of the present study was that smoking increases the likelihood of alcohol consumption.
The same nding was found in the studies of Thrul et al. (39), McKee et al. (40), Piasecki et al. (41). In this regard, Thrul et al. (39) in a study showed that the simultaneous consumption of cigarette and alcohol increases the perception of rewards for consumption (39). On the other hand, some studies have shown that the simultaneous consumption of alcohol and cigarette may have a greater effect on the mesolimbic system, which in turn stimulates the reward system in the brain, and further stimulation of this system leads to increased adolescent desire to consume these two simultaneously (42,43).
Having sex was another factor that increased the chances of consuming alcohol, alcohol consumption can be associated with engaging in sexual experiences (44). In a study, Dogan et al. (45) showed that alcohol consumption in adolescents affects the number of sexual partners. Explaining this nding, it can be said that having a positive attitude towards a behavior affects the likelihood of doing that behavior. In some adolescents, there is a view that alcohol consumption has a positive effect on sexual experiences and this view leads to alcohol consumption among them (46). Some people also believe that alcohol consumption causes a pleasurable sexual relationship and increases sexual attraction and the positive aspects of sexual behavior, all of these factors affect the increase in alcohol consumption (38, 47).
Being alone also increased alcohol consumption. Consistent with this nding, McKay et al. (48), in a study showed that being alone is effective in alcohol consumption. In addition, loneliness and gender are associated with alcohol consumption, so that being a woman and experiencing loneliness put a person at greater risk for drinking alcohol. For example, several studies have shown that alone adolescents may use alcohol, cigarette, and illegal drugs, probably Adolescents use alcohol as a form of self-medication to reduce loneliness (49,50).
Another factor that was shown to be effective in alcohol consumption was insomnia. This nding is consistent with Barrow's research (50,51) which showed that insomnia creates a vicious circle with alcohol consumption. As insomnia increases the risk of alcohol consumption, alcohol consumption can become problematic as well, which exacerbates insomnia. The same nding was found in the research of Rohers et al. (52) Their study found that people who experience insomnia use alcohol to improve sleep quality. On the other hand, it has been found that a history of committing suicide increases the chances of alcohol consumption. This nding is consistent with the research of Pompili et al. (53) who showed in their research that there is a two-way relationship between alcohol consumption and suicide. Explaining this nding, it can be stated that according to studies, suicide is directly related to anxiety and depression, and many people with a history of suicide use alcohol as self-medication, and when they suffer from anxiety, low mood or life problems, they turn to alcohol to forget their problems. However, constant use of alcohol can cause tolerance, dependence and ultimately addiction in the individual (54). Although alcohol consumption can temporarily reduce suicidal ideation, in fact it makes the problem worse. In most cases, long-term alcohol abuse makes the suicidal ideation more frequent and powerful and increases the likelihood of attempting suicide (55,56). In addition, alcohol abuse generally exacerbates the other factors in uencing suicide. For example, alcohol exacerbates the symptoms of many disorders, such as bipolar disorder, borderline personality disorder, and depression, all of which can contribute to suicide.
Alcoholism can also cause problems at work, within the family, interpersonal relationships, and the legal system, these problems affect suicide (55).
On the other hand, the effect of daily activity on alcohol consumption cannot be ignored. In this regard, in a study Conroy et al. (57) showed that after controlling age and gender, daily physical activity was associated with alcohol consumption. If a curious and energetic teenager does not have good entertainment and it is not possible for him/her to have proper daily activities, he/she will be drawn to activities and entertainment that are not good. Therefore, addressing the issue of alcohol consumption in adolescents and young people and preventing it by emphasizing the role of daily activities is very necessary and important.
It has also been found that a history of being beaten increases the chances of alcohol consumption in adolescents. Studying the research related to the long-term effects of child abuse has shown that most adolescents and adults who have had traumatic events as children are more likely to consume alcohol than others. Research shows that childhood abuse experiences can have long-term effects on all aspects of health, development, and well-being (58), and can lead to impaired performance and high-risk behaviors such as alcohol consumption (59). Waner et al. (60) believe that prolonged exposure to bullying predisposes the child to violence and high-risk behaviors in the future. Children who have been abused have also been found to be more aggressive and delinquent than their peers. These children are pessimistic on their social networks. These signs may be in uential in shaping the tendency to consume alcohol (61).
It was also found that parental supervision is a deterrent and effective factor in reducing alcohol consumption in adolescents. The same nding was obtained in the study of Benjet et al. (10). A study by Strunin et al. (62) also found that parental supervision was effective in limiting alcohol consumption in adolescents. Parental supervision has a signi cant effect on delaying the tendency to consume alcohol.
Adolescents and young people who have less family support and supervision show self-destructive behaviors. The higher the level of family support in adolescents is, the less they are exposed to alcohol. In fact, parental supervision is a protective factor against alcohol consumption (63, 64).

Strengths And Limitations
This study has several strengths, including the fact that a standard questionnaire was used to measure the prevalence of alcohol among students and the samples were selected by a scienti c method. Furthermore, the sample size was high and various risk factors for adolescent alcoholism were examined, also, due to the fact that the countries included in the study were culturally, religiously, socially, demographically and healthily diverse, these cases led to the study of various factors that affected the prevalence of alcohol in adolescents. In addition to the cases mentioned, this study also faced other limitations. First, a self-report questionnaire was used to measure the prevalence of alcohol in students, which may have led to bias in the answers, because the prevalence of alcohol may be underestimated and students may have concealed their alcohol use or not mentioned the factors affecting it for fear of being reprimanded by their parents and school teachers. Second, because the GSHS did not provide information on the prevalence of alcohol in the parents of these students, this important in uencing factor has not been investigated. Third, in this study, it was found that marijuana use, smoking and having sex are some of the main factors affecting the prevalence of alcohol in adolescents, but more information in this regard, such as the age of rst smoking, marijuana use or sexual intercourse and how often they were done were not available, nally, for the purpose of this study, the missing data were not replaced by statistical methods and therefore such data were removed from the analysis. The results of this study and previous reports showed that using tobacco and smoking cigarette are affected by various factors. Therefore, in order to prevent the spread of alcohol in adolescents, various factors and their risk should be considered as well, all these factors should be considered in the development of treatment and prevention programs. It is also suggested that policy makers and therapists of children and adolescents pay special attention to the prevalence of alcohol in adolescence and the factors affecting it, particularly in this study it was found that using marijuana increases the risk of alcohol consumption, which is important and should be considered for prevention. Also, more research is needed to provide better interventions to reduce alcohol consumption in adolescents.

Conclusion
Due to the importance of the prevalence of alcohol in adolescents and its role in creating high-risk behavior in adulthood, identifying and controlling the factors associated with it is of great importance.
Using marijuana, having sex, loneliness, insomnia, suicide plan, and being beaten were among the most important factors associated with adolescent alcohol use in EMR. Therefore, it is recommended that school counselors, parents and policy makers of prevention and treatment programs pay attention to these issues.

Declarations
Ethics approval and consent to participate The study was approved by the ethics committee of the vice chancellery of research and technology, Kermanshah University of Medical Sciences (IR.KUMS.REC.1398.711) and the written informed consent was obtained from each participant.

Consent for publication
All authors consent to this manuscript's publication.
Availability of data and materials The data are available on www.who.int/chp/gshs/factsheets/en.

Competing interests
The authors declare that they have no competing interests.

Funding
The Research Deputy of Kermanshah University of Medical Sciences funded the study.
Authors'contributions VF developed this manuscript, supported by TAJ and SS. MM managed all the research. TMM contributed to data analysis and interpretation. BR provided additional literature review. MA and SHB revised the manuscript All authors contributed to the subsequent revisions of the paper and have approved the nal paper for submission.