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Illicit and traditional drug use among ethnic minority adolescents in East London
Public Health (2006) 120, 329–338
ORIGINAL RESEARCH
Illicit and traditional drug use among ethnic minority adolescents in East London A.A. Jayakodya, R.M. Vinera,*, M.M. Hainesb, K.S. Bhuib, J.A. Headb,e, S.J.C. Taylorc, R. Booyd, E. Klinebergb, C. Clarkb, S.A. Stansfeldb a
Department of Paediatrics, Royal Free and University College London Medical School, University College London, UK b Centre for Psychiatry, Institute of Community Health Sciences, Barts and the London Queen Mary’s School of Medicine and Dentistry, Queen Mary University of London, UK c School of Medicine and Dentistry, Institute of Community Health Sciences, Centre for General Practice and Primary Care, Barts and the London Queen Mary’s Queen Mary University of London, UK d School of Medicine and Dentistry, Institute of Community Health Sciences, Centre for Child Health, Barts and the London Queen Mary’s Queen Mary University of London, UK e Department of Epidemiology and Public Health, University College London, UK Received 24 November 2004; received in revised form 2 June 2005; accepted 13 October 2005
KEYWORDS drug use; Adolescents; Ethnicity; Acculturation
Summary Objectives: To explore ethnic variations in the use of illicit and traditional drugs, and the association of indicators of acculturation with drug use among an ethnically diverse representative sample of early adolescents in East London. Study design: A cross-sectional questionnaire survey. Methods: Confidential questionnaires were used to assess 2789 male and female pupils in years 7 and 9, aged 11–14 years old, from a representative sample of 28 secondary schools in East London. Results: In total, 10.8% reported having ever tried illicit drugs and 7.3% reported ever using cannabis. Compared with white British adolescents, cannabis use in the previous month was significantly higher amongst black Caribbean adolescents. Lifetime cannabis use was significantly higher amongst black Caribbean and mixed ethnicity young people, but was lower amongst Bangladeshi, Indian and Pakistani adolescents. Living in UK for 5 years or less markedly reduced the risk of lifetime and recent cannabis use when controlled for ethnicity and social class. Glue or solvent use was reported in 3.2% of adolescents, with use significantly higher amongst Bangladeshi young people. Lifetime paan use was reported by 14.1% of the sample, and was almost completely confined to South Asian or mixed ethnicities. Conclusions: Ethnic differences in illicit drug use were found in the study population, and significant differences were found between ethnic groups often identified as
* Corresponding author. Tel.: C44 20 7380 9445; fax: C44 20 7636 2144. E-mail address: [email protected] (R.M. Viner).
0033-3506/$ - see front matter Q 2005 Published by Elsevier Ltd on behalf of The Royal Institute of Public Health. doi:10.1016/j.puhe.2005.10.009
330
A.A. Jayakody et al. ‘black.’ Further research is needed in understanding cultural-specific risk and protective factors in different ethnic groups, and the importance of cultural identity in mediating health risk behaviors. The high use of paan and glue/gas/solvents by Bangladeshi young people poses an unappreciated public health problem that may require targeted interventions. Q 2005 Published by Elsevier Ltd on behalf of The Royal Institute of Public Health.
Introduction Illicit drug misuse amongst young people is a significant public health concern. While substance use rates amongst adolescents appear to have stabilized recently after significant increases through the 1990s, UK national surveys suggest that over one-quarter of 11–15 year olds have ever tried illicit drugs.1–3 Children aged 14 years and under make up 30% of ethnic minority groups in UK, with 40% of Bangladeshis being aged 14 years or under, compared with 19% of the white British population.4 Half of ethnic minority people live in London,4 where drug use rates are the highest in England.5 Despite these figures and substantial research on smoking and drinking amongst ethnic minority adolescents,6,7 little is known about illicit drug use in these groups in UK. Additionally, attempts to address ethnicity in national samples have grouped adolescents into ‘white’, ‘black’ or ‘Asian’ categories;1 a practice that may conceal significant differences in health behaviours between ethnic groups.8 In a small study of 132 young people from inner London,9 white adolescents were most likely to report the highest levels of substance misuse, with Bangladeshi adolescents reporting the lowest levels, and black African and Caribbean adolescents reporting intermediate rates. Given in UK Government’s targets of reducing the use of Class A drugs and the frequent use of all illicit drugs by all young people by 2008,10 a more detailed understanding is needed of drug use amongst black and ethnic minority adolescents in order to ensure that interventions are culturally sensitive and therefore effective in such communities. In addition, little is known about British adolescents’ use of substances traditionally used recreationally in some cultures, such as paan and khat. Paan, a chewed or smoked mix of areca nut, an acacia extract and inorganic lime wrapped in betel leaf and sun-dried tobacco is traditionally used in many South Asian countries and is known to be highly prevalent in Asian immigrant communities in UK.11 Small studies have suggested that some British Asian children are experienced paan users;
12
however, few young people are aware of the health risks associated with paan use,13 which include those associated with tobacco use and an independently increased risk for oral cancer.14 Less is known about the use of khat (quat, qat, qaadka, chat), a drug predominantly used by those from the Arabian peninsula and Horn of Africa (Somalia, Ethiopia) that produces amphetamine-like effects by chewing, brewing or smoking the leaves of the Catha edulis plant.15,16 Acculturation, defined as ‘phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original culture patterns of either or both groups’,17 is believed to be a mediating factor in adolescents’ adaptation to their environment and their adoption of the health risk behaviours of their peers. Acculturation has been measured in different ways including duration of residence, country of birth, languages spoken and cultural participation.18 Research from the USA on the effect of migration status on adolescent health has found that foreign-born young people are at a lower risk of health problems and risk behaviours than those born in the host country, but the protective effect diminishes over three generations.19 However, the effects of the process of acculturation on health risk behaviours, such as substance use, has been little studied in UK. In this study, data from a representative ethnically diverse sample of young people aged 11–14 years were used to examine the hypotheses that the prevalence of illicit and traditional drug use varies by ethnicity, and that indicators of acculturation are associated with drug use.
Methods Research with East London Adolescent Community Health Survey (RELACHS) is a school-based epidemiological study of a representative sample of 2790 adolescents from year 7 (11–12 years) and year 9 (13–14 years) attending 28 schools in East London in 2001.20 All 42 eligible schools in Hackney, Tower Hamlets and Newham were stratified by borough
Illicit and traditional drug use among ethnic minority adolescents in East London and school type (comprehensive, voluntary, other). Thirty schools were selected at random and balanced to ensure representation of single-sex and mixed-sex schools. In each of the 28 schools that agreed to participate, representative mixed ability classes were selected (two classes from year 7 and year 9). Data were collected by studentcompleted questionnaire, completed individually in classrooms under the supervision of trained researchers. Researchers addressed pupils’ queries and checked the questionnaires for missing data. Parents were informed of the study by letter, and were given the opportunity to opt their child out of the study. Written consent was obtained from the young people. The study protocol was approved by the East London and the City Research Ethics Committee. The overall response rate was 84% (85% in non-whites, 77% in whites, 3.5% refused to participate, 12.2% were absent). Adolescents completed self-report questionnaires regarding whether they had ever used a range of drugs and frequency of drug use. The questions were taken from the office for national statistics (ONS) surveys for adolescents.21 Adolescent self-reported drug use is a widely used questionnaire method to measure the prevalence of drug use,21,22 and is thought to be more accurate than face-to-face interviews. Slang names for drugs were included in the drugs questions so as to ensure comprehensibility by all the pupils. In order to detect false-positive responding, a fictitious drug (deccopan) was included in the questionnaire. Only six pupils responded that they had used deccopan and they were excluded from these analyses. Questions on paan and khat use were adapted from the ONS smoking questions. The questionnaire asked whether pupils had tried chewing paan (betel leaf) with tobacco (either wet or dry smokeless tobacco) at least once in their lifetime, whether they had tried it last week, and if so how many quids they had chewed. Pupils were also asked whether they had tried khat at least once in their lifetime and the frequency of khat use. Class A drugs are defined in UK as opiates (including heroin), ecstasy, LSD, cocaine, crack and amphetamines (injected) (Misuse of Drugs Act 1971). Sniffed or oral amphetamines are classified as class B drugs; however, they were included with class A drugs in these analyses due to the very low rates of overall amphetamine use in this cohort and in order to separate them from cannabis use (rated class C at the time of writing). Ethnicity was self-assigned using an adaptation of UK Census 2001 categories (Table 1).23 Black young people were asked to classify themselves as either black African, black British or black
Table 1
331
Self-assigned census 2001 ethnic categories.
Census 2001 ethnic categories
Collapsed categories for analyses
White
White UK White other
Mixed
Asian
Black
Other
UK Irish Greeka Turkisha Orthodox Jewisha Kurdisha Other White and black Caribbean White and black African White and Asian Other Indian Pakistani Bangladeshi Other Caribbean African Somalia Britisha Other Chinese Vietnamesea Other
Mixed ethnicity
Other Indian Pakistani Bangladeshi Other Black Caribbean Black African Black British Other Other
a Additional categories added to Research with East London Adolescent Community Health Survey questionnaire.
Caribbean. Those from South Asian ethnicities were asked to classify themselves as either Asian Indian, Pakistani or Bangladeshi. White young people were asked to classify themselves as white British or from other white groups (e.g. other European, Turkish, Kurdish). Those of mixed white and black Caribbean, white and black African, white and black, white and Asian and mixed ‘other’ ethnicities were categorized as ‘mixed’ ethnicity. Due to small numbers, Chinese, Vietnamese and other ethnicities were categorized as ‘other’ ethnicity. Other sociodemographic data collected included years lived in UK, whether either parent was currently employed and household crowding (defined as O1.5 people per room, excluding bathroom and kitchen).
Analyses All analyses were weighted to take account of unequal probabilities of selection. As the sample selection used a stratified cluster design with pupils clustered within schools, all statistical analyses were performed using the survey estimation commands of STATA (Version 8.1). Data analysis
332 Table 2 Year
Year 7
A.A. Jayakody et al. Prevalence of cannabis use by ethnicity, age and sex. Ethnicity
White British
White other
Bangladeshi
Pakistani Asian Indian
Black Caribbean
Black African
Black British
Mixed ethnicity
Other ethnicity
Total
Year 9
White British
White other
Bangladeshi
Pakistani
Asian Indian
Black Caribbean
Black African
Ever used cannabis % (95% CI)
Used cannabis within last month % (95% CI)
Un weighted bases
Un weighted bases
Boys
Girls
Boys
Girls
1.8 (0.6, 5.6) 145 0
1.4 (0.3, 5.3) 140 1.8 (0.3, 11.7) 52 1.8 (0.5, 7.0) 132 0 35 0
0.64 (0.09, 4.4) 145 0
0.7 (0.09, 4.9) 140 0
39 1.4 (0.3, 5.3) 171 0 56 2.2 (0.3, 14.2) 38 0
52 0
39 2.6 (1.0, 6.7) 171 0 56 5.9 (1.4, 21.3) 38 0 43 3.2 (0.8, 12.0) 61 3.4 (0.5, 20.5) 28 7.7 (2.9, 19.0) 52 0 29 2.4 (1.5, 4.0) 662 18.3 (12.8, 25.5) 135 9.5 (3.1, 25.8) 31 12.1 (8.1, 17.7) 193 8.0 (2.8, 20.5) 45 3.6 (1.1, 10.8) I 24.6 (12.1, 43.5) 31 3.7 (0.9, 13.7) 56
61 6.5 (1.6, 22.4) 41 2.2 (0.6, 8.5) 81 0 31 4.0 (1.0, 14.6) 52 2.7 (0.4, 17.1) 32 1.9 (1.1, 3.4) 657 15.9 (10.7, 22.9) 155 12.4 (4.7, 29.0) 31 4.5 (2.2, 8.8) 181 2.3 (0.3, 14.4) 44 3.1 (0.7, 11.8) 79 25.4 (15.0, 39.7) 47 10.1 (5.1, 18.9) 79
43 0 61 3.4 (0.5, 20.5) 28 0
132 0 35 0 61 3.1 (0.4, 19.0) 41 0 81 0
52 0
31 2.0 (0.3, 12.9) 52 0
29 0.8 (0.3, 662 10.9 (6.7, 135 3.3 (0.5, 31 7.4 (4.4, 193 0
32 0.5 (0.2, 657 10.2 (6.2, 155 6.3 (1.6, 31 1.1 (0.3, 181 0
1.9)
17.2)
19.9)
12.1)
61 1.5 (0.2, 10.0) 66 15.0 (5.7, 34.2) 31 3.7 (0.9, 13.7) 56
1.6)
16.2)
21.9)
4.4)
81 3.1 (0.7, 11.9) 79 21.2 (11.8, 35.3) 47 8.8 (4.2, 17.4) 79
Illicit and traditional drug use among ethnic minority adolescents in East London Table 2 Year
333
(continued) Ethnicity
Black British
Mixed ethnicity
Other ethnicity
Total
Ever used cannabis % (95% CI)
Used cannabis within last month % (95% CI)
Un weighted bases
Un weighted bases
Boys
Girls
19.5 (8.3, 39.5) 24 30.0 (18.1, 45.4) 41 13.7 (5.2, 31.6) 29 13.5 (11.1, 16.3) 651
17.0 (7.4, 38 17.4 (8.8, 45 21.3 (9.1, 24 10.9 (8.8, 723
was conducted in two stages. In the first stage, descriptive statistics were generated to describe the frequency and distribution of illicit and traditional non-illicit drug use by ethnicity. Analyses were then conducted using logistic regression to examine the associations of drug use, ethnicity and years lived in UK, controlling for socioeconomic status (overcrowding and parental employment), sex and year group.
Results The cohort consisted of 25% Bangladeshi, 21% white British, 10% black African, 9% Asian Indian, 7% Pakistani, 7% mixed ethnicity, 6% black Caribbean, 6% white other, 4% black British and 4% other ethnic groups. In total, 22% of males and 20% of females were born outside in UK. Data on illicit drug use were available for 2723 (98%) adolescents, of whom 295 (10.8%) had tried illicit drugs of any type at least once in their lifetime. Data on paan use were available for 2687 (96%) adolescents.
Age of first trying illicit drugs Of those who reported ever trying drugs, data on the age when they first tried any illicit drug were available for 263 (89%) adolescents. Amongst those in year 7 (70 subjects), the mean age of first trying drugs was 9.5 years [95% confidence intervals (CI): 9.0, 10.0], and the mean age was 12.5 years (95% CI: 12.3, 12.7) amongst those in year 9 (193 subjects). Amongst those in year 9, 3.1% subjects had first tried drugs at less than 10 years of age, 37.8% between 10 and 12 years of age, and 59.1% at 13
32.9)
31.5)
42.1)
13.5)
Boys
Girls
15.8 (6.0, 35.6) 24 25.0 (14.2, 40.1) 41 13.7 (5.2, 31.6) 29 8.6 (6.6, 11.0) 651
8.3 (2.7, 38 8.1 (3.1, 45 12.5 (4.1, 24 6.7 (5.1, 723
22.9)
19.9)
32.5)
8.8)
years of age or older. There was no association between age of first trying drugs and ethnicity.
Cannabis Data on cannabis use were available for 2723 (98%) adolescents, of whom 198 (7.3%) had used cannabis at least once in their lifetime. Table 2 presents data on lifetime cannabis use and cannabis use within the last month. Overall, there was no significant difference in lifetime cannabis use by sex; however, lifetime use significantly increased between years 7 and 9 (c2Z99.34, P!0.001). One hundred and fifteen of 2723 (4.2%) adolescents reported using cannabis within the last month, with the highest proportions seen in white British, black Caribbean, black British and mixed ethnicity groups. The associations of lifetime and monthly cannabis use with ethnicity, years lived in UK, sex and socio-economic statuses are shown in Table 3. Lifetime use was significantly more likely in year 9 than year 7 students of both sexes (P!0.001), but was not associated with sex or socio-economic status after adjusting for all other variables in the model. When adjusted for socio-economic status, sex, year group and years lived in UK, Bangladeshi, Indian and Pakistani ethnicity were associated with lower risk of use, whilst black Caribbean and mixed ethnicity young people were significantly more likely to have ever tried cannabis. Residing in UK for 5 years or less was associated with reduced risk of lifetime use compared with living in UK for more than 10 years, independent of ethnicity and socioeconomic status. Use in the last month showed similar associations, being less common in Indian young people, more likely in year 9 than year 7
334 Table 3
A.A. Jayakody et al. Adjusted odds ratios (ORs) for illicit drug use by ethnicity.
Ethnic group
Sex Socio-economic status
School year Time lived in UK
White British White other Bangladeshi Pakistani Asian Indian Black Caribbean Black African Black British Mixed ethnicity Other ethnicity Female compared with male Either parent employed Household overcrowding Year 9 compared with year 7 O10 years 6-10 years 5 years or less
Ever tried cannabis OR (95% CI)
Used cannabis in last month/week OR (95% CI)
Ever tried glue, gas or solvent OR (95% CI)
1 0.8 0.6 0.3 0.2 1.9 0.8 1.2 1.7 1.1 0.8
1 0.6 (0.2, 2.1) 0.5 (0.3, 1.0) 0a 0.3 (0.1, 0.8)* 2. 6 (1.3, 5.1)* 1.0 (0.4, 2.3) 1.3 (0.5, 3.1) 1.7 (0.9, 3.3) 1.3 (0.5, 3.2) 0.7 (0.5, 1.1)
1 1.7 1.9 1.5 1.9 1.4 1.7 0.8 1.1 0.2 1.2
1.0 (0.7, 1.5)
1.0 (0.6, 1.6)
1.4 (0.9, 2.1)
0.9 (0.6, 1.4)
0.8 (0.5, 1.5)
1.0 (0.6, 1.4)
2.8 (2.3, 3.5)***
3.6 (2.5, 5.2)***
0.8 (0.7, 0.96)*
1 1.1 (0.5, 2.2) 0.1 (0.0, 0.4)***
1 0.8 (0.3, 2.4) 0.1 (0.0, 0.6)*
1 1.0 (0.5, 2.0) 1.2 (0.7, 2.2)
(0.4, (0.3, (0.1, (0.1, (1.1, (0.4, (0.6, (1.0, (0.5, (0.6,
1.9) 0.9)* 0.7)** 0.5)*** 3.4)* 1.5) 2.4) 3.0)* 2.3) 1.1)
(0.8, 4.0) (1.1, 3.5)* (0. 7, 3.3) (0.9, 3.7) (0.6, 3.2) (0.9, 3.3) (0.3, 2.5) (0.4, 2.5) (0.0, 1.5) (0.8, 1.7)
CI, confidence interval; Adjusted ORs are presented for each ethnic group separately, with white British young people as the reference group. ORs are adjusted for all variables in the table. *P!0.05, **P!0.01, ***P!0.001. a OR not calculated as no cases in category of interest.
students, more likely if the young person had lived in UK for 5 years or less, and more likely in black Caribbean young people.
Class A drugs Data on class A drug and amphetamine use were available for 2723 adolescents (97.6%) (Table 4). In total, 57 (2.1%) had tried class A drugs at least once in their lifetime, of whom seven had tried ecstasy, 24 had tried cocaine, 11 had tried heroin, 13 had tried LSD, 24 had tried crack and 11 had tried amphetamines. Lifetime use of class A drugs was higher in boys and was slightly higher in year 9 than in year 7 students. Highest lifetime use appeared to be amongst mixed ethnicity and white other young people, although significance tests were not undertaken due to small numbers.
Glue, gas and solvents Data on the use of glue, gas or solvents were available for 2714 (97.3%) adolescents (Table 4). Of the overall sample, 88 (3.2%) had tried sniffing or inhaling glue, gas or solvents at least once and 35 had used glue/gas or solvents in the past month.
The pattern of glue/gas/solvent use appeared to be different to that for cannabis use; use was higher in younger boys and older girls, and appeared to be higher amongst Bangladeshi, Pakistani and Indian adolescents than amongst white British or black adolescents. Table 3 shows adjusted odds ratios by ethnicity for lifetime glue/gas/solvent use controlled for socio-economic status, sex, year group and years resided in UK. Bangladeshi young people were more likely to have ever tried glue/gas/ solvent compared with white British young people. Lifetime use was associated with younger year group. Time lived in UK was not associated with glue/gas/solvent use.
Traditional drug use In the whole cohort, 378/2687 (14.1%) had tried paan at least once in their lifetime, 4.1% (111) were occasional users (less than weekly) and a further 1.5% (41) chewed paan weekly or more often. There was no significant difference between the sexes in paan use in the whole cohort. As expected, paan chewing was almost completely confined to the South Asian or mixed ethnicity groups, with 76.5% of all pupils who reported lifetime paan use being
Illicit and traditional drug use among ethnic minority adolescents in East London Table 4 Year
Year 7
Prevalence of other illicit drug use by ethnicity, age and sex. Ethnicity
White British
White other
Bangladeshi
Pakistani
Asian Indian
Black Caribbean
Black African
Black British
Mixed ethnicity
Other ethnicity
Total
Year 9
335
White British
White other
Bangladeshi
Pakistani
Asian Indian
Black Caribbean
Ever used glue, gas or solvents % (95% CI) Un weighted bases
Ever used Class A drugs or amphetamines % (95% CI) Un weighted bases
Boys
Girls
Boys
Girls
3.5 (1.4, 8.3) 145 5.0 (1.2, 17.9) 39 3.9 (1.9, 8.1) 170 0
2.2 (0.7, 6.6) 139 1.9 (0.3,.12.6) 52 6.6 (3.3, 12.9) 132 5.9 (1.5, 20.7) 35 1.5 (0.2, 9.9) 60 5.5 (1.3, 20.1) 41 2.2 (0.5, 8.3) 81 5.4 (1.3, 19.4) 31 5.7 (1.8, 16.3) 52 0
3.0 (1.2, 7.0) 145 3.0 (0.4, 18.4) 39 2.8 (1.1, 6.6) 170 0
38 0
0.7 (0.09, 4.5) 140 1.8 (0.3, 11.7) 52 0.9 (0.1, 5.9) 132 2.8 (0.4, 17.4) 35 1.7 (0.2, 11.3) 60 0
43 1.6 (0.2, 10.4) 61 0
41 1.0 (0.1, 6.7) 81 0
28 7.6 (2.8, 18.8) 51 0
31 0
31 2.2 (0.8, 5.7) 192 4.5 (1.1, 16.5) 45 4.9 (1.6, 14.3) 66
32 3.8 (2.5, 655 2.6 (1.0, 154 3.0 (0.4, 31 5.7 (3.1, 181 6.2 (2.0, 44 2.2 (0.6, 79
29 2.3 (1.4, 660 2.6 (1.0, 134 3.0 (0.4, 31 3.7 (1.8, 193 0
0
0
31
45
56 8.8 (2.8, 38 2.7 (0.4, 43 8.1 (3.4, 61 3.4 (0.5, 28 5.2 (1.3, 51 0
24.2)
17.0)
18.1)
20.5)
18.6)
29 4.1 (2.8, 5.9) 660 1.6 (0.4, 6.1] 134 0
5.6)
6.8)
18.3)
10.3)
56 0
3.7)
6.9)
18.6)
7.5)
17.7)
8.5)
52 2.8 (0.4, 17.3) 32 1.0 (0.5, 2.2) 656 2.0 (0.6, 6.0) 154 0
45 4.6 (1.5, 13.4) 66 4.7 (0.7, 26.6) 31
31 1.2 (0.3, 4.7) 181 2.0 (0.3, 13.0) 44 0 79 0 45
336
A.A. Jayakody et al.
Table 4 (continued) Year
Ethnicity
Black African
Ever used glue, gas or solvents % (95% CI) Un weighted bases
Ever used Class A drugs or amphetamines % (95% CI) Un weighted bases
Boys
Girls
Boys
Mixed ethnicity
24 0
Other ethnicity
41 0
0 (1.2, 10.8) 79 3.0 (0.4, 18.3) 38 2.0 (0.3, 13.2) 45 0
2.4
Black British
3.6 (0.21, 10.2) 56 0
29 1.9 (1.1, 3.3) 649
24 3.4 (2.3, 5.1) 720
1.5
Total
Bangladeshi, 10.7% Indian, 6.9% Pakistani and 5.9% from mixed and other ethnicities. Lifetime use in the South Asian groups is shown in Table 5. Use was not significantly associated with years lived in UK or socio-economic status. Only four subjects (0.2%) reported ever trying khat, with users from a range of ethnicities.
Discussion This study reports distinct patterns of illicit and traditional drug use among young adolescents of different ethnicities from a recent large population-based sample. Overall, the prevalence of drug use was low; 11% of the sample aged 11–14 years reported having tried illicit drugs, whereas recent UK national data suggest that 11% of 11 year Table 5
Girls
56 0
(0.6, 9.1) 79 0
24 7.1 (2.3, 19.9) 41 3.9 (0.5, 23.0) 29 3.1 (2.0, 4.8) 650
38 6.1 (2.0, 17.4) 45 4.4 (0.6, 25.5) 24 1.6 (0.9, 2.9) 720
olds rising to 34% of 14 year olds have tried illicit drugs.1 However, this probably reflects low prevalence amongst the large Bangladeshi, Pakistani and Indian groups, as the prevalences of cannabis use amongst black Caribbean and white British young people were comparable with age-appropriate national rates.1 These findings support perceptions and anecdotal data that young people from South Asian ethnicities are at low risk for cannabis and class A drug use.9 However, Bangladeshi young people of both sexes reported high proportions of lifetime glue/gas/solvent use and nearly half reported that they had tried paan at least once in their lifetime, which is comparable to a prevalence of around 40% reported by other studies amongst young Asians in UK.12 Glue and paan use, while less risky than ‘hard’
Prevalence of paan use by ethnicity, sex and year group.
Year
Ethnicity
Ever chewed paan % (95% CI) Boys Girls
Year 7
Bangladeshi Pakistani Asian Indian Non-Asian Total Unweighted bases Bangladeshi Pakistani Asian Indian Non-Asian Total Unweighted bases
32.2 (25.4, 39.8) 14.6 (7.3, 26.8) 15.3 (6.8, 30.9) 1.82 (0.8, 3.9) 11.81 (9.5, 14.6) 652 49.5 (42.4, 56.6) 15.4 (7.2, 30.0) 19.32 (11.7, 30.3) 1.06 (0.4, 2.8) 18.59 (15.7, 21.8) 662
Year 9
40.7 (32.4, 49.6) 17.9 (8.1, 34.8) 15.1 (8.2, 26.1) 0.49 (0.1, 1.9) 11.03 (8.8, 13.8) 647 48.9 (41.6, 56.3) 12.4 (5.1, 26.9) 12.0 (6.4, 21.2) 2.1 (1.1, 4.0) 15.82 (13.3, 18.8) 726
Illicit and traditional drug use among ethnic minority adolescents in East London drugs, are both associated with significant morbidity. The lack of association of paan use with years lived in UK suggests that use is not restricted to recent immigrants but is endemic in young people in this community. The highest levels of lifetime cannabis use were reported by black Caribbean, mixed ethnicity and white British young people after adjustment for socio-economic status, year group, sex and years lived in UK. Important differences were identified amongst ethnicities commonly grouped together as ‘black’. Black Caribbean young people are more likely to be recent cannabis users than white British young people, contrary to the report by Karlsen et al.9 However, cannabis use amongst black African and black British adolescents was not significantly different to that amongst white British adolescents, with black African adolescents reporting cannabis use patterns that appear to be more similar to those of Bangladeshi young people. Residency in UK for 5 years or less was associated with markedly lower risk of lifetime and recent cannabis use when adjusted for ethnicity, socioeconomic status, year group and sex. These results appear to confirm findings from the USA which suggest that immigrant young people (particularly those living in the USA for 6 years or less) are at lower risk of health problems and risk behaviours such as cannabis use when compared with lifetime residents,19 suggesting that acculturative factors appear to modify the initiation of risk behaviours in young adolescents. However, given that risk increases with time lived in UK, further work is needed to investigate associations between cultural identity, acculturative processes and drug use in the transition through adolescence.
Strengths and limitations The study data were collected confidentially from a large, unique, predominantly ethnic minority population-based sample. Questions were drawn from previous ONS surveys and included a fictitious drug check question. Analyses were adjusted for measures of socio-economic status, sex and age. A number of limitations should be considered when interpreting these data. Given the cross-sectional nature of the data, the direction of relationships and causal relationships cannot be determined. The use of self-reported data on drug use may underestimate the prevalence. It is possible that such under reporting may partially explain the low reported use of cannabis and class A drugs amongst young people from South Asian ethnicities; however, these groups reported a higher prevalence of
337
glue/gas/solvent use. Additionally, the majority of studies that have compared self-report with objective measures of substance use have concluded that confidential self-report in adolescents provides accurate and reliable data,21,24,25 including among different ethnic minorities.26
Conclusions Patterns of use of illicit and traditional drugs by young people vary between ethnicities and within groups commonly categorized as ‘black’ and ‘Asian’ groupings, with black Caribbean and mixed ethnicity young people at highest risk for cannabis use. The high use of paan and glue/gas/solvents by Bangladeshi young people may pose an unappreciated public health problem. Identified variations may reflect cultural differences in sanctioned and restricted substances, and may result in different trajectories of drug use through adolescence and into adulthood. Policy relating to drug use in adolescents must consider culturally specific behaviours within intervention strategies, and further work is needed into understanding cultural determinants of risk and protection in drug use and the importance of cultural identity and migration in mediating health risk behaviours.
Acknowledgements RELACHS was commissioned by East London and The City Health Authority to inform their Health Action Zone and the authors thank them for their financial support. The authors also thank Tower Hamlets, Newham and City and Hackney Primary Care Trusts for additional funding. Russell Viner is funded by a Fellowship from the Health Foundation.
References 1. Boreham R, McManus S. Smoking, drinking and drug use among young people in England in 2002. London: The Stationery Office; 2002. 2. Miller PM, Plant M. Drinking, smoking, and illicit drug use among 15 and 16 year olds in the United Kingdom. Br Med J 1996;313:394–7. 3. Sutherland I, Shepherd JP. The prevalence of alcohol, cigarette and illicit drug use in a stratified sample of english adolescents. Addiction 2001;96:637–40. 4. Scott A, Pearce D, Goldblatt P. The sizes and characteristics of the minority ethnic populations of Great Britain—latest estimates. Popul Trends 2001;6–15. 5. London Health Observatory. http://www.lho.org.uk/HIL/ Lifestyle_and_Behaviour/Drug_Misuse/DrugMisuse.htm. London Health Observatory (last accessed 19 April 2004).
338 6. Best D, Rawaf S, Rowley J, Floyd K, Manning V, Strang J. Ethnic and gender differences in drinking and smoking among London adolescents. Ethn Health 2001;6:51–7. 7. Stillwell G, Boys A, Marsden J. Alcohol use by young people from different ethnic groups: consumption, intoxication and negative consequences. Ethn Health 2004;9:171–87. 8. Bush J, White M, Kai J, Rankin J, Bhopal R. Understanding influences on smoking in Bangladeshi and Pakistani adults: community based, qualitative study. Br Med J 2003;326:962. 9. Karlsen S, Rogers A, McCarthy M. Social environment and substance misuse: a study of ethnic variations among inner London adolescents. Ethn Health 1998;3:265–73. 10. Home office. Updated drug strategy 2002. Home Office Drugs Strategy Directorate, London, 2002. 11. Warnakulasuriya S. Areca nut use following migration and its consequences. Addict Biol 2002;7:127–32. 12. Farrand P, Rowe RM, Johnston A, Murdoch H. Prevalence, age of onset and demographic relationships of different areca nut habits amongst children in Tower Hamlets, London. Br Dent J 2001;190:150–4. 13. Prabhu NT, Warnakulasuriya K, Gelbier S, Robinson PG. Betel quid chewing among Bangladeshi adolescents living in east London. Int J Paediatr Dent 2001;11:18–24. 14. Merchant A, Husain SS, Hosain M, Fikree FF, Pitiphat W, Siddiqui AR, Hayder SJ, Haider SM, Ikram M, Chuang SK, Saeed SA. Paan without tobacco: an independent risk factor for oral cancer. Int J Cancer 2000;86:128–31. 15. Griffiths P, Gossop M, Wickenden S, Dunworth J, Harris K, Lloyd C. A transcultural pattern of drug use: qat (khat) in the UK. Br J Psychiatry 1997;170:281–4. 16. Hassan NA, Gunaid AA, El Khally FM, Murray-Lyon IM. The effect of chewing Khat leaves on human mood. Saudi Med J 2002;23:850–3.
A.A. Jayakody et al. 17. Redfield R, Linton R, Herskovits MJ. Memorandum on the study of acculturation. Am Anthropol 1936;38:149–52. 18. Salant T, Lauderdale DS. Measuring culture: a critical review of acculturation and health in asian immigrant populations. Soc Sci Med 2003;57:71–90. 19. Blake SM, Ledsky R, Goodenow C, O’Donnell L. Recency of immigration, substance use, and sexual behavior among Massachusetts adolescents. Am J Public Health 2001;91: 794–8. 20. Stansfeld SA, Haines MM, Head JA, Bhui K, Viner R, Taylor SJ, Hillier S, Klineberg E, Booy R. Ethnicity, social deprivation and psychological distress in adolescents: school-based epidemiological study in east London. Br J Psychiatry 2004; 185:233–8. 21. Goddard E, Higgins V. Drinking and drug use among young Adolescents in 1998. London: The Stationery Office; 1999. 22. Rogers A, Karlsen S, McCarthy M. Camden and Islington Young People and Health Project. Survey of health behaviours and attitudes in 993 15 year olds in C & I schools. London: Department of Epidemiology and Public Health, University College London Medical School; 1995. 23. Office for National Statistics. Census 2001. Office for National Statistics; 2004. http://www.statistics.gov.uk/ census2001/census_background.qs.asp. 24. Brener ND, Billy JO, Grady WR. Assessment of factors affecting the validity of self-reported health-risk behavior among adolescents: evidence from the scientific literature. J Adolesc Health 2003;33:436–57. 25. Buchan BJ, Dennis ML, Tims FM, Diamond GS. Cannabis use: consistency and validity of self-report, on-site urine testing and laboratory testing. Addiction 1997;87:56–61. 26. Wills TA, Cleary SD. The validity of self-reports of smoking: analyses by race/ethnicity in a school sample of urban adolescents. Am J Public Health 1997;97:98–108.
ORIGINAL RESEARCH
Illicit and traditional drug use among ethnic minority adolescents in East London A.A. Jayakodya, R.M. Vinera,*, M.M. Hainesb, K.S. Bhuib, J.A. Headb,e, S.J.C. Taylorc, R. Booyd, E. Klinebergb, C. Clarkb, S.A. Stansfeldb a
Department of Paediatrics, Royal Free and University College London Medical School, University College London, UK b Centre for Psychiatry, Institute of Community Health Sciences, Barts and the London Queen Mary’s School of Medicine and Dentistry, Queen Mary University of London, UK c School of Medicine and Dentistry, Institute of Community Health Sciences, Centre for General Practice and Primary Care, Barts and the London Queen Mary’s Queen Mary University of London, UK d School of Medicine and Dentistry, Institute of Community Health Sciences, Centre for Child Health, Barts and the London Queen Mary’s Queen Mary University of London, UK e Department of Epidemiology and Public Health, University College London, UK Received 24 November 2004; received in revised form 2 June 2005; accepted 13 October 2005
KEYWORDS drug use; Adolescents; Ethnicity; Acculturation
Summary Objectives: To explore ethnic variations in the use of illicit and traditional drugs, and the association of indicators of acculturation with drug use among an ethnically diverse representative sample of early adolescents in East London. Study design: A cross-sectional questionnaire survey. Methods: Confidential questionnaires were used to assess 2789 male and female pupils in years 7 and 9, aged 11–14 years old, from a representative sample of 28 secondary schools in East London. Results: In total, 10.8% reported having ever tried illicit drugs and 7.3% reported ever using cannabis. Compared with white British adolescents, cannabis use in the previous month was significantly higher amongst black Caribbean adolescents. Lifetime cannabis use was significantly higher amongst black Caribbean and mixed ethnicity young people, but was lower amongst Bangladeshi, Indian and Pakistani adolescents. Living in UK for 5 years or less markedly reduced the risk of lifetime and recent cannabis use when controlled for ethnicity and social class. Glue or solvent use was reported in 3.2% of adolescents, with use significantly higher amongst Bangladeshi young people. Lifetime paan use was reported by 14.1% of the sample, and was almost completely confined to South Asian or mixed ethnicities. Conclusions: Ethnic differences in illicit drug use were found in the study population, and significant differences were found between ethnic groups often identified as
* Corresponding author. Tel.: C44 20 7380 9445; fax: C44 20 7636 2144. E-mail address: [email protected] (R.M. Viner).
0033-3506/$ - see front matter Q 2005 Published by Elsevier Ltd on behalf of The Royal Institute of Public Health. doi:10.1016/j.puhe.2005.10.009
330
A.A. Jayakody et al. ‘black.’ Further research is needed in understanding cultural-specific risk and protective factors in different ethnic groups, and the importance of cultural identity in mediating health risk behaviors. The high use of paan and glue/gas/solvents by Bangladeshi young people poses an unappreciated public health problem that may require targeted interventions. Q 2005 Published by Elsevier Ltd on behalf of The Royal Institute of Public Health.
Introduction Illicit drug misuse amongst young people is a significant public health concern. While substance use rates amongst adolescents appear to have stabilized recently after significant increases through the 1990s, UK national surveys suggest that over one-quarter of 11–15 year olds have ever tried illicit drugs.1–3 Children aged 14 years and under make up 30% of ethnic minority groups in UK, with 40% of Bangladeshis being aged 14 years or under, compared with 19% of the white British population.4 Half of ethnic minority people live in London,4 where drug use rates are the highest in England.5 Despite these figures and substantial research on smoking and drinking amongst ethnic minority adolescents,6,7 little is known about illicit drug use in these groups in UK. Additionally, attempts to address ethnicity in national samples have grouped adolescents into ‘white’, ‘black’ or ‘Asian’ categories;1 a practice that may conceal significant differences in health behaviours between ethnic groups.8 In a small study of 132 young people from inner London,9 white adolescents were most likely to report the highest levels of substance misuse, with Bangladeshi adolescents reporting the lowest levels, and black African and Caribbean adolescents reporting intermediate rates. Given in UK Government’s targets of reducing the use of Class A drugs and the frequent use of all illicit drugs by all young people by 2008,10 a more detailed understanding is needed of drug use amongst black and ethnic minority adolescents in order to ensure that interventions are culturally sensitive and therefore effective in such communities. In addition, little is known about British adolescents’ use of substances traditionally used recreationally in some cultures, such as paan and khat. Paan, a chewed or smoked mix of areca nut, an acacia extract and inorganic lime wrapped in betel leaf and sun-dried tobacco is traditionally used in many South Asian countries and is known to be highly prevalent in Asian immigrant communities in UK.11 Small studies have suggested that some British Asian children are experienced paan users;
12
however, few young people are aware of the health risks associated with paan use,13 which include those associated with tobacco use and an independently increased risk for oral cancer.14 Less is known about the use of khat (quat, qat, qaadka, chat), a drug predominantly used by those from the Arabian peninsula and Horn of Africa (Somalia, Ethiopia) that produces amphetamine-like effects by chewing, brewing or smoking the leaves of the Catha edulis plant.15,16 Acculturation, defined as ‘phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original culture patterns of either or both groups’,17 is believed to be a mediating factor in adolescents’ adaptation to their environment and their adoption of the health risk behaviours of their peers. Acculturation has been measured in different ways including duration of residence, country of birth, languages spoken and cultural participation.18 Research from the USA on the effect of migration status on adolescent health has found that foreign-born young people are at a lower risk of health problems and risk behaviours than those born in the host country, but the protective effect diminishes over three generations.19 However, the effects of the process of acculturation on health risk behaviours, such as substance use, has been little studied in UK. In this study, data from a representative ethnically diverse sample of young people aged 11–14 years were used to examine the hypotheses that the prevalence of illicit and traditional drug use varies by ethnicity, and that indicators of acculturation are associated with drug use.
Methods Research with East London Adolescent Community Health Survey (RELACHS) is a school-based epidemiological study of a representative sample of 2790 adolescents from year 7 (11–12 years) and year 9 (13–14 years) attending 28 schools in East London in 2001.20 All 42 eligible schools in Hackney, Tower Hamlets and Newham were stratified by borough
Illicit and traditional drug use among ethnic minority adolescents in East London and school type (comprehensive, voluntary, other). Thirty schools were selected at random and balanced to ensure representation of single-sex and mixed-sex schools. In each of the 28 schools that agreed to participate, representative mixed ability classes were selected (two classes from year 7 and year 9). Data were collected by studentcompleted questionnaire, completed individually in classrooms under the supervision of trained researchers. Researchers addressed pupils’ queries and checked the questionnaires for missing data. Parents were informed of the study by letter, and were given the opportunity to opt their child out of the study. Written consent was obtained from the young people. The study protocol was approved by the East London and the City Research Ethics Committee. The overall response rate was 84% (85% in non-whites, 77% in whites, 3.5% refused to participate, 12.2% were absent). Adolescents completed self-report questionnaires regarding whether they had ever used a range of drugs and frequency of drug use. The questions were taken from the office for national statistics (ONS) surveys for adolescents.21 Adolescent self-reported drug use is a widely used questionnaire method to measure the prevalence of drug use,21,22 and is thought to be more accurate than face-to-face interviews. Slang names for drugs were included in the drugs questions so as to ensure comprehensibility by all the pupils. In order to detect false-positive responding, a fictitious drug (deccopan) was included in the questionnaire. Only six pupils responded that they had used deccopan and they were excluded from these analyses. Questions on paan and khat use were adapted from the ONS smoking questions. The questionnaire asked whether pupils had tried chewing paan (betel leaf) with tobacco (either wet or dry smokeless tobacco) at least once in their lifetime, whether they had tried it last week, and if so how many quids they had chewed. Pupils were also asked whether they had tried khat at least once in their lifetime and the frequency of khat use. Class A drugs are defined in UK as opiates (including heroin), ecstasy, LSD, cocaine, crack and amphetamines (injected) (Misuse of Drugs Act 1971). Sniffed or oral amphetamines are classified as class B drugs; however, they were included with class A drugs in these analyses due to the very low rates of overall amphetamine use in this cohort and in order to separate them from cannabis use (rated class C at the time of writing). Ethnicity was self-assigned using an adaptation of UK Census 2001 categories (Table 1).23 Black young people were asked to classify themselves as either black African, black British or black
Table 1
331
Self-assigned census 2001 ethnic categories.
Census 2001 ethnic categories
Collapsed categories for analyses
White
White UK White other
Mixed
Asian
Black
Other
UK Irish Greeka Turkisha Orthodox Jewisha Kurdisha Other White and black Caribbean White and black African White and Asian Other Indian Pakistani Bangladeshi Other Caribbean African Somalia Britisha Other Chinese Vietnamesea Other
Mixed ethnicity
Other Indian Pakistani Bangladeshi Other Black Caribbean Black African Black British Other Other
a Additional categories added to Research with East London Adolescent Community Health Survey questionnaire.
Caribbean. Those from South Asian ethnicities were asked to classify themselves as either Asian Indian, Pakistani or Bangladeshi. White young people were asked to classify themselves as white British or from other white groups (e.g. other European, Turkish, Kurdish). Those of mixed white and black Caribbean, white and black African, white and black, white and Asian and mixed ‘other’ ethnicities were categorized as ‘mixed’ ethnicity. Due to small numbers, Chinese, Vietnamese and other ethnicities were categorized as ‘other’ ethnicity. Other sociodemographic data collected included years lived in UK, whether either parent was currently employed and household crowding (defined as O1.5 people per room, excluding bathroom and kitchen).
Analyses All analyses were weighted to take account of unequal probabilities of selection. As the sample selection used a stratified cluster design with pupils clustered within schools, all statistical analyses were performed using the survey estimation commands of STATA (Version 8.1). Data analysis
332 Table 2 Year
Year 7
A.A. Jayakody et al. Prevalence of cannabis use by ethnicity, age and sex. Ethnicity
White British
White other
Bangladeshi
Pakistani Asian Indian
Black Caribbean
Black African
Black British
Mixed ethnicity
Other ethnicity
Total
Year 9
White British
White other
Bangladeshi
Pakistani
Asian Indian
Black Caribbean
Black African
Ever used cannabis % (95% CI)
Used cannabis within last month % (95% CI)
Un weighted bases
Un weighted bases
Boys
Girls
Boys
Girls
1.8 (0.6, 5.6) 145 0
1.4 (0.3, 5.3) 140 1.8 (0.3, 11.7) 52 1.8 (0.5, 7.0) 132 0 35 0
0.64 (0.09, 4.4) 145 0
0.7 (0.09, 4.9) 140 0
39 1.4 (0.3, 5.3) 171 0 56 2.2 (0.3, 14.2) 38 0
52 0
39 2.6 (1.0, 6.7) 171 0 56 5.9 (1.4, 21.3) 38 0 43 3.2 (0.8, 12.0) 61 3.4 (0.5, 20.5) 28 7.7 (2.9, 19.0) 52 0 29 2.4 (1.5, 4.0) 662 18.3 (12.8, 25.5) 135 9.5 (3.1, 25.8) 31 12.1 (8.1, 17.7) 193 8.0 (2.8, 20.5) 45 3.6 (1.1, 10.8) I 24.6 (12.1, 43.5) 31 3.7 (0.9, 13.7) 56
61 6.5 (1.6, 22.4) 41 2.2 (0.6, 8.5) 81 0 31 4.0 (1.0, 14.6) 52 2.7 (0.4, 17.1) 32 1.9 (1.1, 3.4) 657 15.9 (10.7, 22.9) 155 12.4 (4.7, 29.0) 31 4.5 (2.2, 8.8) 181 2.3 (0.3, 14.4) 44 3.1 (0.7, 11.8) 79 25.4 (15.0, 39.7) 47 10.1 (5.1, 18.9) 79
43 0 61 3.4 (0.5, 20.5) 28 0
132 0 35 0 61 3.1 (0.4, 19.0) 41 0 81 0
52 0
31 2.0 (0.3, 12.9) 52 0
29 0.8 (0.3, 662 10.9 (6.7, 135 3.3 (0.5, 31 7.4 (4.4, 193 0
32 0.5 (0.2, 657 10.2 (6.2, 155 6.3 (1.6, 31 1.1 (0.3, 181 0
1.9)
17.2)
19.9)
12.1)
61 1.5 (0.2, 10.0) 66 15.0 (5.7, 34.2) 31 3.7 (0.9, 13.7) 56
1.6)
16.2)
21.9)
4.4)
81 3.1 (0.7, 11.9) 79 21.2 (11.8, 35.3) 47 8.8 (4.2, 17.4) 79
Illicit and traditional drug use among ethnic minority adolescents in East London Table 2 Year
333
(continued) Ethnicity
Black British
Mixed ethnicity
Other ethnicity
Total
Ever used cannabis % (95% CI)
Used cannabis within last month % (95% CI)
Un weighted bases
Un weighted bases
Boys
Girls
19.5 (8.3, 39.5) 24 30.0 (18.1, 45.4) 41 13.7 (5.2, 31.6) 29 13.5 (11.1, 16.3) 651
17.0 (7.4, 38 17.4 (8.8, 45 21.3 (9.1, 24 10.9 (8.8, 723
was conducted in two stages. In the first stage, descriptive statistics were generated to describe the frequency and distribution of illicit and traditional non-illicit drug use by ethnicity. Analyses were then conducted using logistic regression to examine the associations of drug use, ethnicity and years lived in UK, controlling for socioeconomic status (overcrowding and parental employment), sex and year group.
Results The cohort consisted of 25% Bangladeshi, 21% white British, 10% black African, 9% Asian Indian, 7% Pakistani, 7% mixed ethnicity, 6% black Caribbean, 6% white other, 4% black British and 4% other ethnic groups. In total, 22% of males and 20% of females were born outside in UK. Data on illicit drug use were available for 2723 (98%) adolescents, of whom 295 (10.8%) had tried illicit drugs of any type at least once in their lifetime. Data on paan use were available for 2687 (96%) adolescents.
Age of first trying illicit drugs Of those who reported ever trying drugs, data on the age when they first tried any illicit drug were available for 263 (89%) adolescents. Amongst those in year 7 (70 subjects), the mean age of first trying drugs was 9.5 years [95% confidence intervals (CI): 9.0, 10.0], and the mean age was 12.5 years (95% CI: 12.3, 12.7) amongst those in year 9 (193 subjects). Amongst those in year 9, 3.1% subjects had first tried drugs at less than 10 years of age, 37.8% between 10 and 12 years of age, and 59.1% at 13
32.9)
31.5)
42.1)
13.5)
Boys
Girls
15.8 (6.0, 35.6) 24 25.0 (14.2, 40.1) 41 13.7 (5.2, 31.6) 29 8.6 (6.6, 11.0) 651
8.3 (2.7, 38 8.1 (3.1, 45 12.5 (4.1, 24 6.7 (5.1, 723
22.9)
19.9)
32.5)
8.8)
years of age or older. There was no association between age of first trying drugs and ethnicity.
Cannabis Data on cannabis use were available for 2723 (98%) adolescents, of whom 198 (7.3%) had used cannabis at least once in their lifetime. Table 2 presents data on lifetime cannabis use and cannabis use within the last month. Overall, there was no significant difference in lifetime cannabis use by sex; however, lifetime use significantly increased between years 7 and 9 (c2Z99.34, P!0.001). One hundred and fifteen of 2723 (4.2%) adolescents reported using cannabis within the last month, with the highest proportions seen in white British, black Caribbean, black British and mixed ethnicity groups. The associations of lifetime and monthly cannabis use with ethnicity, years lived in UK, sex and socio-economic statuses are shown in Table 3. Lifetime use was significantly more likely in year 9 than year 7 students of both sexes (P!0.001), but was not associated with sex or socio-economic status after adjusting for all other variables in the model. When adjusted for socio-economic status, sex, year group and years lived in UK, Bangladeshi, Indian and Pakistani ethnicity were associated with lower risk of use, whilst black Caribbean and mixed ethnicity young people were significantly more likely to have ever tried cannabis. Residing in UK for 5 years or less was associated with reduced risk of lifetime use compared with living in UK for more than 10 years, independent of ethnicity and socioeconomic status. Use in the last month showed similar associations, being less common in Indian young people, more likely in year 9 than year 7
334 Table 3
A.A. Jayakody et al. Adjusted odds ratios (ORs) for illicit drug use by ethnicity.
Ethnic group
Sex Socio-economic status
School year Time lived in UK
White British White other Bangladeshi Pakistani Asian Indian Black Caribbean Black African Black British Mixed ethnicity Other ethnicity Female compared with male Either parent employed Household overcrowding Year 9 compared with year 7 O10 years 6-10 years 5 years or less
Ever tried cannabis OR (95% CI)
Used cannabis in last month/week OR (95% CI)
Ever tried glue, gas or solvent OR (95% CI)
1 0.8 0.6 0.3 0.2 1.9 0.8 1.2 1.7 1.1 0.8
1 0.6 (0.2, 2.1) 0.5 (0.3, 1.0) 0a 0.3 (0.1, 0.8)* 2. 6 (1.3, 5.1)* 1.0 (0.4, 2.3) 1.3 (0.5, 3.1) 1.7 (0.9, 3.3) 1.3 (0.5, 3.2) 0.7 (0.5, 1.1)
1 1.7 1.9 1.5 1.9 1.4 1.7 0.8 1.1 0.2 1.2
1.0 (0.7, 1.5)
1.0 (0.6, 1.6)
1.4 (0.9, 2.1)
0.9 (0.6, 1.4)
0.8 (0.5, 1.5)
1.0 (0.6, 1.4)
2.8 (2.3, 3.5)***
3.6 (2.5, 5.2)***
0.8 (0.7, 0.96)*
1 1.1 (0.5, 2.2) 0.1 (0.0, 0.4)***
1 0.8 (0.3, 2.4) 0.1 (0.0, 0.6)*
1 1.0 (0.5, 2.0) 1.2 (0.7, 2.2)
(0.4, (0.3, (0.1, (0.1, (1.1, (0.4, (0.6, (1.0, (0.5, (0.6,
1.9) 0.9)* 0.7)** 0.5)*** 3.4)* 1.5) 2.4) 3.0)* 2.3) 1.1)
(0.8, 4.0) (1.1, 3.5)* (0. 7, 3.3) (0.9, 3.7) (0.6, 3.2) (0.9, 3.3) (0.3, 2.5) (0.4, 2.5) (0.0, 1.5) (0.8, 1.7)
CI, confidence interval; Adjusted ORs are presented for each ethnic group separately, with white British young people as the reference group. ORs are adjusted for all variables in the table. *P!0.05, **P!0.01, ***P!0.001. a OR not calculated as no cases in category of interest.
students, more likely if the young person had lived in UK for 5 years or less, and more likely in black Caribbean young people.
Class A drugs Data on class A drug and amphetamine use were available for 2723 adolescents (97.6%) (Table 4). In total, 57 (2.1%) had tried class A drugs at least once in their lifetime, of whom seven had tried ecstasy, 24 had tried cocaine, 11 had tried heroin, 13 had tried LSD, 24 had tried crack and 11 had tried amphetamines. Lifetime use of class A drugs was higher in boys and was slightly higher in year 9 than in year 7 students. Highest lifetime use appeared to be amongst mixed ethnicity and white other young people, although significance tests were not undertaken due to small numbers.
Glue, gas and solvents Data on the use of glue, gas or solvents were available for 2714 (97.3%) adolescents (Table 4). Of the overall sample, 88 (3.2%) had tried sniffing or inhaling glue, gas or solvents at least once and 35 had used glue/gas or solvents in the past month.
The pattern of glue/gas/solvent use appeared to be different to that for cannabis use; use was higher in younger boys and older girls, and appeared to be higher amongst Bangladeshi, Pakistani and Indian adolescents than amongst white British or black adolescents. Table 3 shows adjusted odds ratios by ethnicity for lifetime glue/gas/solvent use controlled for socio-economic status, sex, year group and years resided in UK. Bangladeshi young people were more likely to have ever tried glue/gas/ solvent compared with white British young people. Lifetime use was associated with younger year group. Time lived in UK was not associated with glue/gas/solvent use.
Traditional drug use In the whole cohort, 378/2687 (14.1%) had tried paan at least once in their lifetime, 4.1% (111) were occasional users (less than weekly) and a further 1.5% (41) chewed paan weekly or more often. There was no significant difference between the sexes in paan use in the whole cohort. As expected, paan chewing was almost completely confined to the South Asian or mixed ethnicity groups, with 76.5% of all pupils who reported lifetime paan use being
Illicit and traditional drug use among ethnic minority adolescents in East London Table 4 Year
Year 7
Prevalence of other illicit drug use by ethnicity, age and sex. Ethnicity
White British
White other
Bangladeshi
Pakistani
Asian Indian
Black Caribbean
Black African
Black British
Mixed ethnicity
Other ethnicity
Total
Year 9
335
White British
White other
Bangladeshi
Pakistani
Asian Indian
Black Caribbean
Ever used glue, gas or solvents % (95% CI) Un weighted bases
Ever used Class A drugs or amphetamines % (95% CI) Un weighted bases
Boys
Girls
Boys
Girls
3.5 (1.4, 8.3) 145 5.0 (1.2, 17.9) 39 3.9 (1.9, 8.1) 170 0
2.2 (0.7, 6.6) 139 1.9 (0.3,.12.6) 52 6.6 (3.3, 12.9) 132 5.9 (1.5, 20.7) 35 1.5 (0.2, 9.9) 60 5.5 (1.3, 20.1) 41 2.2 (0.5, 8.3) 81 5.4 (1.3, 19.4) 31 5.7 (1.8, 16.3) 52 0
3.0 (1.2, 7.0) 145 3.0 (0.4, 18.4) 39 2.8 (1.1, 6.6) 170 0
38 0
0.7 (0.09, 4.5) 140 1.8 (0.3, 11.7) 52 0.9 (0.1, 5.9) 132 2.8 (0.4, 17.4) 35 1.7 (0.2, 11.3) 60 0
43 1.6 (0.2, 10.4) 61 0
41 1.0 (0.1, 6.7) 81 0
28 7.6 (2.8, 18.8) 51 0
31 0
31 2.2 (0.8, 5.7) 192 4.5 (1.1, 16.5) 45 4.9 (1.6, 14.3) 66
32 3.8 (2.5, 655 2.6 (1.0, 154 3.0 (0.4, 31 5.7 (3.1, 181 6.2 (2.0, 44 2.2 (0.6, 79
29 2.3 (1.4, 660 2.6 (1.0, 134 3.0 (0.4, 31 3.7 (1.8, 193 0
0
0
31
45
56 8.8 (2.8, 38 2.7 (0.4, 43 8.1 (3.4, 61 3.4 (0.5, 28 5.2 (1.3, 51 0
24.2)
17.0)
18.1)
20.5)
18.6)
29 4.1 (2.8, 5.9) 660 1.6 (0.4, 6.1] 134 0
5.6)
6.8)
18.3)
10.3)
56 0
3.7)
6.9)
18.6)
7.5)
17.7)
8.5)
52 2.8 (0.4, 17.3) 32 1.0 (0.5, 2.2) 656 2.0 (0.6, 6.0) 154 0
45 4.6 (1.5, 13.4) 66 4.7 (0.7, 26.6) 31
31 1.2 (0.3, 4.7) 181 2.0 (0.3, 13.0) 44 0 79 0 45
336
A.A. Jayakody et al.
Table 4 (continued) Year
Ethnicity
Black African
Ever used glue, gas or solvents % (95% CI) Un weighted bases
Ever used Class A drugs or amphetamines % (95% CI) Un weighted bases
Boys
Girls
Boys
Mixed ethnicity
24 0
Other ethnicity
41 0
0 (1.2, 10.8) 79 3.0 (0.4, 18.3) 38 2.0 (0.3, 13.2) 45 0
2.4
Black British
3.6 (0.21, 10.2) 56 0
29 1.9 (1.1, 3.3) 649
24 3.4 (2.3, 5.1) 720
1.5
Total
Bangladeshi, 10.7% Indian, 6.9% Pakistani and 5.9% from mixed and other ethnicities. Lifetime use in the South Asian groups is shown in Table 5. Use was not significantly associated with years lived in UK or socio-economic status. Only four subjects (0.2%) reported ever trying khat, with users from a range of ethnicities.
Discussion This study reports distinct patterns of illicit and traditional drug use among young adolescents of different ethnicities from a recent large population-based sample. Overall, the prevalence of drug use was low; 11% of the sample aged 11–14 years reported having tried illicit drugs, whereas recent UK national data suggest that 11% of 11 year Table 5
Girls
56 0
(0.6, 9.1) 79 0
24 7.1 (2.3, 19.9) 41 3.9 (0.5, 23.0) 29 3.1 (2.0, 4.8) 650
38 6.1 (2.0, 17.4) 45 4.4 (0.6, 25.5) 24 1.6 (0.9, 2.9) 720
olds rising to 34% of 14 year olds have tried illicit drugs.1 However, this probably reflects low prevalence amongst the large Bangladeshi, Pakistani and Indian groups, as the prevalences of cannabis use amongst black Caribbean and white British young people were comparable with age-appropriate national rates.1 These findings support perceptions and anecdotal data that young people from South Asian ethnicities are at low risk for cannabis and class A drug use.9 However, Bangladeshi young people of both sexes reported high proportions of lifetime glue/gas/solvent use and nearly half reported that they had tried paan at least once in their lifetime, which is comparable to a prevalence of around 40% reported by other studies amongst young Asians in UK.12 Glue and paan use, while less risky than ‘hard’
Prevalence of paan use by ethnicity, sex and year group.
Year
Ethnicity
Ever chewed paan % (95% CI) Boys Girls
Year 7
Bangladeshi Pakistani Asian Indian Non-Asian Total Unweighted bases Bangladeshi Pakistani Asian Indian Non-Asian Total Unweighted bases
32.2 (25.4, 39.8) 14.6 (7.3, 26.8) 15.3 (6.8, 30.9) 1.82 (0.8, 3.9) 11.81 (9.5, 14.6) 652 49.5 (42.4, 56.6) 15.4 (7.2, 30.0) 19.32 (11.7, 30.3) 1.06 (0.4, 2.8) 18.59 (15.7, 21.8) 662
Year 9
40.7 (32.4, 49.6) 17.9 (8.1, 34.8) 15.1 (8.2, 26.1) 0.49 (0.1, 1.9) 11.03 (8.8, 13.8) 647 48.9 (41.6, 56.3) 12.4 (5.1, 26.9) 12.0 (6.4, 21.2) 2.1 (1.1, 4.0) 15.82 (13.3, 18.8) 726
Illicit and traditional drug use among ethnic minority adolescents in East London drugs, are both associated with significant morbidity. The lack of association of paan use with years lived in UK suggests that use is not restricted to recent immigrants but is endemic in young people in this community. The highest levels of lifetime cannabis use were reported by black Caribbean, mixed ethnicity and white British young people after adjustment for socio-economic status, year group, sex and years lived in UK. Important differences were identified amongst ethnicities commonly grouped together as ‘black’. Black Caribbean young people are more likely to be recent cannabis users than white British young people, contrary to the report by Karlsen et al.9 However, cannabis use amongst black African and black British adolescents was not significantly different to that amongst white British adolescents, with black African adolescents reporting cannabis use patterns that appear to be more similar to those of Bangladeshi young people. Residency in UK for 5 years or less was associated with markedly lower risk of lifetime and recent cannabis use when adjusted for ethnicity, socioeconomic status, year group and sex. These results appear to confirm findings from the USA which suggest that immigrant young people (particularly those living in the USA for 6 years or less) are at lower risk of health problems and risk behaviours such as cannabis use when compared with lifetime residents,19 suggesting that acculturative factors appear to modify the initiation of risk behaviours in young adolescents. However, given that risk increases with time lived in UK, further work is needed to investigate associations between cultural identity, acculturative processes and drug use in the transition through adolescence.
Strengths and limitations The study data were collected confidentially from a large, unique, predominantly ethnic minority population-based sample. Questions were drawn from previous ONS surveys and included a fictitious drug check question. Analyses were adjusted for measures of socio-economic status, sex and age. A number of limitations should be considered when interpreting these data. Given the cross-sectional nature of the data, the direction of relationships and causal relationships cannot be determined. The use of self-reported data on drug use may underestimate the prevalence. It is possible that such under reporting may partially explain the low reported use of cannabis and class A drugs amongst young people from South Asian ethnicities; however, these groups reported a higher prevalence of
337
glue/gas/solvent use. Additionally, the majority of studies that have compared self-report with objective measures of substance use have concluded that confidential self-report in adolescents provides accurate and reliable data,21,24,25 including among different ethnic minorities.26
Conclusions Patterns of use of illicit and traditional drugs by young people vary between ethnicities and within groups commonly categorized as ‘black’ and ‘Asian’ groupings, with black Caribbean and mixed ethnicity young people at highest risk for cannabis use. The high use of paan and glue/gas/solvents by Bangladeshi young people may pose an unappreciated public health problem. Identified variations may reflect cultural differences in sanctioned and restricted substances, and may result in different trajectories of drug use through adolescence and into adulthood. Policy relating to drug use in adolescents must consider culturally specific behaviours within intervention strategies, and further work is needed into understanding cultural determinants of risk and protection in drug use and the importance of cultural identity and migration in mediating health risk behaviours.
Acknowledgements RELACHS was commissioned by East London and The City Health Authority to inform their Health Action Zone and the authors thank them for their financial support. The authors also thank Tower Hamlets, Newham and City and Hackney Primary Care Trusts for additional funding. Russell Viner is funded by a Fellowship from the Health Foundation.
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