Although the vast majority of adolescents in this study were aware of tobacco and alcohol as being harmful to health and correctly identified the most commonly affected organs, up to one-third were unaware that tobacco is a drug and six of every ten students did not describe alcohol as such. This contrasts with their clear notions about drugs classified as illegal substances, such as cannabis, cocaine and heroin. The widespread misconception among preadolescents and adolescents that tobacco and alcohol are not drugs is very likely attributable to the legal nature of these substances for the adult population. The fact that adults consume both substances is seen by children as harmful to health, but they also consider this consumption “normal” within society. However, it is also necessary to consider the impact of advertising and the fact that families in particular, and society as a whole, are tolerant and permissive regarding the consumption of alcoholic beverages. For thousands of years, alcohol has been an integral part of the cultural and culinary heritage of western European countries, particularly those bordering the Mediterranean Sea [16].
Our findings suggest that measures implemented through mass media campaigns and other activities to make children in these age groups aware of the harmful effects of tobacco and alcohol on health have been effective. Nevertheless, such actions do not appear to have been adequate for teens and preteens to link these substances with the concept of drugs, despite having appropriate health information on the potential fatal consequences of consuming tobacco or alcohol. Therefore, it is important to bear in mind the paradox found within the phrase “nondrug-related harmful effect” when planning educational activities in various settings (schools, health centers, institutional campaigns in the media, and others), such that the danger involved in experimenting with tobacco and alcohol is not minimized in the minds of adolescents and preadolescents.
Information about drugs received by children seems to originate primarily from the media. It is striking that in only 31% of cases, this information has come from medical staff. Results from previous studies in the same area have shown similar results [17–20]. Without a doubt, the best information is not that from the mass media, because this is typically overly standardized, indiscriminate and biased [4,21–23]. The media provide information in the same way to both adults and children, and help establish patterns of behavior that are not always healthy. This is especially so for preteens, who are eager to experiment and imitate the attitudes and roles of adult behavior. Moreover, media advertising still encourages the use of certain drugs such as alcohol. Although advertising is regulated in most developed countries, children still receive contradictory messages, in favor of and against using certain substances. This may lead them to associate the use of legal drugs with fun and social maturity. Other people in children’s daily lives may also contribute to such associations with their permissive views on these drugs, and children will eventually imitate them to a greater or lesser extent [5,18,23,24]. According to a study in Spain [5], up to 20% of billboards at outdoor public locations near secondary schools showed advertising for alcoholic beverages or activities related to their consumption, although no advertising could be found for tobacco products. This fact can be explained by continuous anti-drug campaigns, “self-censorship” by the tobacco industry, and the introduction of regulations on tobacco advertising. These measures have almost completely eliminated tobacco outdoor advertising. The fact that cigarette smoking has been increasingly condemned and tobacco advertising more regulated, despite classification as a legal drug just like alcohol, clearly shows that the negative influence of advertising can be completely eradicated if there is a firm commitment to do so.
It is therefore necessary to promote children’s access to accurate information through other means and by people who are the most skilled, at least in theory, to inform them in the most effective and appropriate manner. It is clear that medical staff (particularly those who work in primary health care, such as family doctors, nurses, and psychologists) must take a leading role. Not only should these providers take advantage of adolescents’ visits to their surgeries and clinics (however infrequent such visits may be), these professionals should also take a more proactive approach by fostering and participating in, both as a group and individually, health education activities that are held in schools in their area. These activities can be done in coordination with teachers to support their work because, apart from the children’s own families, teachers are the closest everyday role model for teens and pre-teens. The specific training of teachers on this issue, together with implementation of health education campaigns for parents regarding identified needs and a community intervention program for teens supervised by interdisciplinary groups (health care staff, psychologists, educators), is viewed as the best strategy to prevent experimentation with and use of these drugs by young adolescents [5,25–27].
Certain studies have assessed the effectiveness of programs designed to increase awareness about drugs and strengthen preadolescents’ resources and self-esteem, to counteract the many messages they have received since early childhood to experiment with and consume tobacco and alcohol. These studies conclude that although preteen awareness is an intermediate variable when determining consumption, beneficial effects of the programs tend to dissipate with time and reinforcement activities are required. In addition, such programs have proven more effective if they are interactive and participatory, involve the intervention of peers as mediators, and begin before the transition from primary to secondary school [13,28].
Limitations of the present study
This study was carried out in a medium-sized Spanish province, with its own sociocultural characteristics. Although these characteristics are very similar to those of the country as a whole, this particularity may limit extrapolation of the study results. Concerning possible selection bias, the sample was representative of the study population. With respect to the two controlled variables (rural/urban location and public/private schools), there was no difference between the study population and sample.
The method is based primarily on the “Health Behaviour of School-aged Children” project, sponsored since 1982 by the World Health Organization Regional Office for Europe [14,15]. In our study, we adhered as much as possible to this method to obtain comparable information and reduce or neutralize potential sources of information bias. The questionnaire used was validated by previous studies in different European countries. We also carried out a pilot study to analyze its reliability through a test-retest procedure, and were able to confirm a good level of reproducibility.
In addition, all surveys were administered by the same survey interviewer to avoid any observer bias. The interviewer was present in classrooms at all times to make necessary clarifications and ensure that the data collection procedure was as homogeneous as possible. The questionnaire was anonymous and students were repeatedly reassured that confidentiality was guaranteed, to ensure that they answered the questions as truthfully as possible.
