Decoding substance-use patterns among university students: a comprehensive investigation from Tangier, Morocco

■ INTRODUCTION

The alarming growth in psychoactive substance use, especially among young people, remains a major social concern worldwide particularly during adolescence and young adulthood [1]. Rates of first-time substance use peak between the ages of 18 and 25 in most countries and for most types of drug, underlining the vulnerability of this age group [2]. Thus, the escalation of addictive behaviour is currently a major public health issue. For this reason, alcohol and drugs are expressly mentioned in sustainable development goals for 2030, namely in health objective 3.5, which aims to strengthen the prevention and treatment of substance use, including drug abuse and harmful use of alcohol [3].
Alcohol and psychoactive substance use varies considerably from country to country, influenced by cultural, social, and legislative factors [4, 5].
In regions such as Europe and North America, alcohol consumption is more socially accepted and often integrated into social rituals from a young age, contributing to higher prevalence rates of substance use disorders [6-8]. In contrast, in Arab countries, cultural and religious factors, including the prohibition of alcohol in both religion and law, appear to contribute to lower consumption rates and, consequently, to significantly lower substance-related disorder prevalence rates [9]. However, despite the legal and religious prohibitions, clandestine alcohol consumption and use of other psychoactive substances persist in Arab countries [10] with reports of increasing use among individuals under 30 years of age [11]. According to a recent systematic review [12] of alcohol consumption in the Eastern Mediterranean Region (EMR) since 2010, a prevalence of alcohol consumption of 6.2% was reported among individuals over 15 years of age in the EMR in 2023, with a significant increase from the figure reported by the World Health Organization (WHO) in 2016, which was around 2.6% [13].
In Morocco, a national survey carried out in 2007 on a representative sample of the general population, comprising almost 6,000 participants aged 15 and over. Using the MINI (Mini International Neuropsychiatric Interview) questionnaire to collect data, the survey revealed a prevalence of substance use disorders of 5.8% and of alcohol-related disorders of 3.4% for the general population and, for the 20-29 age group, of 6.6% and 9.2% respectively [14]. In 2022, a study of university students in the eastern region of Morocco, revealed a lifetime prevalence of psychoactive substance use of 28.7% including 24.1% for tobacco, 15.9% for alcohol and 13.4% for cannabis [15]. Furthermore, according to the national MedSPAD-IV Morocco 2021 survey, the 15-17 age group represents a critical period for experimentation and regular substance use, with an increase in consumption between 2013 and 2017 [16, 17].
Certain aspects of the university experience act as environmental risk factors for alcohol consumption patterns among young adults [18]. These factors may include social gatherings, an active social life and cultural norms surrounding certain substances such as alcohol [18, 19]. This environment contributes to higher prevalence rates of substance use among the student population compared to their peers of the same age in certain populations [20, 21].
Dependence on psychoactive substances among university students stems from various risk factors [22]. The academic pressures and rigorous demands of university life can create a stressful environment, leading some students to use substances as a means of stress management [23-25]. Socio-economic factors [26], individual and family [27], such as a family history of addiction [28], social support and personality traits [29, 30], can also play a significant role in the development of addiction. Moreover, there is a substantial link between addiction and the presence of mental disorders [27]. This association between substance use and poor mental health is attributable to shared underlying risk factors such as chronic stress, trauma and adverse childhood experiences [31, 32]. The pursuit of academic performance and the search for an escape from professional challenges can also encourage the use of psychoactive substances [33].
The onset of addictive behaviour is the result of a complex interaction between the individual, his or her socio-cultural environment and the object of addiction [34, 35]. Our research focuses on highlighting the magnitude of this issue and identifying specific factors related to addiction among university students in the Moroccan Northern region in order to make relevant recommendations based on evidence as well as to help framing interventions against substance addiction phenomenon. We consider that the quickest and most effective action against these disorders is based on an approach that focuses on risk factors [36]. The objectives of this study are to estimate the prevalence of psychoactive substance use and associated mental disorders, as well as to identify the factors influencing psychoactive substance use and related disorders among young university students in northern Morocco.

■ MATERIAL AND METHODS

Study design

Our study, conducted in 2023 at Abdelmalek Essaâdi University (UAE) in Morocco, was carried out in nine institutions from different branches and localities in the region (Faculty of Medicine, Engineering Schools, Faculty of Legal and Economic Sciences as well as a multidisciplinary institution with several branches). This was a descriptive and analytical cross-sectional study.

Target population

Sampling frame. A stratified sampling approach based on institutions and gender was utilised to achieve a representative sample of the student population in the northern region of Morocco. The sampling frame was derived from the enrolment data of newly admitted students at UAE.
Sample size. The sample size was determined using the following parameters: an expected pre-valence p = 50%, an error risk α = 0.05 with a 95% confidence interval (CI) and a precision of 3%. Based on these criteria, the minimum required sample size was calculated to be 1067 individuals.
The sample of 1067 students were proportionally allocated based on the size of the student population by institution and gender, using official data provided by UAE regarding its various institutions.

Study questionnaires

Data collection was carried out through individual face-to-face interviews, lasting approximately 15-20 minutes, using a questionnaire designed for UAE students. The questionnaire is in two parts.
The first part addresses socio-demographic information, including gender, marital status, age, monthly household income and study year (from first to seventh year, as the study includes medical students with a seven-year programme). It also considers the participants’ rural or urban origin, their living situation (with family or living alone), medical history, parental substance use, family mental disorder history and any judicial history. Additionally, it encompasses a biographical section that explores experiences of childhood adversity – specifically, any history of physical, psychological, or sexual violence, as well as other negative events during childhood or adolescence, with the emphasis on students recalling any significant negative incidents from that period. This first part also includes additional questions regarding lifetime use of tobacco, alcohol, and cannabis, including whether participants currently use these substances or have used them in the past as well as the age at which they began using each substance. Furthermore, the questionnaire assesses compulsive gaming behaviour through two direct questions. The first question asks participants if they engage in compulsive gaming, while the second question inquiries about the frequency of their gaming behaviour.
The second part was a screening tool for mental disorders i.e., the DSM-IV-based MINI questionnaire. In our study, we used the Moroccan Arabic dialect version validated by the Psychiatric University Centre Ibn Rochd in Casablanca with contributions from doctors Nadia Kadri, Mohamed Agoub and Samir El Gnaoui [37].
Concerning the screening of substance use disorders in the MINI questionnaire, there are two sections: one for screening alcohol-related disorders and another for non-alcohol substance use disorders, each facilitating the exploration of alcohol or other substance dependence and abuse (Whole life + Current i.e., last 12 months). These sections assess substance use by asking specific questions about alcohol, drugs and other substances to which participants respond with “yes” or “no”. The responses obtained help determine if individuals meet criteria for substance abuse or dependence. For screening dependence disorders, at least three positive responses are required while for abuse disorders at least one positive response is required.

Survey procedure

The survey was conducted face-to-face by a team of trained interviewers familiar with the study and the questionnaire used. All interviewers were healthcare professionals including epidemiologists, psychiatrists, medical interns and mental health nurses. The project team developed a work schedule to visit the various university establishments, which was then communicated to the university administration. Subsequently, the administration sent informative letters to the deans of the relevant establishments notifying them about the study.
In each establishment, the administration provided separate offices or rooms for each researcher to ensure interview confidentiality. Student office representatives played a significant role in disseminating information within student groups. Additionally, prior to the survey, information sheets were posted in common areas throughout the institutions.
During the survey, team members took turns in randomly selecting students to locations like cafeterias and libraries to inform them about the study and obtain their consent for inclusion. In certain establishments, the administrators assisted in facilitating the random selection of students from lecture halls.

Variable coding

Once data was collected, the completed questionnaires were stored in the Epidemiology and Public Health Laboratory at the Faculty of Medicine and Pharmacy in Tangier. The data was then entered by the project team using IBM Statistical Package for the Social Sciences version 21 (IBM Corp, Armonk, NY, USA).
For the coding scheme, numerical values were assigned to qualitative variables, with a common practice of using negation as the first choice for responses. For example, responses were coded as follows: “no” was assigned a value of 0 and subsequent choices were coded as 1, 2, 3, etc. In the case of questions regarding parental alcohol or drug use, responses were coded as follows: “yes” = 1, “no” = 0. Similarly, for family mental disorder history, “no” was coded as 0 and “yes” as 1. If a categorical variable did not include negation but consisted solely of choices, coding started from 1; for instance, marital status was coded as follows: “single” = 1, “married” = 2.
For the variable representing the level of education, which could extend up to 7 years due to medical studies lasting seven years, the coding was as follows: 1^st year = 1, 2^nd year = 2 and 3^rd year = 3.

Statistical analysis

Case report forms were designed using REDCap [38, 39] electronic data management tools hosted by Mohammed VI University Hospital of Tangier. Statistical analysis and data entry were performed using IBM Statistical Package for the Social Sciences version 21 (IBM Corp, Armonk, NY, USA). Quantitative variables were described using means and standard deviations while qualitative variables were reported in percentages. Student’s t and χ² tests were used for univariate analysis of continuous and categorical variables. A multivariate analysis was conducted using a stepwise downward binary logistic regression until the final model was obtained.

Ethical considerations

The study was approved by the Tangier University Hospital Ethics Committee (CEHUT) under number 15/2023. The questionnaire was carefully designed and completed with the consent of the students. Precautionary measures were taken to ensure the anonymity and confidentiality of participants.
To ensure our research activities were ethically responsible, interviewers were always accompanied by a team of mental health professionals at the recruitment sites. If a respondent exhibited a clinical disorder detected by the MINI and accepted help, we provided information about the psychiatric team available for support. Immediate assistance options were offered, including urgent referral to the on-call psychiatric team if the individual’s condition warranted it, or scheduling an appointment for follow-up care. All procedures were conducted with respect for participant anonymity.
Data management was performed by the epidemiology and public health laboratory teams at the Faculty of Medicine and Pharmacy of Tangier.

■ RESULTS

Sample description

The sample subjected to analysis consisted of 1168 students from our university. Upon examining the gender distribution, our study comprised 478 males (40.9%) and 690 females (59.1%) yielding a male-to-female ratio of 0.7. The mean age within this sample was 20.63 ± 2.9 years with the majority of students being single (96.2%). Regarding the students’ background, there was a clear predominance of urban origin, accounting for 89.2% of the sample. Notably, a large portion of students resided with their families, constituting 76.8% of the study population, while 23.2% (271 students) opted for solitary living arrangements (Table I). The monthly household income among participants had a mean of 6,741.4 DHS (SD = 8,974.8 DHS).
The description of the sample regarding personal, medical, and family histories, along with early childhood and adolescent experiences, revealed several key findings. A personal history of mental disorders was reported in 5.3% of the students, while 5.5% indicated current treatment for depression, anxiety or substance use disorders. Notably, 6.6% of the participants reported using sleep medications. Additionally, prior judicial issues were documented in 5.2% of the sample.
In terms of family background, 8.6% of students reported a family history of mental disorders, while 8.3% indicated parental substance use.
Furthermore, experiences of childhood violence were significant among respondents: approximately 25% reported experiencing physical violence, nearly 33% reported psychological violence, and about 19% reported sexual violence. The nature of these violent experiences predominantly involved family members, including parents and siblings as well as teachers and neighbours with rare instances involving strangers. Additionally, negative events during childhood or adolescence were reported by nearly 40% of participants, primarily encompassing the death of a close family member (especially grandparents or parents), familial disputes, experiences of violence and bullying as well as academic failures during adolescence (Table I).

Prevalence and determinants of psychoactive substance use among university students

The proportion of tobacco users was estimated at 10.1% (95% CI: 8.4-12), and alcohol use was reported by 5.7% (95% CI: 4.4-7.1) of students. Cannabis use was observed in 7.2% of participants (95% CI: 5.7-8.8). Substance-related disorders had an overall prevalence of 2.4% (95% CI: 1.6-3.4), with alcohol dependence affecting 0.9% of students (95% CI: 0.4-1.6), while dependence on non-alcoholic substances was observed in 1.6% (95% CI: 1.0-2.5) (Figure 1). In addition, the prevalence of alcohol abuse was 0.1% and non-alcoholic substance abuse 0.3%. The average age of onset of substance consumption ranged between 17 and 18 years (Figure 2).
Univariate analysis revealed a significant association between psychoactive substance consumption among students and various factors. Specifically, tobacco consumption among young students was significantly associated with male gender, married civil status, higher household monthly income, living away from their families, compulsive gaming behaviour, parental drug or alcohol consumption and a history of mental disorders and legal antecedents. Additionally, alcohol consumption displayed notable associations with male gender, married civil status, higher household monthly income, living alone away from family, parental alcohol or drug consumption, use of sleep medications, history of childhood physical violence, judicial history and compulsive gaming behaviour. Regarding cannabis consumption, significant associations were found with male gender, higher household income, parental alcohol or drug consumption, mental disorder history, history of childhood sexual violence, legal history and compulsive gaming behaviour (Table II).

Univariate analysis of determinants associated with mental health disorders related to substance use

The psychoactive substance uses disorders detected by the MINI questionnaire showed significant associations with several factors. Specifically, high household monthly income, parental substance abuse, the use of sleep medications, family history of mental disorders, childhood experiences of psychological violence, significant adverse childhood events, history of legal issues and compulsive gaming behaviours were all notably linked to substance-related disorders. Particularly notable are the associations with depressive disorders, anxiety disorders, suicidal risk and antisocial personality disorder (Table III).

Factors influencing psychoactive substance use and associated disorders: multivariate analysis

We conducted a multivariate analysis using a stepwise downward binary logistic regression to determine the specific impact of each factor on the consumption of the psychoactive substances studied as well as the associated mental disorders. This analysis adjusted for other variables to eliminate potential confounding factors until the final model was obtained. In the initial model, for each dependent variable, we included all significant variables from the univariate analysis with a significance level of p > 0.2, as well as variables identified in the literature as known risk factors. For all dependent variables, we incorporated the following variables: gender, marital status, residence, household income, parental drug or alcohol use, personal history of mental disorders, family history of mental problems, criminal history, compulsive gaming and history of violence or negative events during childhood or adolescence.
Ultimately, the risk factors that persisted and exhibited a significant relationship can be categorised into personal factors such as male gender, personal history of mental problems, judicial history and compulsive gaming and family factors, including married marital status, high household income, parental alcohol or drug use, family mental disorder history, living far from family and a history of negative events during childhood or adolescence (Table IV, Figure 3).

■ DISCUSSION

The objectives of this study are to estimate the prevalence of psychoactive substance use and associated mental disorders, as well as to identify the factors influencing psychoactive substance use and related disorders among young university students. We examined the impact of socio-economic variables, history of abuse during childhood and adolescence and comorbidity with other mental disorders. Previous research has suggested that youth addiction to psychoactive substances is a multifactorial condition, which can be influenced by a variety of individual and environmental factors [35, 40].
Substance use disorders accounted for 2.4% of our sample. Substance addictions are frequently perceived as coping mechanisms for academic stress and social pressures [1, 24]. However, these disorders can significantly compromise the physical and mental health of students. The prevalence of these disorders varies across different populations; for example, a systematic review in China suggests that the prevalence is comparable to that in our study [41]. Although the rates in our sample seem lower, it is important to note that such disorders are often under-diagnosed in young adults, highlighting the need for increased awareness and early intervention. In contrast, studies conducted in the United States report considerably higher prevalence rates [42].
In Morocco, a survey conducted on a general population sample of 6,000 found that the prevalence of mental disorders related to substance and alcohol use among young people aged 20-29 was 6.6% for substance use disorders and 9.2% for alcohol-related disorders. These figures are higher than those found in our study among university students. It is worth noting that the sample of young people in this general survey consisted of 1,312 individuals [14].
Regarding the prevalence of substance use, the observed rates were somewhat higher compared to a study conducted among university students in southern Morocco [43] and considerably lower compared to another study conducted in the eastern region of Morocco [15]. Local culture plays an important role in attitudes towards substance use [4], and there is notably a large difference between regions of Morocco and the northern region maintains stricter cultural values regarding the use of substances such as alcohol and tobacco, which contributed to lower prevalence rates.
Our findings underscore a significant gender gap in substance use patterns, emphasising a notable correlation between tobacco, alcohol and cannabis use and gender. We observe a pronounced prevalence of these behaviours among males, consistent with prior literature [44]. Disparities in susceptibility to addictive behaviour based on gender may stem from variations in how stress impacts the neural systems of boys and girls that, as suggested by Bruce S. McEwen and J.E. Garrett [45, 46], with their corticolimbic development, exhibit a greater inclination towards sensation-seeking behaviours, thereby facing an elevated risk of experimenting with and abusing drugs as noted by Bachman [47].
The analysis conducted revealed that young married students have a higher propensity to use psychoactive substances compared to their single counterparts. However, it is critical to note that substance use should decrease, or even cease, as individuals assume responsibilities associated with the transition to adulthood such as marriage and parenthood, as suggested by earlier research [48]. Previous studies have shown that changing family roles and responsibilities are a stronger predictor of changing substance use behaviour than marital status itself, and Homish et al. showed that premarital use of a psychoactive substance was a significant predictor of increased risk of such use during the first four years of marriage [49, 50].
Moreover, the notable correlation between substance use and students residing independently, distant from their families, indicates the potential influence of living conditions on behavioural patterns, supporting earlier research [51, 52]. This phenomenon may be elucidated by the absence of parental supervision and the absence of norms and boundaries that guide parental guidance, which serves as a means to combat substance use among youth [53].
Our survey reveals a notable correlation between family behaviours and individual consumption habits, aligning closely with prior investigations [40, 54, 55]. Specifically, our study highlights a significant association between students’ substance use and their parents’ consumption of drugs or alcohol, thereby contributing significantly to understanding familial influences on substance use behaviour [54]. Newcomb elucidates this connection by attributing it to the family dysfunctions and psychological distress experienced by substance-consuming parents, resulting in inadequate family support for the youth [56, 57]. Additionally, substance use heightens the likelihood of disorders and adverse events within the family such as divorce and job loss, which also contribute to family dysfunction as outlined by Wills and Alt [58].
Similarly, high socio-economic status is widely documented as a risk factor for addiction, a finding corroborated by the results of our study [40, 55].
This may be attributed to the availability of money and means to purchase psychoactive substances [59]. Conversely, other articles suggest that substance consumption is higher among disadvantaged groups due to various factors such as lack of social support to quit, stronger addiction to tobacco and psychological differences like low self- confidence [60].
Our results indicate that the consumption of a specific substance is strongly linked to the consumption of other substances, reinforcing the conclusions previously established in the literature [61]. This relationship can also be seen in our results for compulsive gaming behaviours, illustrating what is known as the co-occurrence of addictive behaviours [62]. Individuals with compulsive tendencies in one area, such as gaming, are likely to develop compulsive substance use behaviours [62-64]. This relationship between the two behaviours can also be explained by the presence of common risk factors. People who are predisposed to compulsive behaviours are also likely to develop addictions to psychoactive substances due to shared risk factors such as neurological changes or certain personality traits [65, 66]. Sleep medications were found to be significantly associated with dependence on psychoactive substances in our study findings. On the one hand, this correlation can be explained by the disruptive effects of alcohol, cannabis and other substances on sleep cycles, inducing difficulties in falling asleep and altering the quality of rest [67]. On the other hand, the student population is frequently confronted with sleep disorders, prompting use of psychoactive drugs to modify their sleep [68]. This bidirectional relationship between sleep disorders and substance addiction can be attributed to the beneficial effects of certain substances on certain sleep disorders, although this may alter sleep quality in the long term [69, 70].
The relationship between substance use and legal problems has been solidly confirmed by previous studies [71]. This correlation can be explained in part by the effects of intoxication, where the use of drugs or alcohol can alter judgment and behaviour, leading to legal transgressions [71, 72]. Moreover, some theories suggest that drug use can influence young people’s social relationships, making them more likely to get involved in legal problems [73].
Adverse childhood experiences and violence are often identified as significant contributors to later addiction problems [74-78]. Our findings reinforce and extend these findings, in particular by confirming the importance of a history of psychological abuse and negative events during childhood and adolescence as major determinants in the context of substance dependence disorders.
The relationship between substance dependence and mental disorders is complex [23]. The use of these substances can be both a cause and a consequence of mental disorders [24]. On the one hand, some people may use psychoactive substances to cope with the symptoms of mental disorders [79]. On the other hand, some types of substance can have side effects that affect mental health [25]. It is also essential to emphasise that genetic and environmental factors, as well as personality traits that play an important role in the development of a child’s personality can simultaneously increase vulnerability to substance dependence and mental disorders [26, 80].
When interpreting our results, it is crucial to recognise limitations such as the inability to establish causality due to the cross-sectional nature of the study as well as potential recall bias or social desirability bias in self-reported responses. Despite these limitations, the multicentre design increases the study’s robustness and reliability by capturing a wide range of perspectives and minimising the influence of local factors. Indeed, a notable strength lies in the breadth of data collection across multiple university establishments, providing a diverse and representative sample that enhances the generalisability of results. Moreover, the use of standardised questionnaires allows for efficient and systematic data collection, minimising potential interviewer bias. Furthermore, rigorous training of data collectors ensures consistency and accuracy in data collection processes with all data collectors being healthcare professionals (either physicians or mental health nurses).

■ CONCLUSIONS

This study provides crucial insights into the prevalence of psychoactive substance use and associated mental disorders among university students in northern Morocco. Identified risk factors like male gender, personal and family mental disorder histories as well as familial factors including marital status, alcohol use by family members, living away from family and experiencing negative events during childhood or adolescence, highlight the complexity of this issue. These findings emphasise the need for integrated approaches to prevention and intervention aimed at improving mental health and mitigating the impact of psychoactive substances in this population.

Acknowledgements/Podziękowania

We extend our heartfelt appreciation to Hassana Belafki for her significant contributions to this project from beginning of the very our collaboration. Though she is no longer with us, her commitment and expertise have been invaluable. We honour her memory and convey our deepest gratitude.

Conflict of interest/Konflikt interesów

None declared./Nie występuje.

Data availability statement

The data presented in this study are available on request for scientific purposes from the corresponding author.

Financial support/Finansowanie

This work is supported by the UAE University within the framework of a call for projects from the UAE University.

Ethics/Etyka

The work described in this article has been carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) on medical research involving human subjects, Uniform Requirements for manuscripts submitted to biomedical journals and the ethical principles defined in the Farmington Consensus of 1997.
Treści przedstawione w pracy są zgodne z zasadami Deklaracji Helsińskiej odnoszącymi się do badań z udziałem ludzi, ujednoliconymi wymaganiami dla czasopism biomedycznych oraz z zasadami etycznymi określonymi w Porozumieniu z Farmington w 1997 roku.

References/Piśmiennictwo