To our knowledge, this is the first national study to determine factors related to alcohol use disorder among adolescents. Our research revealed that higher AUD in Lebanese adolescents was associated with cigarette and waterpipe smoking, internet addiction, child abuse and neglect, bullying, and in adolescents with divorced parents.
Concerning psychometric properties in our study, we found that the AUDIT score had an outstanding Cronbach’s alpha of 0.978, in agreement with other studies31,33,73. Moreover, the one-factor model of the Arabic version was better than that of the Portuguese model74 in terms of internal consistency and number of factors, making this tool useful in identifying risk-taking, signs of addiction, and unhealthy alcohol use among adolescents in Lebanon. Accordingly, using the AUDIT scale to assess AUD among Lebanese adolescents is recommended. However, additional studies are needed to further examine validity features of the AUDIT scale (face validity and criterion validity).
Our results showed that the prevalence of AUD risk among Lebanese adolescents was 28.0%, in line with other studies25,75,76. Besides the correlations with the psychological factors identified in this research, this proportion may also be related to the normalization of alcohol use, its broad availability, particularly in Beirut and Mount Lebanon, the inaction of the government, in addition to existing indefinite policies regarding the illegal sale of alcohol to minors, low excise taxes on alcohol, poor regulatory framework for alcohol advertising and promotion, lack of effectively reported adverse effects of alcohol consumption, and the impact of friends and cousins on the young population23.
A notably higher mean AUDIT score was found in Beirut and Mount Lebanon compared to the other districts. This might be related to the religious distribution in those two districts, while North, South, and Bekaa have most of the Lebanese Muslim rural populations23,26. This distribution further corroborates the validity of the AUDIT scale. Indeed, in Islam, alcohol drinking is forbidden by the Qur’an and is considered to be a satanic act77. Moreover, devout Muslims adhere harshly to the expressions of the Prophet78. Abstaining from alcohol consumption is primarily linked to its illegality but also to the feeling of guilt that followers of Islam may have if they drink78. Accordingly, adolescents raised in families where the Islamic faith is practiced have little or no alcohol drinking problems or misuse.
Cigarette and waterpipe dependence and AUD
In the present study, a higher dependence on cigarette smoking was remarkably associated with higher AUDIT scores, in agreement with other studies8,79. Also, waterpipe smoking was related to higher AUDIT scores, with a few previous studies showing this association79,80. In fact, waterpipe smoking is addictive and associated with nicotine dependence among adolescents81. It is generally assumed that young smokers are at higher vulnerability to AUD than non-smokers at equal rates of alcohol consumption8, consistent with the results reported by Kandel and Chen82. To clarify the association between smoking and AUD, Grucza et al., 2006 suggested that a pharmacological influence may result from smoking by expanding the vulnerability of smokers to develop AUD8. A genetic predisposition or other obscure factors may also be involved in the initiation of youth smoking, which may play a role in developing AUD8. Exposure of adolescents to nicotine may alter gene expression and brain development, thereby modifying future social reactions to other drugs, increasing susceptibility to alcohol and other substance use disorders, and enhancing the impacts of many drugs of abuse. This has also been demonstrated in animal studies exploring the effects of nicotine on the central nervous system of adolescent rats83-87.
Internet addiction and AUD
Our findings revealed that a higher internet addiction was associated with a higher AUDIT score, in line with previous results88. Internet addiction is a potentially dangerous condition with many negative consequences89,90, such as depression, anxiety isolation, loneliness91, loss of self-esteem, in addition to personal, social, and academic problems, and an increased hazardous alcohol use among adolescents88-90. Indeed, adolescents can resort to alcohol misuse to cope with the repercussions following problematic internet use and escape from their reality88. Moreover, problematic internet use and hazardous alcohol consumption may share similar vulnerabilities, such as positive attitudes toward alcohol, family history of alcoholism, and the presence of deviant peers10, thereby raising the probability of presenting together among young people, with a slight advance for problematic Internet use 88. Like in other behavioral addictions, adolescents may abuse the internet to produce a satisfactory outcome92,93. Also, having a behavioral problem such as Internet addiction will decrease the threshold of other addictions, thereby increasing the vulnerability to AUD94.
Childhood sexual abuse, neglect, and AUD
Our results highlighted that an increase in childhood sexual abuse was correlated with higher AUD, consistent with those of other studies documenting this association in adolescents13,95. Several explanatory models are suggested to clarify this association. First, the relationship is likely based on psychiatric issues, as childhood sexual victimization frequently leads to depression and anxiety96. Young people who do not have the appropriate system to deal with bad experiences can drink alcohol to cope with their traumatic childhood or try to escape it, and increase their alcohol consumption, thinking they are solving their problems and falling into alcohol misuse at some point 95,97. Moreover, several studies found that antisocial behaviors can also be a consequence of childhood victimization98,99; thus, youth involved in deviant peer groups will experience more AUD97 .
Furthermore, higher neglect was found to be associated with a significantly higher AUDIT scores, in line with previous research100. Unfavorable life experiences during childhood may lead to the development of post-traumatic stress disorder, which might lead to an inescapable effect on biological stress response mechanisms and mental health, driving victims to respond to their previous traumatic experiences by drinking alcohol101. Also, ignored children cannot develop a valuable relationship with their inert primary caregiver and are more prone to build up a sense of vulnerability, poor social and companionship skills102,103, degradation of self-confidence and self-control100, thereby leading to increased alcohol use.
Bullying victimization and AUD
Our findings showed that higher bullying victimization was significantly associated with more AUD, concurring with those of previous research22,104. Bullying itself is a major global health problem with serious consequences105,106, long linked to issues of self-worth107,108, loneliness, depression, anxiety, and physical symptoms109. It is suggested that AUD is a means to cope with symptoms of mood disorders developed after being bullied109, to ease the anxiety and escape reality. Some may use alcohol as a way to emphasize their social image and improve their previously diminished self-worth109. Additionally, youth tend to seek a peer-to-peer environment because they cannot solve bullying problems on their own, which seems to increase the susceptibility to engage in AUD104.
Separated Parents and AUD
In this context, more AUD was also found in adolescents whose parents are separated compared to those whose parents live together, consolidating previous findings110,111. Deviant conduct is probably produced by low levels of attachment and loyalty to the family, resulting in decreased infant monitoring and parental involvement following parents’ separation 111. Moreover, these findings highlight the crucial role parents play in influencing their children’s behavior towards alcohol and actual alcohol consumption23,111. Parental absence may result in a reduced fruitfulness/efficacy of parenting112 and increased access to alcohol, thereby increasing the likelihood of AUD in adolescents113. Also, since youth must meet emotional demands during their parents’ divorce, prominent links with substance-using peers will be developed114,115. Therefore, peers are thought to be potentially important in determining drinking habits23.
Clinical Implications
The findings of this study carry significant implications for interventions. Due to the immense gaps in the laws and their implementation in Lebanon, there is an urgent need to define new and updated approaches to protect the youth, by raising awareness, setting a legal minimum drinking age116, and enforcing the laws24. Thus, an evidence-based national alcohol harm reduction plan is warranted25. Also, families, schools, public health authorities, and communities have to inform youth about alcohol consumption and focus on its negative aspects117. In this context, families are one of the main sources that drive adolescents into alcohol consumption by making it accessible25,118-120. Parent-child communication about the use of alcohol and its associated harms is also essential in preventing AUD25. Reinforcing school-based alcohol awareness and including a confidential academic-based counseling is also paramount in preventing AUD25.
At the level of community, awareness messages are required to highlight the risks of alcohol consumption, taking the problem into public conversation and helping to promote effective policy implementation23,121. Finally, establishing medical and rehabilitation services and conducting further research in this field are also needed23.
Limitations
This research has some limitations, and few potential weaknesses are worth to mention. First, the current study is limited by its cross-sectional design and thus, showed risk factors associated with Alcohol Use Disorder but could not establish causality. In addition, although 18 religious communities share their convictions freely in Lebanon, some still perceive alcohol as a taboo, and as a consequence, some schools refused to participate in our investigation. Participants were analyzed using a scoring tool and not through a clinical assessment test; therefore, we couldn’t affirm the precision of responses. All the scales used, except the IAT, have not been validated among Lebanese adolescents, which might have led to a non-differential information bias. Finally, a selection bias might be present because of the selection process of schools since public schools were not included. However, the relatively large sample size allows a close approximation of the findings to the general adolescent population, especially since no such studies, taking into consideration a representative sample from all regions, were previously conducted in Lebanon.