The World Health Organization (WHO) defines substance abuse as the harmful use of psychoactive substances such as alcohol, tobacco, and illicit drugs, which together contribute to nearly 17% of global deaths [1]. In India, Global Burden of Disease estimates attribute 3.52% of deaths to alcohol, 10.14% to tobacco, and 0.13% to illicit drugs, despite the lack of a national surveillance system [2]. Adolescence (11–19 years) is a critical yet vulnerable phase, with early initiation into substance use linked to accelerated dependency, poor health and educational outcomes, antisocial behaviours, and high-risk activities such as unsafe sex and violence [3]. Trends show declining age of initiation and rising use across all socioeconomic groups, including students, out-of-school children, and street populations, with multiple and newer substances increasingly reported [4]. Recognizing adolescents as a high-risk group, the Government of India has expanded adolescent health programs to address substance misuse alongside nutrition, mental health, and life skills [5,6]. Given its preventable nature and significant health and social costs, epidemiological surveys are essential for monitoring patterns, identifying risk groups, and guiding interventions.

Understanding the prevalence of substance abuse is essential for estimating its burden and evaluating public health interventions. To date, only one large-scale survey exclusively assessing substance use in children has been conducted by the National Commission for Protection of Child Rights (NCPCR) in 2013 [4]. No published data exist on substance abuse among school-going adolescents in Himachal Pradesh, despite frequent reports of cannabis cultivation, distribution, and use in Kullu district, along with increasing abuse of other substances. This study aims to provide reliable data on the prevalence and determinants of substance use among adolescents, thereby supporting political commitment, priority setting, and healthcare planning.

Study Design and Area

A cross-sectional population based study was conducted in Kullu district of Himachal Pradesh between January and April 2016. As per the 2011 Census, Kullu has a population of 18,306 with a literacy rate of 81% (male: 84%, female: 77%).

Study Population and Sample Size

The study included students of Standard XI (aged 11–19 years) from senior secondary schools. In the absence of local prevalence data, a sample size of 300 was calculated using a prevalence of 25% (based on prior studies), 5% margin of error, and the formula n = 4pq/d².

Sampling Technique

One block was randomly selected from four administrative blocks in Kullu. Of ten senior secondary schools in the selected block, four were chosen through simple random sampling. From these schools, equal numbers of students were enrolled by random selection.

Inclusion Criteria

• Adolescents aged 11–19 years attending school.

• Willing to provide consent.

Exclusion Criteria

• Non-consenting students.

• Students outside the 11–19 year age group.

Study Tools

Data were collected using a pretested, structured, anonymous, self-administered questionnaire adapted from the WHO core questionnaire and locally modified to assess prevalence and risk factors of substance use.

Data Collection

Necessary permissions were obtained from the Directorate of Education and school principals. Written informed consent was taken from parents. Surveys were administered in classrooms under conditions ensuring anonymity and minimal communication among students, with teachers absent during administration. Clarifications were provided as required. Completed questionnaires were collected anonymously. Following the survey, an awareness session on the effects of substance abuse was conducted.

Operational Definitions

• Regular user: Alcohol use ≥3 times/week; daily use of tobacco/cannabis/other drugs.

• Current user: Use of any substance within the past month.

• Occasional user: Alcohol use <3 times/week or intermittent use of other substances within past 6 months.

• Ever user: Any lifetime use of a substance (excluding experimental sips/puffs).

Ethical Considerations

Informed consent was obtained from parents. Participation was voluntary, confidentiality maintained, and no hazardous procedures were involved.

Statistical Analysis

Data from questionnaires were entered into Microsoft Excel and analyzed using IBM SPSS Statistics for Windows, Version 21. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize the data. Categorical variables were analyzed using the Chi-square test or Fisher’s exact test, as appropriate. Variables significant on univariate analysis were included in multivariate analysis. Binary logistic regression was performed to identify associations between risk factors and substance abuse. A p value <0.05 was considered statistically significant.

Of the 300 participants, 131 (43.7%) were females and 169 (56.3%) males. The mean age was 15.94 ± 0.83 years (range: 14–18) for females and 15.89 ± 0.92 years (range: 14–19) for males. The mean age of substance initiation for any substance was 14 years (range: 12–16).

Tobacco Use

Overall, 6.3% (19/300) reported ever using nicotine, with higher prevalence among females (8.4%) than males (4.7%) (Table 1). Current use was reported by 2% (6/300), including 2.3% of females and 1.8% of males. Occasional smoking was observed in 4.3% (13/300) of participants (females 5.3%, males 3.6%), while 2% (6/300) were regular smokers (females 3.1%, males 1.2%).

Alcohol Use

Among participants, 86.3% had never consumed alcohol. Of the 13.7% who had, 12% were occasional users and 1.7% regular users (Table1). Current alcohol use was 7% (females 7.6%, males 6.5%).

Illicit Substance Use

Awareness of illicit substances such as marijuana, heroin, LSD, inhalants, and tranquilizers was reported by 86% of students, more common among males (89.3%) than females (81.7%). Substance use prevalence was 4.7% (males 6.5%, females 2.3%), with marijuana being the most frequently and earliest used drug Table 1. 

Table 1: Baseline Demographic Features and Substance Use among Study Participants (N = 300)

Table 2:  Substance Use Approval / Disapproval by study population

Table 3:  Substance use harm awareness among study population

Attitudes and Risk Perception of Substance Use
Disapproval of use varied by substance: 58.3% for smoking,  51.7% for alcohol, and 46% for illicit drugs Table 2. A substantial proportion gave no opinion (smoking 34.3%, alcohol 35.7%, substances 48.7%). 

Perceived great risk was reported by 39.7% for smoking, 35.3% for alcohol, and 34% for illicit drugs. Lack of awareness of risks was highest for illicit drugs (42%), followed  by  alcohol  (15.7%)  and  smoking  (11.7%) Table 3.

Perceived Availability and Consequences

All participants reported difficulty accessing illicit drugs, while only 1.3% perceived alcohol and cigarettes as difficult to access. Most participants (93%) reported no problems related to substance use; however, 6% reported socioeconomic problems, and 1% reported multiple issues (e.g., relationships, academics). No health- or legal-related problems were reported.

This study highlights a concerning prevalence of substance use among school-going adolescents in Kullu district, with alcohol (13.7%) being the most frequently used substance, followed by tobacco (6.3%) and cannabis (4.7%). The mean age of initiation for cannabis use was 14 years, comparable to findings from Madu and Matla (14.9 years) [8]. Early initiation is particularly alarming, as it is known to accelerate dependency and worsen long-term outcomes.

Compared with international studies, our prevalence rates were lower than those reported by Norbu and Perngparn [9] in Thailand (alcohol 24.8%, smoking 22.9%, marijuana 9.5%) and Boyle and Offord [10] in Canada (alcohol 32%, tobacco 28%, cannabis 10%). Indian studies also show variability, with higher rates of tobacco and alcohol use in some regions, particularly in the Northeast [11-15]. The relatively lower rates in our study may reflect regional differences, sociocultural factors, or underreporting due to social desirability bias.

A notable finding was the higher prevalence of alcohol and tobacco use among females compared to males, contrary to most Indian studies where substance use is predominantly male. Similar patterns, however, have been reported in certain urban and Northeastern populations, suggesting a changing trend in adolescent female substance use [13,16]. In contrast, cannabis use remained higher among males, consistent with most studies.

Despite high levels of awareness regarding health risks, disapproval of substance use was relatively low, particularly for alcohol (51.7%) and illicit drugs (46%). Other researchers in related studies have also found similar results [13,17]. This knowledge–attitude gap indicates that awareness alone may be insufficient to prevent use. Easy availability of alcohol and tobacco, reported by almost all students, further reinforces the need for stricter enforcement of regulatory policies.

Although only a small proportion reported social or academic problems, studies elsewhere suggest that these issues often become more evident with prolonged use. Early intervention is therefore critical before experimentation progresses to dependence.

Limitations

Limitations of the present study includes reliance on self-reported data, which may underestimate true prevalence due to underreporting, and restriction to school-going adolescents, which excludes out-of-school youth who may be at even higher risk.

Substance use among adolescents in Kullu, though lower than in some other regions, represents a significant public health concern. Early initiation, increasing use among females, and limited disapproval despite awareness are worrying trends. Targeted school-based preventive programs, stricter regulation of alcohol and tobacco availability, and community awareness campaigns are urgently needed.

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