INTRODUCTION
Drug craving presents a major public health issue globally, significantly affecting adolescents in Pakistan [1], where the rapid rise in drug use for recreational purposes—from late adolescence into early adulthood is accompanied by a recognition of the risks these substances pose. Such substances distort reality and diminish rational thought upon entering the bloodstream.
Presently, Pakistan sees more than six million adults using drugs, with five million among them grappling with addiction [1]. Worldwide, prevalent drugs like tobacco, alcohol, heroin, cannabis, and various stimulants are regularly consumed by individuals of both sexes [2]. Adolescence is marked by an escalation in negative emotions and risk behaviors [3], leading to a surge in illicit substance use [4]. Among these drugs, such as heroin use is driven by multiple factors, including stress, parental education levels, family conflict and the influence of peers, particularly in males [5]. Psychosocial peer pressures, alongside inadequate parental involvement and educational shortcomings, are significant contributors to addiction [6]. Parental dynamics, specifically acceptance, act as a deterrent to drug use, whereas a lack of parental warmth and understanding has been shown to compound psychological challenges and increase substance dependence [7]. For instance, smoking tends to be more prevalent among male adolescents, attributed to challenges in executive functioning and poor parental relationships [8,9]. Similarly, alcohol misuse and distress are often consequences of problematic parenting styles [10] similar to authoritarian and neglectful parents [11] On the other hand, authoritative and supportive parental interactions offer resilience against adolescent drug use [12].
During adolescence—a critical phase for self-discovery— young people tend to align with their peers, heightening their likelihood of experimenting with substances and other risky behaviors [13]. Peer offerings of alcohol are seen as high-status activity among youth [14], while factors like parental influences and socioeconomic standing significantly shape smoking patterns [15] and the propensity for addiction among Pakistani youth [6]. Drug and alcohol use are further linked to family structure, educational level of parents, and their professions [16]. Evidence suggests that individuals using drugs tend to experience amplified psychological adjustment [17] and social maladjustment problems 18 and related disorders [19]. Specifically, prolonged marijuana [17] and cannabis use [20] are associated with greater psychological challenges. In Pakistan’s Sindh region [21] and the capital [21], studies report that drug users often feel a heightened sense of rejection by their parents, perceive their parents as hostile or neglectful, and frequently engage in poly-drug use, relying heavily on their family’s guidance for life decisions.
The current study
Late adolescent drug consumption has been consistently associated with factors such as peer influence [22], parental acceptance-rejection [16], association with deviant peers, and psychological adjustment [17]. Prior research within the Pakistani context has rarely drawn comparisons between occasional and non-occasional drug craving. This study aims to explore the psychosocial attributes and psychological adjustment within these two user groups in Pakistan. It has been established that the bonding between children, their parents, and peers is crucial, with parental acceptance acting as a protective factor against psychological complications, substance use, and related issues [23]. Notably, drug utilization rates have been observed to be higher in males than in females [24], and a history of low socioeconomic status (SES) has been correlated with cannabis use later in life [25].
This research endeavors to ascertain the impact of psychosocial factors, parental dynamics, peer pressure, and psychological adjustment on occasional drug users. The findings are intended to equip society, including parents, educators, and social welfare groups, with vital knowledge to implement early intervention strategies aimed at reducing substance misuse among Pakistani youth.
METHODS
Participants
Participants were drawn from a pool of students attending six high schools and six colleges within Islamabad and Rawalpindi, the twin cities that make up Pakistan’s capital territory. Eligible participants were: 1) currently enrolled students; 2) residents of the aforementioned cities; 3) possessing more than eight years of educational background; 4) free from other mental health diagnoses or psychiatric clinic visits; and 5) able to provide parent signed informed consent agreeing to participate in the study. Although G Power 3.1.9.7 (Franz Faul, Kiel University, Germany) suggested a sample size of 210 and the Rao Soft (Raosoft Inc., Seattle, WA, USA) sample calculator recommended 240, this study exceeded both suggestions with a total of 338 participants, boasting a mean age of 18.64±1.18 years.
The Institutional Review Board & Ethics Committee (IRB & EC) and the Federal Education Directorate (FED) of educational institutions sanctioned the study’s protocols (ref no: STMU/PSY/IRB23/2020). Some participants were minors; in such cases, expert researchers thoroughly explained the study procedures to the parents, who provided signed informed consent.
Demographic characteristics
Employing a cross-sectional design, the study collected data through comprehensive questionnaires administered by the researchers. These questionnaires solicited demographic details such as age, gender, educational attainment, family structure, monthly family income estimates, drug usage patterns, occasions of drug use, initial drug influence, cravings, family history of drug cravings, and parental education levels.
Measures
Adult Parental Acceptance-Rejection Questionnaire - Short Form
The Adult Parental Acceptance-Rejection Questionnaire Short Form, originally designed by Rohner and Khaleque [26], measures perceptions of parental care, acceptance, warmth, and neglect from childhood experiences. This short form captures the essence of whether children felt accepted or rejected by their parents. It features 48 items, split evenly to reflect maternal and paternal experiences, each rated on a 4-point Likert scale from “almost always true” (4) to “almost never true” (1), yielding scores ranging from 24 to 96. The subscales include warmth/affection (8 items), hostility/aggressiveness (6 items), indifference/neglect (6 items), and undifferentiated/overall rejection (4 items). In this study, reliability coefficients were 0.819 for fathers and 0.832 for mothers, aligning with the previously reported 0.95 [26].
Peer Pressure Questionnaire-Revised
The Peer Pressure Questionnaire-Revised assesses the magnitude of peer influence through 25 items by Saini and Singh [27], each with a 5-point Likert response option from “strongly disagree” (1) to “strongly agree” (5). It reflects the level of peer pressure in current circumstances, with total scores spanning from 25 to 125. Higher scores indicate stronger peer influence. Previous literature cited the reliability of 0.77 [27], while this study reports a Cronbach’s alpha of 0.866.
Adult Personality Assessment Questionnaire
The Adult Personality Assessment Questionnaire, developed by Rohner and Khaleque [26], evaluates self-perceptions across seven personality domains, including aggression, dependency, self-esteem, self-adequacy, emotional responsiveness, emotional stability, and worldview. Each of the 42 items is scored on a 4-point Likert scale from “almost never true” (1) to “almost always true” (4). The total score, which provides a comprehensive picture of psychological adjustment, can range from 42 to 168. This study’s reliability was recorded at 0.705, close to the previously documented [28] 0.86.
Statistical analysis
Initially, data prepossessing steps such as outlier removal and missing value handling were conducted. Next, we assessed the normality of demographic and other variables using the Kolmogorov-Smirnov test. Non-normally distributed variables underwent log transformation for standardization prior to analysis. The Kruskal-Wallis H test was applied to variables that remained non-normal. Categorical variables were analyzed using the chi-square test to contrast occasional drug craving with non-drug craving. For variables showing normal distribution, Pearson’s correlation, independent samples t-tests, and analysis of variance determined mean differences based on gender, drug use frequency, family structure, SES, and age in relation to parental acceptance-rejection, peer pressure, and psychological adjustment. Post-hoc analyses for multiple comparisons were conducted with a 95% confidence interval. Binary logistic regression was utilized to gauge the strength of effects within the Statistical Package for the Social Sciences (SPSS) version 25 (IBM Corp., Armonk, NY, USA).
RESULTS
The current investigation sought to scrutinize the psychosocial factors and psychological adjustments among adolescents and young adults, contrasting occasional drug craving with non-craving.
Prevalence, demographic characteristics, and correlations
Of the 338 participants, 44.1% reported occasional drug cravings. Table 1 delineates the demographic distinctions between the subgroups of occasional and non-occasional drug craving participants, highlighting differences in age, gender, parental education, SES, drug usage patterns, initiation scenarios for drug craving, and familial drug history. Frequencies in Table 1 depict demographic variables, including the prevalence of drug use among users and non-users, distinguished by gender, age, educational level, SES, family structure, type of drug use, and initial drug use circumstances. All variables (peer pressure, father acceptance-rejection, mother acceptance-rejection, and adult personality assessment) achieved the alpha threshold levels of 0.819, 0.832, 0.866, and 0.705, respectively.
Peer pressure showed a positive association with paternal warmth, hostility, indifference, and undifferentiated rejection (ranging from r=0.171 to r=0.421, p<0.01), and similarly with maternal undifferentiated rejection, hostility and warmth (r=0.138 to r=0.192, p<0.05 to p<0.01). Conversely, psychological adjustment correlated negatively with paternal warmth (r=-0.240, p<0.01), suggesting that parental affection fosters better psychological adjustment. Maternal hostility exhibited a positive correlation (Supplementary Table 1).
Drug types and situation-specific drug craving behaviors were found to correlate with the study variables; peer pressure and psychological adjustment showed negative associations with drug types and positive links with context-specific drug craving behaviors. Notably, paternal hostility, indifference, and undifferentiated rejection were negatively related to drug types and context-based drug craving, contrasting with maternal associations (Supplementary Table 1).
Comparative analyses
Significant contrasts emerged between occasional drug craving and non-craving participants, with paternal undifferentiated rejection playing a larger role in occasional drug craving [t (338)=-15.43, p=0.001] than maternal undifferentiated rejection [t (338)=-0.822, p=0.412] (Table 2). Peer pressure significantly influenced adolescents and young adults in terms of drug craving [t (338)=-11.91, p=0.001], and personality assessments indicated higher psychological adjustment challenges among those with occasional cravings [t (338)=-7.82, p=0.001]. Peer pressure and psychological adjustment levels were higher in individuals with occasional drug cravings [t (338)=-1.989, p<0.05; t (338)=2.076, p<0.05]. Parental acceptance-rejection patterns, especially paternal undifferentiated rejection, were more prevalent in joint family structures [t (338)=-2.588, p=0.010], and paternal hostility was notable in nuclear families [t (338)=-2.835, p=0.005].
Gender disparities were evident, with females experiencing more peer pressure than their male counterparts [t (338)=3.866, p=0.001], although no significant differences were found in adjustment. The data indicated a typical Asian paternal role, with heightened rejection directed towards male children [t (338)=5.835, p=0.001], and increased neglect and hostility towards females [t (338)=2.069, p=0.040; t (338)=3.074, p=0.002], in opposite, higher paternal warmth for male [t (338)=-2.017, p=0.046].
SES and age comparisons
Table 3 shows that SES significantly differed across three groups, impacting peer pressure, psychological adjustment, and parental acceptance-rejection. Particularly, mother hostility was most pronounced in higher-income families [F (2,335)=7.033, p<0.01], and a similar trend was observed with paternal neglect [F (2,335)=2.874, p<0.01].
Age differences were also significant, with individuals aged 20-22 years exhibiting the highest levels of peer pressure and psychological adjustment challenges [F (2,335)=17.95, p<0.001; F (2,335)=4.16, p<0.01], as well as higher paternal rejection [F (2,335)=1.181, p<0.001]. Post-hoc Bonferroni-adjusted comparisons underscored that the 20-22 age group is at higher risk, as indicated by significant mean differences in parental acceptance-rejection scores.
Factors associated with drug craving
Stepwise binary logistic regression analysis highlighted factors independently associated with occasional drug cravings. The model (Wald χ2 =93.14, df=7, p<0.001), accounted for a significant proportion of the variance (32.2% to 0.1%) and correctly classified a majority of cases (74.0%). Older adolescents (20-22 years) 7.865 times were significantly more likely to exhibit drug cravings, while higher family income within the middle-class bracket was associated with reduced drug craving likelihood (Table 4).
Further analysis indicated that Model (Wald χ2 =224.685, df=10, p<0.001), accounted for a significant proportion of variances (81.7% to 60.9%) and correctly classified for majority of cases (90.2%). Increased paternal hostility, indifference negligence, undifferentiated rejection, peer pressure and psychological adjustment significantly predicted higher odds of occasional drug cravings 2.50, 1.93, 6.23, 5.28 and 1.04, respectively. Conversely, increased paternal warmth and maternal hostility were associated with reduced odds (0.57 and 0.19 times) of occasional drug cravings.
DISCUSSION
The exploration of sociodemographic attributes linked to occasional drug cravings among Pakistani students remains limited. Our study’s findings are crucial: 1) the prevalence of occasional drug cravings is considerable, at 44.1%, among students in Pakistan’s capital territory, typically from families considered part of the elite class. 2) There is a heightened risk for occasional drug cravings among male students aged 17 to 19 years from high-income, nuclear families with higher parental education levels and those who use tobacco in social gatherings or as a response to stress but without a family history of drug cravings. 3) Aggressive and hostile paternal behavior, paternal rejection and negligence, maternal aggression and hostility, warmth and love significantly correlate with occasional drug cravings. 4) Higher maternal hostility and negligence were more prevalent in high-income families. Binary logistic regression further confirmed the independent associations of paternal and maternal behaviors, peer pressure, and psychosocial adjustment with occasional drug cravings.
Our cross-sectional analysis revealed a significant prevalence of tobacco use (39.9%) among occasional drug users, contrasting with previous studies [29,30] that reported higher rates for heroin and ice (19% and 11%, respectively) and heroin and cannabis [31]. Notably, drug initiation among young adults aged 14 to 16 years stood at 13.9%, marking a deviation from Pakistan’s historical drug use trends. This is compounded by reports of individuals aged 15 to 20 years [32] and 19 to 21 years [32] using drugs to cope with stress, alongside a notable increase in smokers by 9.1% since 2018 [33]. Such early initiation often escalates to severe cravings and addiction, with about 90% transitioning to heroin by age 18 [31-34]. Our findings confirm tobacco’s status as the most widely used drug across genders [2], suggesting a shift in youth attitudes toward social engagement, peer influence, and drug exploration.
Comparatively, previous research indicated drug use rates at 41.6% [35], 8%, [31] and 7.4% [36] among students. Our study identified a greater prevalence of drug craving (44.1%), with primary substances including tobacco (39.9%), heroin (1.8%), ice (0.6%), lysergic acid diethylamide (0.3%), and a small fraction (1.5%) using a variety of drugs. This highlights the significant role of peer pressure and familial dynamics in fostering drug cravings. Literature suggests that perceived parental neglect greatly increases the risk for substance use disorders [13], with peer encouragement for drug experimentation leading to psychosocial and behavioral issues [19,20]. This pattern likely stems from the influence of peers over neglectful or hostile parental relationships. In our cohort, 11.2% resorted to drugs due to stress, 5.0% from sadness, and 15.7% in social settings, underscoring the impact of peer dynamics [13,22,37]. The challenge of resisting peer pressure, driven by the need for acceptance and fear of exclusion, may explain these trends.
Although recent data on the general population’s occasional drug craving rates are lacking, earlier reports suggest a higher prevalence than our current findings [13,30]. Our results align with global observations on adolescent drug experimentation [13,30,38] especially tobacco [15] and, to a lesser extent, heroin and cannabis [31] as primary substances used in peer gatherings and media [39].
Our analysis also highlighted the strong predictive role of paternal rejection in occasional drug cravings, reinforcing the linkage established by previous research between sub-optimal parenting and drug cravings [11,14,22]. One possible explanation could be for the findings that in Pakistan’s patriarchal society, fathers often adopt an authoritarian stance, limiting open communication with their children. Conversely, maternal rejection and hostility were associated with drug cravings, underscoring the children’s need for maternal empathy and protection. Thus, the mother is perceived as a protective figure [40].
In our results, students exhibited higher psychological adjustment levels and showed lower drug cravings, suggesting that psychosocial well-being mitigates the risk of substance use. This is consistent with literature associating psychological challenges with substance use, both licit and illicit [17,19]. It appears that students under stress, or those from families marked by negligence or negative peer influences, are more vulnerable to drug use. We also observed that male students, especially those from joint family systems, are more susceptible to drug cravings than females; these results are in line with past research [30,41]. Cultural norms may lead to under reporting in females, while the dynamics of joint families might contribute to less parental attention, potentially increasing the likelihood of drug use. Moreover, parental rejection was more significant in families with higher SES, potentially due to less parental engagement; the children follow their peers and try out new things for fun, particularly trying elite-class families’ life patron. This finding complements studies linking lower SES with smoking and higher status with alcohol and marijuana use [30,41].
There are limitations to consider: the cross-sectional design and student-based sample size restrict our ability to establish causal relationships. Future longitudinal research should broaden the sample to include general and clinical populations for a more comprehensive understanding. Furthermore, as the data were self-reported by students without parental input, incorporating parent-child dyadic data could offer more robust insights.
In sum, our study unveils a significant rate of occasional drug use (44.1%) among Pakistani students, driven by various factors, including parental acceptance rejection, peer pressure, and psychological adjustment. Given these findings, it is imperative to develop educational and preventative measures targeting institutes, families, and youth, as well as awareness programs for parents about parenting styles and the ramifications of drug use and addiction.
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