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Revista Brasileira de Psiquiatria

Print version ISSN 1516-4446On-line version ISSN 1809-452X

Rev. Bras. Psiquiatr. vol.37 no.2 São Paulo Apr./June 2015  Epub Feb 24, 2015

http://dx.doi.org/10.1590/1516-4446-2014-1389 

Original Articles

Sports practices related to alcohol and tobacco use among high school students

André Bedendo1 

Ana R. Noto1 

1Department of Psychobiology, Universidade Federal de São Paulo (UNIFESP), São Paulo - SP - Brazil

ABSTRACT

Objective:

To examine the relationship between alcohol and tobacco use and sports in a national sample of secondary students.

Methods:

This cross-sectional study enrolled a representative sample of secondary students from public and private schools from all 27 Brazilian state capitals. Students were assessed in 2010 by a self-report questionnaire including questions on drug use and sport activity in the last month (n=13,872).

Results:

Subjects who played sports exhibited a higher frequency of alcohol use and heavy episodic drinking than their peers who did not play sports. Practices that were associated with higher odds of heavy episodic drinking in the last month included gym, weight training (adjusted odds ratio [aOR]: 2.0, 95% confidence interval [95%CI] 1.6-2.4), and soccer (aOR: 1.3, 95%CI 1.1-1.5). Fighting, martial arts, or capoeira were associated with smoking (aOR: 1.9, 95%CI 1.2-3.2).

Conclusion:

These results suggest a relationship between some sports preferences and a higher risk of alcohol or tobacco use among Brazilian secondary students. This relationship should be considered in preventive programs.

Key words: Sports; exercise; alcohol drinking; tobacco; adolescent

Introduction

Adolescence is a critical period in the development of substance use and abuse patterns.1 Alcohol and tobacco are the psychotropic substances most commonly used by Brazilian students between the ages of 14 and 18 years old.2

Since the early 1980s, several studies have explored the association between participation in sports and drug use.3Studies point to physical exercise as a possible therapeutic intervention against the abuse of various types of drugs.4,5 Moreover, the literature presents inconsistent evidence about sports participation as a risk or a protective factor for drug use,6 particularly among adolescent students.

In several studies, sports participation among high school students was associated with higher alcohol consumption,7,8 heavy episodic drinking (HED),9 and tobacco use.10 Conversely, other studies have observed that participation in sports is associated with decreased use of these substances.11,12 However, all these studies focused on North American and European populations.

Several characteristics of sports practice seem to influence its relationship with substance use, including the type of sport4,13 and the frequency of and motivation for participating in sports.3,8,14 Some authors point out the importance of social and cultural aspects14-16 in understanding the relationship between sports and drugs. Adolescents are subject to considerable peer influence regarding alcohol and tobacco use.17,18 Among sports players, alcohol consumption can be encouraged as a way to strengthen group bonds.19 In contrast, the exact nature of the sport can attract different types of students. For example, men who are interested in more aggressive sports may be more susceptible to high-risk behaviors.20

In developing countries, there is still a substantial gap in understanding the relationship between sports and substance use.21 Thus, nationally representative data that could allow comparisons with other countries are essential for recognizing scenarios related to substance use and for guiding the development or adaptation of preventive strategies.

The present study sought to examine the relationship between alcohol and tobacco use and sport participation as reported by secondary school students from a representative sample of all 27 Brazilian capitals.

Methods

Study design and participants

The present study is part of the VI National Survey on Psychotropic Drug Use among Elementary and Secondary Education Students from Private and Public Schools in 27 Brazilian Capitals conducted in 2010.2 This study was conducted by the Brazilian Center for Information on Psychotropic Drugs (CEBRID).

The sample is representative of secondary school students from public and private schools in 27 Brazilian state capitals. Using the national registry of all educational institutions in the country, all schools were listed, and subsamples of public and private institutions were created. In each subsample, three strata were considered: primary schools, secondary schools, and schools that provided both primary and secondary education. For each stratum, proportional samples were allocated according to the number of students, which was estimated from the number of classrooms. This process resulted in a sample of 50,890 students (31,570 primary and 19,230 secondary) and 789 schools (512 public and 277 private). All students in the selected classes were invited to participate in the study.

Data about sports participation was collected among secondary students. Approximately 79% of the students agreed to participate (20.5% were absent on the day of the survey and 0.3% refused). To reduce false-positive answers, one question involving fictitious drugs was inserted. Students were asked if they had already used “Holoten,” “Carpinol,” or “Medavane” to feel “different/high,” and 98 subjects who answered this question positively were excluded.

The present study considered only secondary school students aged 14 to 18 years who answered questions about the main sport activity in which they participated during the last month (n=13,872).

Informed consent procedures

All questionnaires were completed in the classroom under the supervision of a group of trained researchers. The researchers' training included classroom presence, ethics, and procedures for addressing possible questions from the participants. The questionnaire took approximately 50 minutes to administer. To ensure confidentiality, no school employee or officer was present during this stage. All of the questionnaires were completed on a single day, and the completed questionnaires were sealed. All participants were informed about the research objectives and about the voluntary nature of their participation. Students could stop participating at any time, and the data collected were used exclusively for research purposes. The study was approved by the Research Ethics Committee of Universidade Federal de São Paulo (UNIFESP), Brazil (process 0348/08).

Measures

The questionnaire used in the present study was adapted to Brazilian culture from self-report instruments available from the World Health Organization22 and the European School Survey Project on Alcohol and Other Drugs (ESPAD).23

Sports activity

The data collected referred to the month prior to the survey, and were obtained using three questions: a) “Which sports activity did you participate in the most in the last 30 days?” (0 = not a participant; 1 = gym, weight training; 2 = track and field, cycling, or swimming; 3 = basketball, volleyball, or handball; 4 = dancing; 5 = soccer; 6 = gymnastics; or 7 = fighting, martial arts, or capoeira); b) “In the last 30 days, how many times have you participated in the sport reported above?” (0 = not a participant; 1 = 1 to 5 days; 2 = 6 to 19 days; or 3 = 20 days or more); and c) “Why do you participate in the sports activity reported above?” (0 = not a participant; 1 = for fun; 2 = to stay fit or for health reasons; or 3 = professionally). To study the differences between sports participants and sedentary students, a dichotomous variable was created, which included all of the sports mentioned (0 = not a participant; 1 = sports). Gymnastics and dancing were pooled for the purpose of analysis. In some cases, the sports were also classified as individual (gym, weight training; track and field, cycling, or swimming; dancing or gymnastics; and fighting, martial arts, or capoeira) or team (basketball, volleyball, or handball and soccer). In the present study, the terms “sports activity,” “sports practice,” and “sports” are used interchangeably.

Alcohol consumption in the last month

Information about alcohol consumption was obtained through the following question: “In the last 30 days, have you consumed any alcoholic beverage?” (0 = no; 1 = yes, I drank 1 to 5 days during the month; 2 = yes, I drank 6 to 19 days during the month; or 3 = yes, I drank 20 days or more). For analysis, this variable was coded as dichotomous (0 = no, 1 = yes).

Heavy episodic drinking in the last month

Information about HED was obtained using the following question: “In the last 30 days, how many times have you consumed 5 or more drinks on the same occasion?” (0 = never; 1 = 1 time; 2 = 2 times; 3 = 3 to 5 times; 4 = 6 to 9 times; or 5 = 10 times or more). The questionnaire included an explanatory table about dose equivalence. For the purpose of analysis, this variable was also considered dichotomous (0 = no, 1 = yes).

Tobacco use in the last month

Information about tobacco use was obtained using the following question: “In the last 30 days, have you smoked a cigarette?” (0 = no; 1 = yes, I smoked 1 to 5 days in the last month; 2 = yes, I smoked 6 to 19 days in the last month; or 3 = yes, I smoked 20 days or more in the last month). This variable was coded in the present study as a dichotomous variable (0 = no, 1 = yes).

Control variables

Gender, age (years), and school type (sociodemographic variables) were used as adjustments in the logistic regression models. The type of school (public or private) was used as a substitute for socioeconomic status.

Statistical analyses

Chi-square tests were used to identify differences in substance use. Univariate and multivariate logistic regression models were used to predict alcohol consumption, HED, and tobacco use. Sports practice, frequency, and motivation were treated as independent variables. Gender, age, and school type were included in multinomial models as control variables. Sample weights were calculated and respected all stages of the sample design. Non-response was treated with calibration during weight calculation. Simple weights were corrected by sample response rates in each stratum and calibrated for the total number of student admissions at schools (respecting the study population), according to the national school census conducted in 2009 by Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira (INEP). All analyses were performed using the subpop command in Stata software version 1124 and the minimum level of significance was set at 5%.

Results

The sample consisted of 78.9% (95%CI 75.7-81.8) public school students and 57.8% girls (95%CI 56.7-59.0). The participants had a mean age of 15.9 years (standard error: 0.03). Of the 13,872 students interviewed, 62.9% (95%CI 61.2-64.6) reported having practiced some sports activity in the last month, and 63.0% had participated in team sports (95%CI 60.9-65.0). Soccer was the sport most frequently mentioned by the students (41.9%, 95%CI 39.8-44.0), followed by basketball, volleyball, or handball (21.1%, 95%CI 19.0-23.4) and gym or weight training (16.1%, 95%CI 14.9-17.5).

Table 1 shows the prevalence of alcohol and tobacco use within the previous month in relation to the participants' sociodemographic characteristics and sports. Older age and male gender were associated with higher alcohol and tobacco use, while private school attendance was more associated with alcohol consumption. A higher proportion of students who reported participating in sports activities reported alcohol consumption within the month compared with the students who did not participate in sports. The same finding was observed in the comparative analyses in relation to HED. There were no significant differences in tobacco use between sports participants and nonparticipants, nor were there significant differences between those who participated in team vs. individual sports. Regarding the types of sports, gym or weight training was significantly more associated with alcohol consumption and with at least one HED episode within the last month. Fighting, martial arts, or capoeira practice were more strongly associated with tobacco use within the last month compared with other sports. Participation in sports activities for 6 or more days per month was more closely associated with alcohol consumption within the month, including HED, while sports practice for professional reasons was less associated with HED (Table 1).

Table 1 Prevalence of alcohol and tobacco use in the last month, sociodemographic characteristics, and sports practice (n=13,872) 

Alcohol Heavy episodic drinking Tobacco
n (total) wgt% (95%CI) p-value* n (total) wgt% (95%CI) p-value* n (total) wgt% (95%CI) p-value*
Age (years)
14-15 5,100 24.9 (22.1-27.9) 0.000 5,050 11.9 (9.7-14.4) 0.000 5,155 4.9 (4.2-5.8) 0.000
16-18 8,547 37.3 (35.3-39.4) 8,387 23.0 (21.3-24.7) 8,657 9.7 (8.5-11.2)
Gender
Female 7,906 31.5 (29.7-33.3) 0.013 7,798 16.6 (15.0-18.4) 0.000 8,008 6.9 (5.9-8.1) 0.001
Male 5,714 34.4 (31.9-36.9) 5,612 21.9 (19.9-24.0) 5,778 9.4 (8.2-10.9)
School type
Public 8,095 30.6 (28.5-32.7) 0.000 7,993 17.5 (15.8-19.3) 0.004 8,218 7.9 (6.8-9.1) 0.764
Private 5,552 40.8 (38.0-43.6) 5,444 23.9 (21.4-26.6) 5,594 8.2 (6.9-9.8)
Sports (in last month)
Not a participant 4,857 30.1 (27.9-32.5) 0.002 4,783 16.7 (14.7-18.9) 0.004 4,925 7.6 (6.4-9.1) 0.41
Sports 8,790 34.3 (32.2-36.4) 8,654 20.1 (18.4-22.0) 8,887 8.2 (7.2-9.3)
Individual 3,611 38.7 (35.8-41.6) 0.000 3,551 22.8 (20.4-25.3) 0.004 3,648 9.0 (7.4-10.9) 0.20
Team 5,179 31.7 (29.2-34.2) 5,103 18.6 (16.5-20.8) 5,239 7.7 (6.5-9.0)
Gym, weight training 1,697 49.3 (49.6-53.7) 0.000 1,648 31.5 (27.4-36.0) 0.000 1,720 10.1 (7.9-12.9) 0.001
Track and field, cycling, or swimming 751 28.5 (24.3-33.2) 745 14.7 (11.5-18.7) 755 8.1 (5.2-12.3)
Basketball, volleyball, or handball 1,808 27.9 (24.5-31.5) 1,788 13.9 (11.2-17.1) 1,822 5.6 (4.2-7.6)
Gymnastics or dance 764 30.3 (26.2-34.7) 762 15.8 (12.5-19.9) 771 5.3 (3.4-8.2)
Soccer 3,371 33.6 (30.7-36.6) 3,315 21.0 (18.6-23.6) 3,417 8.7 (7.2-10.5)
Fighting, martial arts, or capoeira 399 33.9 (25.3-43.6) 396 19.3 (14.1-26.0) 402 14.2 (9.7-20.3)
Frequency of practice (in last month)
1 to 5 days 4,006 31.8 (29.2-34.6) 0.006 3,952 16.8 (14.8-19.0) 0.000 4,048 7.5 (6.1-9.3) 0.365
6 to 19 days 2,218 37.2 (33.2-41.3) 2,188 22.9 (19.3-26.8) 2,236 8.8 (6.9-11.2)
20 or more days 2,363 37.2 (34.2-40.4) 2,312 24.4 (21.8-27.2) 2,395 8.9 (7.5-10.6)
Motivation for practice
For fun 3,533 31.9 (29.3-34.8) 0.000 3,477 18.7 (16.5-21.2) 0.000 3,566 8.6 (7.2-10.2) 0.598
To stay fit or for health reasons 2,347 40.6 (37.1-44.1) 2,307 24.7 (22.0-27.6) 2,380 9.0 (7.2-11.2)
Professional 299 27.8 (21.0-35.9) 295 14.4 (9.8-20.5) 305 10.7 (6.8-16.5)

95%CI = 95% confidence interval; wgt% = weighted proportions.

*Chi-square test.

A series of analyses were performed to determine whether the practitioners of each sport differed in relation to alcohol and tobacco use when categorized according to practice frequencies or motivations. However, no statistically significant differences were observed (results not shown).

Logistic regression models adjusted for socioeconomic variables confirmed that gym or weight training and soccer were more associated with alcohol consumption, including HED, within the past month, when compared with no sports participation (Figures 1 and 2). Furthermore, tobacco use was more associated with fighting, martial arts, or capoeira practice than with no sports practice (Figure 3). Although there was no statistical significance, the following sports types had the lowest association with alcohol and tobacco use compared with no sports participation: track and field, cycling or swimming; basketball, volleyball, or handball; and dance or gymnastics.

Figure 1 Crude and adjusteda odds ratios for alcohol use in the last month for each sport type (n=13,872). 95%CI = confidence interval. Not a participant of sports as reference (n=4,948). a aOR = adjusted by age, gender and school type. 

Figure 2 Crude and adjusteda odds ratios for heavy episodic drinking in the last month for each sport type (n=13,872). 95%CI = confidence interval. Not a participant of sports as reference (n=4,948). a aOR = adjusted by age, gender and school type. 

Figure 3 Crude and adjusteda odds ratios for tobacco use in the last month for each sport type (n=13,872). 95%CI = confidence interval. Not a participant of sports as reference (n=4,948). a aOR = adjusted by age, gender and school type. 

Interaction terms were also tested for gender and sports practices. The analyses showed interaction effects only for sports and gender for HED (F6,484 = 2.97, p > 0.01) and tobacco use (F6,484 = 2.88, p > 0.01). When observing the logistic regression models, only the interaction of track and field, cycling, or swimming with gender was statistically significant for HED (adjusted odds ratio [aOR]: 2.65, 95%CI 1.46-4.80) and tobacco use (aOR: 2.90, 95%CI 1.10-7.65). However, these sports were not statistically associated with the outcomes of the logistic regressions presented in Figures 2 and 3. Therefore, we assumed those regression models were reliable.

Discussion

The present study investigated the relationship between sports practice and alcohol and tobacco use in the last month among students from public and private secondary schools in the 27 Brazilian capitals. Sports practice was associated with alcohol consumption, including HED; however, the same finding was not observed for tobacco use. Gym/weight training and soccer were associated with both alcohol use patterns that were studied, while fighting, martial arts, or capoeira practice was related to tobacco use. More frequent sports practice was more closely associated with alcohol use within the month. Professional sports practice was less related to alcohol consumption.

There was a greater association between private school attendance and alcohol consumption in our sample. This result corroborates the findings of another study that examined the influence of socioeconomic factors on alcohol use patterns, and found that HED was more prevalent among Brazilian students from higher social classes.25

Sports practitioners have been described as a group with a higher rate of alcohol consumption than nonpractitioners.9,26 Our study reinforces these findings, and suggests that sports practice is not always associated with healthy behaviors. Thus, preventive measures should bear in mind that the practice of certain sports, such as soccer and gym/weight training, for example, might be associated with health risk behaviors (such as HED) in Brazil.

Our findings concerning the association between alcohol consumption (including HED) and individual sports differs from those of other studies that have demonstrated a relationship between alcohol consumption patterns and team sports practitioners.26,27 It is noteworthy that even individual sports are associated with social contact, which may favor interactions that involve the consumption of alcoholic beverages. Moreover, our results may reflect a peculiarity of the sample in terms of the high prevalence of alcohol consumption among individuals who go to a gym or weight train. Gym and weight training was one of the most popular sports among our participants; consequently, it influenced the overall comparison of team and individual sports participants.

Gym or weight training was associated with increased alcohol consumption. The prevalence of alcohol consumption observed in this group was particularly high. Approximately one-half of the students practicing gym/weight training reported having consumed alcohol in the past month, and nearly one-third reported HED. This finding is even more relevant given that the sale, supply, or delivery of alcoholic beverages to individuals under 18 years old, which is the population included in the present study, is prohibited in Brazil and that the law demands the arrest of offenders. Our findings reflect a serious social and legal problem, because, although the prohibition of alcohol sales to minors has been in effect since 1990, it has failed to be effective, possibly due to a lack of population awareness about the consequences of consuming alcohol at this age and to deficient enforcement of the law.

Substance use by adolescents is associated with a number of academic and health problems, and our data suggest that special attention should be given to this population. Our data also reinforce the idea that some sport practitioners do not believe that occasional alcohol intoxication hinders their sports activity.19

Currently, gym practice in Brazil is strongly associated with socialization and a sense of group belonging.28 Understanding values, beliefs, and motivations is critical to developing effective policies regarding drug use in sports29 and improving our understanding of the relationship between sports and substance use; however, because of the quantitative methodology applied in the present study, we were unable gain a deeper understanding of this relationship. Thus, future studies are needed to examine the beliefs and values associated with gym training and to develop risk-reduction programs within this context.

Soccer playing was also related to alcohol consumption when compared with no participation in sports. Both soccer and alcohol consumption are widely disseminated in Brazilian culture. Among secondary school students, soccer is one of the most popular sports in physical education classes30 and alcohol is the most abused drug.2 Perhaps this result reflects a strong cultural association between these variables, which affects both alcohol consumption and soccer playing among adolescents. The cultural influence on the relationship between sports and substance use has been highlighted elsewhere.15,29 In contrast, the possible socialization induced by sports practice seems to also mediate drug use.13 Particularly among college soccer players, drinking for social reasons has been highlighted as one of the most reported motivations for alcohol use.31

In our sample, fighting, martial arts, or capoeira practice was associated more strongly with tobacco use compared with nonparticipation in sports activities. Sports practice has been previously identified as a predictor of tobacco use10 and one previous study associated bodybuilding and fighting sports to daily smoking.32 Tobacco use can decrease aerobic capacity and impair performance; however, practitioners of fighting, martial arts, or capoeira may not associate tobacco-related impairments with their sport. Adolescents have a lower perception of the risk that certain activities, such as tobacco use, may pose to their health.33 Moreover, tobacco use may be a characteristic of normative standards normative standards regarding drug use among the fight practitioners in our sample. For example, the approval of tobacco use among individuals in the group can influence the behavior of the other members. However, it is still not clear whether fighting sports are more related to smoking because players perceive this practice as less likely to impair performance or due to peer influence.32

High-level sports participation is not always associated with less substance use,34 and our study reinforces this assumption. We observed that individuals who practiced sports activities more frequently within the previous month (6 days or more) consumed more alcohol. However, when the type of sport was analyzed separately, no statistically significant differences were observed. It is possible that more frequent sports participation gives adolescents more time without adult supervision, thus facilitating substance use.13 Moreover, engagement in sport can be stressful for participants at different levels of practice.35 Consequently, substance use may be a strategy to relieve symptoms of anxiety or even training-related fatigue,36,37 and alcohol use in particular has been described as a coping mechanism.35

Professional sports practice was less associated with alcohol consumption. Currently, adolescents have a large number of sources of information about the risks of substance use through the media, family, or school. Once substance use is recognized as unhealthy, some groups of adolescents can avoid consumption. For example, professional sports players may avoid alcohol and tobacco use because they know that use of these substances may decrease their performance and negatively affect them during competitions or training. In addition, coaches can encourage athletes to avoid substance use,20 either by repressing such behavior or by creating expectations that the athlete wants to meet.

Adolescents are more susceptible than adults are to peer influences, including risk behaviors for the use of new drugs.38Adolescents tend to act like their peers to promote their acceptance and to feel more integrated into the group, even if such behavior can cause them harm. For example, alcohol use among students is associated with an increased number of friendships.39 Additionally, among sports practitioners, substance use may be encouraged as a way to intensify ties among group members.19 Consequently, the need for socialization may favor alcohol and tobacco use.

The nature of the sport itself can attract people who already engage in high-risk behavior or can create an environment where such behavior is normative.20 Individuals who are similar tend to form groups with greater cohesion, and being recognized as a member seems to increase the sense of identification with the group.40Thus, this relationship appears to be bidirectional, because individuals tend to be grouped by their common characteristics and perceive themselves as being more similar when they feel like part of a group. Adolescents may choose a particular sports activity because they share a number of similar characteristics or styles with other players, even in terms of substance use preferences and patterns.

Regarding limitations of the present study, although different strategies have been used, biases inherent to self-reporting may have occurred. Furthermore, adolescents who were not attending regular classes during the study period were not evaluated. The results of the present study show no causal relationship between sports and substance use.

Some sports were associated with a motivation to stay fit or were practiced for health reasons; thus, their evaluation was limited. Moreover, only the participants' primary sport was analyzed, which did not take into consideration individuals who practice multiple sports. The generalization of the results to other countries with different cultures may not be valid, as both substance use and sports participation are related to culture.

Sports practice is commonly associated with healthy behaviors; however, the present study showed that this relationship is not always true regarding alcohol and tobacco use. Certain practices have been associated with the use of these substances. Thus, sports activities should not be viewed as exclusively associated with healthy behaviors.

Certain types of sports can attract adolescents with similar characteristics, which may favor substance use. Thus, it is essential to observe the context in which the sports are played and the characteristics of the group being studied.

Gyms and venues for playing soccer are widely available in Brazil, and our results suggest the importance of preventive measures related to alcohol consumption in these environments. The wide availability of places to practice facilitates the adolescents' access to these activities, which, in turn, increases the number of individuals involved in these sports. Similarly, the association between tobacco use and fighting, martial arts, or capoeira practice suggests that prevention campaigns should focus on these groups of athletes. Teachers may also be encouraged to discuss substance use with their students, especially regarding the context in which sports are played and particular group characteristics.

Acknowledgements

The authors thank the Brazilian Center for Information on Psychotropic Drugs (CEBRID) and the Brazilian National Secretariat on Drugs Policies (SENAD) for authorizing the database analyses and Associação Fundo de Incentivo è Pesquisa (AFIP) for providing institutional infrastructure.

AB is the recipient of a scholarship from Fundação de Amparo è Pesquisa do Estado de São Paulo (FAPESP). ARN is the recipient of a research productivity grant from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

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Received: February 16, 2014; Accepted: July 7, 2014

Correspondence: Ana Regina Noto, Universidade Federal de São Paulo, Departamento de Psicobiologia, Rua Botucatu, 862, 1° andar, Ed. Ciências Médicas, CEP 04023-062, São Paulo, SP, Brazil. E-mail:arnpsicobio@gmail.com

Disclosure The authors report no conflicts of interest.

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