spirituality and rEligion as protEctors for adolEscEnt drug usE

Objetivo: o estudo teve como objetivo identificar as evidências disponíveis na literatura sobre a importância da religião/espiritualidade como protetores ao uso de drogas. Material e métodos: trata-se de uma revisão integrativa da literatura. Utilizaram-se como descritores: “espiritualidade”, “religião”, “adolescente”, drogas ilícitas”, “alcoolismo” AND “tabagismo”. As bases de dados foram: LILACS, PubMed e CINAHL. Resultados: constatou-se efeito protetor da religiosidade e espiritualidade na prevenção ao uso de drogas, sendo justificado pela menor interação dos adolescentes com os pares desviantes, atitudes conservadora dos amigos e níveis elevados de bem-estar. Conclusões: trazer à luz o efeito positivo da religiosidade e da espiritualidade poderá contribuir para que os profissionais envolvidos com os adolescentes lancem intervenções com vistas a reduzir o consumo de drogas nesse grupo.


Introduction
Adolescence is one of the most important periods of human development, but this is a time when the subject is vulnerable to hazards, both in the biological context as well as the psychological and social (1) .Experimentation and the consumption of psychoactive substances can occur during this period, which is increasingly taking place at an early age (2) .Felipe AOB, Carvalho AMP, Andrade CUB.
The consumption of psychoactive substances is considered a serious problem for public health, and brings great harm to the growth and development of these adolescents (3)(4) .There are several factors that lead to the genesis of this problem such as genetic vulnerability, family problems, depression, low self-esteem, lack of life perspective, pursuit of pleasure, curiosity and the influence of friends (5) .
To promote resilience and healthy adolescent development, there is evidence in the scientific literature of the importance of adolescents being involved in religious and spiritual practices (6) .
In this scenario, the objective here was to identify in the literature the importance of religion/spirituality in the adolescent's life, as a protective factor for preventing the use of legal and illegal drugs.
This study is of great scientific and social relevance, due to the increasing number of adolescents who are consuming drugs, with negative consequences to themselves, family and society.The study should help to elucidate the mechanisms that religion and spirituality use to help prevent drug use among adolescents.Therefore, it may be a theoretical reference for health and education professionals about the need for social programs that strengthen religious and spiritual practices.

Methodology
The theoretical and methodological framework used in this study was Evidence-Based Practice.Thus, we used the method of integrative review to establish a methodological approach.To guide this integrative review, the following question was formulated: is religion/spirituality in the adolescent's life is a protective factor to prevent the use of licit and illicit drugs among adolescents?
To survey articles in the literature a search of the following online databases was carried out: Literature in the Health Sciences in Latin America and the Caribbean (LILACS), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed.As search strategies, controlled descriptors were used, namely: "spirituality," "religion," "adolescent," "illicit drugs," "legal drugs," "alcoholism" and "smoking." The inclusion criteria for the articles were: written in Portuguese, English or Spanish, available in full text, produced between 2003 and 2013, referenced religiosity/spirituality in adolescents, and the age of the subjects was between 10 and 19 years in the study, in the same longitudinal studies.As stated above, we selected articles in which the subjects were adolescents, ages 10 to 19 years.
Exclusion criteria were: theses and dissertations, literature review articles, articles that did not address the proposed theme and that did not determine the chronological age of the subjects.
Initially, we identified 3,793 articles in the selected databases.Of these, 70 articles were pre-selected for inclusion in the study.Later, there was a close reading of the articles and studies that did not respond to the guiding question, had exclusion criteria, or were repeated in the database were all excluded, totaling 58 items.
The main grounds for exclusion of the articles analyzed were age, 24 (41.4%) of the articles addressed subjects over the age of 19 years and 10 (17.2%) of the articles did not include the age of the subjects in the study, only the school period of the adolescents (Table 1).
After implementing the inclusion and exclusion criteria, twelve articles were selected.After this analysis was performed the evaluation of studies included in the integrative review, using the instrument that was developed and validated in Brazil (7) .

Results
The literary corpus consisted of twelve articles which met the inclusion criteria, in which 8.3% were from LILACS, 58.3% PubMed and 33.4% CINAHL.
It was found that only one (8.4%) of the articles was of national context and 96.6% international.Regarding the language of the dissemination of studies, 11 (96.6%) were published in English and only one (8.4%) in Portuguese.
For the year of publication, study prevalence was found in 2012 and 2010 with three (25%) studies, respectively, followed by the year 2011 with two (16.6%)studies and in the years 2009,  2007, 2006 and 2005 there was only one (8.4%)publication.
It was found that the articles were published in various journals, and only two (16.6%)articles published in the same journal, Health Education & Behavior (Figure 1).
As for the impact factor, it was observed that three (25%) articles were published in journals with impact factor greater than 2, and four (33.3%) articles were published in journals with impact factor less than 1 (Figure 1).
Regarding the design of the research, it was found that 12 (100%) were descriptive in nature and used the quantitative approach, in the epidemiological aspect only three studies (25%) were longitudinal.The main location of the research was at the residences of the subjects, seven articles (58.3), and at the schools, four (33.3%) of the analyzed articles.
When looking at the instruments used to evaluate the use of legal and illegal drugs and religiosity/spirituality in adolescents, it was found that all of the studies used different instruments.
Concerning religion and spirituality, the studies measured the internal and external religiosity, according to the questions described in Table 2.It was observed in the articles that the most used question was: what is the importance of religious belief for the teenager?Found in five (41.6%) articles.In all of the studies the answers were graded according to the Likert scale except the question on adolescent religious affiliation.

Title Journal / Impact factor Year
Religiosity and adolescent substance use: evidence from the National survey on drug use and health (8) Substance Use & Misuse -1.109 2012 Religiosity and adolescent substance use in central Mexico: exploring the influence of internal and external religiosity on cigarette and alcohol use (9) Am J Community Psychol.-1.978 2012 Religiosity, Heavy Alcohol Use, and Vicarious Learning Networks Among Adolescents in the United States (10) Health Education & Behavior -1.682 2012 Social norms and the relationship between cigarette use and religiosity among adolescents in the United States (11) Health Education & Behavior -1.682 2011 Religiosity, alcohol use attitudes, and alcohol use in a national sample of adolescents (12) Psychology of Addictive Behaviors -2.321 2011 Positive family relationships and religious affiliation as mediators between negative environment and illicit drug symptoms in American Indian adolescents (13) Addictive Behaviors -2.021 2010 Parental Monitoring, Religious Involvement and Drug Use Among Latino and Non-Latino Youth in the Southwestern United States (14) British Journal of Social Work -0.995 2010 Spirituality within the family and the prevention of health risk behavior among adolescents in Bangkok, Thailand (15) Social Science & Medicine -2.733 2010 Religiosidade, consumo de bebidas alcoólicas e tabagismo em adolescentes (16) Rev Panam Salud Publica -0.85 2009 Alcohol use and religiousness/spirituality among adolescents (17) Southern Medical Journal -0.915 2007 A Longitudinal Study of Coping Strategies and Substance Use in Adolescent Boys (18) J. of Child & Adolescent Substance Abuse -0.618 2006 God Forbid!Substance use among religious and nonreligious youth (19) Am J Orthopsychiatry -1.6 2005  Was the teenager practicing or non-religious.

(8.4)
* There were more questions from the analyzed articles.
It is noteworthy that in three of papers analyzed, the questions about the religiosity and spirituality were different from the questions described in Table 2.The first study aimed to assess the use of religion for coping in male teenagers, so these subjects answered the following questions: when you have a problem, do you pray?, when you have a problem, do you experience the love and care of God?, when you have a problem, do you believe that it is a lesson from God?, when you have a problem, do you take control over what you can do and the rest you surrender to God? and when you have a problem, do you accept that the situation is not in your hands, but in God's hands?
The second article's purpose was to evaluate adolescent belief and spiritual practice with their parents within Buddhist principles.Subjects were asked to answer the first question described in Table 2 and were later questioned: do you believe that religious prayer or meditation can help?, do you believe in karma and reincarnation?And as for spiritual practices these questions included: do you perform prayer or meditation regularly?, and were also asked, when life was stressful, do they performed the practice of giving or offering food to the monks and observe the same five principles (abstaining from killing, stealing, sexual misconduct, lying and using psychoactive substances).
The last article used two scales to assess religiosity and spirituality, the Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS) and Spiritual Connectedness Scale, both use Likert responses.
As for the instruments used to evaluate the use of licit and illicit substance, 6 (50%) of the articles used questions with dichotomous answers, not citing their references.It was found that 4 of the articles used these instruments: the Drug Use Screening Inventory (DUSI), The National Institute of Mental Health's Diagnostic Interview Illicit Drugs Schedule (DIS), Global School-based Student Health Survey (WHO), and the 90-day Timeline Follow-back Calendar (TLFB).It was observed that these instruments were not repeated in other articles.
It is highlighted that 5 (41.6%) articles concurrently analyzed tobacco use, alcohol intake and illicit drug use, 2 (16.6%) articles studied the use of tobacco and intake of alcohol, 2 (16.6%) articles only investigated the ingestion of alcohol, 1 (8.4%) article noted the use of alcohol and marijuana, 1 (8.4%) article only observed the use of illicit drugs, and 1 (8.4%) evaluated the use of tobacco.
Concerning the relationship between gender and adolescent drug use, six (50%) articles investigated this and, of those, only one noted that there was no gender difference in relation to drug use.Other studies showed that the proportion of subjects exposed to alcohol consumption, tobacco and marijuana is higher among boys than among girls.Added to this fact, males begin to use legal and illegal drugs earlier compared to females.It is pertinent to mention that females are more likely to use non-prescription drugs.
There is consensus among the analyzed studies on the protective effect and moderation of religiosity and spirituality to prevent the use

Protective and moderation effects of religiosity and spirituality Factors contributing to the protective properties of religiosity and spirituality
Religiosity was significantly associated with lower chances of heavy drinking (10) Involvement of teenagers who share the same beliefs and ideals (8,18) Lower chance of exposure to alcohol consumption and smoking (16) Provide support, promote efficiency and provide extended outlook on life (18) Negative association with smoking (8,11,15,19) , with illicit drug use (8,15,19) and nonprescription medicine (8) Conservative attitudes toward substance use (8,12) Lower consumption of alcoholic beverages (8-9, 13, 15,18-19) Religious beliefs influence the decisions in your life (12) Adhere to the rules laid down by the authorities (18) High levels of psychological well-being (8) Shapes the adolescent's social relationships (10)(11) Reduces association with deviant peers (13) Promotes respect for the body and mind (18) Figure 2 -Description of the protective and moderation effect of religiosity and spirituality, and the factors that contribute to these properties, extracted from the analyzed articles.
of alcohol, tobacco and illicit drugs, and that this effect occurs regardless of the religious affiliation that adolescent participates.The following diagram (Figure 3) describes the relationship of religion and spirituality in the prevention of substance use.
Figure 3 -The religiosity and spirituality ratio in the prevention of substance use in adolescents

Discussion
It was observed that, from the year 2005, scholars are taking interest in research that outlines the preventive strategies regarding the use of psychoactive substances, and a psychosocial approach to religion and spirituality (20) In the years 2010, 2011 and 2012 there was more than one annual publication.
Due to the significant impact of psychoactive substance use among adolescents, it is necessary to investigate the consumption of drugs in this population, enabling the planning of public policies and prevention programs (20)(21) .Concerning religion and spirituality, it is no different, since there is a very broad field of research, it requires studies that allow us to understand the mechanism of religious and spiritual action in the prevention of drug use (22) .
As for the impact factor, it was observed that 33.3% of the articles were published in journals with impact factor of less than one.It is necessary for researchers to publish their results in national and international journals with high impact factor (23) .
It was found that most of these were crosssectional studies, therefore the causal relationships between religion and drug use cannot be determined.Within this kind of study data can be collected only during a moment in the life of the subject (24) .This aspect has been flagged as one of the limitations in five of the items that made up the present study (8)(9)13,(15)(16) .
The residence and the school were the main research locations.The completion of the study in school facilitates the data collection process, but has the disadvantage of excluding adolescents who are outside the school environment, and school dropout is related to factors such as alcohol consumption and drug use (25)(26)(27) .
The consumption of licit and illicit drugs is more prevalent among males, associated with this fact is that males starts to use these substances early.Regarding the initial consumption of licit and illicit drugs, it was found that the average age of adolescents to consume tobacco and alcohol is 11.5 years and that this contact usually occurs in the presence of family and friends; for drug use it was found, on average that adolescents start at age 12, confirming the fact that the onset of drug use is currently very early (21,28) .
In studies conducted at the national level there is a divergent situation in relation to gender and drug use.In Pernambuco, a study of adolescents showed that boys are exposed to alcohol, tobacco and drugs significantly higher than females (29) .However, a study conducted in São Paulo found that there was no significant difference between the consumption of licit and illicit drugs between the genders (30) .
Corroborating other studies, we found that the non-medical use of drugs was prevalent in female adolescents, who have the habit of consuming tranquilizers and amphetamines.Educational activities conducted among adolescents to prevent the use of these drugs should therefore include this issue in the health promotion agenda in the school context (31) .
It should be noted the studies that comprised this article used different forms of questions about the religiosity and spirituality.This finding is described in another study to point out that there are many variables related to religion; it becomes difficult to compare the studies and even identify the dimensions of the religious experience as it is significant for the alteration of psychoactive substance use (24) .Also it should be mentioned, that most of the analyzed studies assessed the religiosity of adolescents and drug use.It will also be required to investigate dimensions of spirituality in adolescent life.
Note that there are differences between the constructs of religion, religiosity and spirituality.Religion is an organized system of beliefs, rituals and symbols that facilitates access to the sacred, religiosity refers to how the individual believes and follows a religion, and spirituality refers to the personal quest for understanding, related to existential questions and its relations with the sacred (32) .
Studies have shown a protective and moderation effect of religiosity and the abuse of alcohol, tobacco and illicit drugs among adolescents.What does not differ from other studies found was that religiosity and religious participation of adolescents are associated with healthier and less risky behaviors such as drug use (33)(34) .
Another fact worth mentioning is the religious affiliation of the subjects involved in the study, given that there were different types of religious affiliation.However, it was observed that the important thing was the teenager being affiliated with any religion, because the benefit in preventing the use and abuse of substances was positive among those involved with a religion, no matter what.
In a study developed in Panama it was found that, compared to young Catholics, those affiliated with other religions were less likely to get involved with drugs.But young people who reported not be affiliated with any religion had two to three times more likely to become involved with marijuana in relation to young Catholics (35) .Some issues are relevant to the success of the relationship between religiosity/spirituality and the prevention of drug use.It is necessary for the teenager, to participate in religious activities, perceive religion as important, and believe in God's forgiveness.
In another study, conducted with parents and teens about religion, it showed that subjects who perceived their religion as important and were active in religious activities and worship were less likely to engage in risky behaviors, including the use of tobacco, alcohol and marijuana (36) .
Similar data was also found in another state, which emphasizes that the frequent participation in religious services provides more consistent protection from drug use (37) ; which differs from a study in the Brazilian context, which found that students who considered themselves more religious showed less use of alcohol and drugs than those who participated in worship and church services (24) .
Evidence suggests that there are several factors that contribute to the protective effect of religiosity from drug use; the ones that are highlighted are the social relationships and less teenager association with deviant peers.Due to the sharp conflict during this period, the adolescent seeks to fit into a group, which will influence their actions and they will try to adopt the attitudes of their peers, this will be the proof of acceptance (38) .
Belonging to a group causes teens to change their behavior according to the lifestyle of this group, so if the members of this group are consumers of psychoactive substances, the adolescent is more likely to use and abuse these substances (5) .
In this context, it is observed that the internal and external religiosity reduces these risky behaviors, as it provides moral guidance to the young as well as strong social networks (33,39) .Religion is a phenomenon that is connected to a system of values, rules and appropriate interpersonal behavior (34) .This is consistent with the data from this study, since it found that religiousness provides adolescents with conservative attitudes toward drug use and better adherence to established rules.
It is worth mentioning that a study conducted in order to determine the effect of religiosity on genetic measure for alcohol consumption in adolescents and young adults, found that moderate religiosity had an effect on genetic problematic alcohol consumption in adolescence, but not in early adulthood.This fact is a consequence of religion, by providing young people with greater social control (40) .
Religiosity is indirectly related to substance use, being mediated through the self-control of adolescent and by the rejection of deviant attitudes (41) .It is believed that religiosity promotes these youths to adopt the personality type that inhibits the use of these substances (39) .
It is clear, as well, that religiousness raises these adolescents to high levels of well-being, self-efficacy, and self-respect of the body and mind.There is another study that found that adolescents with higher levels of spiritual well-being had fewer depressive symptoms and fewer risky behaviors (6) .
The presence of a higher level of religious beliefs and practices in adolescents allows for better impulse control and greater well-being, which contributes to improved mental health stability and healthier coping in stressful situations (42) .
Despite the fact that this is not this study's focus, it is prudent to mention that the literature found that the religiosity of parents and parenting practices also helped in the prevention of drug use.Research conducted in Brazil found that the biggest difference between teenagers that were users and non-users of psychotropic drugs were their religiosity and their family (22) .
Therefore, parents must accompany the child, meet their friends, set limits and encourage them to participate in religious activities (43) .The parental support was highlighted as a protective factor for adolescents, similar to religious support.The importance of family is no doubt important in drug prevention, as is the family responsible for the transmission of values, as well as monitoring and imposing limits on the teenager (44) .

Conclusion
Bringing to light the positive effects of religion and spirituality can help professionals involved with teens launch interventions aimed at reducing the consumption of drugs within this group; as there is consensus among researchers of the protective and moderation effect of religion and the use and abuse of legal and illegal drugs among adolescents.In this respect it is relevant to establish that this process occurs through the behavior of adolescents when coping with the teenage situations.
It should be noted, also, the need to invest in Brazilian research with longitudinal studies that focus on religion and spirituality as preventive and interventional actions in this field.

Figure 1 -
Figure 1 -Articles published in databases during the period 2003-2013, and some of their main features.Ribeirão Preto, SP, Brazil, 2013

Table 1 -
Main causes for exclusion of articles in the databases.Ribeirão Preto, SP, Brazil,

Table 2 -
Questions relating to religion/spirituality of the subjects in the articles analyzed How many times have you attended religious services at your church? 4 (33.3)What is your religion?3 (25.0)Have you participated in prayer group, youth group or other? 2 (16.6)How important is it that your friends share your religious beliefs? 2 (16.6)How is the teenager involved in your religion? 1 (8.4)