ABSTRACT

Background: Khat (an evergreen plant with amphetamine-like properties) and alcohol are widely consumed among the youth of Ethiopia. The chewing of khat has been practiced for years and is, to a large extent, socially accepted in Ethiopia, Kenya, Madagascar and Somalia, Yemen; some of these countries are introducing control measures to discourage the cultivation and use of khat. Apart from the habitual use of khat, it is reported that it is used by students to improve their academic performance, by truck drivers to keep themselves awake and by laborers to supply the extra vigor and energy they need for their work. Objective: To assess the prevalence and risk factors of khat chewing among in school and out of school youth (15-24 years of age) in Gondar town. Methods: A cross-sectional study was conducted in February 2007 in Gondar town, north west Ethiopia. In-school and out of school youth were selected from randomly selected high schools and house holds systematically. Self administered questionnaire was used for school youth and interview for out of school youth. Results: The study revealed 37.1% life time prevalence rate of khat chewing, 14.6% of cigarette smoking, and 47% of alcohol drinking. The current prevalence rates of chewing, smoking and drinking were 31.4%, 11.9%, and 36.6% respectively. One hundred fifty three (13.1%) use khat and cigarette, 314(26.9%) khat and alcohol. Of the respondents, 155(13.3%) have ever used khat, cigarette, and alcohol. Conclusion: The prevalence of khat chewing is increasing and along with it other substances such as cigarette smoking and alcohol drinking are being used. More over, illicit substances including shisha and hashish are also being taken. The problem is especially worrisome among out of school youth who have no job or who are daily laborers. This summons that attention is to be given to educate the youth and find means of controlling substance use at least in public entertainment places.

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BACKGROUND
Khat (Catha edulis)--also known as African salad, bushman's tea, gat, kat, miraa, qat, chat, tohai, and tschat--is a flowering shrub native to northeast Africa and the Arabian Peninsula. The plant grows mainly in Ethiopia, Yemen and other African countries along the cost of the Indian Ocean. It has been used for centuries as a mild stimulant. For most youths chewing khat is a method of increasing energy and elevating mood in order to improve work performance. Khat plants typically are grown among crops such as coffee, legumes, peaches, or papayas. Fresh khat leaves contain cathinone--a Schedule I drug under the Controlled Substances Act; however, the leaves typically begin to deteriorate after 48 hours, causing the chemical composition of the plant to break down. Once this occurs, the leaves contain cathine, a Schedule IV drug (1-4). Schedule I. This placement is based upon the substance's medical use, potential for abuse, and safety or dependence liability (30) • The drug or other substance has a high potential for abuse. • The drug or other substance has no currently accepted medical use in treatment. • There is a lack of accepted safety for use of the drug or other substance under medical supervision. • Examples of Schedule I substances include Amphetamine, Khat(cathinone),Cocaine, heroin, lysergic acid diethylamide (LSD), marijuana, and methaqualone. Schedule II • The drug or other substance has a high potential for abuse. • The drug or other substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions. • Abuse of the drug or other substance may lead to severe psychological or physical dependence. • Examples of Schedule II substances include morphine, phencyclidine (PCP), cocaine, methadone, and methamphetamine. Schedule III • The drug or other substance has less potential for abuse than the drugs or other substances in schedules I and II.

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• The drug or other substance has a currently accepted medical use in treatment. • Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence. • Anabolic steroids, codeine and hydrocodone with aspirin or Tylenol, and some barbiturates are examples of Schedule III substances. Schedule IV • The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule III. • The drug or other substance has a currently accepted medical use in treatment. • Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule III. • Examples of drugs included in schedule IV are Darvon, Talwin, Equanil, Valium, Xanax, and Cathine Schedule V • The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule IV. • The drug or other substance has a currently accepted medical use in treatment. • Abuse of the drug or other substances may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule IV. • Cough medicines with codeine are examples of Schedule V drugs. The chewing of khat has been practised for years and is, to a large extent, socially accepted in Ethiopia, Kenya, Madagascar and Somalia; some of these countries are introducing control measures to discourage the cultivation and use of khat. Apart from the habitual use of khat, it is reported that it is used by students to improve their academic performance, by truck drivers to keep themselves awake and by labourers to supply the extra vigour and energy they need for their work (3). The psych-stimulant effect of khat is due to the alkaloid ingridient cathinone, which has a similar structure to Amphetamine (1). Khat is consumed primarily for its amphetamine-like stimulant and euphoric effects (1-7,21,23,24,28).

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The use of substances such as alcohol, khat and tobacco is not new in Ethiopia. Home-brewed spirits and beers such as arrack, tej and tella are served in bars and restaurants throughout the country. Until recently the highland population had been relatively free of the habit of chewing khat; the use of khat had been confined to other population groups and to specific rituals. Today, however, it is consumed everywhere in the country by all population groups. In smaller cities and towns it is brought to market as produce. People publicly chew it and it is offered to visitors as a mark of hospitality (4). Several case reports and population studies have shown that there is a clear association between heavy consumption of khat and psychosis. It may produce extreme loquacity, inane laughing, and eventually semicoma. It may also be a euphorient and used chronically can lead to a form of delirium tremens. Galkin and Mironychev (1964) reported that up to 80% of the adult population of Yemen use khat. Upon first chewing khat, the initial effects were unpleasant and included dizziness, lassitude, tachycardia, and sometimes epigastric pain. Gradually more pleasant feelings replaced these inaugural symptoms. The subjects had feelings of bliss, clarity of thought, and became euphoric and overly energetic. Sometimes khat produced depression, sleepiness, and then deep sleep. The chronic user tended to be euphoric continually. In rare cases the subjects became aggressive and overexcited. (1 - 6, 22). In some business circles khat is chewed at meetings where major decisions are reached. It is also a highly valued export commodity, being marketed extensively in countries in the Horn of Africa and in the Middle Fast. Paradoxically, as the production, marketing and export of khat become more lucrative, khat use seems to gain social respectability and it becomes more difficult for Governments to deal with the problem(4). The use of khat is accepted within the Somali, Ethiopian, and Yemeni cultures, and in the United States khat use is most prevalent among immigrants from those countries. Abuse levels are highest in cities with sizable populations of immigrants from Somalia, Ethiopia, and Yemen, including Boston, Columbus, Dallas, Detroit, Kansas City, Los Angeles, Minneapolis, Nashville, New York, and Washington, D.C. In addition, there is evidence to suggest that some nonimmigrant in these areas have begun abusing the drug (27). Khat (Catha edulis) is an evergreen plant that grows mainly in Ethiopia, Yemen and other African countries along the coast of the Indian Ocean. It has been used for centuries as a mild

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stimulant. The fresh leaves are chewed or consumed as tea. For most youths chewing Khat is a method of increasing energy and elevating mood in order to improve work performance (1-4, 7-8, 27-28). The psycho-stimulant effect of Khat is due to the alkaloid ingredient cathinone, which has a similar chemical structure to amphetamine (1, 7). Several case reports and population studies have shown that there is a clear association between heavy consumption of khat and psychosis (1-2, 15). There are no physical symptoms on withdrawal of the type experienced with alcohol, morphine, or the barbiturates. Abandoning the habit, however, is followed by depression. This is demonstrated by lack of interest, loss of energy, and increased desire to sleep. The severity of depression varies and may lead to agitation and sometimes sleep disturbances. Khat is widely consumed among the youth of Ethiopia as shown by several prevalence studies (1, 3-5, 26). According to a community based survey conducted on 1200 adults at Adamitulu district, south Ethiopia in 1997 the prevalence rate of khat chewing was 31.7 %( 7). A study conducted on students of Gondar College of medical sciences showed a 22.3% prevalence rate (26). A similar study done among students of four colleges( Gondar college of medical sciences, Gondar teachers` education college, Bahrdar university engineering faculty, and Bahrdar university education faculty revealed a life time prevalence rate of khat chewing to be 26.7%(5). According to a study in Addis Ababa and other 24 towns across the country, there was a significant increase in the number of Ethiopians chewing khat. khat which was previously known to grow mainly in the eastern part of Ethiopia, was cultivated in all parts of the country. Khat consumption, traditionally confined to a certain segment of the population had become popular among all segments and khat chewing often led to abuse of illicit drugs (4). A nation wide survey carried out among 20,234in school and and out of school youth aged between 15 and 24 years showed that over 23% of out of school youth used khat every day or once weekly and 7.5% of in school youth did so(1). A cross-sectional house to house survey conducted in Jimma town from January to September 2000 showed a prevalence rate of khat chewing to be 30.6 %(6). Several other studies conducted at different times in African countries including Ethiopia, The Middle East, Europe and the USA have explored extensively the effects of khat on the different

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parts of the body and the physical, social, economical and psychological consequences of khat chewing. It is estimated that several million people are frequent users of khat in regions where it is grown and this number is now increasing fast not only in endemic areas but also globally(2,3,11,12-18,21,23). One of the important targets manifesting the effect of khat chewing is the brain. In its action on the brain, some of the chemical components of khat have resemblance to amphetamine in many aspects (2, 10, 15, 16, 22-25). This effect of khat is manifested by euphoria, increased alertness, garrulousness, hyperactivity, excitement, aggressiveness, anxiety, elevated blood pressure and manic behavior. Insomnia, malaise, dizziness and lack of concentration almost always follow. True psychotic reactions occur but with much less frequency than with amphetamines. Although physical dependence on khat is less likely to occur, mental depression, sedation and social separation may follow withdrawal because of rebound phenomenon. A state of mild depression can follow periods of prolonged use. Taken in excess, khat causes extreme thirst, a sense of exhilaration, talkativeness, hyperactivity, wakefulness, and loss of appetite. Repeated use can cause manic behavior with grandiose delusions, paranoia, and hallucinations. It also can cause damage to the nervous, respiratory, circulatory, and digestive systems. Abusers claim that the drug lifts spirits, sharpens thinking, and increases energy--effects similar to but less intense than those caused by abusing cocaine or methamphetamine. Psychic dependence on khat occurs with less intensity than with amphetamine but this effect makes daily consumption of khat the norm. It should therefore be borne in mind that although khat can provide some pleasurable effects temporarily, its overall effects on the brain are not desirable and could even be damaging, particularly with chronic consumption (1, 3, 10, 12,22-25). Gastro-intestinal side-effects are often encountered with khat use. Constipation is the most common gastrointestinal symptom caused by the tannins and alkaloid components of khat. Stomatitis, esophagitis and gastritis which are believed to be due to the presence of astringent tannins are noted in chronic users. Other reported oral side-effects include periodental diseases, dental caries, temporomandibular joint dysfunction and keratosis of buccal mucosa. Oral cancers have been observed in some groups of population with chronic khat chewing ( 5, 9-11,14,23-25). After ingestion, khat produces cardiovascular effects within 15-30 minutes and these effects

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include tachycardia, palpitation and increased blood pressure. Chronic use of khat has also been implicated in hypertension. This is contrary to what some consumers claim that the use of khat is associated with antihypertensive effect (23,25) Loss of sexual desire is reported frequently by men during khat use. Although libido initially may be enhanced, a loss of sexual drive, spermatorrhea (which is sometimes accompanied by testicular pain) and subsequent impotence soon follow. Inhibition of blood flow to the penis and neurological effects are believed to partly play a role in this impairment. However, the situation is often the opposite in female khat users as far as sexual desire is concerned. With chronic use, khat causes a more severe reproductive toxicity including reduction in sperm count and motility, and the appearance of abnormal sperm cells (8,10,23,25). It has been shown that babies born to women who chew khat habitually are smaller and their mothers produce less milk. This demonstrates that the use of khat by mothers can retard the development of their babies and this may have long-term consequences (23,25). Other physiological effects of khat linked primarily to sympathomimetic stimulation include hyperthermia, sweating, mydriasis, “xerostomia”, decreased intraocular pressure, and increased respiratory and pulse rate. More severe adverse effects have been associated with khat use, particularly in the elderly and predisposed individuals. These effects include migraine, cerebral hemorrhage, myocardial infarction, pulmonary edema, disabling neurological illness, and abnormalities in bone marrow. Hepatic cirrhosis has also been noted in khat users. Poor diets and the potentially hepatotoxic effects of khat tannins have been suggested to be contributing factors for this condition (7, 23, 25). Considering subcellular actions of khat, studies have demonstrated that extract of khat leaves is an inhibitor of nucleic acid synthesis, and one of its components, cathinone, causes clumping and condensation of chromosomes, sticky metaphases and anaphasic bridges. Some of these effects are hypothesized to be responsible for the carcinogenic and teratogenic properties of khat(23,25). In addition to the effects of khat per se, some substances consumed together with it are also known to produce significant adverse effects by themselves. One such substance is tobacco taken as a cigarette smoke for brain stimulation. The consumption of tobacco is associated with a number of serious adverse effects including cardiovascular and respiratory disorders, lung cancers, anorexia and addiction. In this regard, increased prevalence of respiratory

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problems has been reported in khat users smoking cigarettes heavily. The concomitant use of alcohol to counteract the stimulant and insomniac effects of khat raises the risk of alcohol abuse. The abuse of alcohol results in a range of public health and medical problems depending upon the amount and duration of consumption. Recently, it has been observed that people with alcohol-use disorders are more likely than the general population to contract HIV. It is therefore possible that the use of khat can promote this process through alcohol consumption, among other possibilities. It is not also difficult to hypothesize that in persons already infected, the combination of khat use and HIV can be associated with increased medical and psychiatric complications. There are also cases of infection with Fasciola hepatica following chewing khat leaves. Fasciola hepatica contamination might occur most likely with fresh picked, damp leaves (1-5, 10, 11, 14-16). The pleasure stimulation (euphoria) obtained when chewing khat induces many users to abuse the drug. This may have damaging effects from social and economic point of view. Some people may arrive at spending a great part of their earnings on khat, thus failing to ensure for themselves and their families important and vital needs. Excess of khat chewing may lead to family disintegration. The chewer very often shows irritability, becomes quarrelsome, and spends much of the time away from home. These facts and the failure of sexual intercourse (in male users) after chewing may endanger family life. In the communities where khat is consumed, there is a general agreement among observers that there is high incidence of absenteeism and decreased productivity, which lead to unemployment and poverty. In addition, the increased susceptibility and risk to infectious diseases and the threat to normal development of the children of the chronic users can be important public health problems. Added to these problems are the well-recognized negative socioeconomic effects of the substances that are usually consumed with khat—tobacco and alcohol (1, 6, 8, 17-25). In some countries where the use of Khat is widespread, the habit has a deep-rooted social and cultural tradition. This is particularly true for Yemen, Somalia and Ethiopia where many houses have a room called a muffraj, Mafrashi, and Bercha respectively that are specially arranged for regular sessions of Khat chewing. The buyers select from among various types of Khat available, which also vary considerably in price, the most expensive (because the most potent) material being, in general, the freshest and that with the youngest leaves(21,27,31). For the consumption of Khat in the traditional social setting, the chewers meet in a house

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some time after noon, usually bringing their own supply. After being welcomed and carefully seated according to their social position, the guests begin to masticate the leaves thoroughly one by one. The juice is swallowed, while the residue of the leaves is stored in the cheek as a bolus of macerated material for further extraction, and is finally ejected. Altogether, each person takes some 100to 200g of the leaves( 6-9birr/100grams); young leaves are most favored, mainly because they are more potent but also because they are more tender to chew. During the session, the group may smoke from water pipes, and there is a generous supply of beverages. The Khat session also plays an important role at weddings and other family events. Khat is frequently used during work by craftsmen, laborers, and especially by farmers, in order to reduce physical fatigue (31). Besides these traditional forms of consumption, Khat is nowadays also chewed by single individuals idling in the streets, particularly in towns and cities where it has been introduced within the last decades. In these regions, Khat is also consumed (sometimes along with alcoholic beverages and other drugs) at gatherings which lack the restraint and well-defined social setting described above(21,30-31). During the first part of a khat session, there is an atmosphere of cheerfulness characterized by optimism, high spirits, and a general sense of well-being. The excitement brought out by the consumption of khat reduces social inhibitions and causes loquacity. Later, depressive tendencies appear, and a mood of sluggishness prevails. The desirable effects of khat leaves, as perceived by experienced users, are relief from fatigue, increased alertness and energy levels, feelings of elation, improved ability to communicate, enhance imaginative ability and capacity to associate ideas, and heightened self confidence. These effects seem to be more readily perceived by the habitual user. The objectively observable effects of khat use consist of mild euphoria and excitement accompanied by episodes of logorrhea and then verbal aggressiveness. There is also an increased sensitivity to sensory stimulation; excessive khat use may cause hyperesthesia. Hyperactivity may be observed and the associated behavioral syndrome can be described as hypothemania; a manifestation of irresponsible fearlessness has also been reported. In exceptional cases, khat consumption may produce an immediate dysphoric reaction which might, however, be due to excessive expectations with regard to potency of a given batch of khat. The late effects of khat use are mainly an inability to concentrate, and insomnia. Impairment of mental health may also be the result of long-term khat consumption; long-term

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chronic users may develop personality disorders and suffer mental deterioration. The symptoms described above, particularly that of toxic psychosis are reminiscent of those induced by amphetamine. A further analogy with amphetamine is that the habitual use of khat is in many instances compulsive, as indicated by the tendency of the chewers to secure their daily supply of the leaves at the expense of vital needs. Drug dependence of the khat type has been described by Eddy et al., and it appears that its only major difference from amphetaminetype dependence is the physical impossibility of increasing the ingested dose beyond a certain limit. Any definitive investigation of tolerance or withdrawal symptoms would, however, require a thorough clinical study involving monitoring of the blood levels of the active khat constituents. An important effect of khat, the induction of anorexia, was already reported in the early Arab literature. This anorexia, along with the tendency of habitual khat users to divert their funds from food to khat, would account for the generally observed malnutrition which predisposes the users to disease. Consumption of khat, like that of amphetamine, causes a number of sympathomimetic effects. At the cardiovascular level, there are arrhythmias and an increase in blood pressure depending on the amount and potency of the material absorbed. The cardiovascular response to physical effort is exaggerated. Acute cardiovascular problems, particularly in older people, have been reported. Habitual use of khat may lead to chronic hypertension which, upon abstinence from the drug, can change into a transient hypotensive state. A further sympathomimetic reaction to khat use is mydriasis. Khat chewing is known to seriously impair male sexual function and to lead to a high incidence of spermatorrhea which is sometimes accompanied by testicular pain. Long-term chronic use may lead to permanent impotence. Dryness of the mouth is commonly, felt during khat chewing, and this may be explained either by the sympathomimetic effect of the drug or by its astringent taste. Since khat leaves have high tannin content, khat chewing frequently causes periodontal disease, mucosal lesions, and a number of irritative disorders of the upper gastrointestinal tract. A common ailment of khat users is constipation, probably caused by the astringent properties of khat tannins. The khat-induced changes appeared to be less pronounced in chronic users, which would indicate that tolerance may develop to the sympathomimetic effects of khat(11,12,15,32,33)

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OBJECTIVES General Objective. The purpose of this study is to determine the magnitude and associated risk factors of Khat

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chewing among school and out of school youth in Gondar town Specific objectives 1. To determine the prevalence of Khat chewing among in and out of school youth 2. To identify the commonest risk factors of Khat chewing

METHODS A cross-sectional school based and house to house survey was conducted from January to February Study design In order to address the main research question, school-based and a house to house cross sectional survey will be conducted in October 2006 in Gondar town, North West Ethiopia. Study area The study area, Gondar town is the capital of North Gondar zone and one of the 21 districts of the zone which ranks sixth in population. The estimated population of the town is 194,773(97625 male and 97148 female) (29). There are four secondary (9-10th) and one preparatory school in the town. During the 1999 academic year there were 10275(4923 male and 5352 female) students from grades 9-10 who had been enrolled. There is one pre-college 2007 in Gondar town, North West Ethiopia. Sampling procedures

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(preparatory) school in the town. A total of 2212(1370male and 842 female) students were enrolled. The total number of students who were enrolled for the academic year was 12487.The estimated number of youth; age 15-24 is 35539(20.3%)(29) There for the estimated number of out of school youth is 23052. The former 21 kebeles in the town have now been condensed to 12 and given names instead of numbers. Five kebeles selected randomly (Abbajalie, Azezo- Dimaza, Medhanealem, Kirkos and Maraki) will be included in the study for the out of school youth. Study population The study populations are students of grade 9-12 in Gondar town and out of school youth in the age bracket 15-24 residing in Gondar town. Sample size and sampling procedures Taking the prevalence rate of khat chewing which was found to be 23%, for out of school youth and 7.5% for school youth and all over prevalence was 15%(1) the required sample size for this study, "n", at confidence interval of 95% and a marginal error of 3%, was determined by: n = D(z2)xp1(1-p1) W2 Where: n = the required sample size D = 2( design effect as two populations are to be studied) z = 1.96(at 95% confidence interval) p = 0.15 (proportion of youth with the out come from a previous study) w = 0.03( 3% marginal error) This gives 1088 adding 10% for non-response the required sample size was 1197 Sampling procedures The following criteria were used in selection of the study subjects: (1) In-school youth: aged 15–24 years, daytime high school students attending grades 9–12 (2) Out-of-school youth: aged 15–24 years, not attending day or night school, unemployed or

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employed. Two randomly selected schools Fasiledes and Edget feleg were included in the study for school youth age 15-24 years and proportional samples to the number of students were drawn from each school. For grade 11-12 students, the only preparatory school in the town, Fasiledes secondary school, was taken. The sampling frames for selection of study subjects were prepared in consultation with the zonal education department and district Education office and respective schools (to obtain details of classes and number of students in each grade). Probability proportional to size sampling (PPS) was used to select classes in the first stage and then systematic sampling was applied to select students in the second stage. A list of classes from each selected school with their corresponding measures of size were prepared. They were listed using the numbering system of the school so that they can be identified easily. Starting at the top of the list, the cumulative measure of size (per sex) was calculated and these figures were entered in a column next to the measure of size for each class. The required sample size from each school was allocated proportional to the number of students in each grade of that particular school. Using an average cluster size, and equal sample size for males and females, the sampling interval (SI) was calculated by dividing the total cumulative measure of size by the number of students to be selected. A random starting number (RS) was then selected between 1 and SI. The unit within whose cumulated measure of size for the RS falls is the first sampling unit and subsequent subjects were selected by adding the SI to the RS. Once inside the classroom, starting from the front right hand seat of the class, a random number was picked and the required number of students was systematically selected. Then the selected students were asked to go to a separate hall where they were oriented on how to fill the questionnaires. They were then seated separately and the questionnaires were distributed. The questionnaires were checked while in the class room for completeness. Out-of-school youth (OSY) were selected from randomly selected kebeles in Gondar town (Medhanealem, Abajalie, Kirkos, Maraki and Azezo-dimaza). The sampling frames for selection of OSY were prepared using the projection of the1994 census report. House holds of the selected kebeles were systematically selected. The sample sizes were distributed to each kebele proportional to the population size of the kebeles. The house holds in each of the

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selected kebeles were obtained from the kebele offices and samples that are required from each kebele were determined proportionally. For example, if a kebele has 1000 house holds and the required sample size for that particular kebele was 100, every 10th house would be visited. Then, the house holds were identified systematically and target youths were selected by lottery system if more than one youths were found in a house hold. A face-to-face household interview was conducted to obtain the needed information. When the identified respondent was not available on the day of visit to a household, appointments were made to return for the interview. The data collectors were advised to go to the house holds at times when the youths would likely be at home such as early in the morning. When it was not possible to trace the identified individual after two attempts, the next household was taken as a substitute Data collection and processing Data collection was done using a standardized pre-coded and pre-tested questionnaire. Ten male and female interviewers were selected from Gondar town. Interviewers had completed high school and had some previous experience of collecting survey data. They were given a two days intensive training about the interview processes and on how to administer the questionnaire. Pilot-testing was carried out in Gondar town on 20 in-school and 30 out of school youths with similar characteristics to the study subjects. Socio-demographic characteristics, history of substance use ( Khat, alcohol, cigarette and others) both for life time prevalence and current prevalence were obtained using the interview instrument. Those who have ever chewed khat, drunk alcohol and smoked cigarette were defined as life time users and those who currently use any of the substances were considered as proportions for current prevalence of that particular substance. Symptoms of substance abuse and dependence were also assessed according to the diagnostic criteria of DSM-IV-TR( Diagnostic Statistical Manual of mental disorders by the American psychiatric association fourth edition Text Revised The Diagnostic and Statistical Manual-IV (DSM-IV) defines abuse as:

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A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: 1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) 2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) 3. recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) 4. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of use, physical fights)

DSM-IV defines dependence as:

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: 1. tolerance, as defined by either of the following:

a need for markedly increased amounts of the substance to achieve the desired effect markedly diminished effect with continued use of the same amount of substance

2. withdrawal, as manifested by either of the following:
 

the characteristic withdrawal syndrome for the substance the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

3. the substance is often taken in larger amounts or over a longer period than was intended

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4. there is a persistent desire or unsuccessful efforts to cut down or control substance use 5. a great deal of time is spent in activities to obtain the substance, use the substance, or recover from its effects 6. important social, occupational or recreational activities are given up or reduced because of substance use 7. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., continued chewing despite recognition that an ulcer, depression, or loss of appetite was made worse by khat consumption) The following operational definitions are appropriate to this study Life time prevalence of khat chewing: the proportion of youth who had ever chewed khat life time prevalence of smoking: the proportion of youth who had ever smoked cigarette Life time prevalence of drinking: the proportion of youth who had ever drunk alcohol Current prevalence of khat chewing: proportion of youth who chew currently and have chewed in the moth of data collection Current prevalence of smoking: the proportion of youth who smoke currently with in the month of data collection current prevalence of drinking: the proportion of youth who were drinking in the month of data collection The data collected were thoroughly checked, incompletely filled questionnaires were discarded. Questions with multiple responses were coded. The data were entered into EPI6 and exported to SPSS 10.0 for analysis. Frequencies, cross tabulations, descriptive statistics such as mean ages of starting chewing, smoking, standard deviations, were computed. Correlations, bivariate and multivariate analyses and regressions were also employed. The

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dependent variables current khat chewing and ever chewing were compared with the independent variables such as sociodemographic characteristics and uses of alcohol, cigarette and other substances. Those variables found to have association with the dependent variables in the bivariate analyses were entered into logistic regression to adjust for confounding. The dependent variables were ever chewing and current chewing of khat. As independent variables, the following were included in the model: sex, age, school status (in or out of school), educational attainment, cigarette, alcohol and other substance use, religion, marital status, occupation, father was chewing, mother was chewing, parents live together, parents control. In addition, the diagnostic criteria of substance abuse and dependence of DSM-IV-TR were included in the questionnaire and analyzed for frequency of symptoms and associations with duration of chewing. Ethical considerations Ethical clearance for the study was obtained from the university of Gondar research and publication office. Official letters were collected from the zonal education department and woreda education office to the respective schools and from the town mayor's office to the selected kebeles. Participation of respondents was strictly on voluntary basis. Informed consent was solicited orally. Measures were taken to ensure the respect, dignity and freedom of each individual participating in the study. Measures were also taken to assure confidentiality through anonymous data collection at places separate from other persons.

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RESULTS Out of the 1197 questionnaires administered, a total of 1167 youth aged between 15 and 24 years were included in the study, making the response rate 97.49%.Thirty questionnaires were discarded for they were incompletely filled. Six hundred ninety nine (59.9%) were males and 468(40.1%) were females. Out of these, 680(58.3%) were below 20 years of age. Concerning marital status, 106(9.1%), 1049(89.9%), 4(0.3%), 8(0.7%) were married, single, divorced and widowed respectively. Eight hundred seventy one (74.6%) were orthodox Christians, 57(4.9% protestant, 233(19.1%) Muslim, 9(0.8%) catholic and 7(0.6%) others. Of these, 655(56%) were out-of-school youth. Among the out of school youth, 460(70.2%) were males and 195(29.8%) were females. And among the in-school youth, 239(46.7) were males and 273(53.3%) were females. One hundred sixteen (9.9%) have attended higher education and 16% are below grade 9. This accounts for 28.8% of the out of school youth.

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Table 1: Socio-demographic characteristics of the study population of in-school and out-of school youth, Gondar town Ethiopia 2007

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Characteristics Sex Male Female Age 15-19 years 20-24 years Religion Orthodox Protestant Catholic Muslim Others Education can't read and write can read and write 1-4 grade 5-8 grade 9-12 grade above grade 12 Occupation No job Daily labourer Shoe shiner House wife Living with family Government employee Petty trader Lottery and news paper distributor Street vendor

Number(percent) (n = 1167) In-School Out-of school 239(46.7) 273(53.3) 479(93.6) 33(6.4) 428(83.6) 8(1.6) 2(0.4) 73(14.3) 1(0.2) 512(100) 460(70.2) 195(29.8) 201(30.7) 454(69.3) 443(67.6) 49(7.5) 7(1.1) 150(22.9) 6(0.9) 3(0.5) 24(3.7) 18(2.7) 144(22) 350(53.4) 116(17.7) 112(17.1)* 114(17.4) 23(3.5) 29(4.4) 219(33.4) 96(14.7) 18(2.7) 16(2.4) 28(4.3

Total 699 468 680 487 871 57 9 223 7 3 24 18 144 862 116 112 114 23 29 219 96 18 16 28 * the

percentages are calculated from the out of school youth

Two hundred forty nine (38%) of the out of school youth are either job less or daily laborers. 21

The life time prevalence of khat chewing was found to be 37.1% and current prevalence 31.4%. Among those who currently chew khat 36% have chewed for more than 2 years and 32.1% chew daily. More than 7% of the ever chewers started chewing below age 15 years, the least age of initiation being 11 years. About 55% started chewing before age 18 years. Thirty six percent of the chewers chew in public recreation areas and 30.7% chew in special rooms arranged for daily chewing session. At each session, different proportion of money is spent and 20.1% spend more than 10 birr per session. Out of those who chew khat 70.1% experience one or more of the withdrawal symptoms and the frequency of symptoms increase with the duration of chewing. The symptoms experienced were: weakness, 110(25.4%), depression 210(48.4%), nausea and abdominal discomfort 17(3.9%), tremor 35(8%), frightening dreams 31(7.1%), loss of appetite 51(11.7%), irritability 22(5%), and anxiety 26(6%)

Table 2: Prevalence of khat chewing and associated socio-demographic factors in Gondar town, Northwest Ethiopia, 2007 Variable Sex Male Female Population (%) 699(59.8) 468(40.1) Current khat users Number (%) 283(40.4) 84(17.9)

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Age 15-19 years 680(58.4) 20-24 years 487(41.6) Religion Orthodox 871(74.6) Protestant 57(4.9) Catholic 9(0.8) Muslim 223(19.1) Others 7(0.6) Marital status Married 106(9.1) Single 1049(89.9) Divorced 4(0.3) Widowed 8(0.7) School status In-school 512(43.9) Out-of school 655(56.1) Occupation No job 112(17.1)* Daily laborer 114(17.4) Shoe shiner 23(3.5) House wife 29(4.4) Living with family 219(33.4) Government employee 96(14.7) Petty trader 18(2.7) Lottery and news paper 16(2.4) distributor Street vendor 28(4.3) * The percentages are from the out of school youth

100(14) 267(54) 243(27.8 6(10.5) 112(50.2) 6(85.7) 47(44.3) 377(35.9) 4(100) 5(62.5) 47(9.2) 320(48.8) 64(57.1) 84(73.6) 13(56.5) 11(37.9) 84(38.3) 40(41.6) 8(44.4) 4(25) 12(42.8)

Table 3. Subjective reasons given by respondents for chewing khat, Gondar town, Northwest Ethiopia, 2007

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Reason Easily availability of khat Ignorance about the harmful effects For adventure Peer pressure Dissatisfaction at home Lack of job To fulfill religious rituals To relieve emotional problems To get concentration for work, study

frequency 41 29 32 86 68 121 54 48 116

percent* 3.5 2.5 2.7 7.4 5.8 10.4 4.6 4.1 9.9

Family disintegration 31 2.7 To pass time and relax 26 2.2 Other** 8 0.8 * Percentages do not add up to 100 because one respondent gave more than one reason ** Other includes: to relieve hunger (3), to increase sexual pleasure (3), and to treat illness (2) Of the chewers, 17% have chewed for less than 1 year, 38% for 1-2 years and 44.8% for more than 2 years. Among the khat chewers, 72.9% also drink alcohol and 57.3% of those who drink alcohol also chew khat. Ninety percent of the cigarette smokers chew khat and 35.3% of chewers smoke cigarette. Females account for 22.8% of the current chewers. Of all the chewers, 10.9% were married, 87.1% single, 0.9% divorced and 1.2% are widowed. Concerning school status, 87.2% of the current chewers were out-of school youth and 12.8% were in-school youth. Currently, 9.2% of in school and 48.8% of out of school youth chew khat. The minimum age of khat chewing was 11 years and the mean age of starting chewing was 18.14 years and standard deviation 2.38. The minimum age of smoking was also 11 years with mean age 18.11 years and standard deviation 2.51. The life time prevalence of smoking cigarette was 14.6% and current prevalence was 11.9%. Of all the cigarette smokers 16(9.4%) are females and among the respondents 22.1% of males and 3.4% of females are life time cigarette smokers. Life time prevalence of drinking alcohol was 47.1% and current prevalence 38.6%. Of those who currently drink alcohol, 24.8% drink daily. One hundred and twenty (10.3%) of the respondents also use substances other than khat, alcohol and cigarette. This accounts for 32.3% of the current chewers. Other substances used were, shisha, hashish, benzene, cocaine and crack. Out of all khat chewers 114%26.3%) also use shisha. This accounts for

24

9.8% of the respondents. About fifteen percent of ever chewers and 18.2% of the ever smokers claimed to have stopped chewing khat and smoking cigarette respectively. The subjective withdrawal symptoms mentioned by the respondents were; depression, weakness, loss of appetite, tremor, disturbed sleep, anxiety, and nausea and abdominal discomfort with the highest frequency of depression where 210(48.4%) of the ever chewers mentioned it. the frequency of the other symptoms were in the order they appear. Table 4. Withdrawal symptoms experienced by khat chewers, Gondar town, Northwest Ethiopia, 2007 Symptoms Frequency ( n = 433) Percent Weakness 137 11.7 Depression 230 19.7 Nausea and abdominal discomfort Tremor Frightening dreams Loss of appetite Irritability Anxiety 68 85 80 89 69 76 5.8 7.3 6.9 7.6 5.9 6.5

Among in-school youth, 9.1% chew khat while among out of school youth 48.8% do so. Among the current khat chewers (n = 367), 283(77.1%) are males and 84(22.9%) are females. Muslims account for 30.5% of all current chewers and of all the Muslim respondents 89.6% chew khat currently. Out-of school youth comprise 91.2% of all current chewers. Out of the 129 current smokers, 125(96.9%) also chew khat currently. Among the current drinkers, 258(88%) also chew khat currently. One hundred and thirteen (97.4%) of those who use other substances such as hashish, shisha, etc., also chew khat. Those whose fathers had been chewing are more likely to chew khat than those whose fathers had not been chewing (45.5%Vs25%). Among those whose mothers had been chewing, 69.1% chew currently versus 29.5% of those whose mothers had not been chewing. The older age groups (20-24years) are more likely to chew khat than the younger age group (15-19 years) 58.9%Vs21.5%)

25

About two third (62.3%) of those whose fathers had been chewing versus 23.7% of those whose fathers had not been chewing, chew currently. Those who had been controlled by their fathers are less likely to chew khat than those who had not been controlled (20.4% Vs 48.2%). History of khat chewing by mother has association with chewing khat. Those whose mothers had been chewing khat are more likely to chew than those whose mothers had not been chewing(69.1%Vs29.4%). There was negative association between khat chewing and mother alive, that is, those whose mothers are dead are more likely to chew than those whose mothers are alive (57.3%Vs 32%). Multivariate analysis of the dependent variable, ever chewing, with socio-demographic predictors revealed that sex, age, religion, occupation, cigarette smoking, alcohol drinking, other substance use, father was chewing, mother chewing and father was controlling, school status ( being in or out of school) has strong association with current chewing(Table 8). Therefore, males more than females, the older age group(20-24 years) more than the younger age groups(15-19 years), Muslims more than any other religion, those who have no job and daily laborers than other occupations, those who smoke cigarette than those who do not, those who drink alcohol than those who do not, those who use other psycho-active substances than those who do not use, those whose parents had been chewing than those whose parents had not been chewing, those whose fathers had been controlling than those who had not been controlled, out-of school youth more than in-school youth were found to chew khat(Table 8). The subjective reasons for chewing given by the respondents were lack of job, to increase performance and get concentration, peer pressure, dissatisfaction at home family disintegration, to relieve tension, depression or anxiety, and to fulfill religious ritual among the others(Table 5). According to this finding, 32.3% of the life time chewers fulfilled the DSM-IV-TR diagnostic criteria of substance abuse and 33.2% dependence.

Table 5. Symptoms of khat abuse experienced by respondents according to DSM-IVTR, Gondar town, Northwest Ethiopia, 2007

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Symptom Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

Frequency (n=433) 200

Percent* 46.2

Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

140

32.3

Recurrent substance-related legal problems (e.g., theft, quarrels, arrests for substance-related disorderly conduct) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with friends, family, spouse or, physical fights)

170

39.2

249

57.5

* Percentages do not add up to 100 because one respondent may have more than one symptom

27

Table 6. Symptoms of khat dependence by ever chewers in Gondar town, Northwest Ethiopia, 2007 Symptom n = 433 Freque Percent* ncy Tolerance, as defined by either of the 166 38.3 following: a need for markedly increased amounts of the substance to achieve the desired effect markedly diminished effect with continued use of the same amount of substance Withdrawal, as manifested by: the characteristic withdrawal syndrome for the substance or; the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms The substance is often taken in larger amounts or over a longer period than was intended There is a persistent desire or unsuccessful efforts to cut down or control substance use 306 70.7

154

35.6

152

35.1

A great deal of time is spent in activities to 146 33.7 obtain the substance, use the substance, or recover from its effects Important social, occupational or 149 34.4 recreational activities are given up or reduced because of substance use The substance use is continued despite 144 33.2 knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., continued chewing despite recognition that an ulcer, depression or loss of appetite was made worse by khat consumption) * Percentages do not add up to 100 because one respondent may have more than symptom

Table 7: Status of substance use among youth in Gondar town, Northwest Ethiopia, 28

2007 Variable Ever chewer Current chewer Ever drinker Current drinker Ever smoker Current smoker Other substance user Ever chewer and ever drinker Ever chewer and ever smoker Ever smoker and ever drinker Ever chewer, ever smoker and ever drinker Current chewer and Current smoker Current chewer and current drinker current smoker and current drinker Current chewer, current smoker and current drinker 125 258 126 126 10.7 22.1 10.7 10.7 frequency of substance use ( n = 1167) 433 367 548 450 170 139 120 314 153 155 155 37.1 31.4 47 36.2 14.6 11.9 10.3 27 13.1 13.3 13.3 percent

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Symptoms

Duration of chewing <1 year N(%) 1-2 years N(%) 73(36.5) 80(34.3) 60(42.9) 93(31.7) 61(35.9) 92(35) 92(36.9) 61(33.2) 68(41) 85(31.8) 117(38.2) 36(28.3) > 2 years N(%) 104(52) 52(22.3) 66(47.1) 90(30.7) 86(50.6) 70(26.6) 124(49.8) 32(17.4) 84(50.6) 72(27) 138(45.1) 18(14.2) Total (n=433)

ABUSE Failure to fulfill role obligation Yes No Taking the substance in physically hazardous situations Yes No Substance related legal problem Yes No Substance related social problem Yes No DEPENDENCE Tolerance Yes No Withdrawal Yes No Taking the substance in larger amount and for longer duration than intended Yes No A great deal of time is spent to obtain, take the substance and recover from its effect Yes No Giving up important social, occupational and recreational activities due to substance use Yes No Unsuccessful attempts to cut down or control substance use Yes No Continue to use the substance despite knowledge that the substance is causing harm Yes No

23(11.5) 101(43.3) 14(10) 110(37.5) 23(13.5) 101(38.4) 33(13.3) 91(49.5) 14(8.4) 110(41.2) 51(16.7) 73(57.5)

200 233 140 293 170 263 249 184 166 267 306 127

9(5.8) 115(41.2)

62(40.3) 91(32.6)

83(53.9) 73(26.2)

154 279

6(4.1) 118(41.1)

62(42.5) 91(31.7)

78(53.4) 78(27.2)

146 287

7(4.7) 117(41.2)

61(40.9) 92(32.4)

81(54.4) 75(26.4)

149 284

9(5.9) 115(40.9)

63(41.4) 90(32)

80(52.6) 76(27)

152 281

8(5.6) 116(40.1)

59(41) 94(32.5)

77(53.5) 79(27.3)

144 289

DISCUSSION

30

Epidemiological studies on khat chewing are rare. Particularly, studies conducted on the youth are very scarce. Most publications on khat deal with the botanical, biochemical or pharmacological aspects while West European scientists tend to focus on problems related to khat. It is only for Yemen that a broader study of all aspects of khat, including social and economic factors, has been carried out. Comparable research in northeast Africa, where khat is equally important, has lagged behind. Only recently have more encompassing studies of khat use in Western Europe and Australia been carried out. These are indications that the once indigenous practice of chewing khat is becoming an international issue. This prevalence study of khat chewing revealed that 31.4% of the youth chew khat currently. This figure is higher than the other studies conducted on this age group and college students (7% for in-school and 23% for out-of school youth and 17.5% for college students), [1, 5].This could be explained by the fact that the cultivation and consumption of khat previously known mainly in the eastern part of Ethiopia is spreading very rapidly to the Northwestern part of the country. There is an increasing trend of khat chewing as indicated by subsequent studies conducted for example among students of Gondar college of medical sciences, 22.3% in 1983(26) and 26,7% in 2001(5). The prevalence of khat chewing determined in this study is comparable to the ones that were reported for Adamitulu(31.7%),[7 ] and Jimma town(30.6). Although both studies conducted had included all age groups from 15 and16 years and above respectively. The usual age of starting chewing khat is at adolescence and it appears to have no upper age limit. This study however, revealed lower rates of lifetime and current khat chewing prevalence compared to a study in Butajira, southwest Ethiopia in 1999, where life time and current prevalence rates were found to be 55.7% and 50% respectively (28). This could be due to the preponderance of Muslims in Butajira where they account for over 90% of the population compared to 19.1% in this study. It is found that 56% of Muslims are ever chewers compared to 33.9% of orthodox Christians that constitute 74.6% of the population. According to this study, it seems that there is a significant association (P< 0.001) between Muslim religion and Khat chewing habit. This finding is in line with those studies reported for Adamitulu(22) and Butajira(28).

31

More males(77.1%) than females were found to chew khat in this study, OR(95%CI) = 3.4( 2.6, 4.4). This is consistent with other studies conducted in Jimma(13), Adamitulu(22) and Butajira(28). This may be because females are more socially restricted than male counter parts. The lifetime and current prevalence rates of cigarette smoking among the study subjects in this study were14.6% and 11.9% respectively. Compared to studies conducted on medical and paramedical students of the Gondar college of medical scienses in 1983 which were 31.9% and 26.3% respectively, there is a decrease both in lifetime and current prevalence rates. However, there is an increase in both lifetime and current prevalence rates of smoking compared to a study conducted in the same college in 2001, showing lifetime and current prevalence rates of 13.1% and 8.1% respectively(5). This may be explained by: the previous study was conducted among college students who came from different parts of the country including rural areas where cigarette smoking is less practiced. This study was conducted however, in a town only, where smoking is not socially strictly sanctioned. In addition khat chewing is highly associated with smoking, therefore, as the prevalence of khat chewing increases the prevalence of smoking may also increase. This finding on the prevalence rate of khat chewing in Gondar town is found to be lower than reported in Butajira where the lifetime and current prevalence rates were found to be 55.7% and 50% respectively (28). This could be due to the preponderance of Muslims in Butajira where they account for over 90% of the population. Muslim religion has significant assosiation with khat chewing habit (p = <.001) This is in line with other studies conducted in Bitajira(28) and Jmma town(13). Males (77.1%) were found to have been chewing more than females (p = <0.001) as in the Butajira(28) and Adamitulu(7) studies showed. This may be because females are culturally more restricted than males. In this study the habit of khat chewing was more frequent in the age groups 20-24 years compared with the younger age group, 15-19 years. As compared to the younger age group, there are more out of school youth in the older age group and more khat chewers are found in the out of school youth. This is consistent with the study conducted in all regions of the country where prevalence rates of khat chewing among school and out of school youth were found to be 7.5% and 23% respectively(1). This could be explained by the fact that

32

young people who are not attending school may have extra time to move around, meet with new friends, and visit public entertainment areas and khat chewing sessions. These places are the areas where most respondents claimed to have been chewing in such places. Contrary to other studies(1,13), in this study no association was found betwwen khat chewing and education. The possible explanation for this difference could be: most respondents in this study (83.8%) were grade 9 and above compared with only 27(2.4%) who have not attended formal education. The mean ages for starting khat chewing and cigarette smoking were 18.14 and 18.11 years respectively. This is similar with what were reported for college students in Gondar college of medical sciences (26) and among four colleges including Gondar(5). The subjective reasons given for khat chewing in this study were also in agreement with the above studies which were "to get concentration", "peer pressure", and "relieve stress" among others. The associations among khat chewing, cigarette smoking, alcohol drinking and other substance use revealed by this study agree with other studies conducted in other parts of the country and on college students including Gondar(1,26). The habit of khat chewing by one or both parents has also indicated increased rates of chewing among youth whose parents have been chewing. This agrees with a finding in Gondar college of medicine students (5). This is a well established fact that young people tend to imitate and exercise what they observe from their elders and parents. In addition, among the muslims where khat chewing is taken as means of increasing concentration for prayer, children are allowed to attend khat chewing sessions. It is difficult to say precisely how much khat is chewed; the practice is widespread, but figures are not easy to come by. The use of khat was long confined to the natural habitats of khat, for the leaves wither soon after harvest; the active ingredients are dissipated and the leaves become unfit for use. This means that the leaves must reach their destination within two days of harvesting. With rise of motorized and air transport, the circle of khat use has become considerably wider.

33

Table 9: factors associated with ever chewing of khat among school and out of school youth in Gondar town, Northwest Ethiopia, March 2007(n = 433) Factor Ever chew OR(95%CI) Number (%) Age 15-19 years* 20-24 years Sex Male Female * School status In-school * out-of school Ever smoke Yes No* Ever drink Yes No* Other substance use Yes No* father was chewing yes No* Mother was chewing Yes No * father controls Yes* No 146(33.7) 287(66.3)

4.7(3.6-6.1

334(77.1) 99(22.9)

3.4(2.6,4.4)

82(18.9) 351(81.1)

3.1(2.2-4.4)

153(35.3) 280(64.7) 314(72.9) 117(27.1)

9.3(5.3-16.1)

3.6(2.6-4.8)

116(35) 215(65) 104(41.6) 146(58.4) 47(15.6) 254(84.4) 93(39.1) 158(62.9)

3.7(13.4-106) 4.4(2.7-7.2) 2.5(1.2-5)

.28(.18-.46) * reference

category

34

As khat chewers spend more time chewing khat than working, khat abuse affects the productivity of the countries involved. Khat users from the lower income group may spend as much as half of their daily earnings on khat. In this study multiple substance use was found to be very common,153(13.1%) of the respondents claimed to have been taking khat, cigarette, and alcohol at the same time. This finding is in line with an other study conducted in 1996, in Addis Ababa and other 24 towns in Ethiopia (4). The reasons given by respondents for substance use were also similar with the above study(Table ) The symptoms of khat use using the diagnostic criteria of DSM-IV-TR for substance abuse and dependence have been tried to be assessed and the frequencies of the symptoms were very high. However, literatures on khat abuse and dependence are very rare. More over, different studies have come up with controversial findings. It is the young economically active age group that chew khat in group and waste away their time. A considerable amount of money is being spent for khat and this can affect the economy of the family. Long term use of khat results in family breakdown and violent behavior and other harmful effects on the body and psyche. Users of khat report increased levels of energy, alertness, self-esteem, sensations of elation, enhanced imaginative ability and capacity to associate ideas when chewing. However, over stimulation of the central nervous system can lead to psychiatric disorders and there are case reports of people developing psychosis after use of khat.

Limitations of the study 35

The response rate was not 100%, and the non-responses were from school youths. This is of course one of the limitations of self-administered questionnaires. The respondents may not also say what really the situations were with respect to their status of substance use for fear of social disapproval. This might underestimate the prevalence of khat, cigarette, alcohol and other substance use. The questionnaires were not administered by health professionals. Therefore, questions of abuse and dependence might not clearly communicated and this could have resulted in exaggerated responses. Because researches on abuse and dependence of khat are lacking, it was found to be difficult to compare this finding with other studies. Moreover, the very few researches available have inconclusive or controversial remarks. For this reason it is difficult to rely on the findings, especially those of subjective symptoms of dependence. Prevalence studies on khat chewing among the youth in areas where khat is not cultivated are rare. Therefore, comparisons made with this study were to those findings where khat has been widely consumed by all age groups. This might be a reason to interpret that khat is chewed less frequently compared to the other studies conducted in areas where khat is endogenous. Had there been any study conducted in area like Gondar where khat does not grow it would have been possible to conclude that khat consumption is increasing, decreasing or the same.

CONCLUSION Although the literature on khat (Catha edulis Forsk) and its prevalence among different

36

segments of the population in Ethiopia is fairly extensive, very few population based studies exist in the study area. While additional information is always desirable to enhance our understanding of the effects of khat on the human body, enough is known now to say clearly that the use of khat should be discouraged everywhere. Despite the dramatic increase in the production and consumption of khat in Ethiopia in recent years, no regulatory measures have been attempted to be taken by the authorities in charge. It is particularly worrisome in view of the recent CIA categorization of Ethiopia as illicit drugs transit hub. The cultivation of khat is financially attractive and spreads into new areas, apparently at the expense of traditional staple and cash crops. In Ethiopia, Khat has been used for centuries in the eastern part of the country. Today khat consumption is widespread throughout the country. There are no laws restricting its use, although the government discourages it. Khat abuse begins at a young age and there seems to be no upper age limit for the average chewer. Use of a substance is likely to lead to multiple drug use, abuse and dependence. Although khat is a legal substance in Ethiopia, it can be an entry point to the use of other elicit drugs. This has to be made aware to local governmental officials and other concerned bodies. It is not only for the above reasons that research into the question whether or not the problem of khat has not been addressed in earnest. The situation is complicated by uncertainty about the official status of khat as a commodity. In general the prevalence of khat chewing and cigarette smoking appear to have increased among the young people compared to previous studies of khat and cigarette use. This finding might seemed to be lower than the prevalence studies on the general population study conducted in Butajira. However, that is a place where khat is endogenous and more Muslims than Christians live contrary to Gondar. The high prevalence rate of khat chewing, cigarette smoking and alcohol drinking as wellas use of substances other than these such as shisha and hashish are striking and need attention by the government, health professionals and the community for future plans on decreasing the consumption of these and other illicit

37

substances. The habit of khat chewing has negative impact on health and socioeconomic matters. This is because the habit of khat chewing reinforces the development of other habits such as cigarette smoking, alcohol intake and use of other substances.

RECOMMENDATIONS 1. There is a very high felt need to educate the public with special emphasis to the young people about the adverse effects of khat on physical, mental and social health.

38

2. The cultivation of khat should be discouraged by offering government subsidies for alternative but equally rewarding cash crops. 3. Use of khat in public entertainment areas, work places, school compounds should be restricted. 4. Heavy taxes should be imposed on khat circulation to discourage its widespread use. 5. The programs on HIV/AIDS control should include substance use prevention and favorable conditions should be created for non-governmental organizations to establish substance abuse prevention and control programs. 6. Government and non-governmental organizations should join efforts to provide adequate access for recreational facilities for marginalized youth. 7. Control measures on circulation of illicit substances should be designed. 8. Teachers and parents have to be made aware the importance of open discussions and follow-ups of young people. 9. Large scale surveys should be conducted periodically to determine trends and patterns of use of khat and other substances of abuse. 10. Studies on khat use and induced disorders such as abuse, dependence, withdrawal delirium, mood and psychotic disorders need to be carried out among those who chew for long duration so as to draw a clear picture of its effect on mental health and recommend about its legal status.

ACKNOWLEDGEMENTS I am very grateful to professor Yigzaw Kebede who helped me throughout the course of this paper from the proposal to the final report in guiding, advising, correcting and commenting in a friendly approach and letting me feel free.

39

I sincerely acknowledge the university of Gondar for the financial coverage of the research. My thanks should go to Ato Mohamedberhan Abdulwahib for providing me with most of the reference materials. I thank Ato Getu Degu for programming my computer with SPSS software and teaching me how to use it. I would like to thank Ato Sisay Melese who gave me encouragement and support with the analysis. So much thanks to the north Gondar zonal education department, Mayor's office, woreda education office, heads of the selected schools, kebele administrators of the selected kebeles and all the study subjects and data collectors as well as supervisors for their help.

REFERENCES 1 Kebede D; Alem A; Mitike G; Enquselassie F; Berhane F; Abebe Y et al: Khat and alcohol use and risky sex behaviour among in-school and out-of-school youth in Ethiopia. BMC Public Health, 2005.

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2. Atalay Alem; Teshome Shibre Khat induced psychosis and its medico-legal implication: A case report. Ethiop Med J 35 137-140, 1997 3. T. Asuni; A. opela: Drug abuse in Africa. Department of psychiatry, college of medicine, university of Lagos, Nigeria, pp55-64, 1986 4. S. Gebre Selassie; ,A Gebre: Rapid assessment of drug abuse in Ethiopia. UNODC Bulletin on Narcotics, Issue 1-004, 1996 5. Yigzaw Kebede: Cigarette smoking and khat chewing among college students in NorthWest Ethiopia. Ethiop. j Health Dev. 6. Andualem Mossie: The prevalence and socio-demographic characteristics of khat chewing in Jimma town, SouthWestern Ethiopia. Ethiop j health sci 12(2), pp69-79, 2002 7. Belew M; Kebede D; Kassaye M; Enquoselassie F. The magnitude of khat use and its association with health, nutrition and socio-economic status. Ethiopian Medical Journal 38(1): 11-26, 2000 8. J.M. Mwenda; M.M. Arimi; M.C. Kyama and D.K. Langat: Efects of khat (catha edulis) consumption on reproductive functions: A review. East African medical journal pp318-323, 2003 9. Al-Hadrani AM. Khat induced hemorrhoidal disease in Yemen. Saudi Medical Journal 21(5): 475-477, 2000 10. Balint GA; Balint EE. On the medico-social aspects of khat (Catha edulis) chewing habit. Human Psychopharmacology 9(2): 125-128, 1994. 11.Doherty JF; Price N; Moody AH; Wright SG; Glynn MJ. Fascioliasis due to imported khat. (letter). Lancet 345(8947): 462, 1995. 12. Giannini AJ; Miller NS; Turner CE. Treatment of khat addiction. Journal of Substance Abuse Treatment 9(4): 379-382, 1992.

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