Abstract
Background
Illicit substance abuse among adolescents is an emerging public health challenge in Sri Lanka, yet evidence on independent risk factors, particularly among high-risk teenagers undergoing rehabilitation, remains limited. Understanding social, familial, peer and school-related determinants is essential to inform targeted prevention and intervention strategies.
Methods
A case–control study was conducted among adolescents aged 10–17 years. Cases (n=108) were teenagers admitted for inpatient rehabilitation for illicit substance abuse at the Youth Drug Addiction Prevention, Treatment and Rehabilitation Centre, Kandy, Sri Lanka. Age-matched and sex-matched controls were recruited from the outpatient department of North Colombo Teaching Hospital, Ragama. Data were collected using a structured questionnaire assessing individual, peer, family, school and psychosocial factors. Associations were examined using χ² tests, and independent risk factors were identified using multivariable logistic regression. Statistical significance was set at p<0.05.
Results
Peer-related factors showed the strongest associations with substance abuse. Peer use of illicit substances (adjusted OR 32.16; p<0.001) and peer encouragement of substance use (adjusted OR 14.26; p<0.001) were the most powerful independent predictors. Other significant independent risk factors included association with antisocial peer groups (adjusted OR 10.4; p<0.001), parental separation (adjusted OR 5.34; p<0.001), perceived school neglect (adjusted OR 3.14; p<0.001), problematic social media use (adjusted OR 2.52; p=0.002) and perception of substance use as a means of gaining social popularity (adjusted OR 2.44; p=0.004). A high burden of psychological vulnerability was observed, with 46.3% reporting prior self-harm-related thoughts.
Conclusions
Illicit substance abuse among Sri Lankan teenagers is predominantly driven by peer influence, family disruption, school disengagement and social vulnerabilities. Prevention and intervention strategies should prioritise peer-focused approaches, family strengthening, school re-engagement and integrated mental health support.
Keywords: Adolescent Health
WHAT IS ALREADY KNOWN ON THIS TOPIC
Evidence from South Asia on independent risk factors for teenage substance abuse is limited.
WHAT THIS STUDY ADDS
Peer substance use, peer encouragement and association with antisocial peer groups are the strongest independent risk factors for teenage substance abuse.
Family disruption, perceived school neglect, problematic social media use and perceiving substance use as a means of gaining popularity remain significant after adjustment for confounders.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Prevention strategies should prioritise peer-group-focused interventions and early identification of high-risk social networks.
Findings support integrated adolescent services combining substance abuse treatment, mental healthcare and school re-engagement.
Introduction
Illicit substance abuse among adolescents is a growing public health concern worldwide, with profound implications for physical health, mental well-being, educational attainment and long-term social outcomes.1 2 Adolescence represents a critical developmental period characterised by neurobiological vulnerability, heightened risk-taking behaviour and increased sensitivity to peer influence, making teenagers particularly susceptible to substance use initiation and progression.3 While global evidence has identified multiple determinants of adolescent substance abuse, including peer pressure, family dysfunction and socio-economic adversity, the relative contribution of these factors varies considerably across sociocultural contexts.4
In South Asia, and particularly in Sri Lanka, adolescent substance abuse has emerged as an increasingly visible challenge for health, education and social protection systems.5 Rapid urbanisation, widening social inequities, changing family structures and increased exposure to digital media have altered adolescents’ social environments, potentially amplifying vulnerability to substance use.6 Despite these concerns, empirical evidence examining risk factors for teenage substance abuse in Sri Lanka remains limited, with most available data derived from school-based surveys or descriptive reports that inadequately capture high-risk populations.7 8
Teenagers undergoing rehabilitation for substance abuse represent a particularly vulnerable and understudied group. These adolescents often experience overlapping adversities, including disrupted family relationships, peer networks that normalise substance use, exposure to violence or neglect and unmet mental health needs.9 Understanding the constellation of factors associated with substance abuse in this population is essential to inform prevention strategies, early identification and targeted interventions.10
This study aimed to identify individual, familial, peer, school and environmental risk factors associated with illicit substance abuse among Sri Lankan teenagers using a case–control design.
Methods
Study setting and population
This analytical case–control study was conducted at the Youth Drug Addiction Prevention, Treatment and Rehabilitation Centre, Kandy, Sri Lanka, one of the country’s principal tertiary referral centres for inpatient adolescent substance rehabilitation. The study was carried out over an 18-month period from March 2024 to September 2025. A case–control design was selected to examine individual, familial, peer-related, school-based and environmental factors associated with illicit substance abuse among Sri Lankan teenagers.
The study population comprised adolescents aged 10–17 years. Cases were defined as teenagers admitted for in-house rehabilitation for illicit substance abuse, diagnosed through clinical assessment by the treating multidisciplinary team, including consultant psychiatrists, in accordance with national clinical protocols. All eligible adolescents admitted during the study period were approached consecutively for recruitment. A minimum sample size of 108 cases was determined a priori based on feasibility considerations and expected effect sizes from previous regional studies.7 Controls were age-matched and sex-matched adolescents without a history of substance abuse who presented to the outpatient department of the North Colombo Teaching Hospital, Ragama, for minor acute medical conditions. This hospital primarily serves the Western Province, ensuring that controls were drawn from a population geographically comparable to most cases. All controls were screened using direct self-report questions to exclude any lifetime history of illicit substance use prior to inclusion in the study. Frequency matching was used to ensure comparability between cases and controls with respect to age and sex, thereby minimising confounding by these variables.
Inclusion criteria
Adolescents aged 10–17 years who were able to comprehend Sinhala or Tamil and who provided informed assent, together with parental or guardian consent, were eligible for inclusion. Adolescents with severe cognitive impairment, acute medical or psychiatric instability at the time of assessment, or those who declined participation were excluded from the study.
Study instrument and variables
Data were collected using a structured, self-administered questionnaire available in Sinhala and Tamil. The primary outcome variable was illicit substance abuse, defined as current or recent use of one or more illegal psychoactive substances requiring inpatient rehabilitation, as determined by clinical assessment by the treating multidisciplinary team. Independent variables were selected a priori based on existing literature and conceptual relevance.4
To our knowledge, no validated, comprehensive questionnaire exists in Sri Lanka for assessing individual, familial, peer, school and psychosocial risk factors among high-risk adolescents undergoing rehabilitation, with only limited local studies such as Jayamaha et al addressing related topics in school-based populations.7 Therefore, we developed a structured, self-administered questionnaire specifically for this study. The development process involved a review of both the limited Sri Lankan literature and relevant global studies to identify key risk domains. Risk factors were grouped into individual, familial, peer, school and psychosocial categories, with items adapted from previously published international instruments and modified to ensure cultural and linguistic appropriateness for Sri Lankan adolescents. The draft questionnaire was reviewed by a panel of paediatricians, psychiatrists and public health specialists to assess content validity and contextual relevance. It was then pretested among 10 adolescents outside the study population to refine clarity, comprehension and cultural suitability.
Individual-level variables included age, sex, history of a diagnosed psychiatric disorder, academic difficulties, memory problems, extracurricular activity difficulties, social media addiction (self-reported excessive or uncontrolled use interfering with daily functioning) and perceptions of substance use as a means of gaining popularity. Familial variables included family structure (intact vs separated parents), parental substance use, parental involvement in substance dealing, household financial difficulties, exposure to domestic violence, loss of a parent and perceived parental neglect.
Peer-related variables comprised peer use of illicit substances, peer encouragement to use substances, association with antisocial groups, experiences of bullying, dissatisfaction with friendships and neighbourhood substance use. School-related variables included perceived school neglect, physical or emotional abuse at school and school disengagement. Psychosocial variables included exposure to physical, emotional or sexual abuse at home or school and self-harm-related thoughts and behaviours, assessed using direct, non-graphic self-report questions. All variables were recorded as categorical responses and analysed accordingly. Clear operational definitions were applied consistently during data collection and analysis to ensure internal validity.
Data collection
The data collection tool was administered in a private, supervised setting to ensure confidentiality and to reduce social desirability bias. Trained research assistants were available to clarify questions without influencing responses. Among cases, data collection was conducted after initial stabilisation during rehabilitation to minimise distress and improve reliability of reporting, while controls completed the questionnaire following outpatient consultation. Questions related to self-harm and suicidal ideation were framed in direct, non-graphic language consistent with ethical standards for research involving adolescents.
Data analysis
Data were entered and analysed using SPSS V.26.0. Descriptive statistics were used to summarise participant characteristics and exposure variables, with categorical data presented as frequencies and percentages and continuous variables as means with SD. Bivariate associations between potential risk factors and substance abuse status were examined using the χ² test. Variables with a p value of <0.10 in bivariate analysis were entered into a multivariable logistic regression model to identify independent risk factors for adolescent substance abuse. Results were reported as ORs with 95% CIs, and a two-sided p value of <0.05 was considered statistically significant.
Results
Sociodemographic characteristics of cases
A total of 108 teenagers with substance abuse were included as cases. The mean age was 15.8 years (SD 2.4; range 10–17 years). Most participants resided in urban communities (n=69; 63.8%). Nuclear family structures were reported by 66.7% (n=72) of cases.
A family history of substance abuse was reported by 31.5% (n=34). Single-parent households due to parental separation or death accounted for 19.4% (n=21). More than half of the adolescents (52.0%; n=56) reported witnessing domestic violence.
The majority of participants were Sinhalese (n=83; 76.9%), followed by Muslims (n=17; 15.7%) and Tamils (n=9; 8.3%). Participants were drawn from 15 districts, with 43.5% (n=47) residing in Colombo District. Most families reported a monthly household income above LKR50 000 (n=85; 78.5%). Family background characteristics of the adolescents with substance abuse are presented in figure 1.
Figure 1. Family background characteristics of the adolescents with substance abuse (n=108).
Patterns of substance use by teenagers
Figure 2 presents the pattern of illicit substances used by the adolescents undergoing rehabilitation.
Figure 2. Pattern of illicit substances used by the adolescents undergoing rehabilitation (n=108).
All 108 cases had been introduced to substances by someone, most commonly by friends (n=92; 85.2%), followed by siblings (n=3; 2.8%), parents (n=2; 1.9%), relatives (n=2; 1.9%) and unknown sources (n=2; 1.9%).
Reasons for initiating substance use
Figure 3 summarises the self-reported reasons for commencing substance use among adolescents undergoing rehabilitation. The figure demonstrates the interplay of individual motivations, peer influence, emotional factors and environmental pressures contributing to initial substance use.
Figure 3. Self-reported reasons for initiating illicit substance use among adolescents.
Factors sustaining continued substance use
Figure 4 presents the perceived drivers that contributed to the continuation of substance use following initiation. These factors span psychosocial, familial, educational and structural domains, reflecting the multifactorial nature of ongoing substance abuse among teenagers.
Figure 4. Factors contributing to continued illicit substance use among adolescents.
A substantial proportion of participants reported prior self-harm-related thoughts and behaviours. Nearly half (n=50; 46.3%) had previously thought of harming themselves, while 21.5% (n=24) reported previous thoughts of suicide. A smaller but concerning proportion had engaged in deliberate self-harm (n=16; 14.2%), and 4.4% (n=5) reported a previous suicide attempt.
Bivariate analysis of risk factors
Table 1 presents the bivariate analysis of potential risk factors associated with illicit substance abuse. Peer-related factors showed the strongest associations, including peer use of illicit substances, peer encouragement to use substances and association with gangs (all p<0.001). Family-related adversities such as parental separation and perceived parental neglect, as well as school neglect, were also significantly associated with substance abuse. Individual-level factors, including a history of psychiatric disorders, perceiving substance use as a means of gaining popularity and social media addiction, demonstrated significant associations.
Table 1. Bivariate analysis of risk factors associated with illicit substance abuse among Sri Lankan teenagers.
| Risk factor | Cases | Controls | OR | CI | P value |
|---|---|---|---|---|---|
| Individual-level risk factors | |||||
| History of a diagnosed psychiatric disorder | 23 (21.3%) | 6 (5.6%) | 4.60 | 1.79 to 11.81 | 0.001 |
| Perception of substance use as a means of gaining social popularity | 54 (50.0%) | 22 (20.4%) | 3.90 | 2.14 to 7.13 | <0.0001 |
| Problematic social media use | 74 (68.5%) | 20 (18.5%) | 4.48 | 2.49 to 8.06 | <0.0001 |
| Perceived lifetime neglect | 36 (33.3%) | 32 (29.6%) | 1.18 | 0.66 to 2.11 | 0.558 |
| Family-related risk factors | |||||
| Exposure to physical abuse within the home | 9 (8.3%) | 4 (3.7%) | 2.36 | 0.70 to 7.92 | 0.163 |
| Exposure to emotional abuse within the home | 24 (22.2%) | 26 (24.1%) | 0.90 | 0.47 to 1.69 | 0.747 |
| Exposure to sexual abuse within the home | 1 (0.9%) | 0 (0.0%) | 3.02 | 0.12 to 75.16 | 0.499 |
| Parental separation | 33 (30.6%) | 6 (5.6%) | 7.48 | 2.98 to 18.76 | <0.0001 |
| Parental death | 9 (8.3%) | 7 (6.5%) | 1.31 | 0.47 to 3.65 | 0.604 |
| Perceived parental neglect | 21 (19.4%) | 7 (6.5%) | 4.10 | 1.58 to 10.62 | 0.003 |
| Household financial hardship | 45 (41.7%) | 44 (40.7%) | 1.03 | 0.60 to 1.78 | 0.890 |
| School-related risk factors | |||||
| Exposure to physical abuse at school | 8 (7.4%) | 13 (12.0%) | 0.58 | 0.23 to 1.47 | 0.253 |
| Exposure to emotional abuse at school | 18 (16.6%) | 14 (13.0%) | 1.34 | 0.63 to 2.85 | 0.445 |
| Exposure to sexual abuse at school | 2 (1.8%) | 0 (0.0%) | 5.09 | 0.24 to 107.4 | 0.295 |
| Perceived school neglect | 65 (60.2%) | 25 (23.1%) | 5.01 | 2.78 to 9.05 | <0.0001 |
| Experience of school-based bullying | 15 (13.9%) | 13 (12.0%) | 1.17 | 0.53 to 2.61 | 0.829 |
| Peer-related risk factors | |||||
| Dissatisfaction with peer relationships | 42 (38.8%) | 28 (25.9%) | 1.81 | 1.01 to 3.24 | 0.04 |
| Peer use of illicit substances | 103 (95.3%) | 19 (17.6%) | 96.49 | 34.61 to 268.98 | <0.0001 |
| Association with gangs or antisocial peer groups | 52 (48.1%) | 5 (4.6%) | 19.12 | 7.22 to 50.64 | <0.0001 |
| Peer encouragement to use illicit substances | 76 (70.4%) | 10 (9.2%) | 23.27 | 10.76 to 50.30 | <0.0001 |
| Substance use among neighbours | 75 (69.4%) | 57 (67.1%) | 2.03 | 1.64 to 3.54 | 0.02 |
Independent risk factors for illicit substance abuse
Table 2 presents the results of the multivariable logistic regression analysis identifying independent risk factors for illicit substance abuse among Sri Lankan teenagers. Peer-related exposures remained the strongest predictors after adjustment, including peer use of illicit substances and peer encouragement to use substances.
Table 2. Independent risk factors for illicit substance abuse identified using multivariable logistic regression.
| Risk factor | Adjusted odds | CI | P value |
|---|---|---|---|
| Perception of substance use as a means of gaining social popularity | 2.44 | 1.83 to 5.67 | 0.004 |
| Parental separation | 5.34 | 2.74 to 9.16 | <0.001 |
| Peer use of illicit substances | 32.16 | 18.3 to 98.4 | <0.001 |
| Peer encouragement to use illicit substances | 14.26 | 10.2 to 41.4 | <0.001 |
| Problematic social media use | 2.52 | 1.91 to 4.31 | 0.002 |
| Association with gangs or antisocial peer groups | 10.4 | 5.4 to 21.7 | <0.001 |
| Perceived school neglect | 4.14 | 3.21 to 7.43 | <0.001 |
Academic and functional difficulties associated with substance abuse
Table 3 summarises academic and functional difficulties among adolescents with illicit substance abuse compared with controls. Cases were significantly more likely to report academic difficulties, memory problems and difficulties in extracurricular activities.
Table 3. Associated academic and functional difficulties among adolescents with illicit substance abuse compared with controls.
| Variable | Cases | Controls | OR | 95% CI | P value |
|---|---|---|---|---|---|
| Academic difficulties | 68 (62.9%) | 14 (13.0%) | 11.41 | 5.75 to 22.61 | <0.0001 |
| Memory difficulties | 68 (63.0%) | 28 (25.9%) | 4.85 | 2.71 to 8.68 | <0.0001 |
| Extracurricular difficulties | 25 (23.1%) | 6 (5.6%) | 5.12 | 2.00 to 13.06 | 0.0006 |
Discussion
This case–control study identified multiple independent risk factors associated with illicit substance abuse among Sri Lankan teenagers, underscoring the complex and multifactorial nature of adolescent substance use. Even after adjustment for potential confounders, factors related to peer influence, family disruption, school neglect, social media addiction and gang association remained significantly associated with substance abuse, highlighting critical domains for intervention.
Peer-related factors emerged as the strongest and most consistent predictors. Adolescents whose friends used illicit substances or actively encouraged substance use had markedly higher odds of substance abuse, reflecting the powerful role of peer norms and social modelling during adolescence. These findings are consistent with international literature demonstrating that peer networks not only facilitate access to substances but also normalise and reinforce continued use.11,13 The exceptionally high prevalence of peer substance use among cases suggests that prevention efforts must extend beyond individual-level education to address peer group dynamics and social environments.14 15
Perceiving substance use as a means of gaining popularity independently predicted substance abuse, pointing to the influence of social identity formation and perceived social rewards. This aligns with theories of adolescent behaviour that emphasise status-seeking and belonging as key motivators during this developmental stage.16 The role of social media addiction as an independent risk factor further reinforces this notion, as online platforms may amplify exposure to substance-promoting content, distorted social norms and risky behaviours.17
Family-related factors also played a significant role. Adolescents from separated-parent households and those reporting parental or school neglect were at significantly increased risk. Family disruption may reduce supervision, emotional support and stability, thereby increasing vulnerability to maladaptive coping strategies such as substance use.18 19 Similarly, perceived neglect by school reflects broader institutional disengagement, academic marginalisation and reduced access to protective adult relationships, all of which may contribute to substance use initiation and persistence.20 21
Association with gangs was another powerful independent risk factor, highlighting the intersection between substance abuse and broader antisocial or criminal networks. Gang involvement may facilitate access to substances, promote risk-taking behaviours and entrench adolescents in environments where substance use is routine and instrumentalised for social cohesion or economic gain.
Notably, a substantial proportion of adolescents reported prior self-harm-related thoughts and behaviours, underscoring the close relationship between substance abuse and psychological distress.22 While causality cannot be inferred, this finding reinforces the need for integrated mental health assessment and support within adolescent substance rehabilitation services.
Taken together, these findings suggest that adolescent substance abuse in Sri Lanka is driven less by isolated individual pathology and more by interacting social, familial and structural factors. Effective prevention and intervention strategies must therefore be multisectoral, combining family-based interventions, peer-focused prevention, school engagement, digital literacy and community-level approaches aimed at reducing gang involvement and substance availability.
This study has several limitations. The case–control design precludes causal inference, and associations identified may reflect bidirectional or complex temporal relationships. Data were self-reported and therefore subject to recall and social desirability bias, particularly for sensitive topics such as substance use and self-harm. Cases were recruited from a rehabilitation centre and may not be representative of all adolescents who use substances, especially those not accessing formal services. Residual confounding by unmeasured variables cannot be excluded.
Conclusion
Illicit substance abuse among Sri Lankan teenagers is strongly associated with peer influence, family disruption, school neglect, social media addiction and gang association. These findings highlight the need for comprehensive, multisectoral prevention and intervention strategies that extend beyond individual behaviour change. Strengthening family support systems, fostering positive peer and school environments and addressing emerging digital and social risks are essential to reduce adolescent substance abuse and its long-term consequences.
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Data availability free text: All data were de-identified for this research report. The datasets used or analysed during the current study are available from the corresponding author on reasonable request.
Patient consent for publication: Consent obtained from parent(s)/guardian(s).
Ethics approval: Regulatory approvals for this study were obtained from the Ethics Review Committee, Postgraduate Institute of Medicine, University of Colombo (ERC/PGIM/2024/080). Participants gave informed consent to participate in the study before taking part. Written informed consent was obtained from parents or legal guardians, along with assent from all participating adolescents. Confidentiality was strictly maintained through anonymisation of data, and participants who exhibited psychological distress during data collection were referred promptly to the treating clinical team for appropriate support.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
Data are available upon reasonable request.
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