School Health Programs and Substance Use: A Multilevel Study of Brazilian Students

Background Adolescence is a critical period for the initiation of psychoactive substance use, which is linked to long-term health risks and social vulnerabilities. In Brazil, the Health at School Program (PSE) represents a key intersectoral policy aimed at promoting health and preventing risk behaviors through the integration of education and primary care. This study aimed to evaluate the association between school participation in the PSE and the lifetime experimentation of tobacco, alcohol, and illicit drugs among Brazilian adolescents. Methods This cross-sectional study analyzed data from 159,245 adolescents (aged 13–17 years) from the 2019 National School-Based Health Survey (PeNSE). The primary exposure was the school’s participation in the PSE. The outcomes were lifetime experimentation with cigarettes, alcohol, and illicit drugs. Multilevel Poisson regression models with robust variance were employed to estimate Prevalence Ratios (PR) and 95% Confidence Intervals (95% CI), adjusted for sex, age, race/ethnicity, and maternal education. Results Approximately 50.3% of students were enrolled in schools participating in the PSE. The overall lifetime prevalence of experimentation was 64.2% for alcohol, 24.0% for tobacco, and 13.7% for illicit drugs. Multilevel analysis revealed that students in schools that did not participate in the PSE had a significantly higher likelihood of experimenting with cigarettes (aPR = 1.056; 95% CI: 1.018–1.095), alcohol (aPR = 1.044; 95% CI: 1.020–1.068), and illicit drugs (aPR = 1.124; 95% CI: 1.070–1.181) compared to students in participating schools. Older age and female sex (for alcohol) were also significant risk factors. Conclusions School participation in the PSE acts as a significant protective factor against the experimentation with psychoactive substances among Brazilian adolescents. These findings underscore the importance of intersectoral health-promoting strategies in the school environment as an effective tool for mitigating risk behaviors in the adolescent population.