International Maritime Health, Vol. 68, No. 1, 2017

ORIGINAL PAPER

Prevalence of consumption of addictive substances amongst Moroccan fishermen

Omar Laraqui1, Salwa Laraqui2, 3, Nadia Manar2, 3, Tarik Ghailan3, Frederic Deschamps1, Chakib H. Laraqui2, 3

1Institut Universitaire De Médecine Et Santé Au Travail, Reims, France

2Ecole Supérieure D’ingénierie De La Santé, Casablanca, Morocco

3Association Marocaine De Recherche En Santé Au Travail, 39, Bd Lalla Yacout, Casablanca, Morocco

Prof. Chakib H. Laraqui, 39 Boulevard LallaYacount, Casablanca, Morocco, tel/fax: 00212 522 44 55 84, e-mail: chlaraqui51@gmail.com

Abstract

Background: The prevalence of toxic habits is constantly increasing in developing countries and all professional sectors are concerned. Seafarers are a particular target because of the dangerousness and complexity of their work. However, few studies have investigated toxic habits in this population. The aim of the study was to determine the prevalence of the use and misuse of addictive substances in seafarers and to appreciate poly-consumptions according to socio-demographic and occupational characteristics.

Materials and methods: This cross-sectional study was conducted amongst 1,219 fishermen. Subjects filled a questionnaire during their medical examination. The questionnaire covered socio-demographic and occupational characteristics, toxic habits (tobacco, alcohol, cannabis and others psychotropic substances). The misuse was assessed by specific tests: dependence on smoking tobacco (Fagerstrom), Cannabis Abuse Screening Test (CAST) and Alcohol Use Disorders Identification Test (AUDIT).

Results: The prevalence of consumption was 58.5% for smoking tobacco, 36.2% for cannabis, and 36.5% for alcohol. Amongst consumers, the prevalence of dependence or misuse was 49% for smoking tobacco, 61.2% for cannabis and 86% for alcohol. Only 115 (9.4%) people had no toxic habit. 56.4% had one toxic habit, 20.4% had two toxic habits, 11.9% had three toxic habits and 1.9% had four toxic habits. The most frequent associations were tobacco-cannabis (10.5%) and tobacco-alcohol (6.1%).

Conclusions: In this sector, occupational health physicians have to play a key role in raising awareness and fighting against toxic habits.

(Int Marit Health 2017; 68, 1: 19–25)

Key words: fishermen, addictive substances, Morocco

INTRODUCTION

The prevalence of toxic habits is constantly increasing in developing countries and all occupational sectors are affected [1, 2]. Seafarers are a particular target because of the dangerousness and complexity of their work [3–5]. However, few studies have partially investigated the toxic habits amongst fishermen in Morocco [6–10]. They respectively showed high prevalence for smoking tobacco (79%, 59.9%, 68.1%, 52.3% and 44.1%), for cannabis use (37.9%, 23.9 %, 41%, 38.9% and 37.8%) and alcohol consumption (64%, 40.4%, 10%, 31.7% and 58.3%). The prevalence of these three toxics was significantly more important than in the Moroccan general male population aged over 20 years (34.5%, 9% and 14%) [11].

All psychoactive substances act on the brain in the same way. They cause a disorder of alertness, a change in the perception of risk and/or an increased risk-taking with consequences in term of public health, prevention and occupational safety [3, 4, 12, 13].

The aim of this study is to determine the prevalence of addictive substances consumption, use and misuse amongst fishermen and appreciate the poly-consummation according to socio-demographic and occupational characteristics.

MATERIALS AND METHODS

Subjects

This epidemiological, observational and cross-sectional study was conducted in three ports of the northern Morocco (Tangiers, Larache and Jebha) in 2014 and concerned 1219 traditional male fishermen older than 20 years with length of employment above 1 year, randomly selected from a complete list of 4213 (29%) fishermen.

Questionnaire

We used an individual and anonymised questionnaire including: sociodemographic and professional characteristics (age, family status, educational level, socio-professional category, and daily working time) and toxic habits: tobacco, cannabis, alcohol and others psychoactive substances.

For smoking tobacco, we have individualised current smokers, former smokers and non-smokers. Subjects were classified as current smokers if they smoked at the time of the survey or if they had stopped less than 3 months before the study and had smoked more than 100 cigarettes throughout their lives. Former smokers were those who had stopped more than 3 months before the study and smoked more than 100 cigarettes throughout their lives. Non-smokers are those who have never smoked or smoked less than 100 cigarettes throughout their lives [14].We quantified the consumption of tobacco in pack-years (number of packs smoked per day multiplied by the number of years of smoking). For the smoking tobacco dependence assessment, the Fagerström test was used [15, 16]. The items are summed to yield a total score of 0 to 10. The classification of dependence is: very low (0 to 2); low (3 to 4); moderate (5); high (6 to 7); very high (8 to 10).

For smoking cannabis, in the same way, we have classified our population to current consumers, older consumers and not consumers. We quantified the consumption in calumet-years. Among cannabis smokers, we used the Cannabis Abuse Screening Test (CAST) [17, 18]. To calculate a score, the responses are coded on a scale of 0 to 4. The total score obtained (which can range from 0 to 24) indicates whether or not the questioned users are at risk. A score of less than 3 indicates no addiction risk, a score of 3 or less than 7 indicates low addiction risk, and a score of 7 or above indicates high addiction risk.

Alcohol consumption is quantified in number of standard drinks per day. A standard drink contains a fixed amount of pure alcohol, i.e. 10 g. A standard drink equivalents approximate number of standard drinks: drink of 10 cl of table wine at 12° = drink of 25 cl of beer at 5° = drink of 3 cl of whisky at 40° = drink of 7 cl of aperitif at 18°. Among drinkers, the Alcohol Use Disorders Identification Test (AUDIT) is a 10-item screening tool developed by the World Health Organisation (WHO) to assess alcohol consumption, drinking behaviours, and alcohol-related problems. A score of 8 or more is considered to indicate hazardous or harmful alcohol use [19, 20].

We defined the use as a moderate or occasional consumption with a low risk to health. The misuse is a consumption that may cause physical, social and/or psychological troubles. The misuse includes hazardous or spot abuse, harmful or repeated abuse and addiction. We considered as having a misuse: dependent cigarette smokers with a Fagerström test score greater than or equal to 5, addiction cannabis smokers with a CAST score greater than 7, hazardous or harmful alcohol consumers with an AUDIT test score of 8 or more.

Procedure of the study

We previously contacted the presidents of the associations of fishermen and the occupational physicians to explain the purpose of the study and obtain their support. The interview lasted between 15 and 20 min for each person, respecting the confidentiality. The questions were formulated orally, if necessary translated into Arabic dialect. The fishermen answered to the questionnaire without difficulty and with enthusiasm.

Statistical analysis

The statistical analysis was performed using the SPSS version 11.5 software package. The differences between groups were compared using t tests for continuous variables and c2 tests for categorical ones. The statistical level of significance was established at 5%. For a proportion, we calculate the lower and upper limits of the 95% confidence intervals (CI).

RESULTS

Demographic and occupational characteristics of fishermen

The average age of total population was 37.9 ± 9.1 years (range 20–82 years). Thirty-two point six per cent were living alone and 67.4% in couple. Thirteen point eight per cent were illiterate, 59.5% had attended primary school, 24.2% secondary school, and 2.5% university. The occupational categories were fishermen (69.2%), mechanics (11.9%) and pilots and co-pilots (18.9%). The average length of employment was 14.9 ± 4.9 years.

Prevalence of toxic habits (Table 1)

Table 1. Prevalence of toxic habits

Toxic habits (n = 1219)

No smokers

Former smokers

Current smokers

Smoking tobacco

285 (23.4%)

221 (18.1%)

713 (58.5%)

Snuff tobacco

993 (81.5%)

76 (6.2%)

150 (12.3%)

Smoking hookah

1105 (90.7%)

38 (3.1%)

76 (6.2%)

Smoking cannabis

567 (46.5%)

211 (17.3%)

441 (36.2%)

Consumption of alcohol

443 (36.3%)

331 (27.2%)

445 (36.5%)

Other psychotropic substances

1074 (88.1%)

32 (2.6%)

113 (9.3%)

The prevalence of harmful habits was as follows: smoking tobacco: 58.5%, 95% CI 55–60; snuff tobacco: 12.3%, 95% CI 10–14; smoking hookah: 6.2%, 95% CI 4.7–7.3; smoking cannabis: 36.2%, 95% CI 33–38; alcohol consumption: 36.5%, 95% CI 33–39 and other psychotropic substances: 9.3%, 95% CI 7.4–10.6.

The average age of onset of smoking tobacco was 16.2 ± 3.8 years, smoking cannabis 17.5 ± 3.7 years, consumption of alcohol 21.3 ± 3.9 years, sniffing tobacco 22.7 ± 4.5 years, smoking hookah 24.7 ± 4.6 years, and using other psychotropic substances 27.1 ± 2.9 years.

The average daily amount of smoked tobacco was 18 ± 6.5 cigarettes, of smoked shisha 0.6 ± 0.2, of sniffed tobacco 15 ± 5.1 snuffs, of smoked cannabis 13 ± 2.1 calumets, and of alcohol 3.5 ± 1.2 drinks.

The harmfulness of tobacco smoking to health was known by 96% of fishermen, alcohol by 92%, cannabis by 67%, tobacco by 35% and hookah by only 27%. Ninety-three per cent of tobacco sniffers were former tobacco smokers. The hookah is considered safer for health by 75% of consumers who consider that dangerous substances smoked are filtered by water.

Attempts of weaning more than 2 days of abstinence were made by 52.6% of tobacco smokers, 68% of alcohol drinkers, 35.5% of cannabis smokers, 22% of hookah smokers and 18% of tobacco sniffers.

The association between sociodemographic characteristics and toxic habits (Table 2)

Table 2. Association between sociodemographic characteristics and toxic habits

N = 1219

ST – 713 (58.5%)

S – 150 (12.3%)

H – 76 (6.2%)

Age [years]:

< 40

≥ 40

P

755 (61.9%)

464 (38.1%)

426 (56.4%)

287 (61.9%)

0.0741

66 (8.7%)

84 (18.1%)

0.0001

60 (7.9%)

16 (3.4%)

0.002

Family status:

Lives alone

Lives in a couple

P

397(32.6%)

822 (67.4%)

246(61.9%)

467 (56.8%)

0.099

36 (9%)

114 (13.9%)

0.022

63 (15.9%)

13 (1.6%)

0.0001

Educational level:

Illiterate

Primary

Secondary

Superior

168 (13.8%)

725 (59.5%)

295 (24.2%)

31 (2.5%)

97(57.8%)

445(61.4%)

159 (53.9%)

12 (38.7%)

31(18.4%)

47 (6.5%)

70 (23.7%)

2 (6.4%)

0 (0%)

24 (3.3%)

24 (8.1%)

0 (0%)

C – 441 (36.2%)

A – 445 (36.5%)

OPS – 113 (9.3%)

Age [years]:

< 40

≥ 40

P

253 (33.5%)

188 (40.5%)

0.016

289 (38.3%)

156 (33.6%)

0.114

65 (8.6%)

48 (10.3%)

0.361

Family status:

Lives alone

Lives in a couple

P

168 (42.3%)

273 (33.2%)

0.002

195 (49.1%)

250 (30.4%)

0.0001

46 (11.6%)

67 (8.2%)

0.067

Educational level:

Illiterate

Primary

Secondary

Superior

55 (32.7%)

246 (33.9%)

140 (47.4%)

0 (0%)

60(35.7%)

233 (32.1%)

152 (51.5%)

0 (0%)

6 (3.6%)

78 (10.8%)

26 (8.8%)

3 (9.7%)

ST – smoking tobacco; S – snuff; H – hookah; C – cannabis; A – alcohol; OPS – other psychotropic substances

The prevalence of smoking tobacco (56.4% vs. 61.9%; p = 0.071), snuff tobacco (18.1% vs. 8.7%; p = 0.0001), smoking cannabis (40.5% vs. 33.5%; p = 0.016) and using psychotropic substances (10.3% vs. 8.6%; p = 0.361) was higher among fishermen over 40 years. The prevalence of smoking hookah (7.9% vs. 3.4%; p = 0.002) and alcohol consumption (38.3% vs. 33.6%; p = 0.114) was higher in subjects under 40 years. The prevalence of toxic habits was higher among people living alone, except for snuff tobacco. The prevalence of toxic habits (smoking tobacco, snuff tobacco, smoking hookah, smoking cannabis and consuming alcohol) was lower among those with a superior educational level except for psychotropic substances.

The average age of tobacco smokers was 37.5 ± 8.9 years, hookah smokers 32.5 ± 7.1 years, tobacco sniffers 42.3 ± 5.2 years, cannabis smokers 38.3 ± 9.3 years, alcohol consumers 36 ± 8.1 years and other psychotropic substances users 39.4 ± 3.4 years.

The prevalence of tobacco smoking (61.9% vs. 56.4%, p = 0.071) and cannabis smoking (40.5% vs. 33.5%, p = 0.016) was higher in subjects above 40 years old. The prevalence of alcohol consumption (38.3% vs. 33.6%; p = 0.114) and smoking hookah (7.9% vs. 3.4%; p = 0.002) was higher in subjects under 40 years old.

The prevalence of toxic habits among people living alone was higher than among those living in pairs except for sniffing tobacco.

Association between socio-professional characteristics and toxic habits (Table 3)

Table 3. Association between socio-professional characteristics and toxic habits

N = 1219

ST – 713 (58.5%)

S – 150 (12.3%)

H – 76 (6.2%)

Length of employment [years]:

< 5

5–15

> 15

P

150 (12.3%)

404 (33.1%)

665 (54.6%)

65 (43.3%)

226 (55.9%)

422 (63.4%)

0.0001

25 (16.7%)

37 (9.2%)

88 (13.2%)

0.032

14 (9.3%)

50 (12.4%)

12 (1.8%)

0.0001

Professional categories:

Pilots/co-pilots

Mechanics

Fishermen

P

230 (18.9%)

145 (11.9%)

844 (69.2%)

127(55.2%)

66(45.5%)

520(61.6%)

0.0001

14(6%)

17(11.7%)

119(14.1%)

0.005

17 (7.4%)

22 (15.2%)

37 (4.4%)

0.0001

Daily working [h]:

≤ 8

> 8

P

337 (27.7%)

882 (72.3%)

189 (56%)

524 (59.4%)

0.322

38 (11.3%)

112 (12.7%)

0.563

15 (4.4%)

61 (6.9%)

0.144

C – 441 (36.2%)

A – 445 (36.5%)

OPS – 113 (9.3%)

Length of employment [years]:

< 5

5–15

> 15

P

41 (27.3%)

210 (52%)

190 (28.6%)

0.0001

51 (34%)

223 (55.2%)

171 (25.7%)

0.0001

9 (6%)

41 (10.1%)

63 (9.5%)

0.315

Professional categories:

Pilots/co-pilots

Mechanics

Fishermen

P

34 (14.8%)

45 (31%)

362 (42.9%)

0.0001

78 (33.9%)

41 (28.3%)

326 (38.6%)

0.038

38 (16.5%)

12 (8.3%)

63 (7.5%)

0.0001

Daily working [h]:

≤ 8

> 8

P

121 (35.9%)

320 (36.3%)

0.956

92 (27.3%)

353 (40%)

0.0001

35 (10.4%)

78 (8.8%)

0.472

ST – smoking tobacco; S – snuff; H – hookah; C – cannabis; A – alcohol; OPS – other psychotropic substances

The average length of employment for the total population was 14.9 ± 4.9 years, for cigarette smokers 15.5 ± 4.2 years, for hookah smokers 10.7 ± 2.8 years, for tobacco sniffers 15 ± 4.3 years, for cannabis smokers 13.8 ± 3.5 years, for alcohol consumers of 13.3 ± 3.7 years and for other psychotropic substances consumers 15.2 ± 4.6 years.

Association between sociodemographic characteristics and misuse (Table 4)

Table 4. Association between sociodemographic characteristics and misuse (dependence)

ST – 353/713 (49.5%)

C – 270/441 (61.2%)

A – 232/445 (52.1%)

Age [years]:

< 40

≥ 40

P

222/426 (52.1%)

131/287 (45.6%)

0.106

171/253 (67.6%)

99/188 (52.7%)

0.002

149/289 (51.6%)

83/156 (53.2%)

0.816

Family status:

Lives alone

Lives in a couple

P

150/246 (60.9%)

203/467 (43.5%)

0.0001

123/168 (72.2%)

147/273 (53.9%)

0.0001

111/195 (56.9%)

121/250 (48.4%)

0.091

Educational level:

Illiterate

Primary

Secondary

Superior

P

62/97 (63.9%)

207/445 (46.5%)

78/159 (49.1%)

6/12(50%)

0.028

34/55 (61.8%)

155/246 (63%)

81/140 (57.8%)

0.605

43/60 (71.7%)

110/233 (47.2%)

79/152 (52%)

0,003

ST – smoking tobacco; C – cannabis; A – alcohol

The average age of people who misuse was 37.2 ± 7.9 years for tobacco smokers, 37.5 ± 6.1 years for cannabis smokers and 36.1 ± 7.2 years for alcohol consumers.

The misuse was significantly more frequent in people under 40 years old for cannabis (67.6 % vs. 52.7%; p = 0.002), but for tobacco (52.1% vs. 45.6%; p = 0.106) and for alcohol (51.6% vs. 53.2%; p = 0.816) the difference was not significant.

For smoked tobacco (60.9% vs. 43.5%; p = 0.0001) and cannabis (72.2% vs. 53.9%; p = 0.0001), misuse was significantly more frequent in people living alone, but for alcohol, the difference was not significant (56.9% vs. 48.4%; p = 0.091).

For smoked tobacco (63.9% vs. 47.2%; p = 0.0001) and alcohol (71.7% vs. 49.1%; p = 0.0001), misuse was significantly more common among illiterate than literate people.

Association between socio-professional characteristics and misuse (Table 5)

Table 5. Association between sociodemographic characteristics and misuse or dependence

ST – 353/713 (49.5%)

C – 270/441 (61.2%)

A – 232/445 (52.1%)

Length of employment [years]:

< 5

5–15

> 15

P

35/65(53.8%)

115/226 (50.9%)

203/422 (48.1%)

0.609

24/41(58.5%)

141/210 (67.1%)

105/190 (55.2%)

0.048

23/51 (45.1%)

115/223 (51.6%)

94/171 (55%)

0.451

Professional categories:

Pilots/co-pilots

Mechanics

Fishermen

P

58/120 (48.3%)

28 /63 (44.4%)

267/513 (52%)

0.443

13/34 (38.2%)

26/45 (57.8%)

231/362 (63.8%)

0.012

34/78 (43.6%)

21/41 (51.2%)

177/326 (54.3%)

0.234

Daily working [h]:

≤ 8

> 8

P

85/189 (45%)

268/524 (51.1%)

0.171

52/121 (42.9%)

218/320 (68.1%)

0.0001

34/92 (37%)

198/353 (56.1%)

0.137

ST – smoking tobacco; C – cannabis; A – alcohol

The average length of employment of people with misuse was 15.3 ± 4.1 years for cigarette smokers, 13.4 ± 3.7 years for cannabis smokers and 13.2 ± 3.9 for alcohol consumers.

For the cannabis smokers, misuse was significantly more common among fishermen than other occupational categories (63.8% vs. 49.4%; p = 0.024). For tobacco smokers (52% vs. 47%; p = 0.282) and alcohol consumers (54.3% vs. 46.2%; p = 0.159), the difference was not significant.

The prevalence of misuse was significantly higher among those working more than 8 h for cannabis smokers (68.1% vs. 42.9%; p = 0.0001) and alcohol consumers (56.1% vs. 37%; p = 0.002). For tobacco smokers (51.1% vs. 45%; p = 0.176), the difference was not significant.

Prevalence of toxic habits associations (Table 6)

Table 6. Prevalence of toxic habits associations

Toxics

N (%)

0 toxic habits

n = 115 (9.4%)

115 (9.4%)

1 toxic habit

n = 687 (56.4%)

T

C

A

OPS

349 (28.6%)

141 (11.6%)

197 (16.2%)

0 (0%)

2 toxic habits

n = 249 (20.4%)

T + C

T + A

A + C

128 (10.5%)

75 (6.1%)

46 (3.8%)

3 toxic habits

n = 145 (11.9%)

T + C +A

T + A + OPS

T + C + OPS

C + A + OPS

55 (4.5%)

42 (3.4%)

41 (3.4%)

7 (0.6%)

4 toxic habits

n = 23 (1.9%)

T + C + A + OPS

23 (1.9%)

Total population

1219 (100%)

T – tobacco; C – cannabis; A – alcohol; OPS – others psychotropic substances

Only 115 (9.4%) people had no toxic habit, 56.4% had one toxic habit, 20.4% had two toxic habits, 11.9% had three toxic habits and 1.9% had four toxic habits. The most frequent associations were tobacco-cannabis (10.5%) and tobacco-alcohol (6.1%).

DISCUSSION

In our study, the interview with fishermen could create a bias and some consumption could be undeclared; therefore, prevalence might to be underestimated.

According to the Health Barometer 2010 of the National Institute of Prevention and Education for Health (INPES, France), the fishery sector was ranked at the first place of consumption of toxic substances: 63.1% were tobacco smokers, 14.5% were hazardous drinkers and 3.4% had used cannabis in the previous month [20]. In our study, the prevalence of toxic habits was 58.5% for smoking tobacco, 36.5% for alcohol, 36.2% for cannabis, 12.3% for snuff tobacco, 9.3% for psychotropic substances and 6.2% for hookah. Five studies amongst fishermen in Morocco [6–10] respectively showed high prevalence for smoking tobacco (79%, 59.9%, 68.1%, 52.3% and 44.1%), for cannabis use (37.9%, 23.9 %, 41%, 38.9% and 37.8%) and alcohol consumption (64%, 40.4%, 10%, 31.7% and 58.3%). The prevalence of these three toxic habits was respectively and significantly higher than that of the Moroccan general male population aged over 20 years (34.5%, 9% and 14%) [11].

In our study, 34.2% of fishermen had more than one toxic habit, 20.4% had two toxic habits, 11.9% had three and 1.9% had four toxic habits. The most frequent associations were tobacco-cannabis (10.5%) and tobacco-alcohol (6.1%). According to the health barometer of the INPES, regular poly-consumption concerns 8.3% of the adult population. The most common combinations were alcohol-tobacco (5.9%), tobacco-cannabis (1.6%) and alcohol-tobacco-cannabis (0.7%) [21]. In our study, 49.5% of the fishermen had an addiction to smoking tobacco, 61.2% were cannabis smokers and 52.1% had risky alcohol-drinking habit. These prevalences were higher than in the general population, according to figures reported by the Moroccan National Observatory for Drugs and Addictions (Observatoire national marocain des drogues et des addictions) with 2% of alcohol abuse, 3.3% of toxic substances abuse and 2.8% of misuse of toxic substances [11].

In Morocco, the prevalence of smoking differs by sector with an average of 52% in urban areas [11]. In a meta-analysis among fishermen [4], the respective prevalences of smoking tobacco in Turkey (81%), Scotland (38%), Greece (40%) and Spain (60%) were as important as in our study (58.5%). Seafarers would smoke more than the general population for several reasons related to poor working conditions, rough and very stressful. Tobacco would be used as a stimulant or anxiolytic [21]. Our fishermen consumed on average 18 ± 6.5 cigarettes per day against 20 cigarettes per day in the Turkish ports and 30 in the Spanish ports [4]. The harmfulness of tobacco smoking to health was known by 96% of our fishermen. In a Scottish series, 88% of smoker sailors thought their current level of smoking was harmful [4]. Snuff tobacco was considered by sailors as less harmful to health than smoking tobacco. It was used for weaning off smoked tobacco.

According to the National Institute for Research and Safety of France (Institut national de recherche et de sécurité [INRS]), the fishing sector is at high-risk of alcohol consumption with 16.6% against 7.7% for general population amongst people between 16 and 64 years of age [22]. In our study, the prevalence of alcoholism (36.5%) was lower than reported in the literature: 68% for Turkish sailors, 80% for Scottish harbourmen and 78% for Greek sailors [4]. This could be explained by an underestimation due to religious beliefs, cultural habits, regulations and laws because alcohol consumption is forbidden by Islam. Consequently, alcohol issues are taboo. The average daily consumption in our series was high, of the order of 3.5 glasses per day. Fifteen per cent of Greek sailors had a daily intake greater than a bottle of wine a day and 12% of Scottish harbourmen exceeded the weekly safety threshold of 21 lenses [4]. The harmfulness of alcohol was known by 92% of our fishermen. Only 7% of Scottish harbourmen considered their level of consumption as harmful to their health [4].

Cannabis is the illicit drug most used in the world [12, 18]. Factors socio-geographical, economic and cultural play an important role in it consumption. Cannabis is grown and consumed massively in northern Morocco because it is cheaper than manufactured tobacco [1]. The prevalence of its consumption in our study was similar than in the literature (36.2% against 40.5%) [20]. The average age of onset of smoking cannabis is 17 years and in the literature, it experimentation is 15 years old in average [22].

The recent craze for hookah is due to the mental representation of the mode of use as being healthier and friendlier than cigarettes [23]. Seventy-five per cent of our fishermen considered that the hookah is safer for health. In Morocco, the prevalence of its use in the general population in 2010 was 4.9%, which was lower than in Tunisia (5.8%) and in Syria (19.7%) [23].

The use of other toxic substances (drugs) by the fishermen is more difficult to assess. In a study of stress among fishermen in Tangier conducted in 2010 [8], the prevalence of psychotropic substances consumption was 4.6%. In our study it was larger, with a rate of 9.3%. In the series described by Novalbos et al. [24], 9% of harbourmen consumed psychotropic drugs during their sea voyages.

Our survey found that fishermen living alone consume more toxic substances than fishermen living in couples except for the snuff.

In our study, the prevalence of toxic habits was greater in people with a low education level except for psychotropic substances. The MARTA survey of the Moroccan population [14] showed that the prevalence of smoking was inversely associated with the level of education among men; thus, the risk was higher among illiterate men than those whose level of education was academic.

Some working constraints increase alcohol consumption: outdoor work (more than half of working time), work in painful or tiring posture, exposure to shaking or vibration, carrying heavy loads, long trips or exhausting or fast [25]. Work stress appears as a possible risk factor exposing to toxic habits. At the seaside, the stress born of high psychological demands, low decision latitude and inadequate professional support, was compounded by difficult and dangerous working conditions [3]. According to the Health Barometer 2010 INPES [21], 36.2% of regular smokers, 9.3% of alcohol users and 13.2% of cannabis users said they had increased their consumption due to problems related to their work over the pasted 12 months. However, these results should not obscure the fact that the professional activity globally remains a protection factor of addictive behaviour, compared to an unemployment situation [26, 27].

CONCLUSIONS

The fishermen are a population at high risk of psychotropic substances use. Collective and individual prevention measures and actions aimed at screening and increasing awareness are needed. The occupational health physicians have to play a key role in the development and implementation of the preventive approach. The support and specialised care facilities must be available to ensure individual attention and early treatment when necessary.

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