Sex Differences in the Factors Associated With Lifetime Alcohol, Tobacco and Cannabis Use Among Ghanaian University Students: A Cross‐Sectional Study

Background: Substance use among university students in Ghana is a pressing concern, with pronounced sex differences yet poorly characterised determinants. This study examined factors associated with lifetime alcohol, tobacco and cannabis use among undergraduate students, with explicit attention to sex-specific patterns. Methods: A cross-sectional study was conducted from January to March 2023 at the University for Development Studies, Tamale. A total of 600 undergraduate students were recruited using quota sampling proportional to school, year and sex, followed by simple random selection (response rate 100%). Lifetime use was defined as self-reported use of each substance at least once, measured using an adapted World Health Organization (WHO) Student Drug Use Survey. Sex-stratified modified Poisson regression with robust standard errors estimated prevalence rate ratios (aPRRs) and 95% confidence intervals (CIs). Results: Lifetime prevalence was 17.7% for alcohol, 17.0% for tobacco and 16.7% for cannabis. Males reported higher use across all substances (alcohol: 31.1%; tobacco: 30.6%; cannabis: 27.4%) than females (11.3%, 10.6%, 11.6%). In the total sample, male sex (aPRR 2.01), older age (>24 years) (1.85) and peer or family drug history (1.41-1.48) predicted higher alcohol use, whereas Islamic faith (0.59) and residing at a friend's house (0.49) were protective. Male sex (3.12) and non-Christian religion (3.28) predicted tobacco use. Male sex (2.56) was the only pooled predictor of cannabis use. Sex-stratified analyses revealed distinct patterns: strict parental supervision and absence of family conflict protected males against alcohol use; Islamic faith protected females; residential autonomy and persistent family conflict were female-specific cannabis risk factors. Conclusions: Sex differences profoundly shape substance use among university students in Ghana. Religion, parental oversight and family dynamics are key protective or risk factors that differ by sex. Prevention strategies must be sex-sensitive and culturally grounded.