A twenty-year retrospective analysis of substance use with recent behavioral addiction indicators (social media, gaming, gambling) among school-going adolescents in Morocco

BACKGROUND: Adolescence is a critical period for the initiation of substance use and other addictive behaviors, which can have long-term health consequences. Monitoring these behaviors is essential to inform prevention and policy strategies in low- and middle-income countries, where evidence remains limited. This study aimed to provide an integrated twenty-year overview of trends in substance use and selected behavioral addictions among Moroccan school-going adolescents and to examine sex differences over time. METHODS: We analyzed 11 nationally representative repeated cross-sectional school-based surveys conducted between 2001 and 2021, including GYTS, GSHS, and MedSPAD. Participants were school-going adolescents aged 13-15 years (GYTS, GSHS) and 15-17 years (MedSPAD). Outcomes included cigarette smoking, shisha, electronic cigarettes, alcohol, cannabis, non-prescription tranquilizers or sedatives, cocaine, crack, heroin, and ecstasy, as well as excessive gaming, gambling, and problematic social media use. Temporal trends were assessed using the Cochran-Armitage chi-square test for trend in proportions and multivariable logistic regression analyses. RESULTS: In 2021, the most prevalent addictive behaviors were social media use (41.2%), excessive gaming (21.5% on school days, 22.6% on non-school days), and gambling (18.3%). Among substances, electronic cigarettes (5.4%), shisha (5.2%), tranquilizers or sedatives without prescription (4.8%), and cigarette smoking (4.6%) were most common, followed by cannabis (3.4%), alcohol (2.6%), ecstasy (1.1%), cocaine (1.0%), and heroin (0.9%). Trend analyses among Moroccan adolescents showed declines in cigarette smoking and shisha use, relative stability in alcohol and cannabis, and marked increases in electronic cigarette and non-medical tranquilizer use. Cocaine and crack use remained uncommon and showed no statistically significant adjusted temporal trends. Across all survey waves, prevalence of substance use and addictive behaviors was consistently higher among male school-going adolescents. CONCLUSION: Rising use of electronic cigarettes, non-medical tranquilizers or sedatives, and behavioral addictions signals a shifting risk profile among Moroccan school-going adolescents, with males consistently reporting higher prevalence. These trends highlight the need for gender-responsive prevention strategies and stronger regulation of emerging substances. Strengthening long-term, standardized surveillance systems is essential to monitor evolving behaviors and support evidence-based policy and adolescent health promotion efforts in Morocco.