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Chapter 2: Nature of Volatile Substance Abuse

Definitional Issues

The core features of VSA definitions across the research literature, are intentionality, the desire to alter one's consciousness and the aim to do so by inhaling a volatile substance.

Essentially, volatile substance abuse may be considered as such if it involves deliberate or intentional inhalation of gases or solvents for the sole purpose of achieving mental excitation or getting a 'buzz'. Indeed, there has been much research evidence that has explored occupational exposure to volatile substances, especially among medical professionals working with dangerous and toxic solutions, and which falls outwith the remit of VSA, but which may present an exaggerated view of the amount of work in the area of inhalant effects.

Another specific niche area, namely, 'poppers', was excluded from the review. These are often classified separately within the research literature.

Across the research literature, there is also conflict in the terms used to describe volatile substance abuse. These include 'volatile substance abuse', 'solvent abuse' and 'inhalant abuse', all of which are used interchangeably in this report.

Abused Products

The research evidence suggests 4 main categories of substances that are abused, these being gas fuels (butane gas), aerosols, solvents and glues.

The 2003 Know the Score publication, 'Volatile Substance Abuse', asserts that the most commonly used substances are:

"Butane gas, used as a propellant for aerosols or as fuel gas for products such as lighters"

and

"Solvents, which are used in many products to keep the ingredients in a liquid state within a canister or bottle."

St George's, University of London, which reports on deaths associated with VSA, has also shown that glue continues to account for a small proportion of VSA deaths, (10% of all substances for deaths recorded in 2004), although its popularity has decreased since the 1970s and 1980s. The actual distribution of substances across all VSA associated deaths recorded by St George's, for the period 1971-2004 are gas fuel (46%), aerosols (18%) and glues (16%). The low use of glue, as compared to other volatile substances, appears to be consistent across all age groups.

Within these 3 substance categories, a plethora of products that can be abused have been identified in the literature. Again, St George's, University of London (2006) provides details of the products associated with death used within each of the three core categories. The data shows that:

• cigarette lighter fuel is the most popular gas fuel product used (accounting for 38% of all substances)
• deodorant/antiperspirants account for 8% of all aerosols used, and are the most popular aerosol product used
• contact adhesives make up almost half of the products used for the glue category, accounting for 7% of all substances used and 47% of all glue types abused (other glues include bicycle tyre repair glue and model glue).

Evidence from the US shows similar trends in popularity between different substances and products. Spiller (2004) reports that, of all cases of solvent abuse recorded by poison control centres across the US for the period 1996-2001 (n=11,670), the three products responsible for most deaths were gasoline (45%), air fresheners (26%) and propane/butane (11%). The precise cause of death is not made clear.

Whilst gas (cigarette lighter refills) and household aerosols clearly account for a large proportion of substances used, there is also evidence to suggest that the array of products being used for inhalation purposes is expanding. In 2004, substances other than gas, aerosols and glues accounted for 10% of all substances associated with VSA deaths (St George's, University of London, 2006). Products in this category (for 2004) include anaesthetic agents, alkyl nitrite and petrol. The use of products outwith the main 3 categories has remained reasonably consistent between 1995-2004, accounting for between 9-18% of all substance use recorded against VSA deaths for that period. There was a low of 2% in 2001, when a corresponding peak in gas fuel usage can be observed.

Although not apparent in more formal research outlets, popular reporting of VSA suggests that recent trends in inhalant abuse include burning of bus shelters to get high and burning of plastic wheelie bins to inhale the fumes (Scotsman, 25 September, 2002). Such observations should, however, be treated with caution since alternative motives, such as vandalism, may also account for such behaviours. St George's, University of London (2006) also note that, in recent years, there has been an increase in the number of deaths resulting from the inhalation of helium.

Given the broad nature of products that can be used, the evidence suggests that VSA is popular, especially among young people, for a number of reasons, including:

• availability - products that can be used are readily available in the home and the school (Kurtzman et al., 2001; Blake and Butcher, 2004)
• cost - the cost of products that can be used is less than the cost of alcohol, cigarettes and other substances (Kurtzman et al., 2001; Blake and Butcher, 2004)
• easy to hide - inhaled products are easy to conceal since they are mostly everyday household items. It is also easy to hide use of volatile substances since inhalation has a short term outwardly visible effect on participants (Kurtzman et al., 2001)
• legality - many of the products that can be used can be legally purchased and do not arouse suspicion among retailers (for example, nail-varnish remover, deodorants and glues)
• low addiction risks - unlike other substances, many of the products used are non-addictive and there is a low risk of dependency. This could, however, be compounded by adolescents simply outgrowing VSA and moving on to other drugs before habitual use of solvents occurs.

Essentially, the evidence shows that volatile substance abuse has a broad profile in terms of products used. Appendix 1 provides a list of substances that are cited in the various sources of evidence reviewed for this research.

Methods of Abuse

A range of inhalation methods are reported in the research literature, including:

Sniffing: "involves the inhalation of vapours directly from an open container or a heated pan" (Kurtzman et al., 2001, p.173)

bagging: "refers to inhalation of vapours from a plastic or paper bag containing the desired substance" (Kurtzman et al., 2001, p.173)

huffing: "implies the oral inhalation of vapours by holding a piece of cloth that has been soaked in the volatile substance against the nose and mouth" (Kurtzman et al., 2001, p.173)

The term tooting is also used in relation to VSA and refers more generally to inhalation of drugs. Buzzing used in this context refers to the sensations experienced through substance abuse.

Volatile substances (in particular aerosols) can also be abused by directly spraying them into the mouth (Kurtzman et al., 2001, p.173). Indeed, St George's, University of London (2006) report that, of all deaths recorded between 1971-2004, the method of administration in 32% of cases was directly into the mouth (this is assumed to be the method of abuse of butane gas lighter refills unless there is evidence to the contrary). Other methods of administration (including sniffing from containers, from cloths/sleeves, plastic bags or from placing plastic bags over the head) show varying levels of accountability since records began, accounting for roughly 2-21% each of administration methods.

Kurtzman et al., (2001) report that habitual users often progress through different inhalation methods from sniffing to huffing then bagging, since the intensity of inhalation increases incrementally using these different methods, producing heightened levels of excitation. This could arguably demonstrate 'tolerance'. That is, using more/stronger solvents to get the same effects, having developed physical/psychological tolerance to the substance.

Variation in abuse methods may also be linked to substance of choice. St George's, University of London (2006) report that direct discharge into the mouth is the most common method of butane lighter refill abuse, whereas aerosols are more likely to be ingested by being sprayed through a cloth and glues inhaled from plastic bags.

Environments of Abuse

Historically, research reported that recreational VSA was essentially a group activity (Richardson, 1989). More recently work from the UK and the US has supported this idea of social solvent abuse with common sites of use being friends homes (McGarvey et al., 1999; St George's, University of London, 2006) and parties (McGarvey et al., 1999). The 2004 St George's, University of London School data for deaths associated with VSA also shows that in 17% of VSA deaths recorded in 2004, the place of abuse was a public place.

Despite this, the evidence shows that the majority of individuals, especially young people, abuse solvents in the home. St George's, University of London provides data relating to place of abuse for VSA death cases recorded from 1995-2004. Consistently, the data shows that most volatile substances are being abused in the home, accounting for 55% of recorded places of death in 2004, and 72% of places of abuse. There has also been a slight increase in the number of cases where the abuse environment is recorded as being the home in the last 10 years.

St George's data also suggests that home abuse accounts for a greater proportion of abuse among over 18s compared to under 18s. Among younger people, the homes of friends and other public places account for around half of reported environments of abuse (compared to <25% among over 18s).

Other environments of use that occur in both the UK and American literature include school and the workplace. These consistently account for only a small number of VSA cases.

Qualitative research commissioned by the Department for Health ( MORI, 2006) explored in more depth the occasions and locations where VSA takes place. It reports that young people engage in solvent abuse in a number of locations including school (both during lessons and recreational time), at home or at friends' houses and other public places. Again, it notes that children's homes may also be locations of abuse.

Essentially, from the evidence that is available, it appears that the high incidence of use in the home highlights the inherent difficulty of identifying VSA and tackling the problem at the social level. It also highlights the need for parental (and guardian) awareness of indicators of VSA (for example, changes in sleep patterns, changes in appetite and drinking patterns, tiredness, irritability and aggressiveness, changes in school performance and changes in general health) to be able to combat VSA. Again, however, the problem exists that many of these vital signs of solvent abuse are similar to those demonstrated among adolescents who are not using solvents.

User Profiles

Age

The research evidence suggests, overwhelmingly, that young people are most likely to be those who abuse solvents (Kurtzman et al., 2001; Spiller, 2004). Further, the research concurs that solvent abuse is likely to be experienced earlier than other forms of drug misuse (Ives, 1999).

The earliest recorded age of death associated with VSA in the UK is 7 years old, ranging to deaths observed for people over 75 (although these are usually suicides). Recent American research has reported VSA among people aged as young as 5 years old (Spiller, 2004).

Most survey evidence relating to self-reported VSA points towards a decrease in popularity among older teens compared to those aged 12-13. The research literature frequently reports reasons for this including low 'street credibility' attributed to VSA among older teens, it being considered only suitable for people who do not have the means to access illicit drugs and the curiosity wearing off among older youths who have already tried VSA. Recently published Department of Health research ( MORI, 2006) also suggests that young people 'at risk' of VSA often perceive it as dirty, dangerous and unglamorous. Indeed, young people interviewed as part of this work reported perceived associations between VSA and becoming a 'junkie'.

Despite this general trend, the Scottish Schools Adolescent Lifestyle and Substance Use Survey ( SALSUS) 2004 survey results suggest that, for use of solvents in the previous month, VSA was 2 times more prevalent among 15 year old boys than 13 year old boys (2% and 1% respectively). The results also showed a greater prevalence of use in the previous year for 15 year olds (4%) compared to 13 year olds (2%).

Further, a shift in proportionality toward older groups has been observed as a general trend in VSA associated deaths, with under 18s accounting for a large proportion of the overall fall in deaths since 1990 (St George's, University of London, 2006).

Gender Differences

The research evidence consistently suggests that prevalence rates for VSA are similar for both males and females. It has also been shown that there are minimal variations in age of onset, lifetime frequency, use in the past year or preferred methods of inhaling between boys and girls (McGarvey et al., 1999). There is also no evidence to suggest that substance of choice is different between males and females (McGarvey et al, 1999) or that environments of abuse differ between the sexes (St George's, University of London, 2006).

In Scotland, the SALSUS 2004 showed no significant differences in the proportion of boys and girls reporting solvent use in the previous year for either 13 year olds (males=2%, females=3%) or 15 year olds (males=4%, females=4%). There were also no differences in reported use in the previous month by gender, or whether pupils had been offered glue, gas or other solvents.

This reflects similar patterns from previous SALSUS surveys with the exception of a high number of 13 year old females in the 2000 survey reporting that they had ever been offered gas, glue or solvents (17% compared to 13% of boys).

In America, data from the National Household Survey on Drug Abuse for 2002 and 2003 showed similar gender patterns of use between males and females (9% compared to 8% prevalence), ( NHSDA, 2005).

One of the only reports to provide evidence counter to this argument is an unpublished report by the Centre for Drug Misuse Research (McKeganey, unpublished) that showed that females taken from a sample of Scottish secondary schools were more likely than their male counterparts to engage in VSA (in school years S1-S3).

Data from the Smoking, Drinking and Drugs Use Survey in England and Wales also shows that, in 2001, 2003 and 2004, females aged 11-15 were marginally more likely to report taking glue, gas, aerosols or solvents in the last year than male peers. In all years, prevalence was 1% greater for girls than boys with rates for girls of 8%, 8% and 6% for the 3 years.

Data from the European School Project on Alcohol and other Drugs ( ESPAD) 2003 survey also reported gender differences in a small number of countries (Belgium, Cyprus, Greece, Portugal and Ukraine), with boys showing higher prevalence rates for lifetime use compared to girls. In only one country did the prevalence rate of lifetime use of inhalants for girls exceed that for boys, this being Ireland.

Whilst the research does, in the main, demonstrate no gender differences, what is clear is that males are more likely to be represented in cases of volatile substance abuse that result in medical attention (Kurtzman et al., 2001.) This is supported by Scottish data reported in the Drug Misuse Statistics Scotland Report ( ISD, 2005) which showed that, of all general acute inpatient discharges with a diagnosis of volatile solvent abuse for the period 2004-05 (n=6), five were male and only one was female.

St George's, University of London also reports that deaths from VSA are more common among males than females, irrespective of age group (St George's, University of London, 2006). In the past 10 years, 81% of deaths in the UK from solvent abuse have been males. The authors do note, however, that although the ratio of female to male deaths has been increasing over this period, this has been due to a decrease in male deaths rather than an increase in female deaths. The proportion of female deaths in 2004 (19%) was lower than in 2003 (28%).

Whilst it seems that there may be an apparent contradiction in the equal prevalence of VSA use between the sexes, but a notably high ratio of male to female VSA related deaths, it is perhaps worth noting that most of the reported prevalence figures relate to 'whether' young people have usedVSA, and do not necessarily take into account frequency of use, or combining VSA with other drugs such as alcohol. It may be that solvents are used more recklessly by some groups than others and this could be explored in future research as a possible contributory factor in understanding gender differences in VSA deaths and serious accidents.

Minority Ethnic Groups

Only limited data exists in the UK that explores ethnic differences in solvent abuse and much of this is anecdotal (Worley, 2001). Analysis of British Crime Survey data conducted by Ives (1999) does show that under 16s in minority ethnic groups are less likely to engage in VSA than white peers, and anecdotal evidence from consultation with practitioners working with vulnerable young people has also shown that they consider it to be more prevalent among white young people (Boylan et al., 2001 cited in Worley, 2001).

In the US, there is evidence to suggest that solvent abuse is more prevalent among white children than black and Hispanic youths. Data from the American school and college survey, Monitoring the Future, shows that senior African American students consistently report lower levels of inhalant abuse than white or Hispanic peers (Johnston et al, 2005). Similarly, data from the National Household Survey on Drug Abuse carried out in the US showed that non-Hispanic black adolescents are less likely than white and Hispanic peers to engage in inhalant abuse (Neumark et al., 1998).

Data from the 2003 National Youth Risk Behavior Surveillance System ( YRBSS) also indicates greater inhalant abuse among Hispanic females (5%) than black females (2%). A 1999 questionnaire survey of 285 juveniles in a young offenders institution in the US also showed that white youths (36%) and youths from other ethnic background (44%) were significantly more likely than black youths to have previously used inhalants.

The common finding in all US studies is lower levels of VSA among black youths compared to white and Hispanic peers.

Socio-Economic Differences

There is a noticeable dearth of research evidence that specifically explores inhalant abuse as related to socio-economic status.

Research by the Centre for Drug Misuse Research ( CDMR), based on a survey of young people in Scotland aged 11-16 (McKeganey, unpublished) reported that VSA was present across all social strata. Findings from the 2003/04 British Crime Survey for glue use also show no notable differences by ACORN group or tenancy type.

With the exception of this unpublished CDMR research, there is little identifiable evidence which explores this relationship and more may be needed to explore any direct association.

Epidemiology and Other Drug Use

In general, prevalence data shows a link between VSA as a 'gateway drug' (along with cigarettes, marijuana and alcohol) to other forms of illegal drug and alcohol abuse. Much of the literature in the field shows that solvents are initially tried through curiosity, out of boredom or to provide a means of escapism. Once tried, the curiosity element diminishes and use can in itself become boring such that other drugs are tried which can provide a greater 'buzz' or higher degree of escapism.

Whilst these reasons for VSA are widely reported in the guidance and information materials available to professional and lay-readers, it appears that much of the empirical research underpinning these assumptions stems from the 1980s. Work by O'Connor, (1983) continues to be cited in contemporary reviews of VSA literature and there appears to be a dearth of more recent consultative work that explores young people's reasons for abusing solvents.

Research commissioned by the Department of Health ( MORI, 2006), and based on self-reported histories of young people who were abusing or had previously abused solvents (or were considered 'at risk' of abusing substances), offers some insight into pathways into VSA. It indicates that many young people learn about VSA through peer networks, often where one or more of their peers is already experimenting and encourages others to do so. The research also shows that many young people try solvents as a group at first, and then progress on to more private use, only after long-term engagement. The 'social' aspects of VSA include sharing of tips between peers about how to achieve maximum excitation and sharing the 'buzz' was seen as being akin to sharing a joint of cannabis.

The Department for Health research also suggests that young people who have previously engaged in VSA may be classified into one of 3 groups, these being experimental users, those who use VSA as a stepping-stone to other drug use or combine it with other drugs and problematic users for whom VSA is long-standing and chaotic.

What is more obvious from recent literature is the link between VSA and other drugs.

Data from the 2003 Smoking, Drinking and Drug Use Survey showed that young people who reported having taken volatile substances by the age of 13 were more likely than those who had not to have taken Class A drugs in the last year (16% compared to 7% respectively).

The 2005 US National Survey on Drug Use and Health ( NSDUH) report states that just over a third (35%) of young people aged 12-13 who have used inhalants at least once in their lifetime have also used another illicit drug. This compares to 7.5% of young people who have never tried inhalants.

The NSDUH report also shows that a greater proportion of adults who reported using inhalants at, or before the age of 13, were more likely to be classified as alcohol/drug dependent or abusers in later life than those whose first inhalant abuse occurred at age 14 or older.

Based on an interview survey with young offenders in a Canadian young offenders institution, Young et al. (1999) report a significant relationship between inhalants and cocaine, with a mean age of initial experimentation for inhalants of 9.7 years and a mean age of first use for cocaine of 14.4. Whilst only 14% of the 212 participants said that they had ever used inhalants, among those who had, solvent abuse had preceded all other substance abuse. Of those who had not used solvents, the drug use progression pattern was consistently found to be alcohol and cigarettes, marijuana, cocaine, hallucinogens and opiates.

An early study by Davis, Thorley and O'Connor (1985), involving case study analysis of four young adult glue sniffers, showed a number of factors that were common to the transition from solvent abuse to illicit drug/alcohol abuse. These included parental deprivation, rejection in childhood and associated mental ill health consequences as well as inhalation of heroin, "snorting" and injecting heroin. American research from the same era showed that solvent abuse among children and juveniles could lead to opiate addiction given a certain set of social circumstances (Altenkirch and Kinderman, 1986).

In Scotland, however, data from the Scottish Drugs Misuse Database shows that, in the year ending 31 March 2005, less than 1% of service users who presented to Scotland's local authorities or health boards, for whom their main drug of misuse was heroin, also reported using solvents.

Further, qualitative data from the Department of Health research ( MORI, 2006) suggests that, for many young people, abuse of volatile substances in conjunction with other drugs tends to be uncommon among 'new' users. It also suggests, however, that more established users may combine VSA with cannabis to improve the effects and, among older users, VSA may be used interchangeably with harder drugs or as a way to enhance the effects of harder drugs.

The evidence would suggest that, whilst the relationship between different types of drug use is not causal, the frequency with which progressive patterns of substance abuse occur may indicate that solvent abuse is a risk factor for subsequent illegal drug use. In this respect, early identification of solvent abuse may indicate 'at risk' groups and act as a trigger for implementing interventions.

As with other epidemiological studies, the reasons for transition from volatile substance abuse to misusing other substances is not clear, and this might suggest a need for more consultative work with solvent users to develop a clearer picture of drug use histories.

Psycho-Social Correlates of Volatile Substance Abuse

VSA has been linked in the evidence to a number of psychosocial problems and associated risk behaviours. Perhaps the 2 strongest themes to emerge from the research evidence are the heightened risks of VSA among young people involved in the criminal justice system and looked after and accommodated children.

Crime and Delinquency

There is a strong body of evidence that links substance use more generally with criminal and antisocial behaviours, especially among young people (Melrose, 2000). The evidence linking VSA and youth offending is less visible since much of the work in this field focuses on illicit drugs, alcohol and tobacco.

Part of the reason for the lack of research exploring direct links between VSA and crime may be that, compared to other drugs, there are relatively few crimes associated with the acquisition of volatile substances due to their ready availability (McVey, unpublished).

Although VSA is not an offence, the Children (Scotland) Act 1995 states that young people can be referred to the Children's Reporter for the abuse of solvents. Referral data from the Scottish Children's Reporter Administration ( SCRA) shows that 44 children were referred to the Children's Reporter on grounds of misused solvents for the period 2003/04. In 2004/05 this number decreased by 34% with 29 children referred in the reporting year. SCRA hold data that shows the nature of previous and subsequent referrals for young people referred on grounds of misused solvents but this data is not readily available.

In England, research by the Home Office suggests that VSA is particularly prevalent among serious persistent offenders and lifetime minor offenders, and also reported associations between VSA, truancy, being excluded from school and being homeless or sleeping rough (Goulden and Sondhi, 2001).

Later research by the Home Office (Pudney, 2002), based on an analysis of behavioural sequences observed in the 1998 Youth Lifestyles Survey, also showed that the average age of onset for volatile substance abuse was broadly the same as the average age for the onset of criminal behaviour.

Studies from America provide stronger evidence for an association between VSA and delinquency. In the US, a special report from the NSDUH, focusing on inhalant abuse and delinquent behaviours, reported that young people aged 12-13 who reported having used inhalants at least once in their lifetime were more than twice as likely to have been in a serious fight at school or at work in the past year than those youths who had never used inhalants ( NSDUH, 2005b). The data show that inhalant users were also 6 times as likely to have attempted to steal.

Other recent American research involving interviews with incarcerated juveniles reported that the majority of young offenders had tried inhalants before the age of 13 (Prinz and Kerns, 2003). Earlier work by Howard and Jenson (1999), involving interviews with young people on probation found prevalence rates of 3% for current inhalant abuse, 20% for use in the last year and 34% for lifetime use. The research also found that convicted youths with current or previous inhalant experience reported significantly less family support and cohesiveness than non-inhaling peers, as well as demonstrating lower self-esteem, lifetime thoughts of suicide and suicide attempts, neighbourhood gang activity, peer and parental substance abuse, intentions to engage in illegal behaviour, substance-related criminality, and substance abuse (Howard and Jenson, 1999).

Finally, research by Malesevich and Jadin (1995) estimates the lifetime prevalence of inhalant abuse among juveniles in US correctional facilities as being around 45%.

Findings such as these highlight the vulnerability of young people at future risk of offending, and perhaps indicate a need for more targeted research to explore ways of preventing VSA as a possible preventative mechanism for future offending.

No data was identified that specifically reported levels of inhalant abuse in young offenders institutions in the UK. Certainly, it appears that this data is not routinely collected either for young people or older prison populations. The Scottish Prison Service Prisoner Survey does not, for example, include questions relating to inhalants, only to illegal drug misuse.

The only evidence relating to levels of inhalant abuse among UK prisoner and young offender populations is an ad hoc unannounced short inspection of HM Young Offender Institution Werrington by HM Chief Inspector of Prisons (Home Office, 2000). It reported that:

"a large number of children who enter young offender institutions have been involved in substance abuse. It is expected that many will have changed from abusing volatile substances, to drugs."

A questionnaire survey of around 100 juveniles within the establishment, of which 77 were returned, showed that 42% of respondents had (at some time) sniffed solvents before entering the institution (n=32). Among these respondents, the product that was used most often was gas, followed by petrol and glue.

The report also revealed that young people had access to a number of substances within the establishment, including petrol, glue, paint stripper, gas, aerosols and paint cigarette lighter refills, some of which had been accessed through classes/workshops in which the young people were involved. Whilst only one respondent said that they had personally abused these substances whilst in the establishment, 29% said that they thought inhalants were currently being used by their peers. The report recommends that:

"staff should be made aware of the issue in protecting juveniles from solvent abuse, and the importance of keeping substances in a secure place." (p.13)

Whilst limited, the research suggests that young people in criminal justice care organisations may be at high risk of solvent abuse, either prior to entry or, in some cases, whilst in custody.

Looked After and Accommodated Young People

Another group that have been shown to be at high risk of solvent abuse is looked after and accommodated children (Social Services Inspectorate, 1997; Melrose, 2000).

Worley (2001) provides a comprehensive review of literature in the area of volatile substance abuse and looked after young people. She describes work by Guirgus and Vostanis (1998) and the Social Work Inspectorate (1997) both of which show that alcohol and solvents are the 2 main substances of choice for looked after young people. In general, her resume of research shows that those in residential care are more likely to fall into vulnerable groups for whom VSA risk is high, including those with histories of familial separation, poor school attendance, or with previous offending histories.

A 2001 Scottish based Local Authority survey of residential children's units also suggested that social care establishments for young people may be high risk environments for VSA. The survey, carried out by the Local Authority social work services team, explored staff awareness of types of products that might be inhaled, access to products and protocols in place to control access to risky substances, estimated prevalence of use in the establishment, referral mechanisms for problematic users, staff awareness of the risks and dangers associated with VSA and residents' perceived awareness of the risks of VSA. This unpublished document suggests that VSA is known to occur within residential homes in Scotland and that staff and residents may benefit from education/training in the area. This survey provides an example of good practice in relation to VSA monitoring in residential care homes for young people, and may provide a template for more regular and systematic Scotland wide research.

In her concluding observations regarding the link between VSA and social housing for young people, Worley asserts that more research is needed in the area of 'vulnerable' young people and substance abuse, in particular focussing on looked after young people, those excluded from mainstream schools and young offenders (Worley, 2001). Our review suggests that this gap still remains unfilled.

Physiological and Psychological Correlates of Volatile Substance Abuse

Research that directly explores the physiological and psycho-social correlates of VSA is not extensive, partly because, for the most part, experimentation with solvents is short term, non-addictive and non-chronic (Shu and Tsai, 2003).

There does appear to be much information about consequences of VSA in the educational and information materials produced by a number of drugs organizations, however, this evidence is presented anecdotally and is rarely linked to empirical or scientific research.

Physiological Risks

Essentially, solvents are used in order to achieve intoxication. The effects of inhalant abuse are short lived and last around 15-45 minutes ( BBC, undated; Know the Score, 2003), depending on the product used. Early physiological effects from inhalation, as reported in the literature, include:

• euphoria
• lowering of inhibitions
• feelings of drunkenness
• disorientation
• blurred vision
• dizziness
• slurred speech
• drowsiness
• hallucinations
• nausea
• blackouts.

Mid-term effects include drowsiness and feeling hung-over. Again, nausea, blackouts and severe headaches can occur after the initial 'buzz'. Spots and rashes can also appear around the nose and mouth (Know the Score, 2003).

A common injury associated with VSA is burns caused by flammable products or exploding canisters (Cox, Hwang, Himel and Edlich, 1996; Kurbat and Pollack, 1998; Oh et al., 1999).

Most of the research literature concerns the longer-term effects of VSA, including:

• brain damage
• kidney failure
• liver failure
• lung damage
• bone marrow damage
• damage to ears and eyes
• damage to reproductive organs.

Evidence also suggests that petrol sniffing can lead to a progressive decline in cognitive function and, after prolonged use, permanent neurological change (Cairney, Maruff, Burns and Currie, 2002).

Whilst the physiological dangers of VSA are widely reported, anecdotal evidence gleaned during consultations with key stakeholders suggests that more scientific work may be required to better understand the dangers of VSA. In particular, it was suggested that there may be a need for research into the properties of the separate butanes contained in 'butane' (i.e. n-butane, or 'normal' butane, and iso-butane) to explore which gives the greater "buzz" and which is the more dangerous in a fuel canister.

Potential impurities in fuel grade 'butane' may also be important. The risk of harm from chronic exposure to butane in not well researched - or at least published. Mechanism of death (cardiac arrhythmia) is also not well researched.

Consultations also indicate that the current internationally recognised procedures for resuscitating patients with heart attacks or arrhythmias involves injection of adrenaline. This could potentially be fatal where arrhythmia/fibrillation is caused by solvent abuse and it was suggested that this issue may need to be brought to the urgent attention of medics and other professionals working with VSA admissions.

Psychological Risks

Although there appears to be recent research exploring the psychological correlates of inhalant abuse, much of this work is non- UK based.

Most recently, data from the 2004 US National Survey on Drug Use and Health showed that people experiencing major depressive episodes ( MDE) in the past year were more likely than those without MDE to have used inhalants in the past year ( NSDUH, 2005a). This supports earlier work that showed that significantly more solvent abusers were depressed than non-solvent abusers among 47 admissions to a regional assessment center for adolescent boys in the US (Jacobs and Ghodse, 1987).

Work carried out in Taiwan, involving analysis of cognitive tests and psychiatric symptoms of six long-term glue sniffers admitted to a psychiatric ward showed that long term abuse was linked to violent behaviour and/or self mutilation (Shu and Tsai, 2003). Psychosis and deteriorating intelligence were also noted after long term use of glue. This research was, however, carried out with a small sample recruited from a psychiatric population and the results should, therefore, be treated with caution.

The National Children's Bureau (2004) report that solvent abuse among young people is often linked to their experience of emotional health and well being and experiences of abuse and violence.

Instances of VSA associated suicide have also been noted (St George's, University of London, 2006).

Deaths Associated with VSA

The most significant risk of VSA is sudden death. Indeed, the most common cause of death among solvent abusers is sudden failure of the heart (DoH, 2005). The Framework Report explains that 'sudden sniffing death' refers to "cardiac arrhythmia or a sudden catastrophic event" (p.5) which is distinct from other forms of heart failure that are progressive and are not usually associated with VSA.

Adgey, Johnston and McMehan (1995) provide a tripartite analysis of cardiac arrest including: cardiac arrhythmia; anoxia, respiratory depression and vagal stimulation; and aspiration of vomit or trauma. All 3 of these may be associated with VSA.

Evidence from other literature suggests that VSA related death can occur as a result of choking on vomit whilst intoxicated, or suffocation if bags are used to assist inhalation (Know the Score, 2003). Death might also occur as a result of drowning, jumping from buildings or other high risk behaviours whilst intoxicated (ibid).

The risk of sudden death means that VSA can be fatal if tried only once. St George's, University of London (2006) reports that, in 2004, in 77% of VSA associated deaths (n=36), there was evidence of a previous history of solvent abuse. For the remaining 23% there was no evidence of their having indulged in VSA before, or the previous history was unknown. The authors point out, however, that this does not conclusively mean that these people died from first time VSA.

Analysis of St George's data from the previous ten years shows a steady increase in numbers of deaths in the UK between 1994-1998 (from 67 to 80 deaths), and a downward trend for the period 1999-2004 (from 75 to 47). The drop in deaths between 2002 and 2003 is the biggest decrease in this period, with deaths falling from 65-53. These numbers compare to peaks of 152 in 1990, 137 in 1988 and 122 in 1991. The lowest ever recorded number of deaths was 2 (in 1971 and 1974). However, the data collection methods in use at that time were inconsistent with current methods.

Data for Scotland in the 10 year period 1995-2004, as provided by the Crown Office and General Register Office for Scotland, shows that it has the fourth highest VSA mortality ratio of all UK jurisdictions. The mortality ratio for Scotland for this period is 134 compared to 158 in the North East of England, 137 in the East Midlands and 136 in Northern Ireland. The 'all England' figure for the same period is 96 and for Wales is 89. There was a drop in the SMR for Scotland between the 10 year periods of 1994-2003 (143) and 1995-2004 (134).

Cause of death can vary depending on the type of product abused. For example, use of adhesives are more likely to be linked to death by trauma, butane cigarette lighter refills are most likely to be linked to death by cold burns to the throat and lungs, causing vagal stimulation and cardiac arrest (Adgey et al.,1995). These authors also report that resuscitation from sudden death due to cardiac arrythmia associated with volatile substance abuse is rarely successful (ibid).

The St George's, University of London data provides an example of good practice in terms of trend monitoring and evidence gathering for VSA prevalence. Consultation with some of the key stakeholders working in the field of VSA suggest that it is unrivalled by other countries. In the US, the Toxic Exposure Surveillance database ( TESS) of the American Association of Poison Control centres does provide similar data on cases reported to poison centres across the country of intentional inhalation of non-pharmaceutical substances. The database also records medical outcomes of inhalation including death resulting from exposure. These centres cover 95% of the US population and this database therefore provides reasonable coverage of deaths associated with solvent abuse for the nation. The TESS was the only data source identified for VSA death monitoring outside of the UK.

That said, however, St George's, University of London note a number of limitations to the data that is available and reported. These include:

• deaths classified as VSA related sometimes emerge after the reporting year. These are subsequently added to later reports but numbers reported may be subject to change as deaths are investigated and re-classified.
• changes in the data collection methods from the period 1971-1982 mean that accurate trend analysis of the whole dataset cannot be carried out. This may not, however, be relevant 24 years on.
• the database includes cases where there is no toxicological proof of inhalant abuse but where circumstantial evidence dictates that the death is classified as being VSA related.

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