Adolescent substance use is an ever-changing topic that can be difficult to stay on top of its many components. Recent data show encouraging declines in the use of some substances such as cigarettes, alcohol, and opioids, although they are still prevalent in the adolescent population. Newer issues such as vaping and the legalization of marijuana bring up new challenges in discussing substance use with young patients. Perceptions of risk and evolving campaigns aimed at young people make these two topics particularly important to address with adolescents. This article reviews the statistics regarding the most commonly used substances in the United States, and some important ways that we can reach out to the adolescent population that is so vulnerable to the harms of substance use. [Pediatr Ann. 2019;48(11):e418–e422.]
Adolescents experiment with many different types of substances but there are a few categories that are more prevalent and persistent: alcohol, tobacco, marijuana, vaping, and in smaller numbers prescription and other illicit drugs. This article focuses mainly on alcohol, tobacco, marijuana, vaping. Opioids are also discussed. Although there are new substances trending each year, there are encouraging data showing that alcohol, cigarettes, heroin, prescription opioids, 3,4-methyl enedioxy methamphetamine (ie, “ecstasy”), methamphetamines, amphetamines, sedatives, and ketamine use were at historic lows in 2018.1 In the past year, use of illicit drugs (with the exclusion of marijuana) was reported at 6.1% in 8th graders, 9.6% in 10th graders, and 12.4% in 12th graders, the lowest levels in the past 20 years.1
It is important to closely monitor the trends in adolescent substance use because this population is particularly vulnerable to peer pressure, advertising, and social influence. Their brain development is still a work in progress so executive functioning and sound decision-making are not maximized. Most adults who have a substance use disorder started using illicit drugs or other substances during adolescence.2,3 Substance use in the adolescent population is also associated with other risky behaviors such as multiple sexual partners and unsafe sexual practices.2 Adolescents who have substance use disorders also report higher rates of physical and mental illness.3 To prevent substance use, curb risky behavior, and treat addiction and other health concerns associated with use, we need to understand the most commonly used substances, trends in substance use, risks of use, and strategies for prevention and treatment.
Adolescents use alcohol more than any other substance, although rates of use continue to decline.1,4 Alcohol use increases as adolescents get older, as shown in the Monitoring the Future National Survey in which 7% of 8th graders, 12% of 10th graders, and 33% of 12th graders reported past alcohol use.4 Binge drinking is the most common way that teenagers use alcohol.4 Binge drinking is defined as 5 or more drinks on one occasion for males and 4 or more drinks on one occasion for females (due to different metabolism rates).4 It is the most dangerous way to drink alcohol and results in significant impairment with high risk of harm. Studies also show high rates of driving while intoxicated or being a passenger in a vehicle operated by an impaired driver in the adolescent population. In 2017, 1 of 18 high school students reported drinking and driving and 1 of 6 high school students reported riding in a vehicle with an impaired driver.5
Underage drinking puts adolescents at risk for numerous detrimental consequences. They are more likely to experience injury or death from alcohol poisoning or alcohol-related accidents.5 They are more likely to be in a motor vehicle accident.5 Judgment is impaired, which lowers inhibition, increases risky sexual behavior, and puts teens at risk for physical and sexual assault.5 Alcohol use also increases risk of poor academic performance, missed classes, lower grades, and even impaired brain development.5 Finally, alcohol use before age 15 years increases the risk of alcohol addiction at some point in life by four times.5
Marijuana is the second most commonly used drug (after alcohol) by adolescents.6–8 Unlike many other substances (alcohol, tobacco, opioids) in which overall use has declined, marijuana use has increased in the adolescent population over the past 10 years.6 The perception of marijuana use has changed dramatically in recent years, with only 1 in 5 adolescents perceiving great risk from monthly marijuana use (in 2014).1,6,7,9 This is in part due to the increased legalization of medical marijuana and recreational marijuana across the US. From 2017 to 2018, usage rates remained fairly steady with approximately 6% of 12th graders reporting daily use.1 Delivery methods for cannabis include smoking, vaping, ingesting, and dabbing (which is smoking or inhaling marijuana in the form of hash oil or wax).10
Cannabis is classified as an illicit substance at the federal level but 33 states and the District of Columbia have passed medical marijuana laws permitting the use of marijuana to treat certain diseases and symptoms under the direction of a medical professional.9 Eleven states and the District of Columbia have also passed recreational marijuana laws legalizing the sale, use, and production of marijuana for recreational use.9 Although the legalization of marijuana is largely limited to the adult population, there is concern that its wider availability could potentially increase adolescent use in those states where marijuana is legalized. This has not yet proven to be the case as levels of use have remained fairly steady.8–10
It is important to note that over the past 30 years, it has been well documented that the potency of tetrahydrocannabinol (THC), the active ingredient in cannabis plant material, has increased significantly (both in the US and internationally).9,10 There are also products being produced that have high concentrations of THC, including wax, dabs, shatter, and butane hash oil.9 This is relevant when assessing the risk potential of marijuana use. Although many adolescents perceive marijuana to be less harmful and risky than other substances, there is still the potential for addiction as well as associated adverse effects. Studies show poorer outcomes in education and employment, poorer cognitive outcomes, lower IQ, impaired social functioning, increased likelihood of vehicular accidents, and higher risk for mental health disorders in those who use marijuana.7,8,10 Research also shows that marijuana can impact the developing brain including the prefrontal cortex, which is where judgment and decision-making occur.8 Health problems, such as heart attacks, respiratory disease, pregnancy complications, and a weakened immune system, are also seen.8,10 Nearly 10% of marijuana users become addicted, and this risk increases significantly with use of the higher-concentration products such as dabs.7,9,10 The younger a person is when they begin using drugs, including marijuana, the higher the likelihood that they will develop substance dependence or addiction in adulthood, and those who use marijuana before age 18 years are 4 to 7 times more likely to develop a marijuana disorder than those who start using at an older age.8,10 Adolescents also tend to see vaping marijuana as a safer way to smoke, likely accounting for the increasing prevalence of this method.9
The current legal status of marijuana in the US is complicated, as the federal classification of marijuana does not match what is occurring at the state level. As it stands, marijuana is classified as a schedule I drug at the federal level, meaning that it has a high potential for abuse, has no currently accepted medical use, and lacks safety for use under the supervision of a physician.8 The American Academy of Pediatrics' (AAP) statement regarding marijuana use opposes the legalization of marijuana but does acknowledge the potential use in children with life-limiting or severely debilitating conditions for whom traditional therapies are not working.8 For this reason, the AAP supports the reclassification of marijuana to a schedule II drug so that research may be performed to determine the risks and benefits of marijuana use for certain conditions.8 The AAP opposes the use of smoked marijuana due to the harmful effects on the lungs and opposes recreational use of marijuana due to the potential harms listed previously.8 Finally, the AAP supports the decriminalization of marijuana use for minors and young adults and encourages a focus on treatment instead of harsh penalties.8
Tobacco can be consumed by several different methods including cigarettes, chewing tobacco, cigars, pipes, lozenges, strips, sticks, hookah, and e-cigarettes (which are discussed separately).11 In 2018, 4.9 million middle and high school students were current tobacco users.11 Although this number sounds high, the use of traditional cigarettes among adolescents in 2018 was actually at its lowest in the history of the Monitoring the Future National Survey, with only 3.6% of 12th graders reporting cigarette use.1 Another survey found that less than 25% of 12th graders reported ever smoking cigarettes and approximately 5% were daily smokers, down from a peak of 25% in 1997.11 Other methods of delivery have also seen a decline in recent years. In 2014, flavored cigars were popular among middle school and high school students with nearly 60% of smokers reporting having tried them.11 Hookah was also popular in 2014, with 20% of smokers reporting using this method.1,11 This rate dropped to approximately 8% in 2018.1,11 A hookah is a device that is typically used in a group and a session usually lasts about 1 hour.11 During a session, the average user inhales 100 to 200 times the amount of smoke they would inhale from one conventional cigarette.11 Due to the long sessions and delivery method, hookah often delivers higher levels of toxic substances than other forms of tobacco use.11 Smokeless tobacco (chew, dip) is less common than cigarette use and more commonly used by males.11
Tobacco use is harmful for numerous reasons, with the most obvious being that smoking damages nearly every organ of the body. Smoking is responsible for nearly 90% of all lung cancers.12 It also contributes to respiratory problems, heart disease, pregnancy complications, and cosmetic effects such as yellow teeth and premature wrinkles.12 Adolescent smokers also tend to engage in other high-risk behavior such as marijuana use, binge drinking, fighting, and unhealthy sexual practices.12 Early use of tobacco also increases the risk of long-term smoking and nicotine addiction, as nearly 90% of adult smokers starting using tobacco prior to age 18 years.11
Vaping is a relatively new method of delivery and has been prevalent in the media recently due to increasing use and increases in lung injury and death related to the use of vaping devices. Adolescent use of vaporizers has risen dramatically in recent years (increasing between 33% and 50% depending the survey).1,13 Currently, vaping ranks second only to alcohol in use by adolescents.1 In 2018, 17.6% of 8th graders, 32.2% of 10th graders, and 37.3% of 12th graders had vaped in the past year.1
The term vaping refers to the use of a battery-powered device with a heating element and includes devices such as e-cigarettes, vape pens, and “mods” (ie, modified vape pens).13 They produce an aerosol, vapor, and small particulates that are suspended in air.13 More than 2 million middle and high school students use these devices, which are often disguised to look like pens or flash drives.14 Many different substances can be used in vape devices, ranging from flavored liquids to nicotine to marijuana.1 Eighth graders report vaping only “flavoring” in most cases, but vaping with nicotine and marijuana increases throughout the high school years, as does the frequency of vaping.1,13 Many students reported not knowing what they were vaping due to inconsistent labeling of products and also sharing vape devices between friends.1,13 Recent evidence has shown that vaping (even non–nicotine-containing liquids) is a risk factor for future nicotine use.13,15
Because the products are fairly new, we do not have much long-term data about the effects of vaping flavored liquid, nicotine, and marijuana on lung function, general health, and brain development. It was initially thought that vaping was less harmful than regular cigarettes.14 In the US, cigarette smoking contributes to about 1 in 5 deaths.15 For this reason, vaping could be a better alternative. However, most nicotine-replacement therapies have a success rate of <7% at the 1-year mark and come with risks of their own.15 So far, the limited studies that have been done show minimal efficacy in smoking cessation with e-cigarettes or other vaping devices.15 Some argue that vaping is less harmful because the main ingredients in the liquid are compounds that have been used extensively in food, pharmaceuticals, and cosmetics.15 However, it is important to note that we have introduced an entirely new inhaled route of long-term and daily exposure to these compounds that is different from dietary ingestion or topical use.15 Although most agree that vaping is likely less harmful than combustible cigarettes, the risk reduction is an area of debate.15 It is also agreed upon that vaping is unlikely to be absolutely safe.15
In fact, at the time of this writing, at least 1,479 patients in the US have experienced severe lung disease and 12 have died due to vaping-related lung injury.16 The patients present with typical pneumonia symptoms but do not respond to treatment and return with fever, shortness of breath, cough, malaise, and gastrointestinal symptoms.17 Testing for infectious agents has been negative in all patients, and computed tomography scans of the lungs show ground glass opacifications.17 Many people who vape have ended up on ventilators in the intensive care unit, and steroids seem to be the most effective treatment.17 It is not yet certain what the cause of this significant lung disease is, and research needs to be done to characterize the chemical composition of vaping liquid, analyze the health effects of vaping, and also determine if the original intended use of helping current cigarette smokers quit is effective.14,15 It is also important to monitor the impact that vaping has on smoking and nicotine use in subgroups such as never-smokers and adolescents.15 The Surgeon General has published a report declaring vaping among adolescents and young adults a major public health concern.15
There are several other substances that are abused or misused by adolescents, although less so than alcohol, tobacco, and marijuana. Approximately 14% of high school students report ever having used illicit or injection drugs, and a similar percentage report having used nonprescription opioids.3 Although some opioid drugs are illegal, such as heroin, there are many opioids that are prescribed by a medical professional, usually for pain relief. These include oxycodone, hydrocodone, codeine, and morphine.18 When used appropriately, these medications can be helpful for some patients; however, their misuse (taking a medication that was prescribed to someone else, taking more than the prescribed amount of a medication, or taking the medication for a longer period of time than indicated) is common.18 In 2016, 3.6% of adolescents reported misusing opioids over the previous year.18 There are promising data in the adolescent population showing that despite the continued rise in opioid overdoses and misuse in the adult population, past year and past month misuse of prescription (non-heroin) opioids by adolescents has dropped significantly in the past 5 years.1,18
Several risk factors have been associated with higher opioid use, such as a family history of substance abuse, favorable parental attitudes about the use of illicit substances, poor parental monitoring, family rejection of sexual orientation or gender, substance use among the peer group, lack of school connectedness, and mental health issues.3 Those who engage in opioid use also tend to engage in other high-risk behaviors such as polysubstance use and risky sexual behaviors.3
Many adolescents do not use just one substance but often combine different drugs such as alcohol, tobacco, and marijuana. Marijuana is seldom used alone and 75% of people who use cannabis also consume alcohol.9 Cannabis use has also been found to be a predictor of tobacco use.9 Those who co-use marijuana and cigarettes also have lower cessation rates for smoking.9 Cannabis and alcohol co-use carries an increased risk of harmful outcomes as well. Those who co-use marijuana and alcohol have higher rates of binge drinking, heavier cannabis use, more severe health problems, high rates of legal, academic, and interpersonal problems, high rates of driving while intoxicated, and high risk for developing dependence.9
Substance use prevention is a difficult topic and there have been few successful campaigns to address the issue. An approach that accounts for the developmental stage of the group seems most effective. Activities that have produced better results in promoting prevention are school-based, peer-led, focused on emotional competence, and have high family engagement and involvement.2
Substance use is rare in elementary school, so prevention strategies should focus on building the necessary skills to make good decisions and avoid peer pressure.19 In early adolescence, avoiding peer pressure was not nearly as helpful as the goal of most children in this age group is to fit in and be like their peers. Enhancing their skills of self-control and decision-making were most beneficial for this group along with mentoring, peer education, and making a public commitment not to use substances.19 Middle adolescence proved to be the most difficult group to reach, as no current method seemed to have an effect on substance use at this age.19 Prevention strategies for late adolescence were most beneficial when focused on the individual person, as this age group shifts to wanting to be unique and stand out from their peers.19 Programs that focus on social influence, refusal skills, health education, and personal goals were found to be beneficial.19 Whatever the approach, we must remain vigilant in educating youth about the harms of substance use and empower them with the skills to resist.
Studies also support that what parents do and say does actually matter to the adolescent population. For this reason, it is important for parents to stay engaged with their children. Simply disapproving of the use of substances can be preventive.20 Parents should also discuss substance use with their children early and often, rather than waiting to have one “big” talk.21 Ensure adolescents know the rules and expectations surrounding substance use, discuss ways to resist peer pressure to participate, model responsible behavior by limiting alcohol intake and avoiding driving after drinking, and show adolescents that you can have fun without substances.21 It is also important for parents to communicate with each other and form a strong network to look out for each other's children. Parents should also be aware of their state's laws regarding furnishing substances (ie, alcohol) to minors as well as “social host” laws that implicate property owners for underage substance use even if they do not provide it to the minor.21
Recognizing and addressing risk factors for substance use early could help prevent use later. Risk factors for substance use include having friends who are using (or even thinking that they do), economic deprivation, family history of substance use, family conflict, lack of parental engagement, and lack of school connectedness.2,3 Protective factors include a commitment to academic achievement, concern about the dangers of substance use, and a strong and supportive bond with parents.18
Although there are some promising data regarding declining adolescent use of cigarettes, alcohol, and opioids, there has been a rise in vaping along with an increase in marijuana use among this group. Different substances come in and out of popularity, but the topic of substance use will always be pertinent to the pediatric and adolescent population. Due to the ever-changing social climate and rapidly shifting trends, it is important to stay up-to-date and be vigilant in discussing these topics with our patients. Taking a nonjudgmental yet educational approach can give adolescents a safe place to disclose what they are using and a place to turn if they need help. We know that just saying “don't do it” is not going to work, so arming ourselves with some important statistics and giving real life examples of the harmful effects of these substances can have a big influence on this population.
- National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services. Monitoring the future survey: high school and youth trends. https://www.drugabuse.gov/publications/drugfacts/monitoring-future-survey-high-school-youth-trends. Accessed October 18, 2019.
- Centers for Disease Control and Prevention. Substance use and sexual risk behaviors among youth. https://www.cdc.gov/healthyyouth/substance-use/pdf/dash-substance-use-fact-sheet.pdf. Accessed October 18, 2019.
- Centers for Disease Control and Prevention. High-risk substance use among youth. https://www.cdc.gov/healthyyouth/substance-use/. Accessed October 18, 2019.
- US Department of Health and Human Services. How common is adolescent alcohol use? https://www.hhs.gov/ash/oah/adolescent-development/substance-use/alcohol/how-common/index.html. Accessed October 18, 2019.
- US Department of Health and Human Services. Risks of adolescent alcohol use. https://www.hhs.gov/ash/oah/adolescent-development/substance-use/alcohol/risks/index.html. Accessed October 18, 2019.
- US Department of Health and Human Services. Marijuana use in adolescence. https://www.hhs.gov/ash/oah/adolescent-development/substance-use/marijuana/index.html. Accessed October 18, 2019.
- Hughes A, Lipari R, Williams M. State estimates of adolescent marijuana use and perceptions of risk of harm from marijuana use: 2013 and 2014. The CBHSQ Report. 2017. https://www.samhsa.gov/data/sites/default/files/report_2121/ShortReport-2121.html. Accessed October 18, 2019.
- Ammerman S, Ryan S, Adelman WPCommittee on Substance Abuse, the Committee on Adolescence. The impact of marijuana policies on youth: clinical, research, and legal update. Pediatrics. 2015;135(3):e769–e785. https://doi.org/10.1542/peds.2014-4147 PMID: doi:10.1542/peds.2014-4147 [CrossRef]25624385
- Schlienz NJ, Lee DC. Co-use of cannabis, tobacco, and alcohol during adolescence: policy and regulatory implications. Int Rev Psychiatry. 2018;30(3):226–237. https://doi.org/10.1080/09540261.2018.1465399 PMID: doi:10.1080/09540261.2018.1465399 [CrossRef]29944032
- US Department of Health and Human Services. Risks of adolescent marijuana use. https://www.hhs.gov/ash/oah/adolescent-development/substance-use/marijuana/risks/index.html. Accessed October 18, 2019.
- US Department of Health and Human Services. Adolescents and tobacco: trends. https://www.hhs.gov/ash/oah/adolescent-development/substance-use/drugs/tobacco/trends/index.html. Accessed October 18, 2019.
- US Department of Health and Human Services. Tobacco's health impact on adolescents. https://www.hhs.gov/ash/oah/adolescent-development/substance-use/drugs/tobacco/health-impact/index.html. Accessed October 18, 2019.
- Miech R, Patrick ME, O'Malley PM, Johnston LD. What are kids vaping? Results from a national survey of US adolescents. Tob Control. 2017;26(4):386–391. https://doi.org/10.1136/tobaccocontrol-2016-053014 PMID: doi:10.1136/tobaccocontrol-2016-053014 [CrossRef]
- US Department of Health and Human Services. Researchers explore health effects of e-cigarettes. https://www.hhs.gov/blog/2018/11/6/researchers-explore-health-effects-of-ecigarettes.html. Accessed October 18, 2019.
- Farsalinos K. Electronic cigarettes: an aid in smoking cessation, or a new health hazard?Ther Adv Respir Dis. 2018;12:1753465817744960. https://doi.org/10.1177/1753465817744960 PMID: doi:10.1177/1753465817744960 [CrossRef]
- Centers for Disease Control and Prevention. Outbreak of lung injury associated with e-cigarette use or vaping. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html. Accessed October 18, 2019.
- Minnesota Department of Health. Health advisory: update on severe acute lung injury among patients who report vaping. https://www.health.state.mn.us/diseases/lunginjuries/index.html. Accessed October 18, 2019.
- US Department of Health and Human Services. Opioids and adolescents. https://www.hhs.gov/ash/oah/adolescent-development/substance-use/drugs/opioids/index.html. Accessed October 18, 2019.
- Onrust S, Otten R, Lammers J, Smit F. School-based programmes to reduce and prevent substance use in different age groups: what works for whom? Systematic review and meta-regression analysis. Clin Psychol Rev. 2016;44:45–59. https://doi.org/10.1016/j.cpr.2015.11.002 PMID: doi:10.1016/j.cpr.2015.11.002 [CrossRef]26722708
- US Department of Health and Human Services. Who influences adolescent marijuana use? https://www.hhs.gov/ash/oah/adolescent-development/substance-use/marijuana/influencers/index.html. Accessed October 18, 2019.
- US Department of Health and Human Services. Strategies for reducing adolescent alcohol use. https://www.hhs.gov/ash/oah/adolescent-development/substance-use/alcohol/strategies/index.html. Accessed October 18, 2019.