Substance use among adolescents (people from approximately 10 to 21 years of age) ranges from sporadic use to severe substance use disorders (1, 2). The acute and long-term consequences range from minimal to minor to life threatening, depending on the substance, the circumstances, and the frequency of use. However, even occasional use can put adolescents at increased risk of significant harm, including overdose, motor vehicle crashes, and consequences of risky behaviors such as higher rates of sexually transmitted infections (STIs) and development of substance use disorders (3, 4).
Regular use of alcohol, cannabis (marijuana), nicotine, or other drugs during adolescence is associated with higher rates of mental health disorders, poorer functioning in adulthood, and higher rates of addiction (5, 6).
Adolescents use substances for a variety of reasons:
To share a social experience or feel part of a social group
To relieve stress
To seek new experiences and take risks
To relieve symptoms of mental health disorders (eg, depression, anxiety)
Additional risk factors include poor self-control, lack of parental monitoring, and various learning or mental health disorders (eg, depression, anxiety, attention-deficit/hyperactivity disorder) (7, 8). Parental attitudes and the examples that parents and caregivers set regarding their own use of alcohol, tobacco, prescription medications, and other substances are a powerful influence.
The COVID-19 pandemic had a mixed impact on adolescent substance use (9, 10, 11). During stay-at-home periods, rates of initiation decreased, but rates of heavy use increased because some adolescents increased their substance use as a mechanism for coping with stress.
The type and potency of substances used by adolescents varies depending on individual, local, and national factors. In the United States, trends that have increased the risk of both acute and long-term consequences for adolescents include the introduction of vaping nicotine and high-potency cannabis products and the wider availability of prescription opioids and fentanyl.
The rates of overdose among youth have significantly increased (12). Overdose increase is primarily due to the presence of synthetic opioids in the illicit drug supply (13).
(See also Overview of Substance-Related Disorders.)
References
1. World Health Organization. Adolescent health. Accessed August 18, 2026.
2. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, (4th ed). Elk Grove Village, IL: American Academy of Pediatrics; 2017
3. Haider MR, Kingori C, Brown MJ, Battle-Fisher M, Chertok IA. Illicit drug use and sexually transmitted infections among young adults in the US: evidence from a nationally representative survey. Int J STD AIDS. 2020;31(13):1238-1246. doi:10.1177/0956462420950603
4. Gray KM, Squeglia LM. Research Review: What have we learned about adolescent substance use?. J Child Psychol Psychiatry. 2018;59(6):618-627. doi:10.1111/jcpp.12783
5. Tervo-Clemmens B, Gilman JM, Evins AE, et al. Substance Use, Suicidal Thoughts, and Psychiatric Comorbidities Among High School Students. JAMA Pediatr. 2024;178(3):310-313. doi:10.1001/jamapediatrics.2023.6263
6. Hansen ER, Kruckow S, Ewing SWF, et al. Adolescent substance use patterns and subsequent risk of mental and behavioural disorders, substance use, and suicidal behaviour: a cohort study. Lancet Public Health. 2025;10(7):e578-e587. doi:10.1016/S2468-2667(25)00115-X
7. Degenhardt L, Stockings E, Patton G, et al. The increasing global health priority of substance use in young people. Lancet Psychiatry. 2016;3(3):251-264. doi:10.1016/S2215-0366(15)00508-8
8. Groenman AP, Janssen TWP, Oosterlaan J. Childhood Psychiatric Disorders as Risk Factor for Subsequent Substance Abuse: A Meta-Analysis. J Am Acad Child Adolesc Psychiatry. 2017;56(7):556-569. doi:10.1016/j.jaac.2017.05.004
9. Dumas TM, Ellis W, Litt DM. What Does Adolescent Substance Use Look Like During the COVID-19 Pandemic? Examining Changes in Frequency, Social Contexts, and Pandemic-Related Predictors. J Adolesc Health. 2020;67(3):354-361. doi:10.1016/j.jadohealth.2020.06.018
10. Serang S, Zhou W, Page L, et al. Adolescents' substance use trajectories across the COVID-19 pandemic: implications of pandemic disruptions and other risk and protective factors. Child Dev. Published online March 27, 2026. doi:10.1093/chidev/aacaf058
11. Temple JR, Baumler E, Wood L, et al. The Impact of the COVID-19 Pandemic on Adolescent Mental Health and Substance Use. J Adolesc Health. 2022;71(3):277-284. doi:10.1016/j.jadohealth.2022.05.025
12. Miech RA, Patrick ME, O'Malley PM, et al. Monitoring the Future national survey results on drug use, 1975-2025: Overview and Detailed Results for Secondary School Students. Monitoring the Future Monograph Series. Institute for Social Research, University of Michigan; 2026.
13. Friedman J, Godvin M, Shover CL, Gone JP, Hansen H, Schriger DL. Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021. JAMA. 2022;327(14):1398-1400. doi:10.1001/jama.2022.2847
Specific Substances
The substances that are used most commonly by adolescents in the United States are alcohol, nicotine (in tobacco or vaping products), and cannabis.
Alcohol
Alcohol is the substance most often used by adolescents. The United States Monitoring the Future Survey on Drug Use reported that, in 2025, by 12th grade, 41% of adolescents have tried alcohol in the past year, 23% have been drunk in the past year, 22% have consumed alcohol in the past 30 days, and 9% have had more than 5 drinks in a row in the prior 2 weeks (1). Rates have generally decreased since 1976.
Heavy alcohol use is also common. Much of the alcohol consumed by adolescents occurs during a binge, putting them at risk of accidents, injuries, unwanted sexual activity, and other adverse outcomes (2). A binge is defined as a pattern of alcohol consumption that raises the blood alcohol level to 0.08 g/dL (17.37 mmol/L) (3). The number of drinks that will cause blood alcohol to reach this level depends on age and sex and can be as few as 3 drinks within 2 hours for younger adolescent girls, although for some survey-based research binge drinking is defined as 5 or more drinks in a day (4).
In some societies, drinking is portrayed in the media as acceptable, fashionable, or even as a healthful mechanism for managing stress, sadness, or mental health issues. Despite these influences, parents can make a difference by conveying clear expectations to their adolescent regarding drinking, setting limits consistently, and monitoring. On the other hand, adolescents whose family members drink excessively may think this behavior is acceptable.
Some adolescents who try alcohol develop an alcohol use disorder (5), with adolescents who try alcohol at an earlier age more likely to develop the disorder. Heritability has been estimated at between 40 and 70% (6), so adolescents who have a family member with an alcohol use disorder should receive appropriate support to ensure their current well-being and counseling about their increased risk of developing a substance use disorder.
Nicotine
The majority of adults who smoke cigarettes began smoking during adolescence. Adolescents who try cigarettes at age 13 years or younger are more likely than other adolescents to continue to smoke tobacco as adults (7).
Rates of conventional tobacco cigarette use among adolescents in the United States fell dramatically in the 1990s and 2000s and continue to decline. The Monitoring the Future Survey reported that in 2025, approximately 3% of 12th graders reported current cigarette use (smoked in the previous 30 days), down from 28.3% in 1991; only approximately 0.8% report smoking every day (1).
Risk factors for adolescent smoking include (8, 9):
Parental or other family smoking
Peer smoking
Vaping tobacco (a risk factor for smoking conventional cigarettes).
Use of alcohol or other substances
Poor school performance
Poor self-esteem
Sensation seeking
Lower socioeconomic status
Exposure to tobacco marketing or media portrayal of smoking
Availability of cigarettes
Adolescents also use tobacco products in other forms. Approximately 3% of 12th graders reported having used smokeless tobacco in the last 30 days in 2025 (1). Smokeless tobacco can be chewed (chewing tobacco), placed between the lower lip and gum (dipping tobacco), or inhaled into the nose (snuff). Pipe and cigar smoking are relatively rare in the United States. Although prevalence remains low, reported use of nicotine pouches has significantly increased. Among 12th graders, the percentage reporting use within the last year increased from approximately 3% in 2023 to 7% in 2025.
Parents can help prevent their adolescent from smoking and using smokeless tobacco products by being positive role models (that is, by not smoking or chewing), openly discussing the hazards of tobacco, and encouraging adolescents who already smoke or chew to quit, including supporting them in seeking medical assistance if necessary (see Cessation in children).
Electronic cigarette products (vaping products)
Electronic cigarettes (e-cigarettes, e-cigs, vapes) use heat to volatilize a liquid containing the active ingredient, typically nicotine or tetrahydrocannabinol (THC). Electronic cigarettes initially entered the market as alternatives to smoking for adults who smoke, and initial models were not used much by adolescents. They have since morphed into "vapes," which are highly attractive to and have become increasingly popular among adolescents over the past several years, especially among adolescents of middle and upper socioeconomic status. Current e-cigarette use (nicotine vaping, not counting other substances) among 12th graders increased markedly from 11% in 2017 to 25% in 2019 (1). However, according to the Monitoring the Future Survey, by 2025 e-cigarette use reported within the last 30 days had decreased to approximately 16%, likely due to successful policy and regulatory changes as well as public health campaigns (10, 11).
Electronic cigarettes cause different adverse effects compared to smoking (12). Other chemicals contained in vaping products can cause lung injury, which can be acute, fulminant, or chronic and, in its most severe form, lethal. In addition, these products can deliver very high concentrations of nicotine and THC. THC and nicotine are highly addictive, and toxicity is possible. E-cigarettes are increasingly the initial form of exposure for adolescents to nicotine, and some evidence shows that e-cigarettes are associated with subsequent "regular" (combustible) cigarette smoking (9). Other potential long-term risks of e-cigarettes are unknown.
Cannabis (marijuana)
In 2010, the rate of current cannabis use among 12th graders surpassed the rate of current tobacco use for the first time. The Monitoring the Future Survey reported that in 2025 the prevalence of current cannabis use among 12th graders was approximately 17%, which is a decrease from 22% in 2019 (1). Approximately 35% of 12th graders reported having used cannabis 1 or more times in their life (1).
The most significant increase in cannabis use is in THC vaping. The number of 12th graders who reported current THC vaping increased from approximately 5% in 2017 to 14% in 2019 (see also vaping products), and has decreased to 12% in 2025 (1).
Other substances
Use of substances other than alcohol, nicotine, and cannabis during adolescence is relatively rare.
In the 2025 Monitoring the Future Survey, the following percentages of 12th grade students reported using illicit substances 1 or more times in their life (1):
Hallucinogens: 6.3%
Cocaine: 1.4%
Anabolic steroids (nonprescription): 1.2%
Methamphetamines (nonprescription): 0.8%
Heroin: 0.4%
Inhalants are (eg, glue, aerosols) were used by 6.4% of 10th graders (12th grade data are not available).
Nationwide in 2021, 1.4% of high school students had ever used a needle to inject any illegal drug (13).
Prescription medications most frequently misused include opioid analgesics (eg, oxycodone), stimulants (eg, medications for ADHD such as methylphenidate or dextroamphetamine), and sedatives (eg, benzodiazepines).
Nonprescription, over-the-counter (OTC) medications that are commonly misused include cough and cold medications that contain dextromethorphan. OTC cough and cold medications are widely available.
Anabolic steroid use is more common among athletes (14), but nonathletes also use them.
Specific substances references
1. Miech RA, Patrick ME, O'Malley PM, et al. Monitoring the Future national survey results on drug use, 1975-2025: Overview and Detailed Results for Secondary School Students. Monitoring the Future Monograph Series. Institute for Social Research, University of Michigan; 2026.
2. National Institute on Alcohol Abuse and Alcoholism: Get the Facts About Underage Drinking: Underage Drinking Statistics. Accessed October 22, 2024.
3. National Institute on Alcohol Abuse and Alcoholism: Alcohol's Effects on Health: Binge Drinking. Accessed October 22, 2024.
4. Donovan JE. Estimated blood alcohol concentrations for child and adolescent drinking and their implications for screening instruments. Pediatrics. 2009;123(6):e975-e981. doi:10.1542/peds.2008-0027
5. Dawson DA, Goldstein RB, Chou SP, Ruan WJ, Grant BF. Age at first drink and the first incidence of adult-onset DSM-IV alcohol use disorders. Alcohol Clin Exp Res. 2008;32(12):2149-2160. doi:10.1111/j.1530-0277.2008.00806.x
6. Carvalho AF, Heilig M, Perez A, et al. Alcohol use disorders. Lancet. 2019;394(10200):781-792. doi:10.1016/S0140-6736(19)31775-1
7. Sharapova S, Reyes-Guzman C, Singh T, Phillips E, Marynak KL, Agaku I. Age of tobacco use initiation and association with current use and nicotine dependence among US middle and high school students, 2014-2016. Tob Control. 2020;29(1):49-54. doi:10.1136/tobaccocontrol-2018-054593
8. Wellman RJ, Dugas EN, Dutczak H, et al. Predictors of the Onset of Cigarette Smoking: A Systematic Review of Longitudinal Population-Based Studies in Youth. Am J Prev Med. 2016;51(5):767-778. doi:10.1016/j.amepre.2016.04.003
9. Soneji S, Barrington-Trimis JL, Wills TA, et al. Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis. JAMA Pediatr. 2017;171(8):788-797. doi:10.1001/jamapediatrics.2017.1488
10. Kcomt L, Mongilio J, Lim C, et al. Comprehensive E-Cigarette Policies Are Associated With Lower Use Among U.S. Adolescents and Young Adults. J Stud Alcohol Drugs. Published online March 24, 2026. doi:10.15288/jsad.25-00377
11. Reiter A, Hébert-Losier A, Mylocopos G, et al. Regulatory Strategies for Preventing and Reducing Nicotine Vaping Among Youth: A Systematic Review. Am J Prev Med. 2024;66(1):169-181. doi:10.1016/j.amepre.2023.08.002
12. Kaur J, Goel S, Shabil M, et al. Health impacts of electronic nicotine delivery systems: an umbrella review of systematic reviews. BMJ Open. 2025;15(10):e100168. Published 2025 Oct 10. doi:10.1136/bmjopen-2025-100168
13. Centers for Disease Control and Prevention: Youth Risk Behavior Surveillance—United States, 2021. MMWR Suppl 72(1):1–99, 2023.
14. Diehl K, Thiel A, Zipfel S, et al. How Healthy is the Behavior of Young Athletes? A Systematic Literature Review and Meta-Analyses. J Sports Sci Med. 2012;11(2):201-220. Published 2012 Jun 1.
Screening for Substance Use in Adolescents
Clinical evaluation, including routine screening questions
Sometimes drug testing
Adolescents should be screened routinely for substance use and also assessed as needed for current substance use if suspected.
Some behaviors should prompt parents, teachers, or others involved with an adolescent to be concerned about a possible substance use disorder. Other behaviors are nonspecific, for example:
Depression or mood swings
A change in friends
Declining school performance
Loss of interest in hobbies
Adolescents who exhibit any of these behaviors should have a clinical evaluation for mental health and substance use. Substance use disorders should be considered as possible causes of these behaviors even if screening is negative. Substance use disorders are diagnosed based on clinical criteria.
Screening adolescents for substance use
Screening for use of tobacco, alcohol, and other drugs, including misuse of prescription medications, is a standard part of health maintenance (1). Universal substance use screening can normalize discussions about substance use, reinforce healthy behaviors and choices, identify adolescents at risk of problematic substance use or of a substance use disorder, guide interventions, and identify adolescents in need of referral for treatment.
There are a number of different validated screening tools. The National Institute on Drug Abuse (NIDA) recommends 2 such electronic screening tools available for use with patients ages 12 to 17, the Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) tool and the Screening to Brief Intervention (S2BI) tool. Each screening tool may be either self-administered by the patient or administered by a health care professional. Self-administration is recommended because it is preferred by adolescents. The tools begin with questions about frequency of use of tobacco, alcohol, and cannabis in the past year. A positive answer prompts questions about additional types of substance use. The tools triage adolescents into 1 of 3 risk categories for a substance use disorder: no reported use, lower risk, and higher risk. Based on the results, the tools offer an action plan based on guidance derived from expert consensus. Although times may vary based on method of administration and number of follow-up questions, these tools can typically be completed in under 2 minutes.
The CRAFFT questionnaire is an older, validated screening tool for alcohol and drug use (2). Because the original CRAFFT questionnaire does not screen for tobacco use, provide information on frequency of use, or discriminate between drug and alcohol use, it is no longer widely used and other screening tools have been developed, including the updated CRAFFT 2.1+N questionnaire, which does have a question about use of tobacco and nicotine.
Screening adolescents for alcohol use
For more specific and comprehensive alcohol use screening, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has developed a guide that suggests beginning with 2 screening questions. The questions and interpretation of answers vary by age (see table ).
NIAAA Alcohol Screening Questions for Children and Adolescents
Age Group* | First Question | Second Question | Interpretation | Risk Levels by Age |
|---|---|---|---|---|
Elementary school (typically 9–11 years) | Do you have any friends who drank any drink containing alcohol in the past year? | In the past year, have you ever had more than a few sips of any drink containing alcohol? | Friends: Any drinking heightens concern Patient: Any drinking highest risk | ≤ 11 years: Any drinking highest risk |
Middle school (typically 11–14 years) | Do you have any friends who drank any drink containing alcohol in the past year? | In the past year, on how many days have you had more than a few sips of any drink containing alcohol? | Friends: Any drinking heightens concern Patient: Any drinking moderate to highest risk depending on age and number of days | ≤ 11 years: Any drinking highest risk 12–14 years: Moderate risk 1–5 days; highest risk > 5 days |
High school (typically 14–18 years) | In the past year, on how many days have you had more than a few sips of any drink containing alcohol? | If your friends drink, how many drinks do they usually drink on any occasion? | Patient: Low, moderate, or highest risk depending on age and number of days Friends: Binge drinking (3–5 or more drinks) heightens concern | 14–15 years: Moderate risk 1–5 days; highest risk > 5 days 16 years: Moderate risk 6–11 days; highest risk > 11 days 17 years: Moderate risk 6–24 days; highest risk > 24 days 18 years: Moderate risk 12–52 days; highest risk > 52 days |
* School level is used because risk increases on transition to a higher level. | ||||
NIAAA = National Institute on Alcohol Abuse and Alcoholism. | ||||
For moderate- and highest-risk patients, ask about:
Drinking patterns: Usual and maximal consumption
Problems caused by or risks taken due to drinking: Missing school, fights, injuries, motor vehicle crashes
Use of other substances: Any other things taken to get high
The NIAAA guide also provides useful strategies to address problems that are discovered.
Drug testing
Drug testing may be useful to identify substance use but has significant limitations. When parents demand a drug test, they may create an atmosphere of confrontation that makes it difficult to obtain an accurate substance use history and form a therapeutic alliance with the adolescent. Screening tests (including at-home tests) are typically rapid qualitative urine immunoassays that are associated with a number of false-positive and false-negative results. Furthermore, testing cannot determine frequency and intensity of substance use and thus cannot distinguish casual users from those with more serious problems. Clinicians must use other measures (eg, thorough history, questionnaires) to identify the degree to which substance use has affected each adolescent's life.
Given these concerns and limitations, it is often useful to consult with an expert in substance use disorders to help determine whether drug testing is warranted in a given situation. However, the decision not to drug test should not prematurely terminate assessment for a possible substance use disorder or a mental health disorder. Adolescents with nonspecific signs of a substance use disorder or a mental health disorder should be referred to an addiction specialist for a complete evaluation.
Screening references
1. COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE; BRIGHT FUTURES PERIODICITY SCHEDULE WORKGROUP. 2017 Recommendations for Preventive Pediatric Health Care. Pediatrics. 2017;139(4):e20170254. doi:10.1542/peds.2017-0254
2. Knight JR, Sherritt L, Harris SK, et al. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res. 2003;27(1):67-73. doi:10.1097/01.ALC.0000046598.59317.3A
Treatment of Substance Use in Adolescents
Behavioral therapy tailored for adolescents
Pharmacotherapy if indicated
Ensuring access to naloxone for overdose prevention
Typically, adolescents with a moderate or severe substance use disorder are referred for further assessment and treatment, often by a behavioral health specialist, or, in some cases, to a specialty substance use disorder treatment program. In general, the same behavioral therapies used for adults with substance use disorders can also be used for adolescents. However, these therapies should be adapted (1, 2). Adolescents should not be treated in the same programs as adults; they should receive services from adolescent programs and therapists with expertise in treating adolescents with substance use disorders.
Adolescents 16 years old and older with opioid use disorder can be treated with buprenorphine (1). Other medications are used off label in adolescents, but data are limited regarding their effectiveness. There is increasing evidence for the use of varenicline for nicotine vaping among adolescents (3).
Nicotine replacement therapy to treat withdrawal symptoms resulting from stopping the use of nicotine may be helpful and can be prescribed by a primary care clinician.
Overdose prevention and treatment
Overdose, when considered together with other poisoning, is the third leading cause of death among adolescents in the United States despite the declining prevalence of substance use (4). As a result, clinicians may provide anticipatory guidance for overdose prevention and facilitate access to naloxone (the antidote to opioid overdose) (5). Naloxone is now available for over-the-counter purchase at grocery stores and pharmacies across the United States and in some other countries.
Test strips designed to detect fentanyl or xylazine support a harm-reduction approach given that they may identify the presence of these drugs (6, 7).
Treatment references
1. Rockhill CM, Ramtekkar U, Becker TD, et al. Clinical Practice Guideline: Assessment and Treatment of Adolescents and Young Adults With Substance Use Disorders and Problematic Substance Use (Excluding Tobacco). J Am Acad Child Adolesc Psychiatry. 2026;65(2):105-138. doi:10.1016/j.jaac.2025.08.006
2. Simon KM, Levy SJ, Bukstein OG. Adolescent Substance Use Disorders. NEJM Evid. 2022;1(6):EVIDra2200051. doi:10.1056/EVIDra2200051
3. Evins AE, Cather C, Reeder HT, et al. Varenicline for Youth Nicotine Vaping Cessation: A Randomized Clinical Trial. JAMA. 2025;333(21):1876-1886. doi:10.1001/jama.2025.3810
4. Raymond-King C, Jeffery MM, Melnick ER. Current Causes of Death among Children and Adolescents in the United States. N Engl J Med. 2026;394(19):1958-1959. doi:10.1056/NEJMc2600445
5. Hadland SE, Schmill DM, Bagley SM. Anticipatory Guidance to Prevent Adolescent Overdoses. Pediatrics. 2024;153(5):e2023065217. doi:10.1542/peds.2023-065217
6. Vickers-Smith RA, Gelberg KH, Childerhose JE, et al. Fentanyl Test Strip Use and Overdose Risk Reduction Behaviors Among People Who Use Drugs. JAMA Netw Open. 2025;8(5):e2510077. Published 2025 May 1. doi:10.1001/jamanetworkopen.2025.10077
7. Rubin R. Here's What to Know About Xylazine, aka Tranq, the Animal Tranquilizer Increasingly Found in Illicit Fentanyl Samples. JAMA. 2023;329(22):1904-1906. doi:10.1001/jama.2023.8625
More Information
The following English-language resources may be useful. Please note that The Manual is not responsible for the content of these resources.
National Institute on Alcohol Abuse and Alcoholism (NIAAA): Alcohol Screening and Brief Intervention for Youth: A Practitioner's Guide
National Institute on Drug Abuse (NIDA): Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) tool
Levy S. Handbook of Pediatric Addiction Medicine. American Academy of Pediatrics; 2026. doi:10.1542/9781610028516.
Drug Information for the Topic
