Drug and Substance Use in Adolescents

Alcohol use is common and is the substance most often used by adolescents. The Monitoring the Future Survey on Drug Use reported that in 2021 by 12th grade, 54% of adolescents have tried alcohol, and nearly 26% are considered current drinkers (having consumed alcohol within the past month) (1). Heavy alcohol use is also common, and adolescent drinkers may have significant alcohol toxicity. Nearly 90% of all alcohol consumed by adolescents occurs during a binge, putting them at risk of accidents, injuries, unwanted sexual activity, and other bad outcomes. A binge is defined as a pattern of alcohol consumption that raises the blood alcohol level to 80 mg/dL (17.37 mmol/L). The number of drinks that constitute a binge depends on age and sex and can be as few as 3 drinks within 2 hours for younger adolescent girls.

Society and the media portray drinking as acceptable, fashionable, or even as a healthful mechanism for managing stress, sadness, or mental health problems. 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 go on to develop an alcohol use disorder. Known risk factors for developing a disorder include starting drinking at a young age and genetics. Adolescents who have a family member with an alcohol use disorder should be made aware of their increased risk.

The majority of adults who smoke cigarettes began smoking during adolescence. If adolescents do not try cigarettes before age 19, they are very unlikely to become smokers as adults. Children as young as age 10 may experiment with cigarettes (1).

Rates of combustible tobacco use among adolescents fell dramatically in the 1990s and 2000s and continue to decline. The Monitoring the Future Survey reported that in 2021, about 4.1% of 12th graders reported current cigarette use (smoked in the previous 30 days), down from 28.3% in 1991 and from 5.7% in 2019; only about 2% report smoking every day.

The strongest risk factors for adolescent smoking are having parents who smoke (the single most predictive factor) or having peers and role models (eg, celebrities) who smoke. Other risk factors include

• Poor school performance

• High-risk behavior (eg, excessive dieting, particularly among girls; physical fighting and drunk driving, particularly among boys; use of alcohol or other substances)

• Poor problem-solving abilities

• Availability of cigarettes

• Poor self-esteem

Adolescents may also use tobacco products in other forms. About 2% of high school students are current users of smokeless tobacco (1); this rate has declined over the past 10 years. Smokeless tobacco can be chewed (chewing tobacco), placed between the lower lip and gum (dipping tobacco), or inhaled into the nose (snuff). Pipe smoking is relatively rare in the US. The percentage of people > age 12 who smoke cigars has declined.

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 Smoking Cessation).

Vaping and Smoking Myths

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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 adult smokers, 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 25.5% in 2019. According to the Monitoring the Future Survey, in 2021 e-cigarette use decreased to 19.6%, and about 40.5% of 12th graders tried e-cigarettes (nicotine and other substances), which is a decrease from 45.6% in 2019 (1).

Electronic cigarettes cause different adverse effects compared to smoking. 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 nicotine2).

The Monitoring the Future Survey reported that in 2021 the prevalence of current cannabis use among high school seniors was 19.5%, which is a decrease from 22.3% in 2019. About 38.6% of high school seniors reported having used cannabis one or more times in their life (1). In 2010, the rate of current cannabis use surpassed the rate of current tobacco use for the first time.

The most significant increase in cannabis use is in THC vaping. The number of 12th graders who reported current THC vaping increased from 4.9% in 2017 to 14% in 2019 (see also vaping products). This percentage decreased to 12.4% in 2021 (1).

In the 2021 Monitoring the Future Survey, the following percentages of 12th grade students reported using illicit substances one or more times in their life (1):

• Prescription drugs (without a prescription): 8.8%

• Inhalants (eg, glue, aerosols): 5.0%

• Hallucinogens (eg, LSD, PCP, mescaline, mushrooms): 7.1%

• Anabolic steroids (oral or injectable): 0.8%

• Methamphetamines (nonprescription): 0.6%

• Heroin: 0.4%

Prescription drugs most frequently misused include opioid analgesicsstimulantssedatives (eg, benzodiazepines).

Nationwide, 1.6% of high school students had used a needle to inject any illegal drug (2).

1. 1. Johnston LD, Miech RA, O’Malley PM, et al: Monitoring the Future National Survey Results on Drug Use 1975-2021: 2021 Overview, Key Findings on Adolescent Drug Use. Ann Arbor, Institute for Social Research, University of Michigan, 2022.

2. 2. Underwood JM, Brener N, Thornton J, et al: Youth Risk Behavior Surveillance—United States, 2019. MMWR Suppl 69(1):1–83, 2020. doi: 10.15585/mmwr.su6901a1

Screening for use of tobacco, alcohol, and other drugs is a standard part of health maintenance. Adolescents and their parents can benefit from advice about safely using and monitoring over-the-counter and prescription drugs. 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) has two 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 one of three 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.

For more specific and comprehensive alcohol screening, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has developed a guide that suggests beginning with two screening questions. The questions and interpretation of answers vary by age (see table NIAAA Alcohol Screening Questions for Children and Adolescents).

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, car 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 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 a specialist for a complete evaluation.