Substance Use in Adolescents

Alcohol is the substance most often used by adolescents. The United States Monitoring the Future Survey on Drug Use reported that, in 2023, by 12th grade, 46% of adolescents have tried alcohol in the past year, 33% have been drunk in the past year, 24.3% have consumed alcohol in the past 30 days, and 10% have had more than 5 drinks in a row in the prior 2 weeks (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 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 constitute a binge depends on age and sex and can be as few as 3 drinks within 2 hours for younger adolescent girls.

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 (4). 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 receive appropriate support to ensure their current well-being and counseling about their increased risk of developing a substance use disorder.

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 (5).

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 2023, approximately 2.9% of 12th graders reported current cigarette use (smoked in the previous 30 days), down from 28.3% in 1991; only approximately 0.7% report smoking every day.

Risk factors for adolescent smoking include (6)

• Parental influence

• Peer influence

• Vaping tobacco (a risk factor for smoking conventional cigarettes)

• Use of alcohol or other substances

• Mental health disorders or learning disabilities

• Poor school performance

• Poor self-esteem

• Availability of cigarettes

Adolescents may also use tobacco products in other forms. Approximately 2.5% of 12th graders are current users of smokeless tobacco (1). 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 United States. 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 Cessation in children).

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. However, according to the Monitoring the Future Survey, in 2023 e-cigarette use decreased to 16.9%. According to that same survey, in 2023 approximately 22.1% of 12th graders tried e-cigarettes (nicotine and other substances) (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 nicotine are highly addictive, and toxicity is possible. E-cigarettes are increasingly the initial form of exposure for adolescents to nicotine, but their effect on the rate of adult smoking is unclear. Other potential long-term risks of e-cigarettes are also unknown (7).

The Monitoring the Future Survey reported that in 2023 the prevalence of current cannabis use among 12th graders was 18.4%, which is a decrease from 22.3% in 2019. Approximately 36.5% of 12th graders reported having used cannabis 1 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 13.7% in 2023 (1).

Use of substances other than alcohol, nicotine, and cannabis during adolescence is relatively rare.

In the 2023 Monitoring the Future Survey, the following percentages of 12th grade students reported using illicit substances 1 or more times in their life (1):

• Inhalants (eg, glue, aerosols): 6.3%

• Hallucinogens: 6.6%

• : 1.3%

• Methamphetamines (nonprescription): 0.6%

• Heroin: 0.2%

Nationwide, 1.4% of high school students had used a needle to inject any illegal drug (7).

Prescription medications most frequently misused include opioid analgesicsstimulantssedatives (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, but nonathletes also may use them.

1. 1. Miech RA, Johnston LD, Patrick ME, O’Malley PM: Monitoring the Future National Survey Results on Drug Use, 1975-2023: Secondary School Students. Ann Arbor, Institute for Social Research, University of Michigan, 2024.

2. 2. National Institute on Alcohol Abuse and Alcoholism: Get the Facts About Underage Drinking: Underage Drinking Statistics. Accessed October 22, 2024.

3. 3. National Institute on Alcohol Abuse and Alcoholism: Alcohol's Effects on Health: Binge Drinking. Accessed October 22, 2024.

4. 4. 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

5. 5. Sharapova S, Reyes-Guzman C, Singh T, Phillips E, Marynak KL, Agaku ITob Control. 2020;29(1):49-54. doi:10.1136/tobaccocontrol-2018-054593

6. 6. 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

7. 7. Centers for Disease Control and Prevention: Youth Risk Behavior Surveillance—United States, 2021. MMWR Suppl 72(1):1–99, 2023.

Screening for use of tobacco, alcohol, and other drugs, including misuse of prescription medications, is a standard part of health maintenance. 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. 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.

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).

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 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.

1). Naloxone is now available for over-the-counter purchase at grocery stores and pharmacies across the United States and in some other countries.

1. 1. Hadland SE, Schmill DM, Bagley SM. Anticipatory Guidance to Prevent Adolescent Overdoses. Pediatrics. 2024;153(5):e2023065217. doi:10.1542/peds.2023-065217