Full length articleTrends in typologies of concurrent alcohol, marijuana, and cigarette use among US adolescents: An ecological examination by sex and race/ethnicity
Introduction
Alcohol, marijuana, and cigarettes are the most commonly used substances among school-aged adolescents in the United States, with current national data indicating annual prevalence rates of 24%, 13%, and 13% respectively among individuals age 12–17 (Miech et al., 2016). To date, most of the research on risk for substance use disorders (SUDs) among adolescents has examined each substance in isolation. However, substance use often occurs concurrently, with 11–15% of adolescents reporting past-year use of alcohol, marijuana and cigarettes (A + M + C; Tomczyk et al., 2016). Moreover, the Substance Abuse and Mental Health Services Administration (SAMHSA, 2015c) documented that 51% of binge drinkers age 12–17 report past-month cigarette use, compared to 2% of same-aged non-drinkers. Similarly, 30% of binge drinkers and 56% of cigarette users in the past month report marijuana use in the same period (SAMHSA, 2015c).
Examining concurrent substance use—or the use of two or more substances within a specified time period—during adolescence is critical, as adolescents who engage in concurrent use are at increased risk for negative health and social consequences compared to those who are single-substance users. For example, concurrent users of alcohol and cigarettes (A + C) are more likely to use illicit drugs, experience social consequences, engage in delinquency, have poorer health, and more treatment utilization than single-substance users (Hoffman et al., 2001, Johnson and Richter, 2002). The increased risk posed by concurrent A + C use also persists into adulthood, predicting more deviant and violent behavior, greater problems related to substance use, and a greater likelihood of arrest by age 29 compared to those adolescents who use alcohol only (AO) by late adolescence (Orlando et al., 2005).
Similar results have been found among concurrent alcohol and marijuana (A + M) and marijuana and cigarettes (M + C) users. Specifically, compared to adolescent AO users, A + M users report higher rates of substance use (Chun et al., 2010), psychological distress (Conway et al., 2013, Kelly et al., 2015a), and behavioral problems (Shillington and Clapp, 2002). Moreover, compared to AO use, A + M use during adolescence is associated with greater risk for SUD (Green et al., 2016, Moss et al., 2014), high-school non-completion, and having a criminal record in young adulthood (Green et al., 2016, Kelly et al., 2015b). Although studied less than A + M use, M + C use during adolescence has also been associated with more severe consequences than single substance use, including greater psychological distress and respiratory problems (Ramo et al., 2012). Among adolescents, M + C use has been found to be more strongly associated with depression, other psychiatric disorders (Boys et al., 2003), and neurocognitive deficits than marijuana only (MO) use or cigarette only (CO) use (Jacobsen et al., 2007). M + C users are also less likely to be involved in prosocial activities (e.g., sports) and report academic achievement (Suris et al., 2007). Yet, when comparing all typologies of use, the greatest risk for health and functional consequences has been found among youth who engage in concurrent use of all three substances. A + M + C use is associated with higher levels of psychological distress (Kelly et al., 2015a), school non-completion (Kelly et al., 2015b) and SUD in adulthood relative to single- and dual-substance use (Moss et al., 2014).
Researchers have also documented differences in single and concurrent patterns of substance use based on sex and race/ethnicity. In general, male adolescents report higher rates of daily alcohol, marijuana, and cigarette use than female adolescents (Lanza et al., 2015, Miech et al., 2016). As for concurrent use, the most consistent sex effect has been found for occasional concurrent users (i.e., lifetime users of alcohol, marijuana and cigarettes, with little recent concurrent use), who are more likely to be female than male (Connell et al., 2010, Gilreath et al., 2014, Gilreath et al., 2015). However, findings have been mixed regarding sex differences in the frequent/recent use of alcohol, marijuana and cigarettes. Gilreath et al. (2014) and Gilreath et al. (2015) found that males were more likely to be frequent/current users of A + M + C than females, whereas Connell et al. (2010) found the opposite sex effect. Sex differences have also been equivocal regarding M + C use (Ramo et al., 2012); whereas some studies have found that male adolescents are more likely to be M + C users than females (Guxens et al., 2007, Victoir et al., 2007), others have found the opposite sex effect (Lanza et al., 2015, Suris et al., 2007), or no sex effect (Aung et al., 2004).
Racial/ethnic differences in adolescent substance use have also been observed. Asian, Hispanic, and African American youth, in general, report lower rates of 30-day use of alcohol, marijuana, and cigarette use than their White peers (Miech et al., 2016, Wallace et al., 2002, Wallace et al., 2003). Conversely, Native American adolescents tend to report higher rates of marijuana and cigarette use than White and other racial/ethnic minority adolescents, and report rates of alcohol use comparable to those of White adolescents (Wallace et al., 2002, Wallace et al., 2003).
Prevalence of concurrent use has been found to hold a similar pattern for Asian adolescents, who show less A + M (Collins et al., 1998, Lanza et al., 2010) A + C (Hoffman et al., 2001), and M + C use than White and other racial/ethnic minority adolescents (Ramo et al., 2012), However, findings regarding racial/ethnic differences in concurrent use have been mixed for Hispanic, African American and Native American youth. Some researchers have noted no difference in substance use typology between White and Hispanic adolescents (Lanza et al., 2010), whereas several others have suggested that Hispanic youth are more likely to be concurrent substance users than Whites (Connell et al., 2009, Gilreath et al., 2014, Gilreath et al., 2015). Among African American adolescents, several studies have documented a lower prevalence of concurrent substance use compared to White adolescents (Connell et al., 2009, Gilreath et al., 2015, Lanza et al., 2010, Tomczyk et al., 2016). However, when examining typology of concurrent use, researchers have found variability in risk between African American and White adolescents. For example, African American adolescents have been found less likely to be concurrent users of A + M (Chung et al., 2013, Lanza et al., 2010, Terry-McElrath et al., 2013) and A + C than their White counterparts (Orlando et al., 2005), but more likely to be users of M + C (Aung et al., 2004, Ramo et al., 2012, Vaughn et al., 2008, Young and Harrison, 2001). Lastly, research examining differences in concurrent substance use between Native American adolescents and adolescents of other racial/ethnic groups are sparse, with equivocal findings. For example, a study comparing adolescents from two Native American tribes to nationally-representative data found that adolescents in one tribe had similar patterns of use to the national population, whereas adolescents in the other tribe were more likely to be past-year concurrent substance users than the national population (Whitesell et al., 2006).
Thus, although sex and racial/ethnic differences in adolescent substance-use typologies have been documented, conclusions are indefinite (see Appendix A, Table 1). The variability in results in the current literature may be due to differences in the sample (e.g., age, region, racial/ethnic composition), operationalization of substance use (which ranges from past two weeks to lifetime use), methodology (e.g., mixture modeling versus population estimates), and the typology of concurrent use examined (Conway et al., 2013, Tomczyk et al., 2016). Only one study to date has examined membership in all possible classes of single and concurrent use of alcohol, marijuana, and cigarettes based on sex and race/ethnicity. Among adolescents under age 16, Moss et al. (2014) found that male adolescents were most likely to be lifetime A + M users, whereas females were most likely to be CO users. The researchers also found that African American adolescents were more than twice as likely to belong to the lifetime MO typology than any other typology, whereas Whites were least likely to have engaged in lifetime MO use. White adolescents were most likely to have engaged in typologies characterized by single or concurrent alcohol and cigarette use (i.e., AO, CO, A + C, A + M + C), whereas African American and Hispanic adolescents were more likely to have engaged in typologies characterized by marijuana use (i.e., MO, M + C, A + M, A + M + C). However, this study was limited in that it excluded Native American and Asian American adolescents, and sex and race/ethnicity comparisons were conducted within-group rather than comparing differences between groups.
Thus, the current study seeks to expand this work by documenting the national prevalence of substance-use typologies (both single and concurrent) among current adolescent users and comparing prevalence rates across sex and race/ethnicity. Specifically, data from the 2011–2014 National Survey on Drug use and Health (NSDUH) will be utilized to examine the following: 1) the 30-day prevalence of single and concurrent patterns of adolescent use of alcohol, cigarettes and marijuana by age, sex, and race/ethnicity; and 2) racial/ethnic and sex differences in the prevalence rates of various typologies of adolescent substance use.
Section snippets
Data and sample
Data were compiled from public-use data files from the 2011–2014 NSDUH (SAMHSA, 2012, SAMHSA, 2013, SAMHSA, 2014, SAMHSA, 2015b), a series of population surveys providing annual nationwide data on substance use patterns in the United States. NSDUH interviews are administered by computer-assisted personal interviewing and audio computer-assisted self-interviewing for illegal drug use and other health-related behaviors (see SAMHSA (2015a) for more detailed survey methodology). Over the 4-year
Prevalence of typologies by demographics
Weighted prevalence estimates of past-30-day substance-use typology are presented in Table 1 by demographic characteristics. The largest category of substance-use typology was AO (37.84%), with nearly three times the prevalence of the next largest category: A + M. The smallest category was M + C users, making up only 5.08% of current substance users. Regarding age, MO users were the youngest class of users, whereas A + C and A + M + C users were the oldest. Males made up the majority of adolescents in
Discussion
Previous literature has documented elevated risk of health and functional outcomes among concurrent adolescent substance users compared to single users, which we also found within the current sample (see Appendix A, Table 2). However, previous literature has been equivocal as to whether typologies of substance use differ based on sex and race/ethnicity. The current study aimed to fill this gap by examining prevalence rates of single and concurrent substance use among current adolescent users,
Conclusion
The current study described the national prevalence of single and concurrent typologies of adolescent substance use by sex and race/ethnicity. We found that the largest category of substance-use typology was AO (37.84%), with nearly three times the prevalence of the next largest category. Yet, concurrent substance use is also prevalent in the U.S., making up over 40% of past-month substance use. Among current substance-users, White, male adolescents report the highest rates of concurrent
Role of funding source
Work by TZ was supported by National Institute of Health awards KL2TR001106 (PI: A. Shekhar), R25DA035163 (PI: C. Masson), and P30DA027827 (PI: G. Brody).
Conflict of interest
No conflict declared.
Contributors
DB conceived of the study and led on all aspects of the analysis and writing. AR wrote sections of the manuscript with input from DB and TZ. PM conducted the statistical analyses and wrote sections of the manuscript. TZ critically revised drafts of the manuscript. All authors contributed to and approved the final draft of
References (50)
- et al.
Simultaneous polydrug use among teens: prevalence and predictors
J. Subst. Abuse
(1998) - et al.
Prevalence and patterns of polysubstance use in a nationally representative sample of 10th graders in the United States
J. Adolesc. Health
(2013) - et al.
Racial differences in trajectories of heavy drinking and regular marijuana use from ages 13 through 24 among African-American and White males
Drug Alcohol Depend.
(2012) - et al.
Outcomes associated with adolescent marijuana and alcohol use among urban young adults: a prospective study
Addict. Behav.
(2016) - et al.
Age and sex differences in factors associated with the onset of cannabis use: a cohort study
Drug Alcohol Depend.
(2007) - et al.
Co-occurrence of alcohol and cigarette use among adolescents
Addict. Behav.
(2001) - et al.
Functional correlates of verbal memory deficits emerging during nicotine withdrawal in abstinent adolescent cannabis users
Biol. Psychiatry
(2007) - et al.
The relationship between smoking, drinking, and adolescents’ self-perceived health and frequency of hospitalization: analyses from the 1997 National Household Survey on Drug Abuse
J. Adolesc. Health
(2002) - et al.
Past 15-year trends in adolescent marijuana use: differences by race/ethnicity and sex
Drug Alcohol Depend.
(2015) - et al.
Racial/ethnic differences in use of alcohol, tobacco, and marijuana: is there a cross-over from adolescence to adulthood?
Soc. Sci. Med.
(2015)
Trends among U.S. high school seniors in recent marijuana use and associations with other substances: 1976–2013
J. Adolesc. Health
Initiation and persistence of alcohol use in United States Black, Hispanic, and White male and female youth
Addict. Behav.
Early adolescent patterns of alcohol, cigarettes, and marijuana polysubstance use and young adult substance use outcomes in a nationally representative sample
Drug Alcohol Depend.
Tobacco and marijuana use among adolescents and young adults: a systematic review of their co-use
Clin. Psychol. Rev.
Simultaneous alcohol and marijuana use among US high school seniors from 1976 to 2011: Trends, reasons, and situations
Drug Alcohol Depend.
Latent classes of polysubstance use among adolescents—a systematic review
Drug Alcohol Depend.
History of marijuana use and tobacco smoking topography in tobacco-dependent adolescents
Addict. Behav.
Psychiatric morbidity and substance use in young people aged 13–15 years: results from the Child and Adolescent Survey of Mental Health
Br. J. Psychiatry
The significance of marijuana use among alcohol-using adolescent emergency department patients
Acad. Emerg. Med.
White and Black adolescent females differ in profiles and longitudinal patterns of alcohol, cigarette, and marijuana use
Psychol. Addict. Behav.
A multiprocess latent class analysis of the co-occurrence of substance use and sexual risk behavior among adolescents
J. Stud. Alcohol Drugs
Social-ecological influences on patterns of substance use among non-metropolitan high school students
Am. J. Community Psychol.
School victimization and substance use among adolescents in California
Prev. Sci.
Substance use among adolescents in California: a latent class analysis
Subst. Use Misuse
Ethnic differences in adolescent substance initiation sequences
Arch. Pediatr. Adolesc. Med.
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