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The leading causes of morbidity and mortality among adolescents and young adults are related to alcohol, smoking, and illicit drug use. According to 2015 data from Monitoring the Future (MTF), alcohol and tobacco use are at the lowest level in the survey’s history, which dates back to 1975. From 1996 to the present, the 30-day prevalence of smoking declined by 83% and 79% in 8th and 10th graders, respectively. Seventy-five percent fewer students reported trying cigarettes in 2015 compared to 1997. Alcohol continues to be the most widely used substance in this population. In 2000, the prevalence of alcohol use in the past 30 days was 22%, 41%, and 50% among 8th, 10th, and 12th graders, respectively; the prevalence has now dropped to 10%, 22%, and 35%, respectively. Marijuana is the most widely used illicit drug with the highest prevalence rate among 12th graders at 35%; other illicit drug use declined across 8th through 12th grades from 34.1% in 1997 to 26.8% in 2015.


Substance use often begins during adolescence or earlier. Adolescents use tobacco, alcohol, and illicit drugs to deal with problems, to enhance school performance, in response to peer pressure, or in response to desires for new experiences. Adolescents are more likely to use drugs if drugs are readily available in their community, if their peer group uses drugs, or if they have a mental health diagnosis such as depression or anxiety. Biologically, the adolescent brain is more vulnerable to substance use disorders, as the prefrontal cortex, which is responsible for judgment and impulse control, is not fully developed until the mid-20s. As there is no pathognomonic clinical presentation of substance use, clinical signs of substance use vary from behavioral and medical to a mental health complaint. The signs of substance use may be as subtle as appearing withdrawn, tired, or agitated. Secondary to substance use, a decline may be seen in school or athletic performance, and changes in peer groups, engagement in illegal activities, or other high-risk behaviors may occur.


Known risk factors for the development of substance use disorder include male gender, gang involvement, academic failure, family history of a substance use disorder, use by peers, earlier age of onset, cognitive disability, and psychiatric comorbidities such as attention–deficit/hyperactivity disorder (ADHD) and depression. Many of these risk factors overlap with other problematic behaviors such as teen pregnancy, truancy, and violence. Protective factors against substance use include community involvement, healthy family and school relationships, and prosocial peers.


The American Academy of Pediatrics recommends annual screening of adolescents for tobacco, alcohol, and illicit drug use, including sports supplements and prescription drugs. Substance use screening should be incorporated into all healthcare visits for early identification of at-risk individuals. The healthcare provider, by creating a comfortable, ...

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