1.
ADOLESCENT SUBSTANCE
USE: AMERICA’S #1 PUBLIC
HEALTH PROBLEM
A Report by
CASAColumbia®
June 29, 2011

2.
Funders
• The Conrad N. Hilton Foundation
• The American Legacy Foundation
• The Carnegie Corporation of New York
© CASAColumbia 2013
2

3.
National Advisory Commission
•
Hon. Jim Ramstad (Chair), Former U.S. House of
Representatives (R-MN)
•
Robert Bazell, Chief Health and Science
Correspondent, NBC News
•
Hon. Jeb Bush, Former Governor (R-FL)
•
Enrique A. Carranza, Parent/Activist
•
•
•
•
Charles E. Irwin, MD, Director, Division of
Adolescent Medicine, University of California, San
Francisco
Peter Mitchell, Chairman and Chief Creative Officer,
SalterMitchell
© CASAColumbia 2013
Hon. Lucille Roybal-Allard, U.S. House of
Representatives (D-CA)
•
Ralph Hingson, ScD, MPH, Director, Division of
Epidemiology and Prevention Research, NIAAA
Anthony Mullen, 2009 National Teacher of the Year
•
Barbara J. Guthrie, PhD, RN, FAAN, Associate
Professor and Associate Dean for Academic Affairs,
Yale University School of Nursing
•
Laurence Steinberg, PhD, Distinguished University
Professor and Laura H. Carnell Professor of
Psychology, Temple University
•
Hon. Linda Tucci Teodosio, Judge, Summit County
Juvenile Court
•
Darrell Thompson, Former NFL Running Back,
Green Bay Packers and Executive Director, Bolder
Options
•
Hon. Leticia Van de Putte, RPh, Texas State
Senate (D-26th District)
•
David Walsh, PhD, Former President and Chief
Executive Officer, National Institute on Media and the
Family
3

4.
Study Methodology
• Reviewed 2,000 publications
• Analyzed 7 national data sets
• Interviewed approximately 50 experts and professionals
• Focus groups with students, parents and school personnel
• CASAColumbia national surveys of:
 High school students (1,000)
 Parents of high school students (~1,000; 75% from same household as
students)
 School personnel—teachers, principals, social workers/counselors,
coaches (~500)
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5.
Risky Substance Use:
A Public Health Problem
Risky Substance Use Leads to Negative Health
Outcomes Including:
• Addiction
• 70+ diseases requiring hospitalization
• Mental health problems
• Accidents, injuries, fatalities
• Sexually transmitted diseases and unplanned pregnancies
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6.
Early Use Increases Risk
9 in 10 People with Substance Use Disorder Begin
Smoking, Drinking or Using Other Drugs before Age 18
• 91.4% of those addicted to nicotine
• 91.6% of those addicted to alcohol
• 96.1% of those addicted to illicit or controlled prescription drugs
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7.
Earlier Use Equals Greater Risk
Percent of Population 12 and Older with a
Substance Use Disorder
by Age of First Use of Any Substance
28.1
18.6
7.4
4.3
Before 15
15 to 17
18 to 20
21+
Source: CASA analysis of the National Household Survey on Drug Use and
Health (NSDUH), 2009.
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8.
Adolescence Is
The Critical Period
For the Onset of Substance Use and Its Consequences
• Teen brain is more prone to risk taking, including substance use
• Teen brain is more vulnerable to damage from substances,
including addiction
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9.
High School Student
Substance Use, 2009
Percent of High School Students Who Have
Used Cigarettes, Alcohol, Marijuana or Cocaine
75.6
46.1
Lifetime Use
Current Use
Source: CASA analysis of the Youth Risk Behavior Survey (YRBS), 2009.
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10.
High School Student
Substance Use, 2009
Percent Using Top 3 Addictive Substances
72.5
46.3
41.8
36.8
20.8
19.5
Alcohol
Cigarettes
Ever Used
Marijuana
Current Use
Source: CASA analysis of the Youth Risk Behavior Survey (YRBS), 2009.
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11.
Trends in High School Student
Substance Use
Percent Ever Used Cigarettes, Alcohol,
Marijuana or Cocaine, by Gender
83.0
80.5
76.9
76.6
82.5
77.4
1999
77.0
74.9
2001
76.9
2003
Female
76.9
73.9
2005
2007
74.3
2009
Male
Source: CASA analysis of Youth Risk Behavior Survey (YRBS), 2009.
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12.
Trends in High School Student
Substance Use
Percent Ever Used Cigarettes, Alcohol,
Marijuana or Cocaine, by Race
90
85
80
75
70
65
1999
White
2001
2003
Black
2005
2007
Hispanic
2009
Other
Source: CASA analysis of Youth Risk Behavior Survey (YRBS), 2009.
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13.
High School Student
Substance Use
Percent Who Have Used
Controlled Prescription and Illicit Drugs
Inhalants
11.7
Ecstasy
6.7
Cocaine
6.4
Methamphetamine
4.1
Over-the-Counter Medicine
3.3
Heroin
2.5
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14.
Consequences of Teen
Substance Use
• Academic: lower grades and academic attainment, higher
unemployment
• Health: traffic accidents, risky sex, chronic health problems, brain
damage, addiction, fatal health conditions, unintentional injuries,
homicides, suicides
• Crime: juvenile and adult property, violent and substance-related
offenses
© CASAColumbia 2013
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15.
Substance Use Disorders
Among High School Students
• 11.9% (1.6 million) of all high school students
• 19.4% of those who have ever tried any substance
• 33.3% of current substance users
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16.
Substance Use Disorders
Among High School Students
Percent by Substance
Any Substance Use Disorder
11.9
Alcohol Use Disorder
7.1
Marijuana Use Disorder
4.9
Nicotine Dependence
2.9
Prescription Drug Use Disorder
1.3
Other Illicit Drug Use Disorder
1.2
More Than One Substance Use
Disorder
3.7
Source: CASA analysis of the National Household Survey on Drug Use and
Health (NSDUH), 2009.
© CASAColumbia 2013
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17.
Substance Use Disorders
Among High School Students, Dropouts, Juveniles
in the Justice System
Percent with Substance Use Disorders
52.4
44.0
34.8
11.9
High School
Students
High School
Dropouts
Juveniles in the
Juvenile Justice
System
Juveniles in the
Adult Corrections
System
Source: CASA analysis of the National Survey on Drug Use and Health
(NSDUH), 2009; CASA Criminal Neglect: Substance Abuse, Juvenile
Justice and The Children Left Behind, 2004.
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18.
Referrals to Treatment
Typically Occur When Teens Are Deeply in Trouble
Percent of Treatment Referrals by Source
48.2
16.5
12.0
11.2
4.7
Criminal
Self Referral
Justice System
Other
Community
Referral
School
Health Care
Provider
Source: CASA analysis of the Treatment Episode Data Set (TEDS), 2008.
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19.
Few Teens Receive
Quality Treatment
• 1.6 million high school students meet medical criteria for a
substance use disorder involving alcohol or other drugs
• Only 6.4% of them (99,913) received treatment in past year
• Only 28% of treatment facilities offer specialized care for
adolescents; most offer substandard care
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20.
Staggering Costs to Society
Costs of Teen Use:
• $68 billion/year for underage drinking ($2,280/year for
every adolescent in the U.S.)
• $14.4 billion/year for juvenile justice
Teen Use Drives Lifetime Costs:
• $467.7 billion/year in government spending on substance
use/addiction ($1,500/year for every person in the U.S.)
• 96 cents of every $1 goes to cope with the consequences;
only 2 cents for prevention and treatment
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21.
American Culture
Drives Teen Use
Messages in American Culture Promote or Condone
Teen Substance Use
• Parental substance use and attitudes
• School influences
• Advertising
• Entertainment media
• Availability
• Peer norms
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22.
Mixed Messages from Families
• 46.1% of children under 18 (34.4 million) live with
risky substance user
• 20.8% of parents of high school students think
marijuana is a harmless drug
• Home/family is most common source of addictive
substances, after friends
• Most parents don't see addiction to nicotine
(61.2%), alcohol (54.9%) or Rx/illicit drugs (53.8%)
as genetic, physical or mental health problems
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23.
Schools Miss the Mark
• Only 27% of high school teachers say their schools train staff to
identify and respond to student substance use
• Less than 40% of high school teachers think their school’s
prevention efforts are effective
• Three-quarters of high school teachers were unable to name a
professional who is available to help students with substance use
problems
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24.
School Responses
Often Punitive
Percent of Teachers Reporting How Their
Schools Respond to Student Substance Use
82.5
59.3
47.3
34.0
14.1
13.2 17.3
20.3
11.0
Suspends
Calls Law
Suggests
Requires
Student
Enforcement Counseling Counseling
Smoking
4.9
Expels
Student
4.7
10.2
Refers to
Health Care
Provider
Alcohol or Other Drugs
Source: CASA National Survey of High School Students, Parents of High
School Students, and High School Personnel, 2010.
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25.
Advertising/Media Glamorize
Substance Use
• Odds of becoming a tobacco user increase with exposure to tobacco
marketing
• Exposure to TV and movie portrayals of drinking linked to teen
drinking
 77% of the most popular TV shows among teens and adults
mention or depict drinking
Advertisements like this one
for Jose Cuervo tequila
glamorize substance use
© CASAColumbia 2013
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26.
Easy Availability Promotes Use
• Easy access = Increased risk of using
• 10th graders who say it’s easy to get:
 Cigarettes (76.1%)
 Alcohol (80.9%)
 Marijuana (69.3%)
• Increased alcohol outlet density linked to increased use
• Key sources for teens are friends and family/home
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27.
Teens’ Expectations Drive Use
• Teens are 2x likelier to initiate alcohol use if they believe that their
peers approve of their doing so
• Teens more likely to use if:
 Low perception of risk/high perception of benefits
 Friends’ use
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28.
Disconnect in Teen Perceptions
Percent of High School Students Who Say the
Following Are Very/Somewhat Cool
Getting Good Grades
71
Being Substance Free
10
Drinking Alcohol
Smoking Cigarettes
Misusing Prescription Drugs
31
54
7
Getting Drunk or High
Using Marijuana
88
48
48
6
43
4
36
4
What "I" Think Is Cool
28
What Most Teens Think Is Cool
Source: CASA National Survey of High School Students, Parents of High
School Students, and School Personnel, 2010.
© CASAColumbia 2013
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29.
Compounding the Risk
• Genetic predisposition or family history of substance use disorders
• Adverse childhood events (e.g., abuse or neglect)
• Co-occurring mental health or behavioral problems
• Peer victimization or bullying
• Other risky behaviors
• Subgroups at risk: child welfare, juvenile offenders, dropouts,
minority sexual identity
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30.
Factors that Mitigate Risk
• Positive family environment
• Positive adult role models
• Strong school/community attachment,
extracurricular activity participation,
goals for the future
• Sense of spirituality, religious
involvement
• High self-esteem, impulse control
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31.
Public Health Approach
to Prevention
1. Help the public understand the risks of teen substance use,
the nature of addiction and its origins in adolescence.
2. Prevent or delay the onset of substance use for as long as
possible through the implementation of effective public health
measures.
3. Identify teens at risk for substance use through routine
screenings, as we do for other public health problems.
4. Intervene early with teens who are using to prevent further use
and its consequences.
5. Provide appropriate treatment to teens identified as having a
substance use or co-occurring disorder.
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32.
Help the Public Understand
•
Conduct public awareness campaigns to educate the public about:
 Nature of addiction
 Consequences of teen substance use
 Facts about why teens use addictive substances
 Link between early use and increased risk of addiction
 How to prevent and respond
•
Promote campaigns that are proven to be effective
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33.
Prevent or Delay Initiation
• Reduce access
 $1 increase in cigarette tax/pack would reduce teen smoking by
2.7% to 5.9%
 10% increase in alcohol price associated with ~5% reduction in
drinking
• Regulate advertising
• Prevention programs
• Engage parents
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34.
Identify Teens at Risk
and Intervene Early
• Health care practice:
 Target teens in primary care and emergency settings
 ~15% of teens screened in primary care settings test positive
• Schools, justice and child welfare programs:
 78.4% of juvenile offenders are substance involved
 Teens in child welfare system at high risk due to parental substance use
and trauma
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35.
Provide Appropriate Treatment
• Addiction is a complex brain disease driven by genetics,
psychological and environmental factors
 Chronic substance use can produce alterations in brain systems and
structures, dramatically altering behavior and disrupting normal human
processes
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36.
Ending Addiction
Changes Everything
www.casacolumbia.org
© CASAColumbia 2013

37.
Speaker Notes
Slide 1:
•
•
Addiction is a complex brain disease.
What this report shows is:
• That this disease, in almost all cases, has its roots in adolescence,
• That it is the number one preventable and most costly health problem we face,
• And that our culture, broadly defined, actually increases the risk that teens will smoke, drink or
use other drugs--and suffer the consequences.
Slide 6:
•
•
•
The epidemiological evidence demonstrates a clear link between using addictive substances
during the teen years and developing the disease of addiction.
Teens who use any addictive substance--including tobacco/nicotine--before the age of 18 have a 1
in 4 chance of having a substance use disorder; for those who wait until age 21 to before using any
addictive substance, their chance goes down to 1 in 25.
Because of the link between adolescence substance use and lifetime occurrence of substance use
disorders, addiction is considered a developmental disorder.
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38.
Speaker Notes
Slide 7:
•
The earlier teens use nicotine, alcohol or other drugs, the greater the likelihood that they will suffer
from a substance use disorder. The converse is also true, every year that first use is delayed, the
risk of addiction goes down.
Slide 8:
•
•
•
Adolescence is the critical period of risk for both using substances and for suffering from the
associated consequences, including addiction.
The reason why teens are more vulnerable to substance use and its consequences is that the
parts of the brain responsible for judgment, decision making and controlling impulses develop
during adolescence and through the mid-20s.
This developmental period creates a perfect storm for teens. When compared with adults:
• Teens are more likely to take risks, like experimenting with tobacco, alcohol and other drugs;
• The adolescent brain is more easily damaged by these addictive substances; and
• Teens are more likely to become addicted when they use them.
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39.
Speaker Notes
Slide 9:
•
3 out of 4 high school students in America have smoked cigarettes, drunk alcohol, smoked
marijuana or used cocaine at least once.
•
Almost ½ of high school students are current users of 1 or more of these substances, meaning,
they have used them in the past month.
•
While substance use is often intertwined with other problems, by itself, it is more prevalent than
anxiety, depression, obesity, and bullying.
Side Note: About 2/3 (65.1%) of students who have ever used any addictive substance have used
more than 1; among high school students who currently use any addictive substance, 46.9 %--just
under ½ currently use more than 1. Of those who have smoked cigarettes, 92% have used another
drug, as have 96% of those who have used marijuana.
Slide 10:
•
Alcohol is, by far, the most commonly used substance, followed by cigarettes and marijuana.
Among high schools students who use these substances, the average age of initiation is between
the ages of 13 and 14.
Side Note: For cigarettes-13.6 years old; alcohol-14.0 years old; marijuana-14.3 years old.
© CASAColumbia 2013
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40.
Speaker Notes
Slide 11:
•
•
•
The good news is that over the past decade, the percent of high school students who are lifetime
substance users has dropped.
The bad news is that these rates are still unacceptably high and declines in current use appear to
have stalled.
Here you can see the trend in lifetime substance use over the past decade by gender.
Slide 12:
•
Since 2007, use has increased among Hispanic students, stayed roughly the same among black
students, and fallen among white students and students of other races/ethnicities.
© CASAColumbia 2013
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41.
Speaker Notes
Slide 13:
•
•
The 4th most commonly used type of drug among high school students is controlled prescription
drugs, with 14.8% of teens reporting lifetime use (not comparable data with that previously
presented as it comes from a different data source).
To put these numbers in perspective, a typical high school class comprised of 30 students:
• 21 or 22 will have used alcohol
• 13 or 14 will have smoked a cigarette
• 11 will have used marijuana
• 4 or 5 will have misused controlled prescription drugs
• 3 or 4 will have used inhalants
• 2 will have tried ecstasy and cocaine, and
• 1 student will have used methamphetamine, over-the-counter drugs or heroin.
© CASAColumbia 2013
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42.
Speaker Notes
Slide 14:
•
•
•
Teen substance use can have serious academic consequences, including lower grades, higher
drop-out rates, reduced likelihood of earning a college degree, and higher rates of unemployment
in adulthood.
Teen substance use also is associated with a range of health and mental health problems,
including depression, anxiety disorders and suicidal thoughts.
It use also contributes to the 3 leading causes of death among adolescents: accidents, suicides
and homicides.
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43.
Speaker Notes
Slide 15:
•
Use of addictive substances during adolescence dramatically increases the lifetime risk of
addiction. For many students, the disease of addiction manifests at an early age.
•
1 in 8 students has already developed a substance use disorder before graduating from high
school.
•
Among current substance users, 1 in 3 meet the clinical criteria for a substance use disorder.
Side Note: all high school students, ages 18 and younger, who met the DSM-IV criteria for alcohol or
drug abuse/ dependence in the past year, or the Nicotine Dependence Syndrome Scale (NDSS)
criteria for nicotine dependence in the past month
Slide 16:
•
Here you see the prevalence of substance use disorders broken out by substance.
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44.
Speaker Notes
Slide 17:
•
The rates of substance use disorders among particular adolescent populations such as high
school dropouts and those involved in the justice system are even higher.
Slide 18:
•
•
Typically, referrals to treatment come late in the game, when teens are already deeply in trouble.
The vast majority of referrals come from the justice system.
Slide 19:
•
An unconscionably few teens who need treatment receive it, and those who do often receive
substandard care.
Slide 20:
•
•
•
Adolescent substance use results in both immediate and long term costs for tax payers.
Because addiction is a developmental disorder that typically originates in the teen years, the long
term costs of addiction can extend over a lifetime.
For every $1 we spend on this problem, only 2 cents are spent on prevention and treatment.
© CASAColumbia 2013
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45.
Speaker Notes
Slide 21:
•
•
American culture is rife with messages that encourage adolescents to smoke, drink and use other
drugs.
These messages help drive this problem and they are created, in large part, by adults.
Slide 22:
•
•
•
•
•
Parents are sending mixed messages through their own substance-related attitudes and
behaviors.
For example, CASAColumbia’s analysis found that almost ½ (46.5%) of parents are engaging in
risky substance use themselves; meaning they currently smoke, drink excessively or binge drink,
misuse controlled prescription drugs or use illicit drugs.
In our survey of parents, 1 in 5 say that they see marijuana as a harmless drug and most don't
see addiction as a genetic, physical or mental health problem
Sending a clear no use message is important: High school students report that the main reason
their peers do not drink or use other drugs is because their parents would disapprove.
Other research confirms that greater perceived parental disapproval of teen substance use is
linked to lower likelihood of teen use.
© CASAColumbia 2013
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46.
Speaker Notes
Slide 23:
•
Lack of funding, lack of evidence-based prevention programs for teens and failure to treat this as
a health problem have led schools to miss an important opportunity for prevention and
intervention.
Slide 24:
•
Too often schools take a punitive approach to students with substance use problems, which can
exacerbate the problem cutting off those in need of help from the institutions and services that
could benefit them.
Slide 25:
•
•
The media’s frequent presentation of substance use as glamorous, fun and stress-relieving,
coupled with limited regulation of alcohol and tobacco advertising, contribute to the pro-substance
use messages that bombard teens every day.
These messages are not benign: Tobacco and alcohol advertising and promotions have been
linked to increased risk of adolescent tobacco and alcohol use, as have images of smoking and
drinking on television and in the movies.
© CASAColumbia 2013
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47.
Speaker Notes
Slide 26:
•
•
•
•
Once the desire for addictive substances is primed in them, high school-age teens have little
problem accessing these products.
High school students who report that cigarettes, alcohol and marijuana are easy to obtain are
more likely to use them.
Adolescents in communities that are densely populated by alcohol outlets are more likely to drink,
and lower prices of these substances contribute to greater access and use.
For the most part, however teens report getting their cigarettes, alcohol and other drugs from their
friends or family, which includes the family medicine or liquor cabinet.
Slide 27:
•
•
•
The mixed messages teens receive from the larger culture shape teens’ perceptions, attitudes and
expectations about smoking, drinking and using other drugs, which in turn influence their use.
For example, teens tend to overestimate the percent of their peers who are using substances and
the extent to which their peers are accepting of use.
Teens who believe their peers are using, or that their peers think substance use is cool, are more
likely to use.
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48.
Speaker Notes
Slide 28:
•
As you can see, there is a vast discrepancy between teens own views and their perception of the
views of their peers. This is important because we know that as teens age, they look increasingly
towards their peers to define social norms.
Slide 29:
•
•
•
Some teens have particular characteristics that make them more inclined to use addictive
substances and that hike the risk of progression from substance use to addiction.
A large body of research confirms that teens who are at increased risk include those who:
• Have a genetic predisposition or a family history of substance use disorders
• Have suffered from trauma in childhood
• Have a mental health or behavioral problem or have been victims of bullying; and those who
• Engage in other risky behaviors, like unhealthy weight control practices or risky sexual activity.
Certain sub-groups of adolescents--such as those who drop out of high school, are involved with
the criminal justice system, have a minority sexual identity or are involved in athletics--also are at
elevated risk.
© CASAColumbia 2013
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49.
Speaker Notes
Slide 30:
•
Researchers have documented a range of factors that mitigate the risk of adolescent substance
use, here are a few important examples:
• Living with parents who model healthy behavior, create a nurturing family environment, play an
active role in their teen’s lives, communicate openly and honestly about substance use, and set
and enforce clear rules;
• Having positive adult role models;
• Forging strong attachments to schools or communities,
• Having a sense of spirituality or being involved in religion; and
• High self-esteem and the ability to control one’s impulses.
Slide 31:
•
•
Parents may be the number one influence on a child’s decision to smoke, drink or use other
drugs, but there is mounting evidence that public health measures designed to address both the
cultural and individual factors that drive teen substance use can prevent such use and its
consequences.
Yet, current approaches frequently are not supported by scientific evidence and the effective
strategies that are available are not widely employed.
© CASAColumbia 2013
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50.
Speaker Notes
Slide 32:
•
•
•
•
•
One public health measure that can help prevent adolescent substance use is conducting public
awareness campaigns to help the public understand the nature of addiction and its origins in
adolescence.
CASAColumbia’s research has found that more than ½ of parents do not identify addiction as
primarily a health problem.
A public awareness campaign would educate the public about what addiction is, what the
consequences of teen substance use are, the factors that drive use, what to look for and how to
respond.
Although some public awareness campaigns around this issue are based in the research, most
have been implemented without evidence supporting their effectiveness.
In fact, some public awareness campaigns that target teens have been shown to increase use.
© CASAColumbia 2013
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51.
Speaker Notes
Slide 33:
•
•
•
Public policies designed to limit access to tobacco and alcohol are some of the most effective
strategies available for preventing or delaying the onset of adolescent substance use.
Raising cigarette and alcohol taxes, implementing smoking bans, and raising the minimum
drinking age to 21 have all been proven effective at reducing teen access and use. Over ½ of the
parents in CASAColumbia’s survey support raising tobacco and alcohol taxes to reduce
adolescent substance use.
In addition, smaller studies suggest that:
• Limiting teens’ exposure to advertising
• Implementing comprehensive school and community based programs; and
• Targeting high-risk teens with specially designed interventions are all promising approaches.
Slide 34:
•
•
•
It is important to identify substance use early and intervene to reduce risk and prevent the
progression from use to addiction.
Screenings and brief interventions are effective public health tools that work well in health care
settings, including primary care and ER visits, but can also work in many other settings where
teens receive services, such as schools, juvenile justice facilities and child welfare programs.
Although research shows that screening and brief intervention techniques are effective among
high school-age adolescents, they are currently not routine practice in any of these settings.
© CASAColumbia 2013
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52.
Speaker Notes
Slide 35:
•
•
•
Addiction is a complex brain disease characterized by structural and functional changes that
disrupt normal brain processes.
Addiction is a serious medical condition but it can be treated effectively. Psychosocial therapies
such as cognitive behavioral therapy and family-based therapies--often in combination--are
effective treatments for adolescents with substance use disorders. Pharmacotherapy is another
treatment option but not widely practiced in adolescent populations.
We also need to expand access to care--by increasing the number of trained health care providers
who can provide treatment, facilities to provide it, and health insurance coverage for treatment.
© CASAColumbia 2013
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