In the 1980s, most high school kids smoked cigarettes and drank alcohol, and many of them smoked marijuana. Back then, only 3% of 12th graders said they had never used cigarettes, alcohol or marijuana in their lifetime. Remarkably, by 2015, the number of high school seniors who said they had never used substances increased to 25%, and 50% reported no use in the past month, up from just 16% in the early 1980s.

This is a tremendous, but almost completely overlooked, public health success. The highly effective Truth Campaign abruptly knocked down youth tobacco use, while other efforts have resulted in a steady 40-year decline in youth alcohol use. Yet, despite successes in reducing use, disheartening rates of addiction among adolescents have not budged. Fewer kids try drugs and alcohol, but those who do are more likely to develop serious problems. A Centers for Disease Control report released in August 2017 found that the overdose death rate for adolescents increased in 2015 after years of decline. An understanding of the contrast between declining rates of substance use and increasing rates of addiction is critical to shaping substance use prevention and policy.

What is different about teen substance use today? For starters, substance use behaviors have all become more extreme, just like sports, rollercoasters and even “binge” TV viewing. Binge drinking has always been common among underage drinkers, but today’s binges are bigger than they used to be. Half of all high school binge drinkers consume 10 or more drinks per occasion, and half of these extreme binge drinkers consume 15 or more. The harms of drinking increase dramatically as quantity increases, including risk of motor vehicle crashes, and in the long term, addiction and liver cirrhosis.

The substances themselves have also changed. The concentration of THC – the main active ingredient in marijuana – has increased dramatically over the past three decades, exposing youth to higher levels of THC than ever before. “Dabbing”, a newly popular way of using cannabis, also results in extremely highly blood levels of THC. Higher THC exposure produces more euphoria but is also more likely to cause medical and psychosocial problems. For example, highly concentrated marijuana products can lead to psychotic reactions lasting for days, weeks or even longer.

Have efforts to reduce teen substance experimentation achieved a public health benefit? Yes. Many substance use problems occur among the large proportion of casual users. Countless car crashes and other injuries have been averted by reducing teen alcohol use. Droves of kids have escaped the grips of tobacco addiction. In contrast to alcohol and tobacco youth marijuana use rates have remained roughly stable since the late 1990s. The surprise is that they have not risen over the past two decades in the face of increasing public acceptance of marijuana, growth of legal marijuana and an increasingly aggressive cannabis industry.

But despite these successes, additional strategies that steer more kids away from alcohol and drug use are needed to reduce the nation’s burden of addiction because 90% of addiction begins in youth, and death rates from overdose and addiction continue to rise. Regulations on marketing and public education campaigns countering claims of health benefits from substance use are needed. E-cigarettes may be a reasonable strategy for those already struggling with nicotine addiction, but the industry should not be allowed to market them as harmless fun, which entices youth who might otherwise never have smoked traditional cigarettes. Although misconceptions that marijuana is “healthy because it’s natural” or “safe because it’s legal” have cultural traction, they are false, and require ongoing, strong messaging of evidence to the contrary. Alcohol, nicotine, and marijuana should be the target of campaigns that expose them for what they are – potentially harmful for youth in any quantity and especially dangerous in concentrated products and extreme ways of using. Our public health response for youth should be similar to that for pregnant women: there is no completely safe level of substance use.

Encouraging use of supposedly ‘less harmful’ substances – such as e-cigarettes or marijuana – as safer alternatives to tobacco, alcohol, or opioids is a fool’s errand. A large study released last month showed that teens that use e-cigarettes are more likely than their peers to initiate use of traditional cigarettes. Marijuana is not a safe or effective substitute for other substances for youth: teens that use marijuana are much more likely to also use alcohol, tobacco, and opioids.

As physicians that specialize in caring for adolescents with substance use disorders, we can attest that the healthiest choice for youth is no use of alcohol, nicotine, marijuana, or other drugs. Over the past four decades an increasing percentage of American high school students have chosen not to use substances, proving that abstinence is a reasonable option for this age group. Our children need a clear and consistent message vigorously championed by parents, educators, and health care professionals that abstaining from all substance use is best for their health.

Robert L. DuPont, MD, President, Institute for Behavior and Health, Inc.; First Director, National Institute on Drug Abuse

Marc J. Fishman, MD, Medical Director, Maryland Treatment Centers, and Assistant Professor, Johns Hopkins University Department of Psychiatry

Scott Hadland, MD, MPH, MS, pediatrician and adolescent addiction specialist at the Grayken Center for Addiction Medicine at Boston Medical Center

Sharon Levy, MD, MPH
The Adolescent Substance use and Addictions Program (ASAP)
Boston Children’s Hospital
Associate Professor of Pediatrics, Harvard Medical School
Sharon Levy, MD, MPH is a board certified Developmental-Behavioral Pediatrician and an Associate Professor of Pediatrics at Harvard Medical School. She is the Director of the.The Adolescent Substance use and Addictions Program (ASAP) in the Division of Developmental Medicine at Boston Children’s Hospital, which is comprised of clinical, research, training and policy arms. She has evaluated and treated thousands of adolescents with substance use disorders, and has taught national curricula and published extensively on the outpatient management of substance use disorders in adolescents, including screening and brief advice in primary care, the use of drug testing and the outpatient management of opioid dependent adolescents. She is the immediate past chair of the American Academy of Pediatrics Committee on Substance Use and Prevention, the President Elect of the Association for Medical Education and Research in Substance Abuse (AMERSA) and serves on the board of directors of the Addiction Medicine Fellowship Director’s Association.